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The Core Study

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Item 5

Providing a 24 hour, 7 day a week service

Target

The CRT visits service users at home, when needed, 24 hours a day, seven days a week.

Why this is important

Crises may occur at any time of day or night. If CRTs are to offer a genuine alternative to hospital admission, they need to be able to offer treatment 24/7, not just in office hours or extended office hours. Studies in the UK and Norway have found significant links between CRT's being available 24/7 and substantial reductions in admissions (see Glover et al., 2005; Hasselberg et al., 2013).

Often it can be during the lonely hours of the night time when someone needs support. Our survey results suggest it is of central importance to service users that they can access support at any time day or night.  

Below is a video clip of service users and carers talking about the importance of being able to access the service 24 hours a day:  

Ways of doing this well

Staffing strategies

Ideally, A CRT would have at least two waking night staff each night to allow home visits to be carried out when required 24/7. If resources do not allow this, some Trusts employ staff to provide night cover across two or more CRT's, to allow home treatment to be provided if required. Camden North Crisis team and Camden South Crisis team pool night staff to ensure that they are still able to answer calls AND visit service users during the night.  North East London Foundation Trust have recently started to do this with 4 separate Crisis teams. 

A single CRT staff member may be able to field phone calls and use A & E or local acute wards to see service users at night, even if home visits are not possible, so at least some service is offered. 

Requirements for all CRT staff to come back to base to write up notes or hand over at the end of a shift in practice limits the hours in which home visits are available to service users. Remote access to patient records [See Item 33] or asking colleagues to record or hand over vital information may help enable staff to visit service users right up to the end of a shift.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

  • Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
  • Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
  • South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
  • South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
  • East South Staffordshire (Tamworth) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
  • Telford and the Wrekin CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • North Somerset Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
  • Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
  • Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
  • Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
  • North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
  • Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
  • Redbridge HTT, North East London NHS Foundation Trust
  • Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
  • Hastings CRT, Sussex Partnership NHS Foundation Trust
  • West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
  • Eastbourne CRT, Sussex Partnership NHS Foundation Trust
  • Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
  • East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
  • Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
  • Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
  • South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
  • Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
  • Edinburgh IHTT, NHS Lothian
  • Gloucester CRT, 2gether NHS Foundation Trust
  • Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
  • Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Twenty-four-hour availability

There is much debate as to the need for teams to be available 24 hours a day. Some say it costs too much to run, others that there is no call for it in their area, but there is a clear rationale for ensuring that this is a core characteristic of CRHT teams. There are two main reasons for providing this. The first is that new referrals can turn up at any hour, not just obligingly during the daytime. At night most referrals will come from A&E and the number will vary according to how busy the department is, but the people who attend will be in some degree of crisis. Failure to gatekeep admissions at night may lead to a disproportionate number of admissions taking place during this period. The second reason is that many of the service users who are supported by the team would otherwise be in hospital. In view of the acute nature of their difficulties, the service users and their carers need someone they can turn to should a difficulty arise, especially in the middle of the night when people feel most alone. If they know they can get immediate help at any time of the day or night they will be more willing to accept home treatment. So while most teams are infrequently or even rarely called out at night, the person on call may get more phone calls from both service users and carers. The team member, having both knowledge of the service user and a home treatment ethos, will often be able to resolve the matter on the phone. The knowledge that staff can be contacted at any time, and if necessary come out, is of great reassurance to service users and carers. It is important to note that a team that does not provide a 24-hour service cannot claim to gatekeep hospital admissions comprehensively. (p.15)

Providing 24-hour, 7-days-a-week service

The ability to respond over a 24-hour period to crisis is much more likely to promote positive risk taking. Practitioners are aware that when they leave a situation after making an assessment, they can easily return, if necessary, as they are often only a phone call and a short journey away. Where longer distances are the norm, for example in some rural areas, decision making must account for that fact. Where community services are only provided between 9 am and 5 pm there is often a 'vacuum' out of hours, where the only options are to go to the local A&E, the local inpatient unit or organise a Mental Health Act assessment. All of these are for the most part unsatisfactory responses. The likelihood, therefore, if faced with these sparse and limited resources, is that decisions will often err on the side of caution and the most restrictive option will be selected. (p.37)

Sainsbury Centre for Mental Health (2001) Crisis Resolution

In general, the team should operate seven days a week, 24 hours per day throughout the year. This can be done if two shifts a day are scheduled for mornings and afternoons. It is useful to have one person operating an 'on-call' system during each shift to respond to new referrals. For late overnight shifts, two people should be available via a pager system for safety reasons in case night call-outs occur. (p.15; plus further info on shift work)

Department of Health (2001) Mental Health Policy Implementation Guide

Hours of operation

  • The service should be available 24 hours a day, 7 days a week
  • A shift system reflecting differing working patterns is required. A minimum of two
  • trained case workers should be available at all times
  • Evening/through the night working is usually an on-call system
  • Medical on call rota should allow senior psychiatrist to undertake home visits 24 hours
  • a day
  • Assessment team for acute assessment of new referral (available 24 hours a day): two
  • trained case workers and a senior psychiatrist
  • Home visits to known service users (available 24 hours a day): two case workers (p.21)