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The Core Study

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Item 27

Staffing levels

Target

a) The CRT caseload of service users receiving acute home treatment is not too high (Fully met = median CRT caseload is no more than 25 per 14 full time equivalent clinical staff; partially met = median CRT caseload is no more than 30 per 14 full time equivalent clinical staff).

b) There is all source agreement that the CRT has the resources to carry out same day crisis assessments and home visits to CRT service users. 

c) There is all-source agreement that the CRT has the resources to offer home treatment wherever possible to all service users who would otherwise be admitted or who may  benefit from early discharge.

d) More than 80% of CRT staff (over the last three months) are permanent staff (not locum, bank or agency staff).

Why this is important

The CRT's role is an intensive one, and in order to ensure that service users are provided with personalised support and regular visits there must be a sufficient ratio of staff to service users.  Department of Health guidance when CRTs were first rolled out nationally was that they should have at least 14 full time staff for a case load of 20-30 service users. In our CRT survey, managers identified adequate staffing as their top priority for improving services.

Ways of doing this well

One way to avoid unmanageable case load sizes is to ensure only clients who would otherwise be in hospital are accepted for treatment.

Recruitment processes are important in order to ensure teams are fully staffed, so working closely with HR can be helpful.  Allowing staff from other teams to shadow CRT staff may create interest for future jobs, and trying to have open environment where staff can talk about their career plans helps to avoid unexpected departures.

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
  • Greenwich CRT, Oxleas NHS Foundation Trust
  • West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
  • Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
  • Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
  • Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
  • South Powys HTT, NHS Wales
  • Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
  • Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
  • South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
  • Waltham Forest HTT, North East London NHS Foundation Trust
  • Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
  • Redbridge HTT, North East London NHS Foundation Trust
  • Hastings CRT, Sussex Partnership NHS Foundation Trust
  • Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
  • Eastbourne CRT, Sussex Partnership NHS Foundation Trust
  • North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
  • Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
  • South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust 
  • South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust 
  • Yeovil CRT, Somerset Partnership NHS Foundation Trust 
  • Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
  • Mendip CRHTT, Somerset Partnership NHS Foundation Trust 
  • Teignbridge CRHTT, Devon Partnership NHS Trust
  • South Hams and West Devon CRHTT, Devon Partnership NHS Trust
  • North Devon CRHTT, Devon Partnership NHS Trust
  • East and Mid Devon CRHTT, Devon Partnership NHS Trust
  • Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust 
  • Chichester CRHTT, Sussex Partnership NHS Foundation Trust
  • Edinburgh IHTT, NHS Lothian
  • Gloucester CRT, 2gether NHS Foundation Trust
  • Hammersmith CRHTT, West London Mental Health NHS Trust
  • Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
  • South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
  • Norwich HTT, Norfolk & Suffolk NHS Foundation Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Size and structure of a CRHT team

The ideal size for a CRHT team depends on:

• the population of the catchment area to be covered

• the level of need in the catchment area

• the number of inpatient admissions from the catchment area prior to the CRHT team commencing operation

• the number of staff needed to maintain an adequate rota, allowing for periods of leave and sickness

• the need for good communication between team members.

The policy implementation guidelines (DH, 2001a) state that there should be 14 clinical staff (not including medical staff ) per 150,000 population but acknowledges that local circumstances mean a team may require a variation from this. Inner city areas may generate far more people in crisis for a given population size than do rural areas because the people living there tend to have more problems and fewer social supports. There is an argument therefore for inner city teams being larger or the population covered being smaller. There are some areas - especially rural areas with small populations - where to follow the guidelines would result in a team with too few staff for an adequate rota. With fewer than 10 or 11 staff a team becomes vulnerable to the effects of holidays and study leave plus unexpected sickness, with the possibility of having only one worker for a particular shift - a situation which could be dangerous.

From the experience of the early teams, a team of 14 can deal with an area that produces about 400 hospital admissions per annum before the team's commencement.

In some areas of the country there are teams that are quite large, with more than 30 staff covering a population of around 350,000. This can create potential problems with staff communication; team handovers need to be handled with firmness and skill, for example, to ensure that they do not take an inordinate amount of time. Nevertheless some of the larger teams have produced good outcomes, so it is too early to say whether they should be recommended or not. (p.14)

Mental Health Foundation (2012) Take Control: Self-management in care and treatment planning

6. Staffing Size

The service should aim to have enough staff to cover two shifts per day, seven days a week. At the same time, team size must be kept manageable enough for communication purposes - between 10 and 15 staff.

Staffing and skill mix

How much work the service can take on will be dictated by both the funding and staffing levels.

General staffing considerations:

• Inner city populations will generate more work than rural or suburban populations.

• There need to be adequate staff to manage the treatment phase. A good rule of thumb would be to plan for a maximum of twice daily visits.

• In urban areas, there should be two shifts daily seven days per week, (i.e. a morning and afternoon/evening shift). Night shifts can be covered by 'on call' staff. Overtime situations may arise when crises emerge at the end of evening shifts. (p.9)