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Crisis Assessment and Treatment Service, Ravenswood Clinic, Ravenswood Rd, Heaton, Newcastle upon Tyne NE6 5TX
Newcastle General Hospital, Newcastle upon Tyne
Institute of Psychiatry, London
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Abstract |
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An emergency response service (ERS) was introduced to streamline the assessment of individuals presenting in a crisis in one sector of a large provincial city. Data on service activity, clinical details and outcome were recorded on consecutive referrals to the service over the first 6 months of operation, and all patients were offered the opportunity to complete the Client Satisfaction Questionnaire.
RESULTS
Seventy-five per cent of those referred accepted the offer of assessment, and the majority were seen in their own home within 2 hours. One in ten individuals were not offered any further mental health input and 17% were hospitalised. The number of admissions via primary care fell by 60% after the introduction of this service. However, at its peak of activity the service received an average of only two referrals per day and three each weekend. Only 30% of referrals were received outside of normal office hours. Service users and general practitioners were found to be more satisfied with the service than the staff that provided it.
CLINICAL IMPLICATIONS
The introduction of the ERS led to a faster, more consistent process of assessment of crisis referrals and assessment undertakings in the community, and appeared to increase the use of alternative treatments for individuals in crisis before resorting to admission. Funding opportunities are restricted for the development of crisis services. The development of emergency response services for the use of current staff from a number of community mental health teams is an option worth considering.
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Introduction |
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The service
In the late 1990s in Newcastle upon Tyne, it was noted that over a 4-year
period there was a twofold increase in GP referrals for urgent psychiatric
assessment of individuals in crisis. There were multiple points of access to
the service for these referrals: some were assessed by junior doctors in
accident and emergency departments; some as emergency assessments at
out-patient clinics; some were seen by members of community mental health
teams, either at home or at resource centres; and some individuals were
admitted directly to hospital via their GPs. However, there was no consistent
or predictable pattern regarding who saw the individuals referred, where they
were seen or the treatment package provided. A substantial number of the
referrals were admitted to hospital, even though it was acknowledged by
primary and secondary care staff that this was often less than ideal.
Discussions between primary and secondary care teams identified that the concerns of the GPs focused on difficulties in providing the appropriate time, skills and resources to assess and manage individuals presenting in crisis in primary care. The concerns of the specialist mental health service providers focused on the need to reduce pressure on in-patient facilities and staff by avoiding inappropriate admissions and identifying and referring individuals efficiently to the most appropriate treatment option. Representatives of the two groups decided to devise a service for individuals presenting in primary care in crisis that met the needs of the individual and addressed the concerns of the professionals.
The agreed goals of the emergency response service were:
The service initially was set up in the West End of Newcastle upon Tyne. This sector comprises about 140 000 people living in a deprived inner-city area with high levels of unemployment and a large ethnic minority population. It was decided that the emergency response service would be extended to other catchment areas in the city if it met the needs of the patients and was acceptable to patients, GPs and service staff. No new staff were employed to provide the service, but the ten CPNs currently attached to community mental health teams in the western sector participated in an on-call rota for the service. Its hours of operation were 9.00 to 21.00 on Monday to Friday and 10.00 to 16.00 over the weekend.
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Method |
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To assess patient views of the emergency response service, all individuals referred during the fourth month of operation (n=47) were offered the opportunity to complete the Client Satisfaction Questionnaire (CSQ; Larson et al, 1979). The CSQ is a self-report questionnaire that has eight closed questions, each answered on a four-point scale (1=very dissatisfied, 4=very satisfied). Six additional questions (answered on the same four-point scale) were added to the CSQ, asking participants specific questions regarding the quality of the response they received from the service. Thus, the questionnaire scores ranged from 14 to 56. Additional open questions also asked subjects what they liked or disliked about the service and offered the opportunity for further comments or recommendations. To assess the GP and ERS staff views of the service offered, all the GPs in the catchment area and all the CPNs working with the ERS were sent a modified version of the 14-item CSQ so that the questions related to their perceptions and satisfaction with the service.
The questionnaire took about 10 minutes to complete. Participants were encouraged to contact an independent research assistant (Janine Williamson) for more information if required. In some instances, the researcher visited practice meetings or emergency response service team meetings to explain the purpose of the questionnaire. Confidentiality was guaranteed and participants were encouraged to provide their honest opinions. Participants who failed to respond after 4 weeks were sent a reminder letter, a further copy of the CSQ and a pre-paid envelope.
Data were analysed using the Statistical Package for the Social Sciences (SPSS, version 9.5). Descriptive statistics were used to compare continuous and categorical ratings.
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Results |
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Characteristics of emergency response service patients
(Table 1)
Two-thirds of the 126 subjects assessed by the ERS were female
(n=83) and 48 (38%) lived alone. The age of the sample ranged from 17
to 82 years (mean=39.3; s.d.=11.7). The limited data available on the
individuals who did not participate in the assessment interview
(n=41) did not reveal any significant demographic differences from
those who were assessed. Although the majority of those assessed (59%) had a
past psychiatric history, only 31% (n=39) were currently known to the
local mental health services. Exploration of reasons for referral revealed
that the 126 subjects reported at least 164 key problems, with about one in
three subjects (n=37) reporting two or more major problems. The most
common reasons for referral were: suicidal ideation or intent (n=52);
depression or severely depressed mood (n=28); personal crisis
(n=21); psychosis (n=17); risk of deliberate self-harm
(n=14); problems related to bipolar disorder (n=8) or
substance misuse (n=6); toxic confusional state (n=2); other
complex or multiple problems (n=12); and not known or not clear
(n=5). After assessment, 14 subjects (11%) were referred back to
their GP, the community mental health team staff took on 41% of cases, 20%
were referred to psychiatric out-patient clinics (including specialist
services such as Problem Drug Use) and 17% (n=21) were admitted.
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Changes in admission via primary care
The ERS team admitted 21 of the referrals from primary care teams. Data
from the hospital information system demonstrated that there were 53 direct
admissions via primary care teams during the equivalent 6-month period of the
year prior to introduction of the service.
Satisfaction with the emergency response service
Twenty of the 47 individuals (43%) referred to the ERS during a
pre-selected 1-month period returned a completed CSQ. The mean CSQ score of
43.1 (s.d.=7.3) indicated that the majority of clients were ‘mostly
satisfied’ with the service. Answers to specific questions revealed that
60% of clients felt that the service met ‘most or all’ of their
needs. Only two of the individuals who made a response gave negative feedback
about the service, although four specifically stated that they would have
preferred to be seen away from their own home. Eight subjects suggested that
the hours of the service should be extended.
Seventy-two GPs returned questionnaires and 67 (75%) had completed sufficient questions to allow a CSQ rating to be made. The mean CSQ score was 39.4 (s.d.=9.1). Forty-three GPs were satisfied or very satisfied with the service; 13% (n=18) felt that it had reduced their workload, 47% liked the quick response and 64% felt that the feedback from assessments was comprehensive and prompt. However, four GPs were unhappy that they had to see each patient before making the referral, eight felt that it increased barriers to seeing a psychiatrist and eight also felt that it delayed the admission process. Overall, 58% of GPs thought that the service was worthwhile, but 44% suggested that the hours should be extended further.
Eight of the ten CPNs working with the emergency response service returned questionnaires. The mean CSQ score was 34.7 (s.d.=5.1). Seven staff commented that working for the service had been a positive experience, although four commented that they had received inappropriate referrals and three had concerns about personal safety. Half of the group felt satisfied with the input that they offered to clients and 75% felt that the service offered appropriate and timely help to the clients referred. Overall, the eight CPNs all thought that the service was worthwhile but 38% (n=3) suggested that the hours should be reduced.
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Conclusions |
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The above successes are balanced by the low rate of referrals to the service, averaging less than one per day in the first 3 months. Although the referral rate increased significantly during the second 3-month period, it still only averaged about two per day during the week and about three per weekend. Furthermore, over the whole 6 months, only a third of the referrals were made outside of office hours. We do not know whether other referral pathways were still being used (e.g. direct referrals to accident and emergency departments or to senior psychiatrists), but the level of activity of the service will need to be monitored carefully to establish whether it represents a cost-effective approach.
The majority of patients, GPs and CPNs who completed the CSQ were satisfied with the service offered. However, given that 90% of individuals assessed were seen in their own homes, it is of interest that, although patients liked the speed of response, a significant minority (20%) stated that they would have preferred the anonymity of being seen elsewhere. (Many of the CPNs expressed a similar view, but for reasons of personal safety.) General practitioners mostly liked the speed of response and the feedback they received from the CPNs. It is noteworthy that the individuals least satisfied with the service were the staff providing it. Some of the CPNs' frustrations related to the service configuration. Although they offered assessments to all the clients referred and recommended a variety of treatments, the CPNs were rarely involved any further in that individual's care. Second, no senior medical input was identified to support specifically the emergency response service staff. This often meant that further expert advice was not available when it was most required. Finally, the CPNs reported significant periods of inactivity and suggested that the service hours could be reduced without a detrimental effect on its quality. In contrast, the GPs and the individuals using the service suggested that its hours should be extended.
In summary, the introduction of the service led to a faster, more consistent process of assessment of crisis referrals. In addition, undertaking assessments in the community appeared to increase the use of alternative treatments for individuals in crisis before resorting to admission. Although this paper supports the general principle of crisis services, it highlights that clinicians believed that an emergency response service might be more effective if the crisis team also offered the care and treatment that they advocate. Although the latter is in keeping with other models of crisis intervention, many of these require the introduction of a new dedicated service, with obvious resource implications (Geller et al, 1995). If funding opportunities are restricted, the development of an emergency response service through the use of current staff from a number of community mental health teams is an option worth considering. However, for maximum efficiency, dedicated senior medical psychiatric input needs to be included in the service specification so that the decisions about case management are made by frontline staff in collaboration with psychiatrists having the appropriate level of expertise and experience.
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Acknowledgments |
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Newcastle and North Tyneside District Health Authority funded this project.
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References |
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TopAbstractIntroductionMethodResultsConclusionsReferences |
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DEPARTMENT OF HEALTH (2001) The Mental Health Policy Implementation Guide. London: HMSO.
GELLER, J., FISHER, W. & McDERMEIT, M. (1995) A
national survey of mobile crisis services and their evaluation.
Psychiatric Services,
46,
893-897.
LARSON, D., ATKINSON, C., HARGREAVES, W., et al (1979) Assessment of client satisfaction: development of a general scale. Evaluation Programme Planning, 2, 197-207.
This article has been cited by other articles:
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  C. Dibben, H. Saeed, K. Stagias, G. M. Khandaker, and J. S. Rubinsztein Crisis resolution and home treatment teams for older people with mental illness Psychiatr. Bull., July 1, 2008; 32(7): 268 - 270. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
