Executive Summary
National Audit Office Value for Money Report
- The NHS in England spent over 8 billion on mental health in
2006-07, more than on any other category of health problem. Most
people with mental health problems receive treatment in the
community, for example from their GP or a Community Mental Health
Team. But acute services are also a crucial part of mental health
services.
- Severe psychiatric illnesses are often episodic in nature, with
stable periods of less intense symptoms interrupted by periods of
crisis in which symptoms become intense. In recent years Crisis
Resolution Home Treatment (CRHT) services have been developed to
provide acute care for mental health service users [Footnote a] living in the community
and experiencing a severe crisis requiring emergency treatment.
Previously, such treatment could only have been provided by
admitting the service user to an inpatient ward. The introduction
of CRHT services was one of the key elements in the 1999 National
Service Framework for mental health; the NHS Plan (2000) made the
provision of CRHT services a national priority; and the Department
of Healths (the Departments) 2002 Public Service Agreement included
targets both for the number of teams and the number of people
treated.
- The main aim was to provide service users with the most
appropriate and beneficial treatment possible. But CRHT was also
intended to reduce inpatient admissions and bed occupancy, support
earlier discharge from inpatient wards and reduce out-of-area
treatments (where a bed can only be found for a person outside
local NHS services).
- In examining whether these aims of the CRHT policy are being
achieved, we focused on the degree to which CRHT teams are
fulfilling their intended role within the Departments mental health
service model. Our examination included a detailed referral and
admissions audit of CRHT teams and inpatient wards, a survey of
referring clinicians, focus groups and feedback from service users
and carers, economic modelling and data analysis covering team
provision, activity, inpatient admissions and expenditure.
Key Findings
- CRHT teams have been rapidly implemented across most areas of
the country. 183 million was spent on providing CRHT services in
2006-07, an increase of 409 per cent in real terms since 2002-03.
The Public Service Agreement target of establishing 335 teams was
met by 2005. The target for treating 100,000 people a year has not
yet been achieved, with 95,397 episodes of CRHT provided to 75,868
individual people reported in the year to 31 March 2007. From
2008-09, the Department plans to introduce more locally managed and
outcomes-based metrics of performance alongside these
targets.
- The introduction of CRHT teams has been associated with reduced
pressure on beds, and the teams are successfully reaching service
users who would otherwise probably have needed admission. CRHT
teams are also supporting the earlier discharge of people from
inpatient treatment for example in around 40 per cent of the
discharges in our sample.
- However, while reported CRHT staff head-count nationally is at
around 90 per cent of the total requirement estimated by the
Department, there are wide regional variations in team provision
relative to local need. Many teams lack dedicated input from key
health and social care professionals, particularly consultant
psychiatrists. This can restrict their ability to provide
comprehensive, multi-disciplinary care, as well as the extent to
which they are integrated and accepted within local mental health
services. We estimate that an additional 10 to 30 million of
resources (depending on exact skill mix and variable costs such as
training) would have to be diverted into CRHT services each year to
increase capacity and improve multi-disciplinary and medical
input.
- A key function of CRHT teams is the assessment of treatment
required by a service user, made in the early stages of an acute
psychiatric crisis, which considers whether CRHT would be a safe
and clinically beneficial alternative to admission for the person
concerned (gatekeeping). We found that having a CRHT staff member
at the assessment makes it far more likely that the assessment will
consider whether CRHT is an appropriate alternative to admission,
and increases the chances that the CRHT team will be involved in an
early discharge.
- Yet our sample testing of 500 admissions showed that only half,
rather than all as intended, had been assessed by CRHT staff before
being admitted. Around one in five of our sample admissions were
considered by ward managers to be appropriate candidates for CRHT.
Other health professionals making referrals to acute mental health
services could have better awareness and understanding of how the
community and inpatient elements of an acute service operate, which
would make the users route through such services more
efficient.
- Our economic modelling estimated that an acute mental health
service making full use of CRHT services in appropriate cases costs
approximately 600 less per crisis episode than one in which CRHT is
not available chiefly because some admissions will be avoided
altogether and others will shorter, reducing the costs incurred
with overnight stays. Increasing the proportion of cases in which
CRHT is considered offers scope for further efficiency savings on a
cautious estimate of some 12 million a year and potentially much
more. Realising such savings needs careful management, however,
especially because very ill service users will form an increased
proportion of those remaining in inpatient wards.
Value for money assessment
- The evidence base suggests that when used appropriately and
safely, CRHT brings clinical benefits and increased patient
satisfaction. It can also reduce the stigma and social exclusion
frequently faced by people suffering from acute mental illness. The
Department has made rapid progress with the implementation of CRHT
since 2001, and many service users across England are seeing its
benefits. But there is further scope to maximise its impact and
improve value-for-money by ensuring CRHT teams are properly
resourced, fully functional and integrated within local mental
health services.
Our Conclusions and Recommendations
For the Department of Health
- Issue: The current CRHT target regime has been an effective
driver to implementation, but is limited by its focus on outputs
(e.g. CRHT episodes) rather than outcomes (e.g. benefits to service
users). The Department plans to place less emphasis on existing
targets for the number of teams and episodes and to encourage the
introduction of more locally managed and outcomes-based metrics of
performance.
Recommendation: The Department should take this
opportunity to develop metrics allowing a rounded assessment of the
local acute services of which CRHT are part, for example
service-user outcome data. Such metrics should be developed in
conjunction with the Information Centre for Health and Social Care,
and could be drawn from sources such as the current Care Services
Improvement Partnership/Department of Health National Outcomes
Measures project or existing local NHS pilot schemes.
- Issue: At present, few local organisations obtain and
report service-user feedback on CRHT services, and those that do
are doing so in a piecemeal and ad hoc fashion.
Recommendation: The Department should make clear
to local commissioners and provider
trusts its expectation that they conduct regular
service-user satisfaction exercises on key areas of service
provision, including CRHT and its interfaces with the wider mental
health pathway. The Department should also discuss
with the Healthcare Commission (and its successor
body) how meaningful national data on CRHT services might be
gathered as part of the national Patient Survey programme.
- Issue: The Mental Health Minimum Data Set (MHMDS) is
intended to collect data on each individual service user, and
ensure that all their contacts with specific services are recorded
and reported on an individual basis. This would provide crucial
information for systematic monitoring of service standards and
performance. [Footnote 11] However, although
basic data are being reported by all mental health providers, other
key information is often not recorded.
Recommendation: The Department should encourage
Trusts to improve their use of the Mental Health Minimum Data Set
to support planned improvements in monitoring. The
Department should discuss with the Information
Centre and the Healthcare Commission (and
its successor body) how to best support this aim through NHS bodies
annual performance assessments.
- Issue: Reducing Out-of-Area Treatments (OATs) was one of
the aims of the CRHT policy, but there are currently no routine
national data available to analyse the extent to which this is
being achieved. The Healthcare Commission has been exploring the
possibility of a routine OAT measure as part of its Better Metrics
project. [Footnote 12]
Recommendation: The Department should work with
the Healthcare Commission (and
its successor body), the Information Centre and
local NHS bodies to produce a robust, national OAT
dataset. For NHS Commissioners and Providers of Acute Mental Health
Services
- Issue: At national level, numbers of reported CRHT staff
are at approximately 90 per cent of the estimated level required.
However, there are wide regional variations in team provision
relative to local need, and many teams lack dedicated input from
key health and social care professionals, particularly consultant
psychiatrists.
Recommendation: NHS commissioners should work with
mental health provider trusts to assess current
CRHT capacity in the context of local need, and invest sufficient
resources to make fully staffed 24/7 CRHT teams an integral part of
the local mental health care pathway. This should include ensuring
that CRHT teams receive full clinical input and support from
consultant psychiatrists, both to provide appropriately skilled and
multi-disciplinary CRHT teams and to encourage acceptance and
knowledge of their role within local mental health services.
- Issue: To realise the full benefits of CRHT, teams need to
be a fully functional and integral part of acute mental health
services, gatekeeping all potential admissions and communicating
effectively with inpatient services to facilitate early
discharge.
Recommendation: Clinical directors and service
managers should seek to maximise effective collaboration
and communication between all elements of the acute mental health
pathway by, for example:
- Encouraging regular dialogue between CRHT and inpatient teams
regarding referrals, admissions and discharges. Depending on local
service configuration, this may be facilitated by co-locating CRHT
and inpatient teams on the same site. Consideration should be give
to this option when updating or replacing acute mental health
facilities.
- Recording at the point of inpatient admission both the purpose
of the admission and an indicative discharge date, with both
inpatient and CRHT teams monitoring progress against this
timetable.
- Integrating training for CRHT and acute inpatient services to
equip staff to operate in both settings.
- Considering the use of staff rotation and joint roles for acute
care staff and managers between inpatient and CRHT teams.
- Issue: The Departments aim is for CRHT teams to gatekeep
all potential admissions to inpatient wards. But we found that CRHT
staff had been involved in only 53 per cent of our sample of
admissions, and had had a bearing on the decision to admit in only
46 per cent. The likelihood of CRHT teams being involved in
admissions was greater for teams available 24/7.
Recommendation: In addition to Recommendations v and vi (above),
provider trusts should enforce written policies
and procedures requiring every inpatient admission to be preceded
by a CRHT gatekeeping assessment. If, in exceptional circumstances,
an admission has occurred without such an assessment taking place,
trust policy should require the CRHT team to have contact with the
service user within 48 hours of admission.
- Issue: CRHT services are generally receiving appropriate
referrals, but could function more efficiently if referrers better
understood the appropriate client group. The majority of potential
referrers to CRHT services do not feel they fully understand local
CRHT services or the client group these services are intended to
serve.
Recommendation: NHS commissioners should work with
local mental health providers, acute trusts, GP practices
and Local Implementation Teams to jointly develop,
negotiate and agree comprehensive local protocols for mental health
referrals. ix Issue: Alternatives to admission as well as home
treatment (e.g. crisis houses, respite housing, acute day units)
provide valued support for acute services, but provision is
patchy.
- Issue: Alternatives to admission as well as home treatment
(e.g. crisis houses, respite housing, acute day units) provide
valued support for acute services, but provision is
patchy.
Recommendation: Commissioners should use data from
the forthcoming Healthcare Commission Acute Inpatient Mental Health
Service Review to review provision of crisis accommodation and
respite facilities in the context of local need. They should work
with provider trusts, local government bodies and
third-sector organisations to ensure that a suitable range
of crisis houses, respite facilities and acute care are available
within the local community.
a. [back from footnote a] Service user is
the established term used in the NHS for people being treated by
mental health services. As this report is aimed partly at a
professional
NHS audience, for ease of reference this term has been used
throughout.
11. [back from footnote 11] For more
detail, see Glover G, The Mental Health Minimum Data Set: a first
sight of the data (North East Public Health Observatory Occasional
Paper No. 24, August 2006).
12. [back from footnote
12]
http://www.healthcarecommission.org.uk/_db/_documents
/Healthcare_Commission_7th_version_better_metrics_
master11Dec06.pdf