Title: Investigating the contribution of the voluntary sector to mental health crisis care in England
Funder: Department of Health and Social Care

Abstract: Background The relationship between the voluntary sector (VS), or third sector, contribution and statutory services and how these might be integrated to provide a whole system response is a contemporary concern (Alcock, 2010). The provision of crisis support to people experiencing a mental health crisis provides an exemplar of this and of particular significance, given the well-publicised weaknesses in the current arrangements in England (Care Quality Commission, 2015). Mental health crises have been conceptualised as a ‘turning point’, with both risks and constructive potential for people experiencing a crisis (Hobbs, 1984). The policy focus has typically framed mental health crises in a biomedical discourse, requiring rapid psychiatric assessment and intervention, although previous research and service users advocate for a wider range of support, including informal community resources (Fenton et al., 2002; Morton, 2009). The Mental Health Crisis Care Concordat, established in 2014 to lever in improvements in access to high quality and effective support, included harnessing the distinctive contribution of the VS to support integrated care pathways (HM Government, 2014). To date, the research endeavour has largely focused on statutory provision, notably in relation to Crisis Resolution Teams (Rhodes, and Giles, 2014; Wheeler et al. 2015) and there are key gaps in the evidence base for effective mental health crisis care (Paton et al., 2016). Studies that have considered the role of VS services have tended to focus on crisis houses, comparing them with standard psychiatric in-patient care and often for women (Howard et al., 2010). There is, therefore, a significant knowledge gap concerning the extent of the VS contribution, including those services not badged as mental health projects but nonetheless providing crisis support, as is the case with VS organisations (VSOs) supporting homeless people, for example. Moreover, little is known about the range of services provided by small VSOs, particularly those operating informally, or about how the division of labour between providers operates on the ground. In addition, variations in the distribution of VS services, and the extent to which their contributions are integrated into local crisis care pathways, are not clear. From previous literature on the VS, there are problems characterised as “voluntary failure” (Salamon, 1987): essentially an inability to match provision with need (Mohan and Breeze, 2016). This suggests that the distribution of VSOs and volunteers will be uneven, raising policy concerns that those experiencing crises may receive more or less support, depending on where they live: something of a “postcode lottery”. Aim and objectives The primary aim of this research is to identify the contribution of the VS to crisis care pathways in mental health and to make policy and practice recommendations to strengthen the crisis care response in mental health. The scope is mental health crisis care in England and the research objectives are to: 1. Identify the different types of VS support being commissioned and provided to respond to the care and support needs of people experiencing a mental health crisis. 2. Develop a taxonomy of the different organisational types of VS support available, service models and populations served. 3. To investigate the experience of different stakeholders and outcomes for service users of the contribution of different types of VS support to the crisis care system. 4. To identify the factors and processes that facilitate the successful contribution of the VS to effective crisis care pathways. 5. To identify the policy and practice recommendations to strengthen the mental health crisis care response. Methods This is a multi-method study involving four work packages (WPs). WP1 scopes the contribution of VSOs to mental health crisis care. A national survey of VSOs will be undertaken to identify the types of mental health crisis support offered by the range of VSOs, supplemented by interviews with national stakeholders (Department of Health, NHS England, professional organisations) and national VSOs to elucidate detail on the different types of organisational forms of VSOs and views on their contribution to the crisis care pathway. The remaining WPs build on WP1 to provide a rich and detailed picture of the VS contribution. WP2 involves detailed mapping of the VSO provision within two regions to develop a taxonomy of crisis care provision thus extending the typology developed from the national survey. This taxonomy will provide a sampling frame to select two case studies per region in order to investigate the contribution of VSO provision to crisis care at both a system (WP3) and individual level (WP4). In the case study sites WP3 will focus on mapping the different elements of the crisis care system at a local level, including capturing small scale community based initiatives. Data on activities, interventions and stakeholder perceptions of the effectiveness of the VS contribution to the crisis care pathway will be collected through a key informant questionnaire, interviews with key stakeholders and focus groups with mental health service users and carers. WP4 will map the crisis care trajectories of 10 service users with experience of different types of VS provision, collecting this data through interviews with mental health service users, carers and statutory providers. Ethical approvals This project will require ethical approval by the Health Research Authority (HRA) and the University of Birmingham Humanities and Social Sciences (HASS) Ethical Review Committee and will be undertaken in compliance with the Data Protection Act and University of Birmingham policies relating to the conduct of research. Analysis The analysis will involve a detailed mapping of the VS contribution, which will be classified to develop a taxonomy of the different organisational forms, populations served and activities provided by VSOs in England. Data from qualitative interviews will be analysed using the Framework method (Gale et al., 2013) and data from the various sources synthesised to address the research questions. Research team The research team brings together expertise in researching VSOs and in mental health, and from a practitioner, commissioner and service user perspective. It combines the nationally recognised expertise of two leading UK research centres, the Health Services Management Centre (HSMC) and the Third Sector Research Centre (TSRC), with the track record of Suresearch, a mental health service user group involved in research. Public and patient involvement People with experience of mental ill-health will be extensively involved in the conduct of research as co-researchers and as members of a Project Reference Group. This involvement will be widened for public representation on the Study Steering Group. References Alcock, P., 2010. A strategic unity: defining the third sector in the UK. Voluntary Sector Review 1(1): 5-24. Care Quality Commission, 2015. Right here, right now. People’s experiences of help, care and support during a mental health crisis. Gallowgate: Care Quality Commission. Available at: http://www.cqc.org.uk/content/right-here-right-now-mental-health-crisis-care-review. [accessed 31/10/16]. Fenton, Wayne S., Hoch, J., Herrell, J. and Mosher, L., 2002. Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness. Archives of General Psychiatry 59 (4): 357-364. Gale, N.K., Heath, G., Cameron, E., Rashid, S. and Redwood, S., 2013. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology, 13(1), p.117. Hobbs, M., 1984. Crisis intervention in theory and practice: A selective review. British Journal of Medical Psychology 57(1): 23-34. HM Government, 2014. Mental Health Crisis Care Concordat. Improving outcomes for people experiencing mental health crisis. Available at: http://www.crisiscareconcordat.org.uk/wp-content/uploads/2014/04/36353_Mental_Health_Crisis_accessible.pdf [accessed 31/10/16]. Howard, L., Flach, C., Leese, M., Byford, S., Killaspy, H., Cole, L., Lawlor, C., Betts, J., Sharac, J., Cutting, P. and McNicholas, S., 2010. Effectiveness and cost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilot patient-preference randomised controlled trial. The British Journal of Psychiatry, 197(Supplement 53), s32-s40. Mohan, J. and Breeze, B., 2016. The logic of charity: great expectations in hard times. Palgrave Macmillan. Morton, J., 2009. Crisis resolution: A service response to mental distress. Practice: Social Work in Action, 21(3), 143-158. Paton F, Wright K, Ayre N, Dare C, Johnson S, Lloyd-Evans B, et al., 2016. Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technol Assess 2016; 20(3).Rhodes, P., & Giles, S. J., 2014. “Risky Business”: a critical analysis of the role of crisis resolution and home treatment teams. Journal of Mental Health,23(3), 130-134. Salamon, L.M., 1987. Of Market Failure, Voluntary Failure, and Third-Party Government: Toward a Theory of Government-Nonprofit Relations in the Modern Welfare State, Non-profit and Voluntary Sector Quarterly, 16(1-2) 29-49. Wheeler, C., Lloyd-Evans, B., Churchard, A., Fitzgerald, C., Fullarton, K., Mosse, L., and Johnson, S., 2015. Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review. BMC psychiatry, 15(1), 74 – 8.

Lay abstract: This study sets out to understand what the voluntary sector provides for people in a mental health crisis and how this fits with crisis support provided by the NHS and Local Authority. Research and national reports have shown that access to the right kind of support at the right time for people in a mental health crisis can be a problem. Some people, also, avoid seeking help because of fears related to hospital admission or poor treatment. As a result, the voluntary sector has, for many years, been providing support for people in a mental health crisis. This ranges from helplines, peer support, befriending or crisis houses, which provide an alternative to inpatient admission. Voluntary sector support is highly valued because it is informal, focuses on social context and builds relationships with the person in crisis. How widely available these different types of crisis support are, what they provide and how they fit with the crisis services offered by the NHS or Local Authority is not well understood. Much of the research used to inform policy and practice has investigated mental health crisis support provided by the NHS. There is, therefore, a gap in our knowledge about the contribution the voluntary sector can make and how the NHS and Local Authorities can and should be working with this sector to ensure that people in a mental health crisis get the right kind of support when they need it. The aims of this research are to: (a) investigate the range of crisis support offered by the voluntary sector in England; (b) explore stakeholder views of the relative strengths and weaknesses of different types of voluntary sector services and (c) recommend what needs to happen for NHS and Local Authority crisis services to work with voluntary sector services better. The study has four elements; (1) identifying voluntary sector organisations across England to identify what they are offering and to who; (2) mapping what voluntary sector organisations are being commissioned and what they are providing in two regions, and using this to identify four case study areas; (3) to build up a detailed picture of the different voluntary sector support and how they are working in practice at a local level and with the NHS and Local Authority services in each case study area and; (4) to understand the experience of crisis care from the perspective of ten service users in each case study area. We will use different methods to collect the data including interviewing national experts in this field, such as leading charities and service user organisations, to gather views on how well different voluntary sector approaches to crisis support are working. In the four case study areas we will gather data through interviews with commissioners, mental health professionals, voluntary sector staff and focus groups with service users and carers, look at key reports and use a questionnaire to gather views on the quality of mental health crisis care and outcomes for service users. This will enable us to understand the contribution that the voluntary sector is making to mental health crisis care and how it could be strengthened. The research team involves service users with experience of a mental health crisis and academics specialising in mental health and the voluntary sector. Before we start, ethical approval will be needed to guarantee that the research is properly conducted and information about people taking part is treated confidentiality. The findings from the study will be widely disseminated to inform mental health policy and practice, with the aim of improving mental health crisis care in England. We will produce guidance on how the NHS and Local Authorities can work effectively with voluntary sector organisations to improve mental health crisis care in England. This will benefit people experiencing a mental health crisis, their families and carers.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: MENTAL HEALTH