Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis

Clibbens N, Baker J, Booth A, Berzins K, Ashman MC, Sharda L, Thompson J, Kendal S, Weich S
Record ID 32018005224
Authors' objectives: Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances. The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes. Mental health crises cause significant disruption to the lives of individuals and families and can be life-threatening. The drive for community care alongside large reductions in hospital beds has led to a proliferation of community crisis services delivered by a diverse range of provider agencies, contributing to difficulties for people in navigating to timely crisis support. There is no single definition of a mental health crisis; people have diverse needs, resulting in a large variation in routes into and through mental health crisis care. Service users report unmet need. Services have diversified quickly in response to reported gaps and delayed responses, and continue to do so. Diversification has led to geographic differences in available crisis care and created a complex web of agencies with different values, referral processes, interventions and access thresholds. It is unclear, in this complex system, which underpinning mechanisms of crisis care are most effective, for whom and in which circumstances. Use stakeholder expertise, current practice and research evidence to develop programme theories to explain how different crisis services work to produce the outcome of resolution of mental health crises. Use a context, intervention, mechanism and outcome (CIMO) framework to construct a sampling frame to identify subsets of literature within which to test programme theories. Iteratively consult, via an expert stakeholder group (ESG) and individual interviews, with diverse stakeholders to test and refine programme theories. Identify and describe pen portraits of UK crisis services that provide exemplars of the programme theories to explain how mental health crisis interventions work in order to explore and explain contextual variation. Synthesise, test and refine the programme theories, and, where possible, identify mid-range theory, to explain how crisis services work to produce the outcome of resolution of the crisis. Provide a framework for future empirical testing of theories in and for further intervention design and development. Produce dissemination materials that communicate the most important mechanisms needed to trigger desired context-specific crisis care outcomes, to inform current and future crisis care interventions and service designs.
Authors' results and conclusions: Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve. Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion. The scope of the realist review was refined through an initial consultation and discussion between the ESG and the research team. A Diamond-9 prioritisation process was used to facilitate discussion between the ESG and the research team and to refine the scope of the review. This process resulted in three initial programme theories for testing, focused on (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. The findings from the three focused reviews were synthesised with mid-range theory. Mental health crisis care is provided by a complex array of agencies, each with different definitions of crises, different values about the nature of interventions and different approaches to prioritisation. This is further complicated by multiple overlapping service boundaries. What is apparent is that these differences can only be accommodated within an inter-agency system in which information and decisions are shared from commissioning through to front-line delivery. Inter-agency working provides mechanisms that trigger seamless service delivery through improved communication and collaboration. For this system to work, representation from all agencies and stakeholders is needed. National co-ordination at policy level ensures that investment is appropriately targeted and that important strategic aspirations are met. National co-ordination should steer, but not dictate, local configurations of the agencies needed. Local crisis services should be configured to meet the crisis care needs of local populations within their geography, taking account of any marginalised individuals or communities they serve. Commissioning for inter-agency working needs a focus on managing complex boundaries and transitions across agencies to avoid gaps and disputes. Attention is also needed on how the inter-agency crisis system engages with wider systems important to resolution of crises, including, for example housing, police, local authority, safeguarding and the justice system. The ultimate aim of inter-agency system should be that there is no wrong door through which to access mental health crisis care, and, once in a service, navigation should be facilitated via a single trusted point of liaison. Evaluation is not restricted by organisational boundaries and aims to provide data that take account of how the whole inter-agency system is operating. Conceptualisations of crises as single events or as the sole responsibility of statutory secondary mental health systems are unhelpful and generate fragmentation, leading to gaps and delays for those seeking crisis care and frustration for leaders and front-line staff. The perception of whether or not a service and service providers are accessible carries more of an inhibitive effect than the way that the service is actually organised. People experiencing a crisis choose to access services they perceive as providing a guaranteed response, that are easy to navigate to and that fit with their definition of the crisis. Although the timing of responses in relation to outcomes remains unclear, what is clear is that people feel safer and have a reduced sense of urgency when they trust services. Trust is established through compassionate interactions and proactive management of transitions and waiting. Involvement of the person and their family or support network in decisions supports a sense of trust and relational safety, which may help meet a need for continuity for some. To sustain compassion, front-line staff need access to support for themselves, as well as resources to deliver crisis care that meets their personal and professional ideals. Training in the knowledge, skills and values required for compassion can build confidence among front-line staff in all agencies. System leaders must provide resources and communicate an expectation for compassionate engagement so that it becomes the norm for staff to seek support. This is achieved in an inter-agency context when there is interpersonal contact between all levels of worker, from commissioning through to front-line delivery, that facilitates learning, communication and appreciation of different roles. Furthermore, co-production of crisis care can be facilitated within the inter-agency system, enabling crisis care to be recognised and valued by the community it serves. Service users perceive a crisis when they feel overwhelmed and anxious and when they perceive that they lack a sense of control. Familiar contacts and a safe environment, coupled with reassurance, can help to shape their perception of the service, but, more importantly, can help to reduce distress, thereby mitigating risk and making it more likely that a service user is able to respond to suggested strategies. With an emphasis on rapport and compassion, professionals are encouraged to exhibit positive behaviours that mitigate against the dehumanisation and stigma that service users may perceive when they encounter a service, and which may precipitate or exacerbate a crisis. Compassion shown to front-line staff by leaders leads to compassionate care. A tension between exerting control and providing support was evident at all levels. As integrated care systems are introduced, there is an aspiration that strategic partnerships will reduce competing priorities, which appear debilitating to organisations. Alongside these strategic partnerships, there is a need for coherent local strategies for compassionate and psychologically safe crisis care cognisant of the fact that high-quality care can coexist alongside the worst examples of care in the same organisation. Strategies should include how compassionate and psychologically safe crisis care is provided. Different values and definitions of crisis are accommodated, allowing challenge and debate to become accepted as an opportunity to drive quality improvement. Community crisis care is likely to continue to be delivered by a complex array of agencies responding to a heterogeneous population that presents with different mental health concerns and perceptions of crisis. Inter-agency working provides a platform for seamless transitions between services and timely responses. To deliver desired outcomes, inter-agency working requires continual systems of engagement locally and nationally involving all providers of crisis care through compassionate leadership, sharing of values and shared understanding of systems. Compassion is central and begins with leaders who can influence the culture of crisis organisations. Compassionate leadership is focused on people over systems, enabling front-line staff to retain their compassion and hope, and to work collaboratively across agencies, and it provides a platform for shared decision-making and co-production. All of this helps people in crisis to recognise the service as designed for them and to have trust in community crisis services. The study achieved its objectives, despite unexpected difficulties resulting from the effects of the COVID-19 pandemic, owing to an agile and committed research team, flexible and accommodating stakeholders and support from the funders. Project milestones were adjusted to accommodate the changing context of the study.
Authors' methods: This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory. Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts. A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. A four-phase realist evidence synthesis, reported in accordance with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) reporting guidelines and comprising (1) identification of candidate programme theories from academic and grey literature; (2) iterative consultation with an ESG and individual interviews to prioritise, test and refine programme theories; (3) focused realist reviews of prioritised theory components; and (4) synthesis to mid-range theory. The principal aim of the review was to generate and test programme theories, and then synthesise these with mid-range theory, to explain what works, for whom and in what circumstances in adult mental health community crisis care. The following were conducted: Google Scholar (Google Inc., Mountain View, CA, USA) searches to identify initial programme theories and logic models, focused searches of academic databases with backward citation searching, grey literature searches and hand-searches by the research team and expert stakeholders to test and refine three theory components. An ESG, with membership from lived experience, health professional, social care, policy expertise, health management and commissioning, was consulted on four occasions across the life of the research to test and refine theories and to connect them with real-world experience. Twenty individual realist interviews were conducted with 19 participants to further test, refine and sense-check theory components where there were gaps in topic expertise or theory; the 19 participants included service users; health, social care, ambulance and police professionals; and research and policy experts.
Project Status: Completed
Year Published: 2023
URL for additional information: English
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • Community Mental Health Services
  • Mental Health Services
  • Adult
  • Mental Health
  • Crisis Intervention
Organisation Name: NIHR Health Services and Delivery Research programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Contact Name: journals.library@nihr.ac.uk
Contact Email: journals.library@nihr.ac.uk
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.