Crisis & Contingency Care Plans: An Evaluation of their Use in the Management of Mental Health Crisis
The Department of Health in England in the spring of 1991 introduced the Care Programme Approach (CPA) as a form of case management to improve the community care of people with severe mental illness in England . The Care Programme Approach is a national initiative that provides a framework for integrated and effective MH (MH) care for patients in the NHS . The Care Programme Approach incorporates a care planning system designed to ensure that patients receive a systematic assessment of their health and social needs and the development of a person-centred care plan to address these needs. The CPA intends to prompt professionals into taking a holistic approach that considers the patient as an individual and their life in general when assessing their needs.
Since the creation of the original CPA guidance in 1991, it has undergone two essential updates to improve its effectiveness and implementation. These updates include the publication of Effective Care Co-ordination in MH in October 1999, which sets out guidance on integrating care management and care programme approach . Also, C&C (Crisis & Contingency) planning became an integral aspect of the CPA process in this update . The most recent update ‘Refocusing the Care Programme Approach’ was published in the spring of 2008. This update highlights good practice and puts recovery at the heart of the person-centred approach . It also sets out how CPA is to be used effectively, including the requirement that care plans are regularly reviewed, and amendments made where necessary to ensure that it always meets the needs of the patient .
The CPA process now routinely expects patients to participate in a joined-up collaborative approach in planning their care, including C&C care planning. This joined-up collaborative approach to care planning, also referred to as Joint Crisis Planning (JCP) is intended to enable patient-centred care delivery . Collaboration is usually between the patient and his/her care coordinator. However, these care planning meetings may include the patient’s relatives or carers if the patient consents to it. Involvement of relatives or carers is usually necessary because during periods of crisis it may be difficult for patients to implement their crisis or contingency plans on their own and require the assistance of others to implement these crisis or contingency plans on their behalf.
It may be helpful here to first define crisis before outlining the requirements of a C&C plan and section 136 legislation.
Wales MH Policy Implementation Guidance on the Care Programme Approach for MH Service Users defines crisis as ‘the subjective experience of lack of control, helplessness and perceived lack of ability to cope that a person experiences when he/she faces a stressful event that extends beyond their current repertoire of coping mechanisms’ . Crisis plans are specific plans of action for implementation in the event of a crisis. Contingency plans are plans put in place to be used at short notice to prevent early warning signs of a crisis from escalating into a crisis . Patients often experience MH crises during out-of-hours necessitating the application of emergency interventions. For appropriate action to be taken during a crisis, anticipating the nature of the crisis and early warning signs is helpful . Crisis plans should set out the action to be taken, based upon previous experience .
C&C care plans are statements recorded in patients’ medical record demonstrating early warning signs of a crisis, and the personalised coping strategies to manage these early warning signs and prevent the crisis from escalating . Measures to prevent harm from coming to the patient should the crisis escalate, and the safety of the patient is at risk, are also recorded. Therefore, C&C plans should contain among other things early warning signs of an impending crisis and coping strategies to mitigate the crisis, contact details of support networks and the support available to manage and de-escalate the crisis and prevent the need for hospitalisation.
Section 136 legislation under the 1983 MHA refers to people identified as having MH needs within public places. This legislation provides the police with powers to remove a person identified as suffering MH issues from a public place to a place of safety if it is in the interest of the person or for the protection of others to do so . Such persons can clearly be deemed as being in the midst of a MH crisis where use of a C&C care plan would be highly relevant and early use could possibly have averted such a crisis.
There have been reservations in the effectiveness of the CPA in MH crisis care since its creation in the early 1990s despite its promises and intentions. Such ineffectiveness was first alluded to by Hogman as early as in 1992 when he wrote about his doubts in the ability of ‘community care’ policies in providing compassionate, safe support for severely distressed MH patients .
More recently, the Care Quality Commission (CQC) an independent regulator of health and adult social care in England published a report on MH crisis care in 2015 which suggested inadequate care for patients in the community especially during periods of MH crises . In the CQC report, they revealed up to 42% of patients experiencing MH crisis have difficulties accessing help at the time they need it and often do not get the right help . This CQC finding was also echoed by the House of Commons Home Affairs Committee eleventh session report on policing and MH where they acknowledged the limited availability of appropriate care to people in MH crisis, especially at night resulting in the police becoming the ‘de facto first aid response for people in a MH crisis’ .
Anecdotally, these views are often expressed by patients in MH crisis when they are detained by the police to places of safety. These patients or their relatives often report that they had no choice but to involve the police when experiencing a MH crisis. The lack of adequate crisis care in the community may partly explain the increasing number of patients in MH crisis detained by the police under section 136 of the MHA and brought to local places of safety. This increasing number of patients detained by the police under section 136 due to MH crises is highlighted by the database of patients detained under section 136 of the Mental Health Act (MHA) within a typical NHS MH Trust. A close examination of this database shows that a significant proportion of patients presented with repeated MH crises despite being well known to MH services. These patients often present with what appear to be similar issues during each crisis presentation. With such repeated MH crises and the associated increase in the number of patients in MH crisis detained by the police under section 136, it is difficult to disagree with the CQC’s assertion of failure or inadequate crisis care in the community.
There are multiple factors that contribute to inadequate community crisis care but the ineffectiveness of C&C care plan use is a significant contributor. The idea behind C&C care plans is that they will address issues presented by patients during MH crises and prevent a repeat of such crisis incidents.
Adequate management of patients in MH crises in the community is essential to limit the need for hospital admissions (whether voluntary or involuntary) and the consequent enormous cost of these admissions to the NHS. A lot has been mentioned over the media about the considerable pressure on public service finances in England of which the NHS is not exempt. The CQC in their 2015/2016 annual overview of the quality of health and adult social care in England described the situation as a challenging time for all health services including MH services as tight resources put the sector under significant financial pressure . It is an open secret that MH services have borne the brunt of the cut in NHS funding. MH services have continued to experience cuts in their funding in recent years. Available data from the King Fund show that around 40 per cent of MH trusts experienced reductions in income in 2013/14 and 2014/15 financial years . This reduction in income has had a negative impact on the number of available beds in hospitals or community resources within various MH services. Therefore, ineffective crisis management resulting in repeated MH crises and the detention of patients under the MHA will not only add to the existing financial pressures in the NHS but will also be very costly for allied services as well as patients and their family.
The following sections in this paper will describe the relevant findings from the literature review with regards to C&C planning and their effectiveness in managing patients experiencing MH crises. The aims and objectives of this study, as well as details of the study performed, will be described. This description will include the findings generated from this study and the suggested recommendations.
The following keywords were entered in Medline, PsycINFO, PubMed and The Cochrane Library as search criteria: crisis plans, contingency plans, mental health crisis care, care programme approach, Section 136 and police, Mental Health Act. These searches generated a relatively small amount of research relating to the use of patients’ C&C care plans in managing crisis. Hence, a further search in Google scholar was conducted using the same search terms in order to include non-databased and unpublished reports (grey literature) in the review. Google scholar search also yielded a paucity of information. Many of the available studies related to the topic appear to focus on highlighting the increasing trend in patients in MH crises and the increasing detention of these patients under the MHA confirming the findings within this study and the seriousness of the issue. Others have analysed the Care Programmed Approach and its implementation across the NHS, but studies analysing the effectiveness of using C&C care plans in managing crisis appear to be lacking.
Professor Thornicroft and his colleagues, in an attempt to understand the increasing trend of sectioning patients experiencing MH issues, undertook their CRIMSON study in 2010. In this study, they noted a similar increase in the number of patients with MH issues admitted on a compulsory basis to psychiatric hospitals in England and Wales per head of population . This increased number is thought to have occurred despite the patients having had CPAs with joint crisis planning (JCP) suggesting lack of effectiveness in JCPs. This contrasted from earlier studies carried out by Henderson and his colleagues in 2004, which suggested the effectiveness of JCPs . Thornicroft and his colleagues highlighted several explanations for their finding, which included crisis interventions plans often being generic and not personalised to patients. The crisis plans were of poor quality with no meaningful interventions to address an impending crisis. The available interventions on these crises and contingency care plans were often not implemented by MH professionals when managing patients in crisis .
The National Institute for Health and Care Excellence (NICE) produced a quality statement and standards for adult MH in 2011 to guide professionals involved in managing patients presenting with MH crises. This statement and standards which are in keeping with the Department of Health Care Programme Approach (CPA) directives and enshrined in my organisation’s CPA policy stipulates that every patient seen by MH services especially those experiencing MH crisis and therefore at risk of future crisis is expected to have a C&C care plan as part of their care planning process . This NICE guidance stipulates that C&C care plan should contain standard information such as early warning signs of a crisis and coping strategies to manage the crisis, named contact and support available to help prevent hospitalisation as well as information about 24-hour access to services . Other standard information to be included in the C&C plans are details of whether and the degree to which relatives or carers are involved in the care planning process, details of patients’ advance statements or decisions and where safety of the patient is at risks and hospitalisation required, where the patient would like to be admitted and the practical needs of the patient in the event of hospitalisation (e.g. childcare, care of other dependants, including pets). Despite this guidance, there continue to be problems in the management of patients experiencing MH crises as highlighted by the care quality commission. The CQC, in their recent report on the use of the MHA in 2018, revealed a year-on-year rise in the use of MHA since 2010. They put forward several suggestions to explain this increasing trend, including inadequate crisis care in the community highlighted as the main contributing factor .
The concerns around inadequate crisis care of community patients in MH crisis led to the birth of the MH Crisis Care Concordat in 2014. This MH Crisis Care Concordat is a national agreement between health services and agencies involved in the care and support of people experiencing MH crises in the community ensuring that these individuals get the needed help they require . Also, the MH Crisis Care Concordat highlights that individuals experiencing MH crisis have a crisis plan that effectively identifies targets and contingency plans that would be instrumental in preventing the need for admissions into hospitals and improve patient’s experience of the NHS .
Bearing in mind the issues highlighted in the sections above, an assumption can, therefore, be hypothesised that the increased frequency of MH crisis in community patients and the associated increased section 136 activity observed in these patients reflects their ineffective C&C care plans. A good understanding of the issues with C&C plans will, therefore, assist in addressing the increasing difficulty in managing patient’s MH crises in the community hence the importance of this study.
Aims and Objectives
The aim of this study was to evaluate the effectiveness of C&C care plans of patients within a typical MH Trust in managing their acute MH crisis as well as preventing recurrence of further MH crisis and or detention of these patients under sections of the MHA (1983). This study, therefore, intended to improve the effectiveness of C&C care plans in managing patients’ MH crisis.
The specific objectives of the study include:
- To examine the content and quality of existing C&C care plans of patients and ascertain if they were fit for purpose and meet the standards outlined in NICE 2011 guidance on managing patients presenting with MH crises.
- To determine whether patients’ existing C&C care plans are being referred to or considered in decision making during crisis assessment and management.
- To investigate the recurrent themes/issues that are associated with patients’ frequent presentation to MH services in crisis and detention under the MHA.
- To assess patients’ and/or relatives’ involvement in the formulation of C&C plans.
Methodology and Methods
The methodology utilised in this study is the evaluation research approach. This research approach provides researchers with the opportunity ‘to judge actions and activities in terms of values, criteria and standards’ while seeking to enhance effectiveness . Utilising evaluation research approach meant this study was able to identify ineffective practices relative to national standards in the use of C&C plans when managing patients in MH crises and hence make recommendations to modify these ineffective practices.
This study was retrospective and utilised secondary data generated from the document analysis of electronic patient records within an acute MH NHS Trust. This data generation method enabled the collection of comprehensive existing data without disrupting participants that were investigated in the study .
A cohort of working-age patients between the age of 18 and 69 with MH issues presenting to my organisation in crisis and detained under section 136 of the MHA between 1st March 2018 to 31st March 2018 was identified from the Trust’s section 136 database. A total number of 148 patients that met criteria for the study were identified and included in the study. Of these 148 patients, 122 of the patients were patients known to the Trust and had previous contacts with the Trust before their detention under section 136 during this study period. These 122 patients were the patients focused on during analysis of the collated results in order to address the objectives of this study as these patients were expected to have C&C plans before their detentions. The remaining 26 of the 148 patients were either new to the organisation or were out of area patients and as such had no C&C plans in their records before their detention in March 2018. A structured template (see appendix 2) was used to gather data via free text and targeted keyword searches from each patient’s case notes and correspondence on the Trust’s records system. Data extracted include socio-demographics of the patients; recurrent themes/issues associated with patients’ frequent MH crises; contents of the current C&C care plans and evidence of their use in decision making during crisis assessment and management; evidence of patients and or relatives involvement in crisis and care planning.
The data generated were analysed via text mining and simple MS Excel tables and charts. These processes enabled the data collected to be structured and summarised using categories and numerical descriptors such as frequency, and percentages. The tables and charts also allowed patterns within the structured data to be derived and inference or descriptive associations drawn about the represented population. These processes enabled sample data to be evaluated in comparison to set standards.
The data utilised in this study were anonymised and stored in a private computer that is password-protected and not accessible to the public. This process ensured that data utilised in the study were managed according to Data Protection Act (1998) to protect the identity and confidentiality of patients whose data were used in the study.
The methodology utilised in this study relied on the robustness of existing data, which was sometimes incomplete. Advantages of the approach were both financial and practical. The approach lends simplicity and ease to any future re-evaluation or study replication. The use of existing data enabled the investigation of distressed, vulnerable individuals during their period in crisis which would be ethically challenging with other approaches such as a mixed-methods approach which would require a direct interview of such vulnerable individuals. However direct interviews would have enabled the development of data-driven approaches that would enhance a deeper understanding of the processes underpinning section 136 and acute MH crises rather than relying on preconceived hypotheses [20,21,22].
This study was about service evaluation and the exploration of current practices and as such Trust ethical approval for this study was acquired from the clinical audit and service evaluation department. The study did not require ethical approval from Integrated Research Application System (IRAS); however, further ethics permission for this study was also granted by Middlesex research and ethics committee. Permission to access relevant records for patients utilised in this study was granted by the Trust clinical audit and service evaluation department.
Figure 1 Shows the age range of study participants
Shows the number male to female participants in the study
Shows the marital status of the study participants
Shows the employment status of the study participants
Shows number of previous section 136 detentions in study participants
Shows outcome of MHA assessment following detention under section 136 in study participants
shows participants’ previous contact with MH services; presence of care coordinator prior to participants’ detention; presence of C&C plans prior to detention; use of C&C plans during section 136 assessment and management
Shows the diagnosis of study participants
Shows contents of participants’ C&C plans in relation to expected NICE standards
This study aimed to offer a better understanding of the effectiveness of C&C care plans within my organisation in managing patients’ MH crises. This study, therefore, examined the quality of patients’ C&C plans and their implementation when patients present in MH crises and are detained under section 136 of the MHA.
This section highlights the overarching themes derived from this evaluation study and analysis, identifying the implications for improving services within my organisation.
The critical findings from this study are that C&C plans were not created for many patients following their contact with the organisation even when they presented in a MH crisis and had a care coordinator in place. In cases where C&C plans were created, the quality and contents of these plans did not meet national standards.
The number of patients detained under section 136 in one month suggests excessive use of section 136 by the police to manage people experiencing MH crises. This finding appears to suggest the failure of crisis management of patients experiencing MH crises and a lack of other support mechanisms leaving the police to deal with these patients. This result is in keeping with the suggestion made by CQC and the House of Commons in their reports . The implication of this in terms of cost to services involved in these detentions is high.
This study as illustrated in figure 6 differs from previous studies in the literature as it revealed personality disorders (53% of the patients) as the prevalent diagnosis compared to psychosis, which was suggested as the principal diagnosis previously in this patient group . However, it is worth mentioning here that patients with cluster B personality disorders tend to have psychosis as part of their experiences during a crisis and these psychotic experiences are often the primary precipitant of the crisis presentation.
The Outcome of Section 136 Assessments
This study showed that 60% of patients evaluated in the study did not require treatment in a hospital or meet the criteria for inpatient treatment; hence, they were discharged home following assessment while 19% met the criteria for formal hospitalisation and 21% met the criteria for voluntary hospitalisation. This result is consistent with a study by Zisman and his colleague in 2014, who noted that section 136 detentions accounted for just under one-fifth (19.2%) of all admissions . These outcomes of assessments suggest that most patients experiencing a MH crisis do not require hospitalisation. This result further suggests that adequate care plans, including C&C plans, could lead to early identification of crisis and earlier action possibly preventing the need for section 136 detentions or hospitalisation.
Number of Previous Section 136 Detentions
Sixty per cent of the patients in this study had repeated detentions under section 136 of the MHA during the one month of study. One of the patients examined in the study had as many as 25 repeated detentions. This finding is consistent with findings in the literature where the majority of those detained under Section 136 had previous contact with MH services . These contacts included previous MHA detentions. Zisman and his colleague in their 2014 study, found some individuals presenting up to five times during their study period of six months . These repeated section 136 detentions could, therefore, be seen as a failure of C&C planning process in managing MH crisis as these plans should prevent repeated crisis presentation or escalation of crisis to the point of detentions under the MHA.
Quality and Content of C&C Plans
Sixty-five per cent of the patients in this study had some form of C&C plans documented in their medical records, while 35% had no C&C plans in their records. In the 65% of patients who had a C&C plans, the quality and content of these C&C plans varied from patient to patient. However, none of the C&C plans was written up as stipulated by NICE or had all the expected standards. Each of the C&C plan had several of the expected standards missing in them. This study revealed that 56% of the patients had possible early warning signs of a crisis and their coping strategies recorded in their crisis plans. 52% of the patients in the study had support available to help prevent hospitalisation included in the crisis plans. Only one patient’s hospital preference (0.82%) was mentioned in her crisis plan. 21% of patients in the study had their practical needs in the event they rare admitted to the hospital mentioned in their crisis plan. Advance statements and/or advance decisions were only mentioned in one C&C plan (0.82). Relatives or carers were rarely involved in the formulation of crisis plans, with only 1.69% of patients in this study had such involvement.
Only 16% of patients in this study were involved in the formulation of their C&C plans. Twenty-two per cent of the crisis plans in this study had information about 24-hour access to services mentioned in them. In the remaining 78% of crisis plans, either there was no mention of available services or a nonspecific and often unclear generic statement appeared. Only 8% of the crisis plans in this study had names of contacts that can be contacted to support the patients in the event of a crisis. The 16% of patients identified as involved in the formulation of their care plans in this study was lower than that reported by the CQC in 2016 when they found evidence of patient involvement in care planning in 71% of records . This finding is surprising despite several published research suggesting that co-production of care plans and developing advance statements with patients can be an effective way for services to prevent the rising number of detentions under the MHA .
This study revealed that crisis plans which adhered to NICE standards were often constructed in a nonspecific generalised manner, lacking personalisation to the patients. These results were in keeping with the findings from the Thornicort et al. 2013 study and appeared to suggest that the completion of C&C plans is a tick box exercise with no meaningful interventions put in place to address patients’ needs or impending crisis . The CQC in their 2016 report also made similar observations that care plans did not take into account patients’ needs .
Use of C&C Plan in Decision Making Following 136 Assessment
This study revealed that in cases where there were C&C plans in place in the patients’ records these C&C plans were often not consulted during the patients’ section 136 assessments. In this study, only one patient (0.82%) had her C&C plan considered in deciding her management during her section 136 assessment and management. This finding is not surprising as the majority of C&C plans examined would have offered little guidance. This lack of use of C&C plans during section 136 MHA assessments, therefore, begs the question of the point of C&C plans. However, we know from research studies that co-production of C&C plans with patients especially where these crisis plans are completed correctly were helpful to patients during crisis presentation and can be an effective way for services to address the rising number of detentions under section 136 of the MHA .
This study did not identify any area of excellent practice with regards to the quality of real C&C plans or their use in managing patient’s MH crisis especially when patients present in MH crises and are detained under section 136 of the MHA. The recurrent theme identified by this study indicates a failure to provide plans for a large proportion of patients. In cases where plans were created, the contents did not follow the standard criteria outlined by NICE guidelines. Patients were rarely involved in formulating the plans and they were often generic and not personalised to patients’ needs. The C&C plans examined in this study can, therefore, be described as not fit for purpose and may have contributed to the observed increase in the recurrence of MH crises in patients and their detention under section 136.
Finally, professionals undertaking assessments of patients in MH crisis detained under section 136 did not refer to or consider patients’ C&C plans when deciding management plans for patients.
Organisations should ensure all clinicians making initial contact with patients are trained in creating C&C plans in line with recommended NICE guidance. Professionals undertaking MHA assessments should familiarise themselves with patients’ C&C plans and consult them in their decision making in order to best support patients.
Organisations should provide prompts at places of safety (where MHA assessment take place) to remind professionals undertaking section 136 assessments to consult patients’ existing C&C plans during such assessments.
Organisations should include the creation of C&C plans as an essential requirement for all clinicians making the first contact with patients, especially those presenting in crisis. This C&C plans should be included in the letters sent to patients and their general practitioner following such contacts.
Organisations should ensure all clinicians making initial contact with patients are trained in creating C&C plans in line with recommended NICE guidance.
Finally, organisations should review their MH C&C planning at regular intervals to ensure that it is ‘fit for purpose’.
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About the authors
Dr Abubakar Isaac-Momoh is a Consultant Psychiatrist for Older Adults at Kent and Medway Partnership Trust (KMPT).
Dr Juliet Agbowu completed her Higher Specialist Training at Kent and Medway Partnership Trust (KMPT) in August 2019. Dr Agbowu is currently a Consultant Psychiatrist at Oxleas NHS Foundation Trust.
Dr Mo Eyeoyibo is Clinical Director and Consultant Psychiatrist in Intellectual Disability at Kent and Medway Partnership Trust (KMPT).