London Mental Health Crisis Hubs Evaluation Summary
December 19, 2022
In the first wave of the Covid-19 pandemic, London NHS mental health trusts put in place mental health crisis hubs to provide safe access to mental health crisis care without having to attend an accident and emergency (A&E) department.
A mental health crisis hub is a service for people who are experiencing mental health crisis, who would otherwise have to go to A&E. Mental health crisis hubs are not designed for people who need urgent care for physical medical conditions. People who need urgent physical healthcare will usually have to go to A&E to be treated initially.
Each mental health crisis hub was set up in a different way. This is due to the different population needs in each location.
In February 2022, NHS England and Improvement (NHSEI) London asked the Health Innovation Network to complete an evaluation with three aims.
- To better understand the different mental health crisis hub models and their impact at a service user, carer, medical professional, and service-level across London.
- To find out what factors affect the roll out and sustainability of NHS mental health crisis hubs.
- Find out the core requirements for mental health crisis hubs to be effective for Integrated Care Systems (ICSs) and Integrated Care Boards (ICBs) to use as an alternative to Accident & Emergency (A&E).
Evaluation design
The structure of the evaluation was based on the London Mental Health Crisis Hub Assessment Framework. This framework was developed in 2020, alongside an organisation called UCLPartners (an Academic Health Science Network like the HIN) and NHSEI London. It was developed for mental health crisis hubs in London to provide safe and efficient models of care for people experiencing a mental health crisis. The framework is informed by the Institute of Medicine’s (IoMs) definition of six key healthcare quality domains:
- Safe
- Timely
- Effective
- Efficient
- Equitable
- Patient Centred
A steering group was set up by the HIN to advise and guide the evaluation. It included three experts by experience (two service users and one carer), representatives from all nine London mental health trusts, the London Ambulance Service (LAS), Metropolitan Police (Met Police), A&E, London ICB representatives and NHSEI London.
The evaluation gathered different types of data, including numerical data provided by the Trusts and information from service users and staff surveys. Interviews were also conducted with service users and staff members from the London mental health crisis hubs, A&E, LAS, Met Police and the ICBs / ICSs.
Mental health crisis models
At the time of this evaluation there were three different types of mental health crisis hubs still running in London. They were all included in the evaluation.
Hubs offering direct access (not via A&E)
- Mental Health Crisis Hub at Goodmayes Hospital – North East London NHS Foundation Trust (NELFT)
- Mental Health Crisis Hub at St Pancras Hospital – Camden and Islington NHS Foundation Trust (CANDI)
Both CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) crisis hubs allows direct access to people who are in mental health crisis and their carers through self-referral, signposting from community services or via the emergency services (LAS and / or Met Police).
Hubs offering access via A&E
- Mental Health Crisis Hub at Queen Elizabeth Hospital – Oxleas NHS Foundation Trust (Oxleas)
People in crisis would need to attend A&E at Queen Elizabeth Hospital to then be referred to the crisis hub. Oxleas (Queen Elizabeth Hospital) represents hubs that provide this type of model in London in this evaluation.
Services provided at A&E
As well as the three models listed above, an A&E service (also known as psychiatric-liaison service) was included in the evaluation. Including the A&E model allowed for comparison between a business as usual model, which has been running for many years, and the more recently set up crisis hubs. The A&E model used in this evaluation is known throughout the report as business as usual model and represents A&E models across London. The A&E model used in this evaluation is King’s College Hospital Psychiatric-liaison service at A&E. This service is provided by South London and Maudsley NHS Foundation Trust (SLaM).
Each service included in the evaluation provide a service 365 days a year, 24 hours a day.
Key terms
- Heath Innovation Network (HIN): The Academic Health Science Network (AHSN) for south London. It is one of 15 AHSNs across England. An AHSN connects NHS and academic organisations, local authorities and third sector and industry, in order to increase innovations across large populations quickly.
- Home Treatment Teams / Crisis Teams: Community-based service to help people experiencing mental health issues and who are in crisis.
- Integrated Care Boards (ICBs): An NHS organisation responsible for developing a plan for meeting health needs in a certain area.
- Integrated Care System (ICS): A partnership which joins together health and care organisations to improve services for people in their area.
- NHS England and Improvement (NHSEI): Provides national leadership and support for the NHS.
- Patient and Carer Equality Framework (PCREF): A framework which sets out the standard of care which patients and carers should expect. It is designed to ensure racial equality in the provision of services.
- UCLPartners (UCLP): AHSN for North London to the Essex coast. It is another one of the 15 AHSNs across England (like the HIN).
Evaluation findings
Although it is relatively early in the lifetime of the two hubs that allow direct access (CANDI – St Pancras Hospital and NELFT – Goodmayes Hospital, which were set up around the Covid-19 pandemic two years ago), the evaluation shows that both hubs are providing a timely service that enables service users and carers to be seen on arrival by a mental health professional.
These hubs are seeing more people going directly to the hub themselves, rather than being referred by other services. The majority of service users who provided feedback said that they felt safe, had privacy, and were treated with kindness and respect by staff who had a good understanding of mental health. However, service users, staff, carers and stakeholders also gave their opinions on how the crisis hubs could be improved.
Key findings
Where possible and relevant, we have compared mental health crisis hubs to hospitals providing support via the traditional A&E route (the business as usual, or BAU, model).
Crisis hub set-up
- Camden and Islington (CANDI – St Pancras Hospital) and North East London NHS Foundation Trust (NELFT – Goodmayes Hospital) offered direct access to crisis care for service users and carers
- Oxleas (Queen Elizabeth Hospital) provided a model where service users were referred to the crisis hub via A&E
- South London and Maudsley (SLaM – BAU site, King’s College Hospital) has a psychiatric-liaison service within A&E at King’s College Hospital
Staffing
- Only CANDI (St Pancras Hospital) employed senior nurses within in their associated A&Es to help and direct service users to the crisis hub if that is the best place for them to receive support and treatment.
- CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) crisis hub staff included those with physical health training, as well as mental health training.
Distance between hubs and A&E
- Distance and ease of transport varied between all mental health crisis hubs and A&Es.
Safe
- The majority of service users, carers and staff said they felt safe at the mental health crisis hubs.
- The emergency services had positive views on the direct access to the CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) hubs. This included a reduction in service users leaving before receiving care.
- There were concerns around the staffing levels at each hub and the impact that has on service user and carer safety.
Timely
- At CANDI’s Hub (St Pancras Hospital), most of the service users were seen within four hours.
- The length of stay was lower for NELFT (Goodmayes Hospital) and CANDI (St Pancras Hospital) hubs compared to the BAU model.
- Service users who stayed in the hub longer than expected due to a lack of mental health trust beds were unhappy with the timeliness of the care.
Effective
Discharge
- Service users experienced different discharge outcomes. The CANDI crisis hub (St Pancras Hospital) had a higher number of attendances that were discharged back to their General Practitioner (GP).
- NELFT (Goodmayes Hospital) had a higher number of service users being discharged to a Home Treatment Team (HTT) or a Crisis Team.
- NELFT (Goodmayes Hospital) had slightly higher rates of mental health inpatient admissions compared to the SLaM BAU site at King’s College London.
- Oxleas (Queen Elizabeth Hospital) had higher numbers of referrals to mental health inpatient beds compared to the SLaM BAU site (King’s College Hospital).
Repeat attendance
- Service users that re-visited CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) hubs, were significantly more likely to go direct to the hub themselves, rather than go to A&E.
Workplace satisfaction
- Most of the staff were happy with their workplace, training and senior leadership.
- Most of the staff felt they were treated with dignity and respect by their colleagues and would recommend their service to friends and family.
Efficient
- Service users are being referred to the CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) crisis hubs through various sources, not just A&E.
- Higher proportion of self-referrals at CANDI (St Pancras Hospital) and NELFT (Goodmayes Hospital) hubs compared with the BAU model.
- High proportion of referrals via the police and Home Treatment Team (HTT) / Crisis Team at NELFT (Goodmayes Hospital).
- Small proportions of crisis hub attendances were redirected to A&E.
- The majority of service users felt they had received the treatment and care required.
Equitable
Age and gender
- Age and gender of service users were well recorded at all sites and is similar between the hubs and the BAU site.
Race
- One Trust recorded race well. This was NELFT (Goodmayes Hospital).
- The BAU site had a higher number of black service users than all other crisis hubs.
- NELFT crisis hub (Goodmayes Hospital) had a higher number of Asian service users than the BAU site.
Sexual orientation
- One Trust had relatively well recorded sexual orientation compared to the other sites. This Trust was NELFT (Goodmayes Hospital).
Existing mental health conditions
- A lower number of attendees at CANDIs crisis hub (St Pancras Hospital) had an existing mental health condition known to the Trust, compared with the BAU site.
Person centred
- 126 service users and carers completed a survey and nine were interviewed to inform this evaluation.
- Most service users said they felt safe, and were treated with kindness, respect and dignity. They also felt they had privacy, that the staff had a good understanding of mental health, and felt listened to by staff.
- Most service users who attended A&E reported they had to explain their story more than once and that their legal rights were not explained to them.
Recommendations
The recommendations below are intended to inform the key factors of an effective mental health crisis hub. A full list of 22 recommendations is available in Section 8 of the full report.
- Mental health trusts should continually improve services using the London Mental Health Crisis Hubs Assessment Framework with the six key quality areas – Safe, Timely, Effective, Efficient, Equitable and Person Centred.
Safe
- Mental health trusts need to collect and report safety data.
Timely
- Mental health trusts should make sure mental health crisis hubs are easy to reach and are accessible.
Effective
- Mental health trusts should consider having staff trained in physical health, alongside mental health professionals within the hub.
- Mental health trusts should understand what happens following discharge to improve care for service users and their carers within the community.
- Mental health trusts should gather regular feedback from mental health crisis hub staff for continued improvement.
Efficient
- Integrated Care Boards should communicate to the public, service users, carers and service providers on how to be referred and access the mental health crisis hubs directly. They should communicate this through a variety of methods, eg posters, leaflets, email, texts and websites and should include why a person may be transferred from A&E to a mental health crisis hub.
- Mental health trusts should consider developing a direct access route to mental health crisis hubs so people do not need to go to A&E first.
Equitable
- ICBs to engage with the local community to ensure equal access to mental health crisis hubs for all.
- ICBs to have culturally relevant discharge support services.
- Mental health trusts to improve recording of service users’ ethnicity and sexual orientation.
- Mental health trusts to give service users of all races and ethnicities the chance to feedback (in line with the Patient and Carer Equality Framework).
Person Centred
- Mental health trusts should apply effective methods for regular feedback from service users and carers on their mental health crisis hub experience to drive continual improvement.
- Mental health trusts should continually train staff to improve patient care. Where possible they should involve service users and community services in the design and delivery of this training.
This page was co-created with experts by experience – people with real-life experience of health and care services – to help make the report findings accessible to all.
