Introduction
The provision of intensive support and treatment at home, for people with acute mental disorders, who would otherwise require hospitalisation, stands out as one of the most significant developments in mental health policy in Ireland over the past several decades. Various and sometimes confusing terms have been employed to describe the acute home treatment approach: for the present purpose, we have opted for the term home-based treatment (HBT), as used in the 2006 Vision for Change document [Department of Health and Children (DoHC), 2006].
Pioneers of the home treatment model in Australia and the United Kingdom identified key elements to its success, including that HBT teams have a gate-keeping role in assessing all those at risk of an inpatient admission (Hoult & Reynolds, Reference Hoult and Reynolds1984; Dean & Gadd, Reference Dean and Gadd1990; Hoult, Reference Hoult1999; Smyth & Hoult, Reference Smyth and Hoult2000). Among other core activities, a role in facilitating early discharge from inpatient care and the availability of HBT team members to carry out frequent domiciliary visits were highlighted. This latter feature was regarded as important in that it enabled staff to administer medications directly while also actively addressing family and other psychosocial stressors contributing to the crisis presentation.
Advantages of HBT over traditional inpatient care were felt to include the lessening of stigma, as a consequence of avoiding hospitalisation, as well as the demystification of the treatment process, as patients, families and carers could witness the activities of clinical staff and participate as allies in the therapeutic process throughout the episode of illness (Smyth & Hoult, Reference Smyth and Hoult2000).
An important distinction from assertive community treatment teams, as originally established in the United States in the 1970s and the more recent innovation of early intervention programmes for psychosis, was that HBT teams aim to disengage when the acute mental health crisis is resolved (Stein & Test, Reference Stein and Test1980).
A number of studies evaluating the impact of HBT have found that it reduces inpatient hospital admissions, enables early discharge from inpatient beds, increases patient satisfaction and engagement with mental health services, impacts positively on staff and is also cost effective (Hoult, Reference Hoult1999; Johnson et al. Reference Johnson2005; Glover et al. Reference Glover, Arts and Babu2006; Jethwa et al. Reference Jacobs and Barrenho2007; McCrone et al. Reference McCrone, Johnson, Nolan, Pilling, Sandor, Hoult, McKenzie, Thompson and Bebbington2009; Nelson et al. Reference Nelson, Johnson and Bebbington2009; Sjolie et al. Reference Sjolie, Karlsson and Kim2010; Barker et al. Reference Barker, Taylor, Kader, Stewart and Le Fevre2011; Hubbeling & Bertram, Reference Hubbeling and Bertram2012, Reference Hubbeling and Bertram2014; Carpenter et al. Reference Carpenter, Falkenburg, White and Tracy2013; Johnson, Reference Johnson, Nolan, Pilling, Sandor, Hoult, McKenzie, White, Thompson and Bebbington2013; Joint Commissioning Panel for Mental Health, 2013; Murphy et al. Reference Murphy, Irving, Adams and Waqar2015; Paton et al. Reference Paton, Wright, Ayre, Dare, Johnson, Lloyd-Evans, Simpson, Webber and Meader2016).
Notwithstanding its impact on policy and practice in several western countries, the HBT model has been beset by controversy. Proponents and detractors, from the outset, disputed a range of issues, notably the uncertainty surrounding the therapeutic ingredient of HBT and whether “24/7” availability of HBT teams is essential to its success. It has also been claimed that negative consequences arise from HBT services, such those of service fragmentation, diversion of resources from patients with enduring mental illness, excessive carer burden, overuse of pharmacotherapy and burnout among HBT team members (Davies & Taylor, Reference Davies and Taylor2010; Tyrer et al. Reference Tyrer, Gordon, Nourmand, Lawrence, Curran, Southgate, Oruganti, Tyler, Tottle, North, Kulinskaya, Kaleekal and Morgan2010; Rhodes & Giles, Reference Rhodes and Giles2014; Menon et al. Reference Menon, Flannigan, Tacchi and Johnston2015).
An analysis of nationwide admission data from the United Kingdom failed to find an association between Crisis Resolution and Home Treatment (CRHT) Team implementation and inpatient bed use (Jacobs & Barrenho, Reference Jethwa, Galappathie and Hewson2011). Nonetheless, a recent Cochrane Collaboration systematic review concluded that home-based crisis intervention can be an effective alternative to hospital admission (Murphy et al. Reference Murphy, Irving, Adams and Waqar2015).
HBT and mental health policy
Home treatment has had a considerable influence on mental health policy in Ireland and in Northern Ireland (NI). The 2006 Vision for Change (DoHC, 2006) document recommended that HBT teams be made available in each community mental health catchment area in Ireland. In NI, following the Bamford Review reports (2005, 2007), the subsequent Bamford Action Plan 2012–2015 (Department of Health, Social Services, and Public Safety, 2014) and the recent report Building on Progress (Crisp et al. Reference Crisp, Nicholson and Smith2016) both prioritised the development of CRHT teams in response to ongoing evidence of inadequate availability of alternatives to acute inpatient admission.
Recent concerns have been expressed in the UK literature that HBT may be associated with increased suicidal risk, increasing frequency of involuntary admissions to inpatient units (Hubbeling & Bertram, Reference Hubbeling and Bertram2012; Carpenter et al. Reference Carpenter, Falkenburg, White and Tracy2013; Hunt et al. Reference Hunt, Rahman, While, Windfuhr, Shaw, Appleby and Kapur2014), and high home treatment readmission rates (National Audit Office, 2007; Lunawat & Karale, Reference Lunawat and Karale2014). These concerns appear to have contributed to a shift in mental health policy in parts of the United Kingdom when the 2002 decision to mandate CRHT services in England was reversed, following a change in government in 2010 (Lloyd-Evans et al. Reference Lloyd-Evans, Paterson, Onyett, Brown, Istead, Gray, Henderson and Johnson2017).
An acknowledged barrier to evaluation and implementation of the HBT model has been the wide variability among HBT teams in terms of their service structures, objectives, resources and outcomes, both within and between jurisdictions (National Audit Office, 2007; Healthcare Commission, 2008; Lloyd-Evans et al. Reference Lloyd-Evans, Paterson, Onyett, Brown, Istead, Gray, Henderson and Johnson2017). Recognition of this difficulty has prompted the development of standard criteria for the resourcing and operation of crisis and home treatment services, with evidence of programme fidelity required as a necessary condition for formal accreditation (Home Treatment Accreditation Scheme, 2015; Lloyd-Evans et al. Reference Lloyd-Evans, Paterson, Onyett, Brown, Istead, Gray, Henderson and Johnson2017).
Potential advantages of standardisation are that cross-national evaluation is facilitated through improved comparability between different services and that existing or newly established HBT teams are better able to access the supports and resources necessary for optimal functioning. Recently, a 39-item Crisis Resolution Team (CRT) Fidelity Scale has been developed as a tool to facilitate service planners and managers in defining the CRT model while also providing benchmarking data against which an individual team’s fidelity to the model can be assessed. The authors acknowledge, however, the need to explore the feasibility and utility of this measure in non-UK contexts (Lloyd-Evans et al. Reference Lloyd-Evans, Bond, Ruud, Ivaneka, Gray, Osborn, Nolan, Henderson, Mason, Goater, Kelly, Ambler, Morant, Onyett, Lamb, Fahmy, Brown, Paterson, Sweeney, Hindle, Fullarton, Frerichs and Johnson2016, Reference Lloyd-Evans, Paterson, Onyett, Brown, Istead, Gray, Henderson and Johnson2017).
HBT service development in Ireland
The first home treatment service project for acute mental disorders in Ireland was established in South West Dublin as the Clondalkin Project in 1989, by Dr Ian Daly and colleagues (Bowe et al. Reference Bowe, Devitt and Kelly2011). This initiative was followed by the introduction of HBT teams in the Cavan Monaghan area under the leadership of Dr John Owens in 1998, in West Clare by Dr Maire McLoughlin in 2002, in Ballyfermot and Meath in 2003, in North Kildare by Dr Pat Gibbons in 2004 and in Belfast in 2005. Subsequently, home treatment service implementation in Ireland and NI, supported by national mental health policy documents in both jurisdictions, has expanded rapidly, particularly in urban settings.
While outcome data is available from only a limited number of services, the existing Irish literature suggests that the impact of home treatment services has been generally positive. Reported findings, from both the Irish and Northern Irish jurisdictions, are consistent in suggesting that HBT teams have facilitated reduced admission and readmission rates, reduced service costs and increased clinical effectiveness. Importantly, there is Irish research suggesting that HBT service provision is associated with high levels of patient, carer and GP satisfaction, and reduced carer burden (North Eastern Health Board, 2001; Bannon & McDonald, Reference Bannon and McDonald2003; Kennedy, Reference Kennedy2003; McCauley et al. Reference McCauley, Bergin, Bannon and Russell2003, Reference McCauley, Rooney, Clarke and Carey2005; McLoughlin et al. Reference McLoughlin, Abba-Aji and Omoseni2005; Gibbons & Cocoman, Reference Gibbons and Cocoman2006; Conboy-Browne et al. Reference Conboy-Browne, McCann and Steemers2010; Dixit et al. 2010; Connolly, Reference Connolly2012; Gibbons et al. Reference Gibbons, Lee, Parkes and Meaney2012; Iqbal et al. Reference Iqbal, Nkire, Nwachukwu, Young and Russell2012; Nwachukwu et al. Reference Nwachukwu, Nkire and Russell2014; Morrow et al. Reference Morrow, McGlennon and McDonnell2016). Synergies have also been described as a consequence of Irish HBT services being delivered in conjunction with other interventions within the broad spectrum of modern community mental health care, such as primary care liaison and early intervention in psychosis (Wright & Russell, Reference Wright and Russell2007; Nkire et al. Reference Nkire, Sardinha, Nwosu, McDonough, De Coteau, Duffy, John, Waddington and Russell2015).
In evaluating the impact of health services, including mental health services, context is an important but frequently overlooked consideration and services that succeed or fail in one jurisdiction may not do so in another (Moore et al. Reference Moore, Audrey, Barker, Bond, Bonell, Hardeman, Moore, O’Cathain, Tinati, Wight and Baird2015). Context is recognised as particularly salient in the delivery of complex interventions, such as HBT, in which multiple and interacting components are involved (Thornicroft et al. Reference Thornicroft, Alem, Antunes Dos Santos, Barley, Drake, Gregorio, Hanlon, Ito, Latimer, Law, Mari, McGeorge, Padmavati, Razzouk, Semrau, Setoya, Thara and Wondimagegn2010). The relative paucity of indigenous Irish research, much of which has not been published in indexed journals, may increase the reliance on evidence from mainland United Kingdom (Semrau et al. Reference Semrau, Barley, Law and Thornicroft2011) even though Irish community mental health needs, socio-cultural environment and service components, may not be comparable.
At present, there is no identifiable directory or network of HBT services in Ireland and no central repository of information that could usefully inform model specification while facilitating comprehensive evaluation and service planning. The Irish research literature is largely confined to evaluations of individual HBT programme activities and these typically fail to reference evidence from similar services in other parts of the country. Moreover, to date, there has been no attempt to compile the existing published research or to present a composite profile of the state of development of the HBT model in Ireland.
There is also a suggestion that the enthusiasm for the HBT model in mental health service direction, particularly in the Republic of Ireland (ROI), may have waned. Recent priorities include developing national clinical programmes, with in some instances, an orientation towards general hospital emergency departments as a primary locus of care (National Clinical Programme, 2014).
Against this background, we carried out an online survey of HBT service provision on the island of Ireland. We presented preliminary results at the joint College of Psychiatrists of Ireland/Royal College of Psychiatrists in Northern Ireland Winter Meeting in November 2016. Our goal was to stimulate networking and collaboration among stakeholders involved in delivering HBT services, while also identifying the challenges of defining the HBT model and opportunities for its future development.
Aims
a) To complete a cross-sectional survey on the island of Ireland in order to determine the geographic distribution as well as the structure, function and staffing of home treatment teams for acute mental disorders.
b) To elicit consultant psychiatrist perceptions of the effectiveness of home treatment and to identify perceived barriers to its implementation.
Methodology
Materials
A Survey Monkey® questionnaire was developed, with the content informed both by relevant literature and the authors’ experience in the area. The survey comprised an introductory section, briefly outlining the context and aims of the study, followed by 28 questions of different formats, qualitative and quantitative, related to the structure, process and outcomes of home treatment teams as well as eliciting opinions on the advantages and disadvantages of home treatment.
Informants and procedure
The initiative was supported and facilitated by the College of Psychiatrists of Ireland (CPI) in collaboration with the Royal College of Psychiatrists in Northern Ireland (RCPsych in NI) in advance of a jointly-sponsored Winter Meeting in November 2016.
All Clinical Directors listed by the CPI (n=26) and by the RCPsych in NI (n=5) were identified and the survey was disseminated by email. Following a limited initial response, the survey was forwarded to the Executive Clinical Directors (ECDs) of the 16 Adult Community Mental Health Services listed by the CPI. Subsequently, in an effort to further increase the response rate, the authors made email and/or telephone contact with individual consultant psychiatrists identified by ECDs as clinical leads of HBT teams in their respective catchment areas.
Data analysis
Survey data was analysed using Survey Monkey’s descriptive package. Quantitative data was tabulated whereas qualitative data, arising from all verbatim responses to open questions, was collated according to their thematic content as identified by consensus following discussion among the authors.
Results
In total, 30 completed surveys were received (26 from the ROI and four from NI). This gives an overall response rate of 71.4%. All 16 adult mental health services in the ROI responded. Of these, six services (31%) reported that home treatment teams dedicated to the management of acute mental disorders had not been established. Respondents reporting the absence of HBT services represented rural and urban areas along the western seaboard, parts of the midlands and the south-east. Four of the five trusts in NI responded, all of which reported having functioning CRHT teams.
Out of 16, 11 (68%) services in the ROI responded that they had at least one HBT team which the majority (12/20, 60%) described as “Home-Based Treatment” while four respondents used the term ‘Home Care Team’.
HBT service commencement
The earliest reported HBT team in Ireland was set up in 1989 in Clondalkin, in west Dublin followed, after a gap of several years by teams in Monaghan in 1998 and Cavan in 2000. From the mid-2000s, the number of HBT services established has increased rapidly, as illustrated in a cumulative format in Fig. 1.
Fig. 1 Cumulative increase in home-based treatment (HBT) teams from 1989 to 2016.
Rationale for setting up home treatment services
When setting up their HBT teams, 11 of 21 (52%) services had referred to published home treatment guidelines. Respondents ranked clinical need as the most important impetus, followed by national policy directives and the reported experience of peer services in the UK and Ireland. A minority cited the impetus of increased availability of funding and the need for HBT services as a response to inpatient bed reduction following hospital or inpatient unit closures.
For 17/21 (81%) of respondents, the primary function of HBT was to provide an alternative to inpatient admission while 2/21 (9.5%) saw HBT’s primary function as enhancement of support following inpatient discharge.
Hours of service
All four NI trusts reported that their CRHT teams operated on a 24- h basis, 7 days per week. In contrast, none of the mental health catchments in the ROI reported 24-h HBT service availability, but 14/17 (82%) described the provision of a 7-day HBT service, ranging from 8 to 12 h per day (mean=9.4 h).
Staffing
HBT nursing staff-to-population ratios across the country ranged from 1 HBT nurse/10 000 population served to 1/31 000 population, with one service reporting a ratio of 1/50 000 attributed to staff shortages (mean was 1 Community Mental Health Nurse per 16 614 population, median: 1 per 15 000 population).
Nursing staff were assigned exclusively to the HBT service in 18/21 (85%) of responders. All HBT teams had nursing and medical staff working on the teams. Social work and Occupational Therapy services were available in 12/21 (57%) while 9/21 (43%) had access to clinical psychology, 5/21 (24%) to psychotherapy (including family therapy), 4/21 (19%) to peer support workers, 3/21 (14%) to addiction support and 2/21 (9.5%) to community support worker input. One service reported a mental health pharmacist available to the team.
Operating procedures
Eleven out of 20 services reported that they had formal criteria for admission to home treatment. The majority of HBT admission assessments, 13/20 (65%), were carried out jointly by medical and nursing staff. A gate-keeping role on the part of HBT teams (defined as having a significant role in deciding who should be offered an inpatient admission) was reported by 14/20 (70%) of respondents.
Out of 21, 20 (95%) HBT teams reported that formal clinical review meetings took place involving a consultant psychiatrist, with a frequency of once weekly in 11/21 (52%) services while 5/21 (24%) reported twice weekly reviews. One service reported formal clinical reviews three times a week and one service reported that four formal reviews were carried out each week. Two services reported that the frequency was flexible, depending on need.
Out of 21, 13 (62%) services reported that staff had received training in HBT service delivery and had a programme of continuing professional training for HBT staff.
Data collection and outcome measurement
A clear majority of services (18/20, 90%) reported that they routinely collect data on their HBT activities and document this information while 17/20 (85%) conduct audits of their activities. Five of 16 services (31%) confirmed that they had published data about their activities or experience with HBT.
Out of 20, 11 (55%) respondents reported that their HBT teams do not use routine outcome measures. Those that do, employed the following: carer/patient satisfaction scales (6/9, 66%), social and occupational functional scales (2/9, 22%) and clinical outcomes measures (22%). Other standardised instruments mentioned included the Camberwell Assessment of Need and Clinical Global Impression scales. None of the respondents reported routinely using quality of life scales.
Perceived advantages and disadvantages of HBT
In response to a question on the outcomes of HBT since its introduction, all respondents reported that their HBT services resulted in enhanced patient/carer experience. Out of 16, 14 (87.5%) stated that HBT was cost-effective, whereas 15 of 19 (79%) expressed the opinion that HBT decreased admissions to inpatient care.
Free-text responses to an open question on the perceived benefits of HBT are listed under the headings of identified themes, in Tables 1 and 2. Regarding the perceived advantages of HBT, qualitative analysis revealed three prominent themes.
Table 1 Advantages of home-based treatment (HBT)
Table 2 Disadvantages of home-based treatment
CMHT, Community Mental Health Team; HTT, home treatment team.
Almost all respondents reported a perception of enhanced patient/carer experience while improved efficiency in the use of inpatient resources and heightened professional reward / satisfaction arising from delivering the HBT service also emerged. Regarding the perception of enhanced patient/carer experience, responses such as ‘better public profile locally, reduced stigma, enhanced engagement’ were typical as well as increased option and choice for patients and their families. Perceptions of staff benefits were reflected in such responses as ‘upskilling of staff, more multidisciplinary involvement’ and ‘high staff professional rewards’ with a reduction in staff attrition. The benefits of a multidisciplinary approach to care were also highlighted.
In response to a similar question on perceived disadvantages of the HBT model, the predominant theme that emerged was the potential for a negative impact on broader service provision in terms of fragmentation, disruption of continuity of care, communication difficulties and tensions between HBT teams and other service components. These issues were reflected in responses such as: ‘Raises expectations on community mental health teams – patients expecting the same level of support from Community Mental Health Teams’ as well as a number of comments about a perception of increased risk in home treatment.
A minor theme emerged of perceived resistance to the HBT model. This was attributed in part to professionals but in part, also, to established patient/carer expectations.
Perceived barriers to HBT service delivery
In a separate question on perceived barriers to HBT service delivery, the most important barriers identified were lack of staff training, inadequate staff numbers and a lack of management commitment.
Other barriers cited included staff shortages, difficulties recruiting other multidisciplinary team (MDT) staff, financial considerations, resistance to changes in practice, risk management issues, unrealistic expectations by patients and staff, not having a robust gate-keeping role and increasing demand for the service due to deficiencies in other areas of the community team.
Reasons for the absence of HBT services
In response to a question addressed to services that had not set up HBT teams regarding the reasons behind this decision, two categories of response emerged from free-text responses, as outlined in Table 3 (above). Resourcing issues related to staffing and funding were highlighted as well as the allocation of staff according to more traditional service priorities. A few respondents raised concerns over the effectiveness of the home treatment model itself.
Table 3 Perceived reasons for the absence of home-based treatment (HBT) services
CMHT, Community Mental Health Team; MDT, multidisciplinary team.
Discussion
Main findings
This is the first published description of the status of HBT services across the island of Ireland and the first attempt to capture the existing Irish literature in a single document. Our survey findings are generally consistent with those of a recent study that targeted CRHT managers in the United Kingdom (Lloyd-Evans et al. Reference Lloyd-Evans, Paterson, Onyett, Brown, Istead, Gray, Henderson and Johnson2017) as well as evidence from Norwegian evaluative research (Hasselberg et al. Reference Hasselberg, Grawe, Johnson and Ruud2011; Karlsson et al. Reference Karlsson, Borg, Eklund and Kim2011) which found a high degree of variability in the manner in which individual teams operated and an overall lack of progress in implementation of national mental health policy with respect to standards and resourcing.
We found that the geographic spread of HBT services across the island of Ireland was patchy with an aggregation of teams in certain urban and rural areas, while large swathes of the country remain without any HBT service provision. Closer examination of this geographic distribution, considering the reported dates of commencement of HBT teams, suggests that for the longer established HBT services, the main impetus was provided by psychiatrist leaders who championed the model in their own catchments. The influence of mental health policy, however, is apparent in the development of HBT teams that were set up more recently. Of 17 currently operating HBT teams in the ROI, 12 commenced in the period following publication of the Vision for Change (2006) document.
Despite evident resource limitations, an important finding from our study is that the majority of services with HBT teams reported that their activities, structures and processes included several of the key elements described in the HBT model, namely: multidisciplinary initial assessments and formal admission criteria, formal structures for individual care planning, a role in gate-keeping potential inpatient admissions, staff training and audit of clinical activities. In this respect, it appears that the extent to which Irish HBT teams are meeting recognised fidelity criteria compares favourably with other jurisdictions. Moreover, the overwhelming majority of our respondents, from services who had established HBT teams, viewed the HBT role as successful in terms of providing improved quality of care to patients and carers as well as contributing to a more efficient use of scarce inpatient resources.
Are 24-h HBT services necessary?
A striking difference between the provision of home treatment services in NI and the ROI is that each of the four responding NI trusts reported that their CRHT services operated on a 24/7 basis, whereas no HBT team in the ROI provides 24-h service. Despite this, it is clear that the great majority of ROI respondents regarded their HBT services as cost-effective. This prompts the question of whether or not 24-h HBT staff availability is a necessary component, given the obvious cost implications.
As long as the therapeutic ingredients within the HBT model remain uncertain, it follows that no single element in the delivery of HBT can be regarded as essential (Wheeler et al. Reference Wheeler, Lloyd-Evans, Churchard, Fitzgerald, Fullarton, Mosse, Paterson, Galli Zugaro and Johnson2015). In an Irish context, arguably, 24-h staffing may not be key to the success of HBT services, as long as structures and processes are in place to ensure effective communication, continuity of care and integration with other acute service components. However, further research is needed before firm conclusions can be drawn in this regard and 24-h staffing could be justified in terms of cost and perhaps considered essential to the success of HBT teams serving larger catchment areas in Irish cities.
HBT service provision and inpatient admission rates
It is of interest that when the results of survey responses from the ROI are juxtaposed with national psychiatric inpatient admission statistics, evidence emerges that HBT teams are present in four of the five Irish counties with the lowest inpatient admission rates but within none of the five counties with the highest admission rates (Daly & Craig, Reference Daly and Craig2015). Clearly, a causal relationship between the operation of HBT teams and lower inpatient admission rates cannot be inferred and further research, both in urban and rural areas, is required to comprehensively address the question of the overall impact of HBT on hospital admission rates in an Irish context.
It may be the case that in some areas, the establishment of HBT services in Ireland has been a consequence rather than a cause of lower admission rates. Also, some services may have set up HBT teams using resources, particularly in mental health nursing, accrued from previous deinstitutionalisation of long-stay settings or simply as a result of the benefits of an historically higher budgetary allocation.
It would seem particularly useful to explore the phenomenon whereby Irish mental health services which may have the greatest potential for improved efficiency, through the introduction of HBT teams, appear least likely to have done so. The scope of the present study did not extend to an exploration of a possible association between the per capita funding of individual services and the establishment of HBT teams and this represents one outstanding question to be addressed.
In light of the recognised historic underfunding of Irish mental health services, it is not surprising that our survey respondents cited resource limitations in response to a question regarding the perceived barriers to HBT service provision. However, some respondents also reported that they were influenced by awareness of reports of negative findings from evaluations of HBT services. This raises the possibility that these respondents may have been influenced by published reports from the United Kingdom and it highlights the need, not only for well-conducted Irish outcome studies, but also for improved communication of existing Irish research and concerted efforts to share clinical experience from both Irish jurisdictions.
Implications for mental health policy
An important distinction between the Vision for Change (2006) and The NHS Plan (2000)/The Mental Health Policy Implementation Guide (2001) (Department of Health 2000, 2001) as well as the Bamford Review (2005) mental health policy documents is that the latter mandated home treatment services whereas the remit of Vision, frequently criticised, was limited to recommendations.
As a consequence of UK mental health policies, HBT teams were established in every service area in England and Wales and NI but this has not occurred in the ROI. In other respects, however, it would appear that the mandatory element has been no more successful in the United Kingdom than in Ireland in ensuring that sufficient resources have been allocated to HBT teams. In both jurisdictions, psychiatrists and mental health nurses are the only clinical professions represented consistently and there is limited involvement of allied health professions.
Limitations
The results of this descriptive cross-sectional survey are subject to the caveat that they are based solely on participants’ self-report. The study is also limited by its overall response rate of 71%, although all executive clinical directors in the ROI and four of five NI health and social care trusts responded.
Insofar as many of our respondents were consultant psychiatrist service directors, we cannot ascertain the extent to which they were personally familiar with the day-to-day operation of HBT teams. The views of mental health nurses or other HBT MDT members are not reflected and the absence of the patient and family perspective is an obvious limitation.
The methodology also failed to capture and identify all HBT teams in the country as there were no responses from a minority of HBT teams which we knew to exist. Finally, the questions in the survey were necessarily limited in scope and number in order to facilitate timely responses. For example, questions on the content of care and how it is delivered could have been included. Similarly, our questionnaire did not seek information on the extent to which MDT staff were dedicated exclusively to the HBT role. Also, while we elicited information on the ratio of nursing staff/population, we did not seek information on total numbers of HBT staff per population, information which would have facilitated comparison across jurisdictions. Other service level information, related to patient profiles, length of stay and frequency of contacts could also have been elicited.
Conclusions and recommendations
Our survey findings reveal that the number of home treatment teams serving people with acute mental disorders has grown considerably on the island of Ireland. This development however, while facilitated in part by mental health policy, has been limited in geographic scope, inconsistent and notably lacking in national coordination. As a result, many parts of the country have no HBT services while in common with similar services that exist in the United Kingdom and other jurisdictions, Irish HBT teams fall short of the standards and resource allocation that have been agreed by expert consensus.
Nonetheless, the responses of service providers suggest that clinical practitioners who have implemented home treatment are convinced of its effectiveness and perceive that, as a consequence of their activities, patient clinical outcomes and consumer satisfaction levels are enhanced. In this regard, it may be that existing hybrid or variant models of home treatment are viable and effective in an Irish context and future Irish research could provide the evidence base to resolve the enduring questions surrounding the importance of fidelity to programmatic criteria agreed in other jurisdictions.
With regard to the future viability and indeed the survival of the HBT approach to service provision for people with acute mental disorders, there are signs that the model may be less favoured in Ireland at present than previously. Irish clinical innovators who championed the model have largely departed the field, while demands for out-of-hours crisis mental health services located in general hospital emergency departments appear to have largely replaced the voices calling for improved acute community services. In addition, the identified priorities of recently articulated national clinical programmes appear to lie in areas of perceived specialist need, as compared with the broader response to acute disorders that HBT offers (National Clinical Programme for Mental Health, 2014).
Therefore, in the current mental health policy and service planning environment at a national level, it may be that a grass-roots initiative is required on the part of HBT service providers, in collaboration with those users and carers who have experienced the benefits of HBT interventions, in order to harness the collective energy and experience in the area, across the island of Ireland.
To this end and drawing from the results of the present survey, we recommend the establishment of an All-Ireland Forum for Home and Crisis Treatment Programmes which we envisage as serving the following functions: (a) to compile and share Irish HBT research evidence and clinical experience thus far, (b) to define the HBT model and establish staffing and operational criteria for HBT teams in an Irish context, (c) to facilitate the evaluation of existing and future HBT services using robust methodologies and (d) to advocate for continued provision of the resource elements that are evidence based and essential to favourable outcomes in the clinical and functional domains and optimal levels of service user and carer satisfaction.
Acknowledgements
The authors thank the support offered from the College of Psychiatrists of Ireland and in particular Grace Smyth as well as Nora McNairney in The Royal College of Psychiatrists in Northern Ireland. The authors also thank the input of Dr Rachael Cullivan, Dr Neta Chada, Dr Pat Gibbons and Dr Karen O’Connor as well as all the respondents and participants in the study.
Financial Support
This survey received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of Interest
Benjamin O’Keeffe has no conflict of interest to disclose. Vincent Russell has no conflict of interest to disclose.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this survey was not required by their local REC.
