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Those planning and implementing crisis and out-of-hours mental health services need to ensure that service users' views are sought and acted upon, writes researcher Heather Hurford.

Crisis resolution teams are required to be in place by 2004.¹ Detailed guidance has been published on the design, management and operation of these services,² within a national policy framework that envisages that mental health care will be planned and delivered around the needs and wishes of service users.

Demand for these crisis services is likely to depend on a number of factors, including their ability to work together and respond to the experiences and needs of service users. Moreover, they are being developed at a time when services are evolving at many levels in response to policy requirements and where there are risks attached to planning any one element at the expense of a whole picture of local provision. Therefore, it is important for mental health services commissioners and providers who are still grappling with the role of crisis services to ensure that their planning is informed by the views of service users.

Dacorum Primary Care Trust in Hertfordshire, together with local partner agencies, consulted service users prior to developing crisis and out-of-hours services (see below). The focus of the consultation was on services for people aged 18 to 65, and it was planned and funded under the local health improvement programme. The findings offer helpful insights on service users' perceptions of crisis and suggest areas where research on a larger scale is needed to provide more rigorous evidence. Nevertheless, although people's experience of crisis was very varied, a number of key themes emerged.

Service users defined a crisis as an inability to cope with normal life. Being unable to sleep and the consequences of lack of sleep were perceived as significant contributors to the development of crises for over half the sample. Loneliness was also important, as were being very high or very low with disturbed thoughts, and feeling unable to cope with practical domestic tasks. Crises were particularly likely to occur when people experienced more than one of these factors.

We then asked where users had sought help in a crisis, and it seems that this happens in stages. Often people are reliant on the response of the first person they contact for the subsequent support offered or pattern of events. Nearly half the sample relied on family or friends as the first line of support when they start to feel unable to cope with their normal lives. One-third had contacted their key worker in the first instance. Others had used existing out of hours services, the Samaritans, accident and emergency departments or their GP. For 15 out of the 24, this initial contact had led directly or indirectly to hospital admission.

What would help to prevent crisis? Service users said that being able to contact other people at any time of the day or night was the most important point. Also, support or self-help groups, talking therapies, a telephone helpline, and befriending were variously identified as most useful. In addition, support with practical, domestic tasks was a strong theme, and they felt that having an occupation or carrying out purposeful activities were very beneficial, as much for the opportunity for social contact as for the occupation itself.

Not surprisingly, for those with young children, support with child care was a critical issue. Meanwhile, being listened to and taken seriously by service staff was considered to be important: this issue underpinned many of the responses and was emphasised strongly by a few people who had had very difficult experiences with professionals.

More broadly, the elements contributing to crisis, and the extent to which they may or may not feel manageable or preventable, appeared to be inextricably bound up both with the complexities of sustaining the everyday business of life and with the prevailing organisation of mental health service provision.

Therefore, crises seem to be just as much a consequence of social exclusion, which is a feature of many clients' lives, as the mental health problem itself. Obviously, while some aspects of crises are inevitable features of particular illnesses that require high level intervention from specialist mental health services, others could be addressed through improved social and vocational opportunities for people with mental health problems. If social support at this level is available, in many cases the escalation to problems that require more intensive professional intervention may be prevented or reduced.

When it came to the intervention of specialist services, many of the service users wanted a broader range of provision, particularly talking therapies, alternatives to hospital and improved hours of access. People also talked about a need for information, continuity, and, above all, consultation.

It should be noted that these findings are similar to those resulting from recent nationally conducted service user consultations on broader mental health service provision,³ and the implications for service development are becoming clear.

For example, services whose main purpose is to provide general, non-specialist support with daily living skills, practical tasks or emotional support to promote or maintain a person's ability to live independently in their own home are gaining prominence in the national policy agenda, particularly through the Supporting People initiative. A recent review of the effectiveness of these low intensity support services found that user-centred outcomes from this type of service are consistently positive. Users consistently valued the support of a support worker or volunteer, often in preference to other more formal service interventions.⁴

However, policy guidance and local implementation of the National Service Framework continue to focus more on high intensity services - crisis intervention teams, assertive outreach, and home treatment. Yet the consequences of focusing service interventions on acute crisis responses at the expense of preventive work are that service users remain disempowered and services overstretched. So unless high intensity interventions are built alongside the kind of lower intensity social and community support identified in this study, these highly expensive services will remain reactive, and make unattainable the vision of a mental health system that supports people in settings of their own choosing.

Consequently, planning for the development of crisis and out of hours services should be extended "downwards" to include a capacity to prevent crises. There are a number of possibilities, including befriending services, 24-hour telephone helplines, the employment of suitably life skilled people at a care assistant level in existing services and social prescription schemes.

Housing providers and locally based voluntary sector organisations are particularly critical, yet in many areas these agencies remain marginal to local NSF implementation processes. They should be seen not just as partners in consultation but as integral elements of a local mental health service infrastructure, providing complementary skills, knowledge and opportunities for funding to those that exist in health and social services. If the needs and aspirations of service users are genuinely central to mental health service development, a broader, more socially inclusive approach is imperative.

The research

Current users of services of the local community mental health team, of an inpatient ward and of mental health charity Mind were invited to participate. Twenty-four service users agreed to take part - all of whom had severe and enduring mental health problems. The research was conducted by an independent researcher and took a qualitative approach, using semi-structured face to face interviews. Interviews were simultaneously recorded in writing and the findings analysed thematically. A separate group of users assisted in the design and piloting of the interview schedule and offered comments on the findings and analysis.

Heather Hurford is an independent mental health service researcher and consultant.

References

¹ Department of Health, National Service Framework for Mental Health, DoH, 1998

² Department of Health, The Mental Health Policy Implementation Guide, DoH, 2001

³ The Mental Health Foundation, Being There in a Crisis, MHF, 2002

⁴ A Murray, G Shepherd, S Onyett and M Muijen, More than a Friend: The Role of Support Workers in Community Mental Health Services, Sainsbury Centre for Mental Health, 1997