Crisis resolution services are set to become a new component within mental health service provision. So how does one set up and run an effective crisis resolution service?
Good planning is the key to ensuring that a crisis service will meet its objectives. Service developers need to start by assessing the local demand for crisis work and questioning assumptions about the need for separate services.
Professor Tom Burns, consultant psychiatrist at the South West London and St George's NHS mental health trust, advocates integrating crisis services within existing mental health teams.
"Crises in mental health are not like heart attacks. They build up over days and weeks - not minutes," says Professor Burns. "We have found being able to respond promptly within the same day is what is needed and requests for immediate response have virtually disappeared. Such a same day response should be well within the capacity of a well functioning community mental health team and offers the added advantage of continuity of care. The patient isn't passed from one group of staff to another."
However if the level of local demand requires a separate crisis team developers should examine how the whole mental health system functions. Too many crisis services are set up as a sticking plaster on top of service infrastructures that are in crisis.
A crisis service steering group should be formed. Membership must include influential service users. The steering group should incorporate the ideas of the stakeholders on whom the success of the crisis service will hinge. Service users should have a substantial influence on service design, objectives and outcomes.
The steering group must address issues common to all crisis services as well as local ones. Common challenges include determining the target population to be served, budgets, the staffing and skills mix, operating hours, liaison with primary care and establishing respite care. Local decisions to be examined might include the catchment area, user needs, service structure, partnerships and service evaluation.
Cuts
The budget will determine the scope of the crisis resolution service. Open All Hours, a report published by the Sainsbury Centre for Mental Health in 1997 cited service costs of £481,000 a year for a 14-staff, 24-hour team.
Wider budgetary issues should also be considered to determine the service's viability. Will the crisis service be targeted for cuts in a few years' time?
The team manager should be involved in decisions on the broad operational issues, such as initial and risk assessment strategies, acceptance and exclusion referral criteria and effective client interventions. How will the service address clients with substance and alcohol misuse problems, personality disorders and mental illnesses with a learning disability component?
Staff should reflect the local community and have a wide mix of skills. Training should be provided soon after appointment, emphasising skills in client engagement, initial and risk assessment procedures. Once inducted, staff should be involved in developing operational policies such as the shift hours of the service, emergency guidelines, operational procedures and administration issues in order to "own" policies.
Crisis services should establish access to respite accommodation as American and Australian studies have demonstrated that these can decrease hospital admissions.
Strategies for discharging clients must be decided. After working through the crisis, it is the team's responsibility to ensure activities occur that link clients to support services. Clients should exit crisis services feeling empowered and having learned coping skills for the future.
• Michael Bryant is internet information manager at the Sainsbury Centre for Mental Health. Tel: 020-7716 6780.
