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Intensive home treatment, admission rates and use of mental health legislation

  • Naida F. Forbes (a1), Helen T. Cash (a2) and Stephen M. Lawrie (a3)
Abstract
Aims and method

We examined the local impact of introducing a home treatment team on the use of in-patient psychiatric resources and rates of detention under the Mental Health (Care and Treatment) (Scotland) Act 2003.

Results

Rates of admission to hospital and duration of hospital stay were unchanged. However, there was an increase in episodes of detention in the year following the team's introduction.

Clinical implications

Offering home treatment as an alternative to in-patient care may be associated with an increase in compulsory treatment. If true, this is incompatible with the ‘least restrictive alternative’ principle of the recently revised mental health legislation.

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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.
Corresponding author
Naida F. Forbes (naida.forbes@nhslothian.scot.nhs.uk)
Footnotes
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Declaration of interest

N.F.F. was until recently employed by Midlothian Community Health Partnership.

Footnotes
References
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1 Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. Department of Health, 2000.
2 Johnson, S, Nolan, F, Hoult, J, White, IR, Bebbington, P, Sandor, A, et al. Outcomes of crises before and after introduction of a crisis resolution team. Br J Psychiatry 2005; 187: 6875.
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 Department of Health. Mental Health Act 1983: Code of Practice (2008 Revised). Department of Health, 2008.
5 Keown, P, Tacchi, MJ, Niemiec, S, Hughes, J. Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatr Bull 2007; 31: 288–92.
6 Johnson, S, Nolan, F, Pilling, S, Sandor, A, Hoult, J, McKenzie, N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the North Islington crisis study. BMJ 2005; 331: 559602.
7 Shajahan, P, Agnew, T. Availability of patient records and psychiatric admission rate. Psychiatr Bull 2006; 30: 449–51.
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Intensive home treatment, admission rates and use of mental health legislation

  • Naida F. Forbes (a1), Helen T. Cash (a2) and Stephen M. Lawrie (a3)
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eLetters

Home Treatment and an Increase in Detentions

Philip McGarry, Consultant Psychiatrist in Home Treatment
25 January 2011

Forbes, Cash and Lawrie reported that the number of detained admissions increased following the setting up of a Home Treatment Team in Midlothian, while there was no reduction in admissions overall (1). In their discussion they identified a number of potential reasons for this rather disappointing result. However they did not discuss the relevance of staffing, nor the degree of adherence to the ‘high fidelity’ model of Home Treatment.

Middleton et al looked at ‘Gatekeeping’ and concluded that admissionswere more likely to be reduced if the team had a dedicated consultant psychiatrist and worked on a 24 hour basis (2). It was also noted that teams which were more ‘mature’ were more effective gatekeepers. Forbes etal stated that in Midlothian the medical input is from a part-time staff grade doctor, the team operates from 8am to 12pm and in the period reported the team was only in its first year. We have little doubt that if Dr Forbes can persuade the commissioners to invest further in the service, bed reductions will be made.

In Belfast we have a Home Treatment Team which was set up in April 2007 covering a population of 350,000. It has 1.5WTE dedicated consultants and operates 24 hours a day. We took on the role of gatekeeping all admissions in April 2009, and over the next 12 months the admissions dropped by 27%.

Forbes and colleagues propose that their team may have had a ‘low threshold for accepting risk’, in the context of the introduction of formal risk assessment procedures for all patients seen. They argue further that thresholds for risk are falling with an increasing use of community detention powers and longer term hospital detentions.

This reflects concerns raised by the Care Quality Commission in its recent annual report, which noted that while the number of detentions to hospital had not reduced, the number of Community Treatment Orders (CTOs) had ‘greatly exceeded the number anticipated at the time the new legislation was introduced’(3). The premise on which CTOs were predicatedwas that they were a less restrictive alternative to hospital admission. In truth the evidence is that they are becoming an additional way of managing perceived ‘risk’, which has now regrettably become a key driver in psychiatric practice.

There is a grave danger that the natural instincts of the large majority of psychiatrists to move away from a paternalistic and risk adverse model of care are being compromised by paying too much heed to theoften confused and fear based concerns of policy makers and the media who want us to ‘move into the community’, while simultaneously guaranteeing that adverse outcomes will not occur!

References

1- Naida F Forbes, Helen T Case, Stephen M Lawrie. Intensive Home Treatment, admission rates and use of Mental Health Legislation. Psychiatrist. Psychiatric Bulletin (2008) 32. 378 – 379.

2- Hugh Midleton, Gyles Glover, Steve Onyett, Karen Linde. Crisis/Home Treatment Teams, Gate-Keeping and then role of the Consultant Psychiatrist. Psychiatric Bulletin (2008) 32. 378 – 379.

3- Care Quality Commission Annual Report 2009 – 2010. Monitoring theuse of the Mental Health Act in 2009 – 2010. Care Quality Commission October 2010

Philip McGarry is Consultant Psychiatrist in Home Treatment in the Belfast Health and Social Care Trust.

Ashling O’Hare is Consultant Psychiatrist in Home Treatment in the Belfast Health and Social Care Trust.

Ciaran McNally is ST6 in the Belfast Health and Social Care Trust.
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Conflict of interest: None Declared

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Role Of Intensive Home Treatment in Compulsory Admissions

MOHINDER KAPOOR, Specialty Registrar (ST5) in Old Age Psychiatry
24 January 2011

I have to say that I was really intrigued by the findings of the paper looking at the impact of a crisis resolution service on the use of in-patient psychiatric resources and detention under the Mental Health Act (1). The increase in compulsory treatment was, in my opinion, to be entirely expected as other studies have mentioned this association before (2,3). However, what I am a bit puzzled about is the explanation the authors provided regarding this finding; since they suggested that this team probably had a low threshold for accepting risk and was more likely to consider use of the Mental Health Act. I certainly don’t believe this to be an explanation that would ring true with other crisis teams. For I am under the impression that the staff in most crisis teams have a very high threshold for admitting someone; this is, I think, to do with their role of gate keeping admissions (and controlling the beds).

The other important aspect that, I think needs to be considered here relates to the fact that they don’t have control over admissions under the Mental Health Act outside working hours. This study mentions that their working hours are between 08.00 and 24.00. It would be useful to see the numbers of people admitted under section between 24.00 and 08.00 hours. Patients admitted outside crisis team working hours were being assessed by professionals undertaking their own risk assessments. Also it should be remembered that many patients assessed and admitted under section during working hours are not always assessed by crisis team staffmembers; community mental health teams undertake their own mental health act assessments involving their own staff.

Finally, the other key aspect to be considered here is the staffing levels within the crisis team. They mentioned one part-time staff grade psychiatrist but no dedicated consultant in the team. This in itself may explain the fact that the teamhas to rely heavily upon others to undertake assessments. Once professionalsoutside crisis team make a decision to detain someone there is nothing that crisis team can do about it; they simply have to find a bed for the detained person.

Declaration of interest: None

References:1 Forbes N F, Cash H T, Lawrie S M. Intensive home treatment, admission rates and use of mental health legislation. The Psychiatrist, 2010; 34(12): 522 - 524. 2 Keown P, Tacchi MJ, Niemiec S, Hughes J. Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatr Bull 2007; 31: 288-92 3 Tyrer P, Gordon F, Nourmand S, Lawrence M, Curran C, Southgate D, Oruganti B, Tyler M, Tottle S, North B, et al. Controlled comparison of two crisis resolution and home treatment teams. The Psychiatrist, 2010; 34(2): 50 - 54.
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Conflict of interest: None Declared

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Not all 'Crisis Teams' are the same

Nicky Goater, Consultant Psychiatrist
05 January 2011

I am concerned by the publication of the paper by Forbes et al (1). It claims to add to the literature relating to the introduction of a Crisis Resolution and Home Treatment Team (CRHT), by demonstrating little impact on bed use and increased compulsory admissions. This is misleading as the study actually shows the effect that a new CRHT, which does not adhere to the consensus model, may have as part of a complex, changed system.

The paper describes admission and compulsory admission rates before and after a service redesign (which includes the inception of a CRHT) but reports these as if the set up of the CRHT was the only important change. In reality the changes included a reduction in in-patient beds, reprovision of beds several miles away, and presumably uncertainty and anxiety in staff during the change period.

I am not surprised by the lack of impact on bed use and the increase in compulsory admissions. The CRHT did not include key elements associated with reduced admissions as determined by evidence and the National Audit Office Report (2-4). First, the Midlothian team had no designated consultant or social worker (although there was 'ready access' to the latter). Second, the CRHT did not do its own face to face gatekeeping in all cases, and the proportion admissions subject to gatekeeping by the CRHT are not supplied. Third, the team did not operatea 24 hour service.

It is vital to communicate accurately with commissioners and others about the economic value, safety and effectiveness of psychiatric services. Not all teams providing frequent visits outside of hospital area CRHT, but the distinction is not likely to be widely understood. The development of accreditation criteria for CRHT’s is now urgent.

1. Forbes N F, Cash H T, Lawrie S M. Intensive home treatment, admission rates and use of mental health legislation. The Psychiatrist, 2010; 34(12): 522 - 524. 2. Joy CB, Adams CE, Rice-K. Crisis intervention for people with severe mental illnesses. Cochrane Database of Systematic Reviews, 2007. 3. Glover G, Arts G & Babu KS. Crisis resolution/home treatment teams and psychiatric admission rates in England. British Journal of Psychiatry,2006; 189:441-54. National Audit office. Helping people through mental health crisis: Therole of Crisis Resolution and Home Treatment services. London: The Stationary Office 2007.
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Conflict of interest: None Declared

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Home treatment teams and compulsory admissions, more information needed.

Dieneke Hubbeling, consultant psychiatrist
22 December 2010

Forbes, Cash and Lawrie found that the number of compulsory admissions increased in absolute numbers after the introduction of an intensive home treatment team and a reduction in hospital beds (1). Tyrer et al. also described an increase in compulsory admissions after the introduction of home treatment teams (2). These findings do raise concernsabout the current policy of gate-keeping home treatment teams.

Looking at our own data, in the London borough of Wandsworth there were 151 compulsory admissions in Quarter 2 of 2008-2009, 119 compulsory admissions in Quarter 3 of 2008-2009 and 144 in Quarter 4 of 2008-2009. There was a reduction of 6 inpatients beds in March 2009 and in Quarter 1 of 2009-2010 there were 181 compulsory admitted patients, this dropped to 151 in Quarter 2 of 2009-2010 and dropped again Quarter 3 to 126. The closure of 6 beds might well explain the increase in compulsory admissionsin Quarter 1 of 2009-2010 but after three months the number of compulsory admissions dropped to the previous level.

A temporary increase in compulsory admissions after a reduction in hospital beds and the introduction of a home treatment team should be avoided, if possible, but the consequences for service planning are far less severe than with a more permanent increase in involuntary admissions.Maybe, with a larger reduction of inpatient beds the number of compulsoryadmissions would return to previous levels after a longer time period had passed.

1.Forbes, N.F., Cash, H.T. & Lawrie, S.M. Intensive home treatment, admission rates and use of mental health legislation. The Psychiatrist 34, 522-524(2010).

2.Tyrer, P. et al. Controlled comparison of two crisis resolution and home treatment teams. The Psychiatrist 34, 50-54(2010).
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Conflict of interest: None Declared

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Are Crisis Resolution Teams Toxic?

Paul F Reed, Consultant Psychiatrist
06 December 2010

I read with interest the paper by Forbes et al1 which investigated the impact of a crisis resolution service. I am intrigued by their finding that the introduction of the crisis service was followed by an unexpected increase in the absolute numbers of patients detained under the Mental Health Act. In their discussion a number of possible explanations are explored. However I believe there is one possible explanation which is notfully discussed , although it is perhaps hinted at in the clinical implications section of their abstract. This is that the intervention might impact negatively on some patients.

This is now the third study to find this association2,3 with only one group failing to replicate it4. Tyrer et al3 explicitly discuss at some length the notion that negative effects on some patients of this type of service is one of the most plausible explanations for the increase in compulsory admissions. Furthermore, they suggest that any benefit from crisis services through reducing informal admissions may be cancelled out by the increase in compulsory admissions.

There does not yet seem to be a consensus around this important issue. Further research to explore the association is therefore warranted. Also of importance in my view is research to clarify any risk factors that predict compulsory admission to hospital following a period of treatment by crisis services. Identification of such factors could potentially be used to improve services to patients.

1 Forbes N F , Cash H T, Lawrie S M. Intensive home treatment, admission rates and use of mental health legislation. The Psychiatrist, 2010; 34(12): 522 - 524.

2 Keown P, Tacchi MJ, Niemiec S, Hughes J. Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatr Bull 2007; 31: 288-92

3 Tyrer P, Gordon F, Nourmand S, Lawrence M, Curran C, Southgate D, Oruganti B, Tyler M, Tottle S, North B, et al. Controlled comparison of two crisis resolution and home treatment teams. The Psychiatrist, 2010; 34(2): 50 - 54.

4Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, et al.Randomised controlled trial of acute mental health care by a crisis resolution team: the North Islington crisis study. BMJ 2005; 331: 559 -602
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Conflict of interest: None Declared

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