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Local implementation of the crisis model: the Buckinghamshire community acute service

  • Danny Allen (a1), Wendy Blaylock (a2) and Stefan Mieczkowski (a3)
Abstract
Aims and Method

Buckinghamshire crisis and home treatment team was struggling to meet its commissioned care episodes and found itself detached from community mental health teams (CMHTs) and acute day hospitals. An operations management consultant, using ‘lean’ principles developed in industry, worked alongside staff to redesign the service.

Results

Improvements in staff capacity and ability contributed to more care episodes and reduced ward-stay times, compensating for the impact of a ward closure. Re-examination of individuals needs through case-review led to the development of ‘patient typing’, facilitating clear care pathways according to need. Finally, two proven modalities of community-based service were fused together.

Clinical Implications

Placing value to patients, carers and referrers ahead of old demarcations and practices has enabled a more flexible and responsive service to develop and grow.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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1 Department of Health. The Mental Health Policy Implementation Guidelines. Department of Health, 2001.
2 Smyth, MJ, Hoult, J. The home treatment enigma. BMJ 2000; 320; 305–9.
3 Glover, G, Arts, G, Babu, KS. Crisis resolution/home treatment teams and psychiatric admission rates in England. Br J Psychiatry 2006; 189: 441–5.
4 Marshall, M, Crowther, R, Almarez-Serrano, A, Creed, F, Sledge, W, Kluiter, H, et al. Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev 2003; 1: CD004026.
5 Priebe, S, Jones, G, McCabe, R, Briscoe, J, Wright, D, Sleed, M, et al. Effectiveness and costs of acute day hospital treatment compared with conventional in-patient care. Randomised controlled trial. Br J Psychiatry 2006; 188: 243–9.
6 Marshall, M. Acute psychiatric day hospitals. BMJ 2003; 327: 116–7.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Local implementation of the crisis model: the Buckinghamshire community acute service

  • Danny Allen (a1), Wendy Blaylock (a2) and Stefan Mieczkowski (a3)
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eLetters

Re: Innovative and Effective Approaches to Crisis Services

Withheld for confidentiality reasons -, psychiatric patient
29 July 2010

As a patient, I was recently under the care of a London crisis intervention team. The compassion of the individual staff members was negated by systemic flaws in the way the service was delivered.

The experience was very unsettling. Different staff would arrive twice daily at my home because shift patterns would not allow the same workers to see me regularly. Consequently, a constructive, consistent relationship with members of the crisis team was not possible. A stream of strangers entered my small, cramped flat, and the crisis team actually became part of my mental trauma.

The problem with the crisis team as an institution is that it is about cost-cutting rather than caring. It felt like a mere sticking plaster on a huge mental wound.

While cost-cutting remains the ethos, patients are bound to suffer. The loss of in-patient beds is putting pressure on community services that the latter cannot sustain. Cost-cutting may masquerade as stream-lined efficiency and effectiveness, but it is really the way to hobble and cripple psychiatric provision.

Good treatment cannot be delivered without flexibility and variety, both community-based and hospital-based. The crisis team concept is an insufficient half-way (and half-baked) house between community and hospital.

Declaration of Interest:

I am a psychiatric patient.

The name and address of the London Trust and the address of the patient have been withheld for confidentiality reasons.
... More

Conflict of interest: None Declared

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Innovative and Effective Approaches to Crisis Services

Dr Alexis Bowers, Locum Consultant Psychiatrist
21 June 2010

Dear Editor,

Given the dour economic climate, Mental Health Trust's are having to respond innovatively to meet their stakeholders demands whilst continuallydriving up the quality of their service (Royal College of Psychiatrists, 2009).

In response to this, Allen et al (2009) describe an innovative approach to respond to a reduction in inpatient bed numbers. Here in Hertfordshire there is a drive to improve community based mental health services with a commensurate reduction in inpatient facilities. Providinga responsive and safe service is top of our agenda and therefore responding to this challenge requires a flexible and innovative approach to service delivery.

The North West Hertfordshire Crisis Assessment and Treatment Team hashistorically assessed and managed all patients at home. To improve patient safety and the efficiency of medical and nursing staff we audited a number of parameters in April 2010. Only 7% of patients had received a full body physical examination and only 27% had been seen by a psychiatrist within a week of referral. Only 8% of discharged patients had a completed summary sent to their GP. In light of these findings a service change was implemented.

We decided to set up designated CATT clinics in secondary care centres which were local to our patients. It was hoped that this new service would encourage patients to become actively engaged with their treatment plan by leaving their accommodation and attending appointments. It would also reduce time spent travelling by staff members thereby increasing face-to-face clinical time. One appointment per session is ableto be converted to a home visit should this be required. The ultimate aim was to provide a higher quality (namely safer and more responsive) serviceto our patients and stakeholders.

On re-audit, 53% of patients had received a full body physical examination (this identified no designated examination room in one centre and is now in the process of being rectified), 100% had been seen by a psychiatrist within a week of referral and 77% of discharged patients had a completed summary sent to their GP.

Although we do not have sufficient longitudinal data yet, it does appear that time spent with the crisis service has been reduced which has generated capacity for facilitating early ward discharges.

References

Allen, D., Blaylock, W. and Mieczkowski, S. (2009) Psychiatric Bulletin, 33, 252-254.

Royal College of Psychiatrists (2009) Mental health and the economic downturn: National priorities and NHS Solutions, NHS Confederation Mental Health Network and the London School of Economics and Political Science.
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Conflict of interest: None Declared

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