Key questions regarding residential alternatives to standard acute psychiatric care, such as crisis houses and short-stay in-patient units, concern the role that they fulfil within local acute care systems, and whether they manage people with needs and illnesses of comparable severity to those admitted to standard acute wards.

To study the extent to which people admitted to residential alternatives and to standard acute services are similar, and the role within local acute care systems of admission to an alternative service.

Our approach combined quantitative and qualitative methods. Consecutive cohorts of patients in six residential alternatives across England and six standard acute wards in the same areas were identified, and clinical and demographic characteristics, severity of symptoms, impairments and risks compared. Semi-structured interviews with key stakeholders in each local service system were used to explore the role and functioning of each alternative.

Being already known to services (OR = 2.6, 95% CI 1.3–5.2), posing a lower risk to others (OR = 0.49, 95% CI 0.31–0.78) and having initiated help-seeking in the current crisis (OR = 2.2, 95% CI 1.2–4.3) were associated with being admitted to an alternative rather than a standard service. Stakeholder interviews suggested that alternatives have a role that is similar but not identical to standard hospital services. They can divert some, but not all, patients from acute admission.

Residential alternatives are integrated into catchment area mental health systems. They serve similar, but not identical, clinical populations to standard acute wards and provide some, but not all, of the functions of these wards.

Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched.

To explore short-term outcomes and costs of admission to alternative and standard services.

Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services.

All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12–2.86), TAG (difference 1.40, 95% CI 0.39–2.51) and GAF functioning (difference 4.15, 95% CI 1.08–7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK£3832 v. £9850). Standard services cost an additional £2939 per unit HoNOS improvement.

The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.

Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions.

To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services.

Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission.

After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services.

Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

Little is known about the preferences and experiences of people with mental illness in relation to residential alternatives to hospital.

To explore patients' subjective experiences of traditional hospital services and residential alternatives to hospital.

In-depth interviews were conducted with 40 purposively selected patients in residential alternative services who had previously experienced hospital in-patient stays. Transcripts were coded and analysed for thematic content.

Patients reported an overall preference for residential alternatives. These were identified as treating patients with lower levels of disturbance, being safer, having more freedom and decreased coercion, and having less paternalistic staff compared with traditional in-patient services. However, patients identified no substantial difference between their relationships with staff overall and the care provided between the two types of services.

For patients who have acute mental illness but lower levels of disturbance, residential alternatives offer a preferable environment to traditional hospital services: they minimise coercion and maximise freedom, safety and opportunities for peer support.

Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards.

To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP–RCT) design (ISRCTN20804014).

We used a PP–RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission.

Forty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (randomised or preference arms), but women who obtained their preferred intervention were more satisfied with treatment.

Although the sample sizes were too small to allow definite conclusions, the results suggest that when services are able to provide interventions preferred by patients, those patients are more likely to be satisfied with treatment. This pilot study provides some evidence that women's crisis houses are as effective as traditional psychiatric wards, and may be more cost-effective.

Alternatives to traditional in-patient services may be associated with a better experience of admission.

To compare patient satisfaction, ward atmosphere and perceived coercion in the two types of service, using validated measures.

The experience of 314 patients in four residential alternatives and four standard services were compared using the Client Satisfaction Questionnaire (CSQ), the Service Satisfaction Scale – Residential form (SSS–Res), the Ward Atmosphere Scale (WAS) and the Admission Experience Scale (AES).

Compared with standard wards, service users from alternative services reported greater levels of satisfaction (mean difference CSQ 3.3, 95% CI 1.8 to 4.9; SSS–Res 11.4, 95% CI 5.0 to 17.7). On the AES, service users in alternatives perceived less coercion (mean difference –1.3, 95% CI –1.8 to –0.8) and having more ‘voice’ (mean difference 0.9, 95% CI 0.6 to 1.2). Greater autonomy, more support and less anger and aggression were revealed by WAS scores. Differences in CSQ and AES scores remained significant after multivariable adjustment, but SSS–Res results were attenuated, mainly by detention status.

Community alternatives were associated with greater service user satisfaction and less negative experiences. Some but not all of these differences were explained by differences in the two populations, particularly in involuntary admission.

Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched.

To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction.

Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored.

No significant difference was found in intensity of staff– patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives.

Similarities in care may be more marked than differences at alternative and standard services. Staff–patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.