Item 6

McGlynn (2006) CRHT: A Practical Guide

Gatekeeping to hospital beds

We can see no evidence of CRHT teams, nationally or internationally, being effective in achieving reductions in hospital bed use if they do not have the right to gatekeep, i.e. to assess most or all referrals prior to hospital admission. This issue has probably resulted in more friction than anything else between teams and between professional groups, but is one of the most critical for CRHT teams. It therefore has to be addressed, however uncomfortable the process may appear. It is logical to assume that if a CRHT team is expected to reduce the pressure on acute inpatient units by 30%, as suggested in the NHS Plan (DH, 2000a), the team must focus on those who would have been admitted to hospital if it had not existed. To do so the team has to target anyone at risk of hospitalisation. Without the gatekeeping role, other professionals may continue admitting as before, and few cases may be referred to the CRHT team.

All users of mental health services who are at risk of hospitalisation should have the right to assessment for treatment at home and for this reason gatekeeping should be absolute and extend to all assessments for hospital admission, including Mental Health Act assessments and assertive outreach cases. It is recognised, however, that on occasion the team may be unable to carry out an assessment because of the timescales involved, and in such cases the involvement of the CRHT team should not hold up the process. (p.15)

National Audit Office (2007) Are CRTs seeing the patients they are supposed to see?

'Evidence from 25 Ward Manager Interviews when asked to identify the most significant functions that CRHT teams should perform Key function A: Gatekeeping hospital admissions (x25)

This is the process in which CRHT staff are involved in all potential admissions to inpatient wards in order that inappropriate admissions can be prevented, and the CRHT team provide treatment to the patient at home or in the community instead. Some managers reported that the gatekeeping function was enabled by the support of the inpatient unit, with more appropriate admissions and a decrease in the number of sectioned patients resulting, but others said this function was hindered by Consultant Psychiatrists by-passing the team.' (p.5)

'The Department of Health intends that CRHT teams act as 'gatekeepers' to admission, but in fact this function is under-realized

"The [function of gatekeeping is the] routing of all potential acute admissions through a single point in order to determine the optimal level of care. This involves the clinical decision, made collaboratively, to provide care at home or via inpatients. All referrals for inpatient beds should come through the CRHT team. Whenever possible this will involve collaboration with the care coordinator and sector Consultant Psychiatrist.

Each CRHT service will manage the throughput of referrals in close collaboration with multidisciplinary colleagues, while at the same time offering a range of community based options; in particular that of intensive home based treatment. The aim of the assessment by the CRHT team is to determine what input may be offered to the service user and/or carer by the CRHT team rather than to repeat the clinical assessment already undertaken by the referrer. It is considered good practice for the assessment to be undertaken collaboratively by the referrer and CRHT clinician together if possible, to facilitate collaborative working, as well as effective communication and care planning." From Liverpool CRHT 'Operational Specification and Protocol for Crisis Resolution and Home Treatment' (p8):' (p.8)

'4. This evidence strongly supports the inclusion of CRHT staff as gatekeepers; it shows that assessments are much less likely to consider home treatment as an alternative to admission without a CRHT staff member present.  5. This evidence strongly supports the inclusion of CRHT staff as gatekeepers; it shows that assessments are much less likely to consider home treatment as an alternative to admission without a CRHT staff member present.' (p.9-10)

'CRHT teams that were not staffed 24/7 had less success in gatekeeping admissions

9. A concern for successful gatekeeping is where admissions occur outside of the hours when the CRHT team is fully staffed. Of the teams visited, 11 were staffed 24/7, 13 operated on-call and 1 was covered at night by another team

10. Our analysis compared whether teams that were staffed 24/7 versus teams that were not were involved in the majority or minority of the 20 admissions reviewed in this research. It shows that teams that are staffed 24/7 are significantly more likely to be involved in the majority rather than a minority of admissions.

11. This evidence suggests CRHT services should be staffed 24/7 for more effective gatekeeping. However, one CRHT Manager did suggest that 24/7 staffing needs to be clearly linked to a local audit of activity. Where only a few night-time crises happen or where they are rare, it could be unduly costly to have waking staff on duty all night. These hours are far less likely to be times when CRHT staff members can make efficient use of their time by following up other functions such as routine home treatment. In instances where local audit identifies a relatively low level of crisis assessment activity across night hours, 24/7 staffing could potentially be achieved using an integrated acute service model, whereby on-call CRHT team members assist with staffing of wards overnight.' (p.13-14)

'The gatekeeping function overall is not as consistently applied as policy intends

16. If people are admitted without considering what alternatives (such as home treatment) are appropriate, then there is no process in place to consider whether people would be better treated closer to home, without the disruption caused by admission. It follows that admissions will be higher in number and that some beds will be inappropriately taken by people who are not necessarily bestserved by being admitted, and that the availability of beds for other potential patients is restricted. The Department of Health's intended impacts will not be achieved if 'all potential admissions' (as is intended) are not assessed for the applicability of home treatment.' (p.14-16)

'The ability of CRHT teams to effectively gatekeep admissions is being diminished by common barriers […]' (p.16)

'Staff across teams have inconsistent ideas about when CRHT staff should and should not be involved in (gatekeeping) admissions 

29. Gatekeeping is a crucial factor in the cost-effectiveness of overall acute mental health service delivery. The CRHT team may be the best service to be involved in some Mental Health Act assessments, and they may be needed to assess whether a transfer between units is no longer necessary where home treatment would provide a better alternative. CRHT teams need clearly agreed protocols with other mental health teams about being informed and involved in all potential admissions. These may vary across services due to local circumstances and support services, but within one service, there should be agreement across all professionals about why and how CRHT teams are incorporated into the acute care pathway.' (p.21-24)

'The gatekeeping function of CRHT teams is closely aligned to the responsibility for managing the allocation of beds, although this bed management function is not consistently implemented across teams' (p.28)

'CRHT teams with a strong gatekeeping function were more likely to be involved in discharges' (p.45)

'At present the most usual process for gatekeeping seems to be agreement established between units to manage a transfer, with early discharge/discharge to home treatment only being seriously considered at the next ward round or bed management meeting, after the person has settled into the receiving ward. The receiving ward in any inter-unit transfer should automatically consider informing the local CRHT team, so some consideration could be made about the potential for discharge into home treatment at the earliest point. This could mean the person does not occupy a bed at all before being discharged.' (p.71)

'The value of having CRHT staff gatekeeping admissions lies not only in diverting inappropriate admissions and enabling home treatment, but also in enabling early discharge.' (p.71)