What is good acute psychiatric care (and how would you know)?
Authors: Derek K. Tracy, Dina M. Phillips
Journal: World Psychiatry (2022)

There is an old joke told of a tourist asking for directions, only to be advised by a local: "Well, I would not start from here". We have the acute mental health services we have inherited. Asylums closed during the great era of deinstitutionalization, clunkily evolving into our current inpatient estates. Crisis teams were established (without any real evidence) to provide choice and less coercive treatment, but often seem to function solely for – in dreadful contemporary management-speak – "admission avoidance". As a thought experiment, if you were to start afresh, setting up services without the baggage of existing buildings and services, what would you create? And dream some more: your budget is limitless, and recruitment and retention of staff is not a problem. You would not build what we have now – but why not, and what would you replace it with? Would you have inpatient wards? Sure – better equipped, with finer facilities and more staff; but how many, and why, and what exactly would happen on them? Home treatment teams: not everyone wishes to be in hospital in a crisis, but which interventions should they provide? How creative might you get with new models of treatment, engaging social care, the third sector, and local communities? So, first we hit a wall of reality as we are reminded that we have budgets, staff shortages, and buildings in various levels of disrepair. We enter a world of opportunity costs: maintaining a ward might mean reducing a community service or hiring fewer occupational therapists. And then we hit an evidence wall. What are wards for, what do they do? Containment, safety, care? All of these surely, but perhaps the emphasis has been on the first two (and many people are unaware that much of the initial "locking of wards" was with intent to stop the public walking into space containing people at their most vulnerable, not the other way around). But does "containment" work? German data suggest that locked units do worse than open ones in terms of suicide1. Parallel challenges can be thrown at home treatment teams. The evidence supports them saving money (not a bad thing of itself) and reducing hospital admissions2, but their impact on safety and reducing coercive care is limited, and data on patient experience are modest3. One can ask what "effectiveness" means: are "preventing harm" and "avoiding admission" the limits of our vision and ambition for acute care? Evaluations have often emphasized these, as they are easier to measure. What might you alternatively explore (and how would you weigh that sunlight)? More short-term crisis-focused psychological interventions (which ones?); a more trauma-focused service philosophy; better working with housing and domestic violence teams? As a follow-on, we bet your answers will be very different depending upon whether you use, work in, manage, or commission services. In this issue of the journal, Johnson et al4 provide a comprehensive overview of the existing evidence in acute mental health care, and the gaps and opportunities for innovation. They argue convincingly that key steps are reducing coercion, addressing trauma, diversifying treatments and workforce, and making decision making and care truly collaborative. They rightly recognize and call-out the complex ethical realities of research with individuals often at their most vulnerable. We were particularly struck by their description of presentations at the emergency department. Who can fail to be struck by the frequent inadequacy of such environments, and high reported rates of prejudicial treatment of mental health crises? A second area that resonated loudly is the description of initiatives working with the police. These have grown out of concern that such crisis-interfaces can be common, but, without adequate training or resource, they risk actually causing harm. In the UK, this has recently been brought into sharp focus by public concern about a specific intervention – the Serenity Integrated Mentoring model – whose underpinning evidence base and the lack of clear service-user input into its design have been heavily criticized. We need to move beyond preoccupations with "avoiding admission", "bed numbers", and "length of stay". The first sets-up services that perceive inpatient care as failure; to the latter two, we are never sure what the "right" number is, and which person, upon being admitted to a ward, would ever inquire or care about a unit's average length of stay? We can hold a basket of all the agreed necessary parts: co-design and co-production; compassionate, thoughtful care; and a range of psychosocial and pharmacological interventions. The first of these is surely self-evident, yet inadequately truly practiced – if you work in acute care, ask those who use your service how engaged they feel in this process. The second is not rewarded by systems that prioritize "avoiding harm" over "doing good". Johnson et al note how the existing literature on inpatient care often highlights poor practice: this is important, but "good" is not the absence of "bad", and we need to do better at welcoming sunshine. The detail of the type and range of services and care remains, perhaps, the trickiest and least understood part. But therein is the opportunity for growing, testing, and evaluating models and outcomes. Why something works (or does not), which factors underpin this (the clinical issues, intervention, clinicians, or geography/environment), and what is transferable, especially to low- and middle-income countries. To us, there appear to be two major contemporary opportunities. First, we agree with Johnson et al on the need for better co-design and co-production of services, and research with those who use them. On Twitter, the hashtag #CrisisTeamFail has gained traction as individuals describe their poor experiences of care: this needs to be heard, understood, and engaged with, not responded to in a defensive manner by professionals. There could be none more invested in improving services, knowing where the gaps are, and measuring what matters than users and their support networks. Everyone appreciates real-world budgets, but we must still be having thoughtful conversations about what we can nevertheless all do together with the resources that we have. The call from those using services is consistent. Clear routines and fostering of healthy habits, not days seemingly solely built around medication and meal times. More occupational therapy and meaningful activities, ensuring that these are a focus for staff engagement, managerially emphasized and supported above note-keeping and computer entries, and not disrupted or stopped by inanities such as missing batteries and lost pieces of equipment. People understand that home treatment teams operate shift-systems and staff turnover, but personalizing care to understand individuals' perspectives and concerns, including around home visits and possible illness-triggers, is not complex. Above all, respect and kindness, not least in the emergency department: the time has long-passed to hear prejudicial comments from professionals. Second, there is an international trend to more "integrated services". In the UK, a quiet but profound shift is occurring towards integrated care systems5 that join mental health, acute and community physical health, social care, and local resources with served populations. Johnson et al note the growth of innovations such as "crisis cafés" and "crisis houses", and correctly identify how voluntary sector services helpfully work in different ways to (the often monolithic) health care industry. There are many fertile opportunities for collaboration. True population-based research is needed: messy data sets outside the gold-standard randomized controlled trials – in other words, real people in their daily lives. We might not have chosen to start from where we currently are but, to mix our metaphors, the longest journey begins with a single step.