Too often, mental health crisis care is a blue light issue….
“Get in; sort it out; it’s done and then go.”
COVID-19 is not going away. While Australia basks in being one of the world leaders in controlling the spread of the virus another island nation, the United Kingdom, and its European neighbours are moving back into lockdown to reduce the spread and deaths resulting from infection. Meanwhile, healthcare leaders are continuing to trumpet the importance of managing mental ill-health and crisis care during and after the pandemic. So many situational factors exacerbate mental ill-health come into play during lockdowns—relationship and family tensions, job losses, financial strain, and loss of education opportunities. Clearly, mental ill-health will be a major long-term consequence of the pandemic.
The question this raises is how prepared are we with a workforce that can meet the demand and supply factor? In the U.K., a key part of the Long-Term Mental Health Plan is to increase the workforce to support mental health crisis care. A recent report, The contribution of the voluntary sector to mental health crisis care: a mixed-methods study, has looked at the role that voluntary sector organisations can play and potentially boost the workforce. The report provides a series of recommendations to make the interaction between the public and the voluntary, or third sector organisations, more effective. To understand more #CrisisTalk spoke with the report’s principal author, Dr. Karen Newbigging from the University of Birmingham.
Workforce capacity and capability
This is one of the great challenges to scaling mental health crisis care—how to meet the supply and demand issues. While we use the term ‘voluntary sector organisations’ to refer to charities, voluntary organisations, and/or community groups, it may also include social enterprise organisations. The report shines a light on the power of this sector to enhance both capacity and capability of public sector services delivering mental health care.
There is an increasing emphasis on mental health in the public discourse leading to communities being more comfortable in speaking about mental health and suicide prevention, which in turn creates a demand for service.
“Our research found that users of public sector services felt let down,” said Dr. Newbigging. This echoed previous reports that have found that voluntary sector crisis support is more valued in the U.K. than the National Health Service (NHS). People felt the voluntary organisations treated them with kindness. In fact, some people have said they had a better response from police and ambulance services than they did from mental health services.
There is also a range of capabilities within voluntary sector organisations that are not available in the public sector, at least in any coordinated way, and they are particularly good at engaging with people from marginalised communities. This needs to be harnessed far more effectively than is currently the case. The report identifies five types of voluntary organisations that deliver services related to mental ill-health crises, either directly or indirectly:
Type 1: mental health crisis specific. Provide an immediate response offering crisis support through a helpline, a ‘safe space’ and maybe an alternative to hospital admission.
Type 2: general mental health organisations providing a wide range of services for people experiencing a crisis, promoting the well-being and recovery of people experiencing a mental health problem.
Type 3: set up to support a specific population that may be vulnerable to mental health crisis, supporting the rights and well-being of a specific population. Often providing a wide range of welfare and social activities to these populations who many not access public sector services.
Type 4: respond to specific social issues or life events through a wide range of support, including counselling, access to welfare benefits, housing and health, and often dealing with specific life events: rape, domestic violence, bereavement.
Type 5: community and social organisations open to the whole population to provide social care and welfare support, often as part of a wider mission.
What we need is a coherent system, which integrates the skills and values of the voluntary sector and the public sector to deliver quality care. Dr. Newbigging says, that the idea of a seamless pathway is a problematic concept because crisis is not, in the main, a single event. Rather, it’s often a complicated narrative that ebbs and flows, and therefore it’s more helpful to think about crisis care in a system that delivers care fit to need.
Providing an effective response to need
Too often, mental health crisis care is viewed as a blue light issue. “Get in; sort it out; it’s done and then go.”
For some people, a crisis may be a single event, but for most, this is not the case. A person should be able to access a system that meets their needs at the time. The report draws on the Crisis Care Concordat, which sets out how organisations could work together better to make sure that people access help when they are having a mental health crisis. The Concordat proposed four elements that comprise an effective mental health crisis system:
- Prevention—part of the solution, but not all
- Urgent care—addresses the intense period of despair
- Quality of care—influences future use of services
- Recovery—also preventive element
Dr. Newbigging says that in the U.K., the current response is predicated on a view of a mental health crisis as an event. This means the focus is often on responding to the presenting crisis rather than taking the time to understand the context of the crisis and therefore using the opportunity to focus on prevention, early intervention, and recovery. What this means is that the system should offer people the care that they need and want when they need and want it. Dr. Newbigging acknowledges that some people do need an urgent care focus and the health system may well be best placed to respond. Both the voluntary sector, and the range of public sector services have a part to play as illustrated in the figure below. The challenge is figuring out what different organisations will do and how they can best complement each other’s efforts so that an individual is able to access the support they need to resolve the immediate crisis and address the contributory factors.
So… what is the “secret sauce” for greater cohesion so that the sense of kindness and compassion experienced by people in crisis who access voluntary sector support prevails?
Dr. Newbigging says there needs to be a better understanding and development of what should constitute a crisis care system and the respective roles of public sector and voluntary sector services. This will support better integration and strengthen relationships, making sure that it’s done in a way that won’t compromise the independence and values of the voluntary sector. One way to develop this is to shadow each other’s services and to have joint supervision to understand the roles they play.
The study found that when the relationship between type 1 voluntary sector organisations and NHS services was most developed, there was evidence of a mutual understanding of each other’s role. This included having agreement about information sharing and approaches to risk.
The awareness and appreciation of other types of voluntary sector organisations, however, was often less developed and there was a general lack of up-to-date information about what was available. Effective collaboration at the level of the individual service user was focused around providing an urgent and immediate response, and there was little evidence of a coherent pathway, although voluntary sector organisations and NHS services would signpost and/or refer to each other. (page 28)
The report says that service users valued self-referral, rapid response, face-to-face support, and having peer workers as an increasing part of the workforce. This is gaining prominence in Australia too, but this should not be at the neglect of the role of the healthcare system for some people.
Debate needs to clarify what is a mental health crisis so services can deliver better care. As Dr Newbigging has said some people do require an urgent care focus and the health system may well be best placed to respond. So, it is important that the system is flexible enough to achieve a balance between the clinical and wider social and emotional needs of individuals seeking support.
Building workforce capability
Those working on crisis lines get minimal information about the person, which means that often complexities are not evident. This can be further compounded when response lines are led by algorithms, not really listening to the person’s story and the meaning of the crisis experience for the individual, and responding to verbal cues that can mask the reality of the situation. This can make the experience more alienating and disempower the person’s control.
There is an argument for the triage process to be managed by highly trained people with experience in mental health crisis care, so there is a better understanding of how to effectively support the person. Often the understanding of risk differs between health professionals, peers, and the individual because context for each is different. The emotional consequences of constant exposure to crisis calls are a challenge, and the risk of burnout for the workforce is problematic.
Access is also an issue. The research found that people living in the countryside, people from minority groups, and people with ongoing mental health needs had problems getting help in a crisis. Crisis support from the voluntary sector can add to, and provide an alternative to, public sector mental health care.
Funding for the voluntary sector can be fragile, suggesting a lack of trust and understanding of how the voluntary sector works. Public money calls for accountability, which in turn comes with deliverables and defines how the voluntary sector should behave. The result is that the flexibility of the voluntary sector and individualised response, which is so valued by service users, can be compromised.
Some larger voluntary organisations have become businesses. Their funding capability is professionalised, and they can attract funding with little challenge. Contrary to this, small, effective grassroots organisations cannot scale because of the constant challenge of trying to raise funds to survive. Too often, these are providing support to marginalised communities and only serve to grow inequalities, further hampering effective care.
Re-thinking the mental health system
COVID-19 and its consequent pressures on mental ill-health is an opportunity to re-think the system in a way that responds to the needs of the individual. This is something that is often talked about, yet rarely delivered.
The report comes as a timely follow-up to the International Declaration for mental health crisis care. It demonstrates how the workforce may be enhanced to meet the increasing need for support. It also brings to the forefront the importance of that first interaction with the health system as an opportunity for prevention.
The voluntary/community/third sector provides enormous economic value to many countries. Strengthening relationships and harnessing skills and values between government-run services and community-managed organisations in a time of economic challenges makes sense. In fact, it’s imperative, if we truly want to re-engineer mental health crisis care, that it is available for everyone… everywhere… every time.
All figures and illustrations are reproduced from the illustrated summary of the findings, available at: https://www.birmingham.ac.uk/documents/college-social-sciences/social-policy/publications/contribution-of-the-voluntary-sector-to-mental-health-crisis-care.pdf
Or the original report:
Newbigging K, Rees J, Ince R, Mohan J, Joseph D, Ashman M, et al. The contribution of the voluntary sector to mental health crisis care: a mixed-methods study. Health Serv Deliv Res 2020; 8(29).
Sue Murray, International Correspondent
A health promotion advocate in Australia dedicated to improving the health and well being of all people. Throughout her career, she has focused on health for the community and has expertise in communications, education, and organisational development.
Sue currently leads the Zero Suicide Institute of Australia, which aims to support the healthcare system to understand and more effectively manage those who are vulnerable to suicide and suicidal behaviour.