Managing episodes of acute mental illness without admission to hospital has been advocated since the 1960s (Reference Wasylenki, Gehrs and GoeringWasylenki et al, 1997). In England, government policy for mental healthcare proposed the setting up of 335 crisis resolution teams nationally for this purpose (Department of Health, 1999, 2000). The studies cited to attest to their likely efficacy (Reference Joy, Adams and RiceJoy et al, 1998) describe work from the 1970s and 1980s. At the time it was argued that this evidence base was dated, taking old fashioned asylum care as its reference point, rather than services based around community mental health teams which, by then, were the norm (Reference Pelosi and JacksonPelosi & Jackson, 2000).

Johnson and colleagues (Reference Johnson, Nolan and Hoult2005a ,Reference Johnson, Nolan and Pilling b ), working in North London, have reported a before-and-after and a randomised controlled trial of a crisis resolution team. Both indicated a substantial reduction in admissions. However, both described a service which had recruited one of the foremost clinical leaders in the field. It is thus reasonable for us to ask whether similar gains could be achieved widely.

Between 2001 and 2004 there was a rapid expansion in the number of crisis resolution teams in England (Glover & Barnes, Reference Glover and Barnes2002, Reference Glover and Barnes2004, Reference Glover and Barnes2005). We set out to explore the extent to which these were successful in reducing admissions, comparing admission trends in areas grouped on the basis of their implementation history.

The same government policy also mandated the setting up of a national network of assertive outreach teams providing intensive community-based support for frequently relapsing and difficult-to-engage patients. These were implemented more quickly than crisis resolution teams. We studied these in parallel.

METHOD

RESULTS

Over the 6 years, admissions in the 229 primary care trusts overall fell by 23% for younger and 0.5% for older people. For all ages combined, the median change was –11%, (interquartile range +6% to –23%). Crisis resolution teams were already in place in 34 (15%) of the primary care trusts by 2001; 14 (6%) and 51 (22%) added teams in 2002 and 2003 respectively, leaving 130 (57%) with no team. Crisis resolution teams that were always on call were in place in 12 (5%) primary care trusts in 2001, with 10 (4%) and 30 (13%) reaching this level of provision over the next 2 years respectively. Assertive outreach teams appeared more rapidly; 144 primary care trusts (63%) had this facility by 2001, with 23 (10%) and 36 (16%) following in 2002 and 2003 respectively, leaving only 26 (11%) uncovered. Assertive outreach teams providing evening and weekend working were seen in 86 (38%) primary care trusts in 2001, with a further 18 (8%) and 38 (17%) achieving this in 2002 and 2003 respectively.

Simple inspection of the change in hospital admission numbers suggested that crisis resolution teams were associated with greater falls; 74% of primary care trusts with a broadly defined crisis resolution team and 83% of those with a narrowly defined team in place by 2001 showed a fall in total admissions, compared with only 60% of those with no team by 2003/4. The impact appeared greater for older patients and for women. By contrast, the effect of assertive outreach teams was erratic with, if anything, smaller proportions of primary care trusts with assertive outreach teams showing a fall.

Figure 1 shows plots of the modelled trends in the average annual hospital admission numbers for primary care trusts, grouped by year of first provision, from the mixed analysis of variance. The two plots on the left are drawn from the model using broad definitions for both team types. Those on the right are based on restrictive definitions and include an additional category for primary care trusts with teams but not reaching the narrow definition level. Both graphs in relation to crisis team provision show the line for primary care trusts with teams in place by 2001 falling much more sharply than that for those with no team. For assertive outreach, primary care trusts with no provision show sharper falls than others although, in this case, in the model using restrictive team definitions the plots are not statistically significantly different even at the P<0.05 level.

Fig. 1 Modelled trends in mean annual hospital admissions for people of both genders and age-groups, for primary care trusts grouped by team provision status. CRT, crisis resolution team; AOT, assertive outreach team.

Models were calculated for all hospital admissions, and for the four age/gender subgroups. For broadly defined crisis resolution teams, only the model for women aged 35–64 years showed a significant effect at the P<0.001 level. For restrictively defined crisis resolution teams, this level was reached by the models for all admissions, and admissions for older men and women. The model for younger women was highly significant (P=0.003), but not that for younger men (P=0.03). Broadly defined assertive outreach team status was significantly associated with less reduction in admission at the P<0.01 level only in the model for older women (P=0.005), narrowly defined status not at all. Models for bed usage generally produced weaker significance levels. At the P<0.01 level, only restrictively defined crisis resolution team status figured significantly (all people, P=0.005; younger women, P=0.005; older men, P<0.001). To check that the process of data smoothing for the 69 primary care trusts with isolated defective data points had not substantially altered the result, all these analyses were re-run omitting these records. Apart from generally weaker significance levels, the pattern was unchanged.

If greater reduction in hospital admissions was a consequence of implementation of crisis resolution teams, it should follow in time. Figure 2 shows plots for modelled admission numbers in primary care trusts classified by the year of first provision of restrictively defined crisis resolution teams for younger and older working age adults separately. In the chart for those aged 35–64 years, the gradient of the plot for primary care trusts introducing teams in 2002 shows a marked change at the appropriate point. This time-related feature was seen in plots for both women and men in this age-group, but not in plots for younger people. The plot for areas introducing teams by 2001 shows a falling trend preceding 2001; as noted above, many of these teams were in place several years before this date.

Fig. 2 Modelled trends in mean annual admissions for younger and older people, for primary care trusts grouped by 24/7 crisis team provision. CRT, crisis resolution team.

Finally, we explored the extent to which crisis teams were associated with reductions in hospital admissions and bed requirements. Table 1 shows the differences between the changes seen in primary care trusts with teams established by 2001 and those with no teams. Restrictively defined crisis resolution teams were associated with an attributable reduction of a little over 20% in admissions. The reduction for older adults was about one and a half times that for younger working age adults. When all crisis teams were included, significant falls, but of only half the magnitude, were seen for people aged 35–64 years; for younger adults, no significant fall was seen. Attributable falls in bed usage were lower and less statistically significant.

DISCUSSION

This paper reports an uncontrolled observational study of trends in psychiatric hospital admission across England and their relationship to the implementation of crisis resolution teams and assertive out-reach teams. Clearly other factors influencing admissions would have been at work at the same time, but with such large changes in the provision of these teams over such a short period it seems reasonable to explore whether any impact is discernible.

There was a widespread fall in hospital admission numbers over the period we studied, in areas with and without new teams. Hence this observation alone in any single area is insufficient to establish the effectiveness of a crisis resolution team. We were able to demonstrate that areas which implemented crisis resolution teams showed greater reductions in admissions for older working age adults than areas which did not, and that where these were always on call, reductions were more marked and were also seen for younger adults. The scale of the reduction in admissions (20% with teams always on call) was much smaller than that reported by early authors (Reference Hoult, Rosen and ReynoldsHoult et al, 1984), but close to the two recent English reports (Reference Harrison, Alam and MarshallHarrison et al, 2001; Reference Johnson, Nolan and HoultJohnson et al, 2005a ). Occupied-bed days also fell in areas with teams always on call, although the difference was smaller (10% overall) and statistically significant only for older working age adults.

Implementation of assertive outreach teams was not associated with any additional reduction in admissions. This was not surprising since the evidence that they reduce admissions in a modern English context is more equivocal (Reference Burns, Creed and FahyBurns et al, 1999; Reference Marshall and LockwoodMarshall & Lockwood, 2000; Reference Killaspy, Bebbington and BlizardKillaspy et al, 2006). The effectiveness observed in the Cochrane review (Reference Marshall and LockwoodMarshall & Lockwood, 2000) arose entirely from two American studies of the 1980s – the only English study included showed no difference. Moreover, assertive outreach teams only care for a small proportion of those who are admitted to hospital, so their impact on total admission rates could only be limited.

The questions raised by the study fall into two broad areas: the reliability and scope of the data and their interpretation.

Our admission data source was deficient in scope in two ways. First, it excluded NHS patients admitted to the independent hospitals sometimes used for overspill provision. Second, the government target number of crisis resolution teams (335) indicated about one for each primary care trust, but the alignment of boundaries was not always exact. Routinely collected data might also be of poorer quality than those collected for research. The period studied was characterised by an unusually large amount of administrative reorganisation which may have had additional adverse effects on the data we used. We have described the data cleaning process we undertook before joining the admission and team data for individual areas. However, these types of weaknesses would be expected to obscure, not produce the type of detailed patterns seen.

Other factors may have had a confounding influence if they were introduced in parallel in the same areas as crisis resolution teams. We attempted to study three such factors. The number of in-patient beds in England was fairly stable in the first half of the period studied, reflecting government sensitivity about possible shortages (Department of Health, 1997). In the second half it fell by about 5%. We attempted a systematic analysis to establish whether primary care trusts with crisis teams were served by hospital trusts which had reduced beds more than others. However, this proved unworkable, since most hospital trusts cover several primary care trusts and the allocation of beds is seldom firmly fixed.

We also explored whether data on crisis accommodation and day hospital provision were sufficiently clear to be brought into the model. In both cases the difficulty was the heterogeneity of these types of service (Reference Briscoe, McCabe and PriebeBriscoe et al, 2004). Whereas some appeared to offer realistic alternatives to admission, others did not; for most our data were unclear. Crisis accommodation showed limited growth (from 160 to 220 beds nationally) and day hospital capacity appeared to reduce.