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The Mental Health Foundation is asking the government to help set up more community-based crisis intervention services as there is wide recognition that acute wards alone cannot meet the needs of service users. Anabel Unity Sale reports.

Every year thousands of people with severe mental health problems use acute psychiatric services. In the year to 31 March 2001, there were more than 100,000 admissions to hospital for severe mental health problems such as schizophrenia, psychosis and manic depression.

A report published this week by the Mental Health Foundation says hospital crisis services are not meeting the needs of these users. Being There in a Crisis, produced in conjunction with the Sainsbury Centre for Mental Health, says current care in the UK is failing to meet demand and struggling against a backdrop of negative publicity.

The report's conclusions are stark. "Psychiatric in-patient services are over-stretched and often able to admit only the most seriously ill people, and most services offer little more than medication and containment."

Alison Faulkner, head of user initiatives at the Mental Health Foundation, describes hospital-based crisis services as unsatisfactory. The increased emphasis on community care services has resulted in acute services being left behind. She says: "Acute wards have rather lost their focus and role in the crisis system."

This is not helped, she says, by the practice adopted by some hospital wards of sectioning people under the Mental Health Act 1983. She says: "This makes any potential patients want to avoid hospital-based crisis services as much as possible."

Faulkner has herself used acute crisis services. The last time was two years ago and she found the ward's environment threatening, and says she witnessed other users being treated badly by staff. "I was ignored by staff," she says. "The quieter you are the less likely you are to get into trouble."

Terry Simpson is the national co-ordinator of national advocacy organisation Ukan. He also has first-hand experience of acute crisis services, having been sectioned twice. He last used traditional crisis services 15 years ago.

He says the dual roles of in-patient crisis services conflict. Policing the behaviour of users and looking after people thought to be a danger to themselves or others do not go together. "If a person is in a crisis they should be able to talk freely about what is happening to them," he says. "Traditional crisis services can sometimes hinder a person's rehabilitation because they don't do this."

Staff working in mainstream crisis services do not have the time to work effectively with users, according to Richard Brook, chief executive of the mental health charity Mind. He says: "The physical conditions of many services are also poor and many users report the environment as untherapeutic."

Angela Greatley, a fellow in mental health and social care at the King's Fund, says this is often the case in acute psychiatric services in big cities because of the high demand they face. She says that although acute hospitals offer users "time-out" from their crisis, the use of medication is commonplace, and they rarely offer alternative forms of therapy.

Greatley says: "Some people may not like the side-effects of taking medication or want to try talking therapies and work through their problems in a systematic way."

Some users, she adds, do not find acute crisis services a therapeutic environment because they are not responded to as individuals. "A big ward environment can be depersonalising because it runs to a set of rules that are about the institution and not the individual," she says.

Being There in a Crisis reviews the Mental Health Foundation's crisis programme, which has supported the development of seven complementary and alternative crisis services in the past three years. The programmes include crisis houses - safe places for people to go to in a crisis - as well as drop-in centres and helplines. The review concludes that these user-led crisis services have real value and are appreciated by those using them.

Its main recommendation is for national investment to help establish community-based crisis services for people with severe mental health problems. Developing such services, it argues, will mean that users can access help when and where they want, without relying on traditional crisis services.

The report's authors call on the government to "act on the evidence that acute wards and crisis teams cannot meet all needs" and to "ensure that people in crisis have access to a wide range of services, from user-led crisis houses to telephone helplines".

It urges local mental health agencies, including commissioners and providers, to ensure that referrals made by individuals and mental health teams are to both types of crisis service equally.

Faulkner says she can see no reason why community-based crisis services should not become part of the range of everyday health services available. "Everyone should have access to a crisis service outside of a hospital because it can do different things."

The report also recommends community-based crisis services be developed for specific target groups, such as women and people from ethnic minority backgrounds.

According to Faulkner, developing crisis services for people from ethnic minority backgrounds would make a huge difference. "We know that young black men do not come into contact with crisis services often," she says. "It is important to provide help earlier that is more accessible so they do not put off entry to the service."

Peter Beresford, chairperson of Shaping Our Lives, a national organisation for users of social care services, supports the idea of operating non-medicalised, user-controlled crisis services. He says: "Community-based crisis services are important because people want somewhere where the diagnosis process [of acute services] is not replicated."

Brook also supports the idea. He says: "It is very clear from previous evidence that women and people from ethnic minorities traditionally find it hard to access and use mental health services." Such services, he adds, must also take into account local need and existing provision.

Greatley says user group-specific crisis houses would give people the opportunity to come to terms with their crisis in a more protected environment than that of an acute ward. She adds: "Small crisis houses can be more responsive and understanding of the mental illness of someone from a particular cultural group."

So how do people with severe mental health problems respond to community-based crisis services?

The research suggests that most users are very receptive to community-based crisis services and welcome the alternative to psychiatric wards - not least because it allows them to remain in their own homes.

In addition, such services can lead to users feeling more in control of their lives. According to Brook: "For many users crisis services are less stigmatising and threatening than hospital in-patient care. They offer support that can be hard to access in other ways in the community."

Although the report recommends developing more community-based crisis services, Faulkner stresses that such services should work alongside existing acute services. The report warns: "Residential crisis services must not develop at the expense of hospital in-patient care."

Brook agrees. "A community-based crisis service should be seen as a positive and useful additional resource," he says. Close liaison between both types of crisis services, he says, is essential if the community-based services are to succeed.

Having a variety of crisis services to choose from would also be welcomed by doctors, social services, community nurses, according to Simpson. He adds: "It is a lot easier for professionals to leave you in your own life if you are already living it."

Beresford says there is room for both types of crisis services. He says: "Making this kind of crisis provision available is important but it should not be seen as an alternative to acute wards."

While there is plenty of room for the improvement of acute services, community-based crisis services can also provide the answers for some users. As Faulkner says: "If people can learn to value themselves while in crisis services then that is half the battle won."

- Being There in a Crisis is available from the Mental Health Foundation, on 020 7802 0300