Crisis Care – alternatives to admission

Crisis Houses: An alternative to Hospital Admission? A look at real world crisis houses at Tees, Esk and Wear Valley NHS Mental Health Foundation Trust.

Up North the Durham & Darlington Crisis house run by Tees, Esk and Wear Valley MH Foundation Trust has been sitting empty since December 2017 while service users aren’t informed it exists. Is this TEWV’s way of maintaining the hospital/medical model status quo by ensuring Crisis Houses are destined to fail, or is it something to do with Crisis House model itself?

The current UK government’s review of the Mental Health Act is placing strong emphasis on reducing detentions. As such, better community services including support in a crisis are high on the agenda with strong calls to introduce more services that support people in acute distress outside the hospital environment. (1)

The question is whether such services would be effective and safe for patients and provide genuine alternatives to hospital. When crisis teams were introduced they too were intended to be a service for people who would otherwise be admitted to hospital. The course of time has shown that suicide is far higher under crisis teams than in inpatient care (2). Nevertheless, steps are being taken to improve community based services.

‘Crisis Houses’ are one of the options frequently mentioned in debates around better community services in crisis and alternatives to hospital. But do we know what would happen if crisis houses were rolled out on a wider scale?

Recently Recovery in the Bin were told about a consultation by Tees, Esk and Wear Valley NHS Mental Health Foundation Trust on the continuation of their County Durham and Darlington Crisis House which opened 4 years ago. The consultation highlighted that an inpatient bed costs the Trust £380 per day whereas a Crisis house bed cost the Trust £480 per day, though the consultation doesnt mention effectiveness – and cost -effectiveness – of shorter stays in the Crisis House than hospital.
The sobering figures showed that very few service users were considered ‘appropriate’ for the Crisis House. Admissions were via the crisis team and the Crisis House had in fact been closed since December 2017 with not a single referral accepted and the staff working elsewhere in crisis services. Unsurprisingly the Trust wanted to ‘review the role and function’ of the Crisis House.


We felt more information was needed on the circumstances behind this situation and asked a member of our group who is under the care of the Trust to find out more.The Trust provided further information as follows:

Question 3.
How have you determined that the lack of referrals to the crisis house are not a result of overzealous gatekeeping?
Trust Response: The crisis and recovery house provides an alternative, safe, supportive environment for intensive home based treatment for those experiencing a period of acute distress and who would benefit from a planned period of time away from home. The service is not used as an alternative to inpatient admissions and is not an element of the gate keeping process.

Question 6.
How many service users have the crisis house on their care plan or have been informed it exists?
Trust Response: Service users are made aware of the crisis and recovery house service, if and when it is appropriate to their care and treatment. As admission is made directly from the crisis teams based on immediate need, it is not identified within individual’s crisis plans (part of the overall care plan).

Question 2.
How have A&E attendances for mental health problems changed during the 4 years the crisis house has been open?
Trust Response: The crisis and recovery house does not provide emergency mental health care services. As such, we would be unable to ascertain any correlation between the service and A&E presentations.

Not all questions were answered (a FOI request may be needed) and we felt the responses that were received raised more questions.

While it is probably obvious to readers how insufficient the Trust responses are we nevertheless spell it out below.

The Trust replied that the Crisis House is not an alternative to hospital admission. Their consultation documents, in contrast, say the crisis house provides ‘an alternative..for intensive home based treatment’ and then explains that intensive home based treatment is ‘an alternative to hospital admission’. It seems somewhat illogical to consider the house not to be an alternative to hospital admission.

The Trust’s reply dismisses the possibility that the empty beds at the Crisis house may be a result of overzealous gate keeping. Yet it also claims all admissions are via an assessment by the crisis team when a service user is in acute distress. In fact, service users are only informed the crisis house exists if the crisis team decide that the house is an appropriate option. It is difficult to imagine a clearer example of impossible to challenge gatekeeping.

The Trust makes clear the Crisis House is not included in advanced crisis planning for known service users – it is not put on crisis plans for example. This seems somewhat contrary to the principles of the crisis care concordat. Furthermore, it calls into question the Trust’s consultation documents which claim that admissions to the crisis house are ‘planned’. A service user in acute distress informed of the Crisis house as an option following assessment by the crisis team is unlikely to experience much delay between assessment and admission to ‘plan’ admission to the house.

The Trust, which is consulting on the function and role of the Crisis House, claims they cannot ascertain any correlation between the Crisis house and A&E attendances for mental health problems on the basis that the crisis house does not provide emergency mental health services. But the Crisis house is designed to provide intensive home based intervention – which is an alternative to hospital admission for people in mental health crisis. The purpose of crisis planning is to prevent mental health emergencies. In addition, the consultation specifically pinpoints psychiatric liaison services as one of the reasons why there has been a reduction in the use of the Crisis house and yet psychiatric liaison is a service that receives referrals from A&E and may divert service users toward the crisis team. A&E attendances for acute mental distress and service users in crisis are essential for understanding and evaluating the role, function and impact of a crisis house.

This ‘case study’ of community based crisis services raises a lot of questions for TEWV to reflect on about the standard of crisis care and crisis planning they deliver and the extent to which they involve service users in decisions about their own care. It also raises questions about the effectiveness of consultations with patients and the public by NHS organisations, especially the quality of relevant information given to ensure stakeholders are enabled to provide fully informed opinions.

Over and beyond these considerations however, there is the wider question of how community based services might be implemented in practice if the drive to reduce detentions continues to call for greater emphasis on support outwith the hospital. And will service users ultimately benefit?

Is TEWV crisis house typical or are crisis houses working better elsewhere? What ensures the model works and why, at TEWV, has it resulted in a farcical scenario, reminiscent of 1980s satire Yes Minister (3), where patients around the country cannot get hospital beds but at TEWV an entire crisis house is sitting entirely empty?

(1) Dorothy Gould is currently seeking views on alternatives to hospital admission to feed into the mental health act review