Right here, right now: What this means for commissioners

What our report means for commissioners

As part of our commitment to the Crisis Care Concordat, CQC undertook a review of the quality, safety and effectiveness of care for those experiencing a mental health crisis, putting people at the heart of the issue.

The findings of this review are brought together in our report Right here, right now, which includes a number of recommendations for commissioners.

A sense of scale

“It was approximately seven hours before I got crisis support and that was only a call not a visit, which would have been more useful. As my crisis worsened I took a small overdose as I was not coping or getting any immediate help.”

• In 2013/14, nearly three million adults were registered with depression on local GP registers, and almost 500,000 were registered for a serious mental illness.
• In the same year, more than 1.5 million people were in contact with NHS trusts providing specialist mental health services in the same year.
• Around 5% of all A&E attendances are recorded as relating to mental health problems.
• Over 4,000 people had attended A&E multiple times (on average at least once a month) in the five years before being admitted to hospital in 2012/13 for a mental health related condition.

Shared responsibility

We found that people are not getting the care they need, when they need it. Not being able to access the right help at the right time is unacceptable and can cause a crisis to escalate, leading to greater mental distress or physical harm.

The introduction of the Crisis Care Concordat in February 2014 challenged commissioners and providers alike to commit to a set of core principles to address this. The Concordat is clear that people experiencing a mental health crisis should have access to the help and support they need 24 hours a day, seven days a week – a crucial step towards achieving parity with physical health care.

However, only 14% of respondents to our call for evidence told us that they received the response they needed, and almost half did not feel confident that they would receive a timely or helpful response if they experienced a future crisis. A health and care system where such a low proportion of people think they get the urgent help they need is one that is unsafe and inherently unfair.

Our report highlights the key role that commissioners play in making sure that people receive high-quality care quickly.

Joined-up working

Tackling mental health successfully is not something that can be achieved in isolation. Health services, social care services, police forces and the voluntary sector, along with other local partner agencies must work together to provide an effective, person-centred response.

Multi-agency working at a local level is at the heart of the Crisis Care Concordat’s vision. The Concordat expects that “in every locality in England, local partnerships of health, criminal justice and local authority agencies will agree and commit to local Mental Health Crisis Declarations”.

In the majority of areas we visited in our local area inspections, we found a strong commitment to multi-agency working. We also found evidence that these groups were considering issues with local care pathways for people in crisis. However, feedback from our inspections suggests that there is some way to go before multi-agency working is embedded in all aspects of crisis care.

Our report challenges organisations to look carefully at when, where and why local services comes into contact with a person in crisis and how they can work collaboratively to challenge unacceptable responses.

Effective commissioning

We found that the help, care and support available to people in crisis varies across the country, and that a person’s experience depends not only on where they live, but what part of the system they come into contact with. This is unfair and unacceptable, and raises serious questions about safety.

“My GP initially referred me to the early intervention in psychosis team which didn’t help since they weren’t the right team for me. I eventually went to A&E since I became suicidal and tried to kill myself…”

We also found that:

• A substantial minority of people who visited their GP during a mental health crisis were not satisfied with the help, care and support they received.
• Contacting mental health teams and telephone support lines outside of regular working hours can be very difficult.
• Some crisis resolution home treatment teams are struggling to offer an adequate home treatment function.
• Over half of liaison psychiatry services may be unlikely to offer a reliable quality of care or outcome.
• Gaps in service provision often related to children and young people, for example, people under 18 having difficulty accessing health-based places of safety when they need it.

When reviewing provision, commissioners need to look at the demographics of their local area and the needs of their local population. They should use evidence-based approaches that are aligned with national objectives. They should make full use of commissioning guidance to inform their decision-making process.

Our recommendations

While our review has highlighted some examples of very good practice, there is still too much variation across the country, and even variation within the same local authority areas.

We recommend that representatives of local Crisis Care Concordat groups:

• Make sure that all ways into crisis care give people the help, care and support they need at the time they need it.
• Hold commissioners to account for commissioning crisis services that are based on evidence-based good practice, and are in line with the Concordat key principles.
• Engage with local, regional and national partners to make sure that best practice and innovative examples are shared within, and across, local areas.

We also encourage commissioners to:

• Review local referral arrangements for talking therapies.
• Make sure that crisis resolution home treatment teams are resourced so they can respond to people’s need at any time.
• Commission services that deliver parity in the quality of service received by people that are experiencing a crisis outside of 9am to 5pm.
• Commission liaison psychiatry services – and other services relevant to the A&E pathway – that consider the needs across local population groups and the times those at risk of crisis are likely to present.
• Revisit the key findings from our report on health-based places of safety, A safer place to be, to make sure that they are planning enough provision of health-based places of safety to meet the needs of the local population.