Not all ‘crisis teams' are the same

I am concerned by the claims made in the paper by Forbes et al. ¹ It purports to add to the literature relating to the introduction of a crisis resolution and home treatment team (CRHTT), by demonstrating little impact on bed use and increased compulsory admissions. This is misleading as the study actually shows the effect that a new CRHTT, which does not adhere to the consensus model, may have as part of a complex, changed system.

The paper describes admission and compulsory admission rates before and after a service redesign (which includes the inception of a CRHTT), but reports these as if the set up of the CRHTT was the only important change. In reality, the changes included a reduction in in-patient beds, reprovision of beds several miles away, and presumably uncertainty and anxiety in staff during the change period.

I am not surprised by the lack of impact on bed use and the increase in compulsory admissions. The CRHTT did not include key elements associated with reduced admissions as determined by evidence and the National Audit Office. ^2-4 First, the Midlothian team had no designated consultant or social worker (although there was ‘ready access’ to the latter). Second, the CRHTT did not do its own face-to-face gatekeeping in all cases, and the proportion of admissions subject to gatekeeping by the CRHTT is not supplied. Third, the team did not operate a 24-hour service.

It is vital to communicate accurately with commissioners and others about the economic value, safety and effectiveness of psychiatric services. Not all teams providing frequent visits outside of hospital are a CRHTT, but the distinction is not likely to be widely understood. The development of accreditation criteria for CRHTTs is now urgent.