1 Background

Mental health crisis is defined as “occurring when the level of distress and risk presented by a young person is not adequately supported or contained by the system that is in place for them.” [1] (p. 13). Although over half of mental health disorders arise during adolescence, and the greatest benefits of mental health interventions are attained when implemented as soon as possible after onset of symptoms [2], it is estimated that only 25% of children and young people with a diagnosable mental health disorder are receiving treatment in the UK [3]. With the lack of early support being accessed by young people experiencing adverse mental health, it is unsurprising that the number reaching crisis point is growing.

Unfortunately, in the UK, Child and Adolescent Mental Health Services (CAMHS) are not always able to meet the demand for their services, leading to long wait times for specialist mental health support, and ultimately leading to more young people reaching crisis point [4]. Possible ramifications of not addressing poor mental health in childhood and adolescence are the likelihood of mental disorders continuing into adulthood, impacting both mental and physical well-being, which could potentially limit opportunities to live a fulfilled life [5]. However, not only can poor mental health and mental health crisis have long-term consequences, but also severely damaging short-term effects, including suicidal ideation, self-harm, and currently one of the leading causes of death for children and young people in the UK, suicide [6].

In 2015, the Care Quality Commission’s report, Right here, right now [7], reviewed the quality and effectiveness of crisis services in the UK and found them to be insufficient, often leading those in crisis to attend A&E as they had nowhere else to go. Furthermore, when attending A&E in crisis, less than half of young people reported a positive experience [7], along with other crisis services, A&E was scrutinised for being “under-resourced, understaffed, and overstretched” [8]. As a result, crisis services have been at the forefront of the mental health service reform agenda in the England, with the call to improve crisis services evident in key health documents, including the Crisis Care Concordat [9], Future in Mind [3], and the Five Year Forward View for Mental Health [10].

The development of crisis mental health services continues to be at the forefront of policy in the UK and internationally [11]. Despite this current policy discourse, little is actually known about the current organisation of crisis services in the UK, or the experiences of those accessing them [12]. A recent systematic review explored the currently available evidence on the organisation, experiences, effectiveness, and aims of crisis services for children and young people [13]. The review demonstrated a wide range in crisis services available globally, with many having positive effects on those that utilise them, and established three categories of organisation of crisis services; triage/assessment-only; digitally mediated support approaches; and intervention approaches and models [13]. This research aims to contribute to the growing field of research conducted on crisis mental health services, to help fill gaps identified within the field.

The context of the current research is Greater Manchester, England, an area that has witnessed devolution of its health and social care budget, a process whereby power and funding is transferred from central to local government [14]. As a part of the devolution process, Greater Manchester has made a significant investment into mental health services for children and young people, with a newly created Crisis Care Pathway, to offer a solution to the calls for better crisis service provision across the 10 localities of the city-region.

In 2017, the Crisis Care Pathway was established in Greater Manchester, with the aim to improve the experiences of children and young people accessing crisis care services and avoid A&E admissions [1]. The pathway comprises six newly created and enhanced established services (see Table 1).

Table 1 Crisis care pathway services
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As part of the Crisis Care Pathway’s plan, these crisis services should work together, and with wider mental health services in the community, to support young people on their path to wellness. A key intention of the current study is to examine the extent to which this aspiration has been realised in practice.

Since the creation of the Crisis Care Pathway in 2017, these services have been slowly implemented across the 10 boroughs of Greater Manchester and have evolved according to need. The information provided in Table 1 is the most relevant and up to date description of services as they currently stand. Methods of effective and consistent data collection were not designed into the implementation of the Crisis Care Pathway, making it difficult for managers to evaluate the effectiveness of this new crisis service delivery system. However, funders and managers of the Crisis Care Pathway wanted to evaluate this new pathway, so that services can continue to improve for the benefit of the young people accessing them. They asked the University of Manchester to conduct a third-party study to investigate this for them. As there was no rigorous data that the team at the University of Manchester could access to evaluate the services, it was decided between NHS managers and the research team that a survey study would be conducted (between November 2022 and January 2023) with professionals working within crisis services in Greater Manchester, to compare their perspectives of crisis services with the original aims of the Crisis Care Pathway [1] and answer the following research questions:

  1. 1)

    How do professionals believe crisis services can be improved for young people in Greater Manchester?

  2. 2)

    What actions can crisis services take to improve their service provision?

2 Methodology

2.1 Aims & design

The aim of the current research was to explore how crisis mental health services for young people can be improved from the perspective of professionals. To achieve this, a brief online survey, including a mixture of quantitative, Likert scale items and qualitative, open-ended questions, was undertaken with professionals working within crisis mental health services for young people in Greater Manchester. The survey was designed to take no longer than 10 min to complete by participants, to consider their busy working schedules, and increase the likelihood of completion.

2.2 Quantitative data generation

Participants were asked to evaluate current crisis service provision in Greater Manchester through a set of 14 Likert scale questions. These questions were based on the original Crisis Care Pathway document [1] which set forth the aims of crisis services in Greater Manchester. The 14 statements were reviewed and confirmed by mental health service organisational leaders in the NHS as a reliable evaluation scale. Participants were asked, “To what extent do you agree with the following statements?” The results of these questions are presented in three categories (“Agree,” “Neither,” “Disagree”).

2.3 Qualitative data generation

The last section of the survey asked participants “How do you think crisis mental health services for young people could be improved?”. The question also asked participants to consider “the services already available,” and “the NHS’s long-term plan” when responding. It was made clear that this was the final question of the survey and participants were asked to provide as much detail as possible in their response. The aim of including this information was to encourage participants to provide detailed responses.

2.4 Participants

The survey was distributed to professionals working within crisis services in Greater Manchester. A gatekeeper at the NHS (National Health Service), who acted as Programme Manager for the Crisis Care Pathway, was utilised to gain crisis professionals as participants in this study. This gatekeeper distributed the survey to relevant managers in crisis services, who then cascaded it to the professionals working in their respective teams. This snowballing distribution technique was useful for obtaining responses from different services which provide care for young people in crisis across Greater Manchester.

The survey asked participants to state which crisis service they were affiliated to, so that the distribution of participants could be gauged. The options of services to choose from in the survey included; CAMHS Home Treatment Team, Greater Manchester Assessment and In-reach Centre, Mental Health Liaison, Rapid Response Team, and Safe Zones. These services were deemed to be the most relevant by the crisis service Programme Manager. However, “Other” was also provided as a response category, to reflect those who worked within other services providing crisis care for young people, such as A&E. There were 61 responses to the survey. However, 1 response did not record any data, so this was removed from the sample, leaving a total of 60 responses. The distribution of participants among services is reported in Table 2 below.

Table 2 Crisis service affiliation
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Participants specific profession or role was not recorded in the survey, as this would increase the risk of identification of participants when linked to their service. This makes it difficult to ascertain if all roles within these services are represented in the sample. However, as relatively small teams, the number of participants in this study from the CAMHS Home Treatment Team, Mental Health Liaison, the Rapid Response Team, and Safe Zones is enough to represent the target population of the professionals working within these crisis services. Whereas for the Greater Manchester Assessment & Inreach Centre, this sample is far from representative. Although still a small team, two participants is not representative of the professional workforce for this service.

2.5 Analytic strategy

Quantitative sections of the survey were used for descriptive purposes, with the qualitative section being the primary focus of this study. The Likert scale data from the survey focuses on the extent to which the key aims of mental health crisis services in Greater Manchester were being realised. The Likert scale responses are presented through a stacked bar chart (Fig. 1), presented in the findings section of the paper, to clearly visualise aspects of crisis services which were perceived by participants as being in most need of improvement. Missing item level data is removed, with the percentage score of those who responded to the evaluation question reported.

Fig. 1
figure 1

Likert scale statements and responses

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Likert scale statements

a. Crisis mental health services are delivered at a time that works for young people

b. Crisis mental health services are delivered in a place which works for young people

c. Crisis mental health services are delivered in a way which works for young people

d. Crisis mental health services are organized around young people and their needs

e. Crisis mental health services provide young people with the right amount of help for the right length of time to keep them safe and supported

f. Crisis mental health services are quickly available for young people

g. Crisis mental health services are responsive and flexible

h. People working with young people in mental health crisis services are trained and supported so they feel confident to better help young people when they are struggling

i. Different services and agencies work together effectively to provide support for young people in mental health crisis

j. Families and carers of YP in crisis are fully involved in their care, every step of the way

k. Movement between services is clear and well planned

l. Services are transparent and clear with young people in crisis about their care

m. Mental health services for young people are effective

n. Mental health crisis services for young people are fully integrated

Analysis of the qualitative data collected in the survey builds on the key findings from the descriptive quantitative results, to understand professionals' perspectives on how improvements can be made to current crisis services offered in Greater Manchester. Qualitative data was subjected to inductive reflexive thematic analysis [22], using NVivo software to help with the coding process. The first author conducted the first three stages of the reflective thematic analysis process: data familiarisation, systematic data coding, generating initial themes. Two other co-authors were then involved in the remaining three stages of analysis: developing and reviewing themes, refining, defining and naming themes, and the report writing process. This was particularly helpful in the developing and reviewing stage, as during this stage codes and themes could be sense-checked against the supporting quotes from the raw data. Whilst interpretation is a key element of this method [22], it is key that themes are representative of the data collected. Once themes were developed from the qualitative data, these findings were used to gain a deeper understanding of participants responses to the quantitative section of the survey.

2.6 Participant’s self-assessed knowledge of crisis service

The survey asked participants to rate their understanding of crisis services in Greater Manchester. Table 3 displays the survey results of the crisis services knowledge self-assessment. In summary, the survey demonstrates that only 15% of participants considered to have a “full understanding” of how the whole crisis support system for young people works, with 50% stating they had “some knowledge” about the whole crisis support system. Almost 27% of participants stated they know how “other services linked to my service” supports crisis care for young people, and a further 8% reported they only had “knowledge about how the service they worked within” supports young people in crisis. These findings clearly highlight a perceived lack of knowledge among professionals about the support crisis services provide in Greater Manchester, with 85% of participants declaring to not have a full understanding of said services.

Table 3 Self-assessed crisis service knowledge
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2.7 Findings

The full results of the surveys Likert scale questions are displayed in Fig. 1. Whilst the results of the Likert scale questions indicated that there was room for improvement across all evaluative measures, there were some areas that were reported to be in more need of improvement than others. A minimum threshold of 20% (with a 1% leeway under) was deemed as significant because this would mean that 1 in 5 professional staff were negatively reporting on an evaluation measure. There were 6 statements which reached the threshold of negative responses, demonstrated by participant selection of “Disagree” to the evaluation question. Figure 1 suggests that crisis services for young people in Greater Manchester require improvement in the following areas: Being delivered at a time that works for young people (19.23%); providing young people with the right amount of help for the right amount of time (19.23%); providing crisis services which are quickly available (24.53%); for different services and agencies to work together effectively (19.23%); clear and well-planned movement between services (37.25%); and for services to be fully integrated (26%).

These findings clarify professionals’ perspectives about what aspects of current crisis services offered in Greater Manchester can be improved. The following reflexive thematic analysis of the qualitative survey data utilises these key findings from the quantitative data to examine the possible reasoning’s behind the 6 key areas of improvement identified and discuss how crisis services may be able to resolve these identified issues.

2.8 Qualitative themes

Results from the thematic analysis of the qualitative survey questions are displayed in Table 4 as super-ordinate themes; the challenges of navigation, issues of accessibility into and between services, and the need to improve integration, alongside their respective sub-ordinate themes.

Table 4 Super-ordinate & sub-ordinate themes
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2.9 The challenge of navigation

The first super-ordinate theme discussed, which presented a significant problem to current mental health crisis services for young people was the challenge of navigation. It is clear from survey responses that navigating crisis services was an issue faced by both service users and staff working within crisis services.

“The interface working within crisis mental health services for young people can be confusing and challenging to navigate. It is not always clear what the roles and responsibilities of the professionals involved from children's services are…” (Participant 34, Mental Health Liaison)

The confusion about who does what makes navigating crisis services a challenge for those working within crisis services and for those trying to access them.

2.9.1 Inconsistency

An inherent factor contributing to the challenge of service navigation is the inconsistency in crisis service provision across Greater Manchester, with one response noting how, “Mental Health Crisis Services vary across locality.” (Participant 23, Safe Zones). Not only does this lead to difficulties in navigating services, but also inequalities, with another response stating, “some areas have greater resources than others, which can be a barrier when promoting young people’s social and mental wellbeing.” (Participant 5, Rapid Response Team).

2.9.2 Overreliance on A&E

From the lack of consistency in offer of crisis services, it is unsurprising that many young people in crisis will be directed to A&E as a consistent offer regardless of location, despite this being perceived as an undesirable destination for young people experiencing mental health crisis.

“My main worry is A&E departments, lots of children, young people and parents are directed to A&E in a crisis however that kind of environment for a person experiencing a mental health crisis is not appropriate in my opinion.” (Participant 43, Safe Zones)

Survey responses suggested that there was an overreliance on A&E, even for those registered to other mental health services, due to current gaps in crisis service provision, particularly out of hours.

“Most young people in care and who are under the care of CAMHS are experiencing self-harm/suicidal thoughts in the evening and during night time and carers/young people feel that currently crisis support does not meet their needs which leads to repeated A&E attendances and by the time MHL practitioner review the young person the crisis has reduced. This however creates a reliance on accessing A&E and leads to potentially unhelpful admissions.” (Participant 21, Other)

Gaps in current crisis services provision may have contributed to participants negative responses to the first and sixth Likert scale questions. 19.23% of participants disagreed with the first statement (see Fig. 1a) which asked participants if they agreed that services were delivered at a time that works for young people. A further 24.53% of participants disagreed with the sixth statement (see Fig. 1f) when asked if services were quickly available. If a young person reaches crisis point in the evening the quickest access to professional support is through attending A&E if specialist crisis mental health services are not available. However, it was suggested that rather than attending A&E, young people in crisis should be attending services which are appropriate for their needs.

“I feel there needs to be a safer, more suitable place for anyone who is struggling with their mental health. This needs to be suited to a variety of needs and have the correct support for the people who are accessing it, by this I mean staff that are appropriately trained to support the people who turn up and also to have support for the staff that are providing this service.” (Participant 43, Safe Zones)

2.9.3 24/7 crisis service provision

A suggestion was made across several survey responses, that may help resolve the current overreliance on A&E and provide a solution to the negative responses to the first (see Fig. 1a; services are delivered at a time that works for young people) and sixth (see Fig. 1f; services are quickly available) statements from the quantitative section of the survey. This suggestion was the implementation of 24/7 crisis service provision. The desire for 24/7 provision of young people’s crisis services amongst participants was strong, whether an overreliance on A&E was identified in participants responses or not. But for others, this was identified as a direct solution.

“I feel some services may need to be 24/7 in order to prevent people attending A&E.” (Participant 43, Safe Zones)

However, it was conceded that for the delivery of 24/7 provision to be possible, investment would be needed; “Improved investment to meet the 24/7 aim.” Other participants provided more detail about how 24/7 crisis service provision could be achieved, through redistribution of current resources.

“I think the 24 hour offer could be covered using a rotation of staff from across the crisis pathway, bolstered by a robust out of hours referral process in liaison with trust helplines and All Age Mental Health Liaison services.” (Participant 19, CAMHS Home Treatment Team)

The next two super-ordinate themes, Issues of accessability into and between services, and How to improve integration, will contain more suggestions which may provide resolutions to this challenge.

2.10 Issues of accessibility into and between services

The second super-ordinate theme to be discussed is that of issues of accessibility into and between services. Access follows on from the previous super-ordinate theme of The challenge of navigation, with elements of this theme linking closely to the challenges previously discussed. The sub-ordinate themes discussed in this section demonstrate the challenges currently faced surrounding accessibility of crisis services in Greater Manchester, and some potential solutions developed from analysis of survey responses.

2.10.1 Transition of care

The eleventh statement (see Fig. 1k) from the quantitative data collected in the survey received the most negative response, with 37.25% of participants disagreeing with the statement that “movement between services is clear and well planned”. Participant responses to the qualitative section of the survey help develop an explanation for the poor response rate, highlighting several issues with the transition of care between services, affecting the accessibility of services. One of the major challenges identified was the transition to adult services for young people aged 16–18, creating another gap in service provision and leaving those in this age range in a precarious position.

“I believe currently long-term support is proving to be a bit more difficult such as HITT not taking ages from 16+ and then miss communication from Adult services, stating they will not take anyone till they are 18, this is leaving some YP without any support.” (Participant 46, Rapid Response Team)

Those working in crisis services that are willing to offer support for this age range are impacted by the age restrictions of other services, due to the transition of care into and out of their service, making it difficult for them to manage.

“PCNFT CAMHS not taking up to 18 year olds restricts HIT having full offer… PCNFT CAMHS not taking up to 18 year olds makes it difficult for GMAC and the wards to manage flow and discharges.” (Participant 50, Greater Manchester Assessment & Inreach Centre & CAMHS Home Treatment Team)

However, it was not just the transition to adult services that appeared to be an issue within current practice. The transition process between crisis services and beyond do not seem to be as efficient as they could be.

“i think we need better transition between services. Often when we make recommendations after working intensively with young people (…) the recommendations are not adhered to and we are told that the young person needs a SPOA assessment by CAMHS which is a 90 minute assessment. It would work better if we were able to make referrals and recommendations for things such as psych reviews, family therapy, psychotherapy etc.” (Participant 51, Rapid Response Team & CAMHS Home Treatment Team)

This response demonstrates how referrals play a key role in the process of transition between services. Deeper analysis of referrals may assist in developing practical solutions to issues identified in the movement between services (see Fig. 1k), identified in the quantitative data.

2.10.2 Referrals

Referrals were identified by many participants as a source of contention. There were clear frustrations with current referral practices that prevented staff from referring to desired crisis services. There appeared to be challenges with referring into the Rapid Response Team. Participants requested easier referral access into the Rapid Response team from a range of services which are currently unavailable, including, “police and ambulance,” (Participant 51, Rapid Response Team & CAMHS Home Treatment Team) “GP’s and emergency services,” (Participant 33, Rapid Response Team) “liaison 24/7,” (Participant 50, Greater Manchester Assessment & Inreach Centre & CAMHS Home Treatment Team) and several requests for “A&E”. Put simply, “Rapid response are difficult to refer to” (Participant 13, Mental Health Liaison).

However, referring into the Rapid Response Team was not the only referral challenge identified. Survey responses also highlighted issues the Rapid Response Team faced when trying to refer outward.

“I think RRT should have more options to refer into/clearer pathways to do this as i find we are often struggling to get that support after the 72 hours.” (Participant 46, Rapid Response Team)

Referrals persisted throughout participant responses as a key challenge when navigating the pathway, which may explain the considerable number of negative responses to the eleventh statement (see Fig. 1k), identifying movement between services as a key area for improvement. As referrals act as a major route of access within the movement between services, expanding referrals between services is a clear action crisis services can take to improve accessibility and movement between services.

2.10.3 Single point of access

A solution suggested by participants for the challenges faced in the referral process was a single point of access and referral for crisis services.

“Single entry pathways into the crisis pathway rather than referral to each separate service” (Participant 49, Other)

A few specifically suggested this to be achieved through a phone line, with one specifically noting expanding the current role of 111 to support this.

“For there to be there to be a single point of access phone number for Crisis services” (Participant 19, CAMHS Home Treatment Team)

“Expanding the 111 and MHST pathway would enable further referrals into RRT” (Participant 49, Other)

Having a single point of entry and referral would simplify the movement between services and enable service users and staff to better navigate crisis services, reducing the likelihood of incorrect referrals, causing longer waits for young people in crisis.

2.10.4 Length of service provision

However, once the service has been accessed there appeared to be some disagreement about the length of support offered. Survey responses to the fifth Likert scale statement (see Fig. 1e) also suggests dissatisfaction with the length of service provision, with 19.23% of participants disagreeing with the statement that crisis services are offering the right amount of help for the right length of time. In response to the qualitative survey question, some participants indicated that the support offered is not long enough, suggesting that “some young people require longer than 3 days crisis support and need that time to build trust in the practitioners who offer support” (Participant 21, Other). Other responses noted that service users would prefer longer length of support also.

“Learn from the feedback provided by young people - they are clear that would prefer longer term support.” (Participant 48, Safe Zones)

Although some survey responses expressed a desire for “More flexibility with number and duration of sessions,” (Participant 42, Safe Zones) another opinion was expressed, which suggested that the length of support was not the issue, but rather professionals' comfort with drawing support to a close with young people.

“For example yp in central may receive longer that the agreed 5 sessions, where in Pennine areas the sessions will meet the agreed session length. This is mainly linked to confidence of practitioners being able to draw sessions to a close. This is creating again a service that isn't uniformed.” (Participant 23, Safe Zones)

As previously discussed, the transfer of care between services has proven to be a challenge for professionals, so it is understandable that some may feel reluctant to end care, without the confidence of a secure next step for the young person in their care.

2.10.5 Distinction of crisis services

However, there may be another factor contributing to the desire, shared amongst some professionals who took part in this survey, to extend the length of support offered within current crisis services. This is the distinction between crisis mental health services, and general mental health services. It is more than likely that young people reaching crisis require mental health support before and after crisis point and therefore need long term support.

“I think that often a lot of young people have a deeper underlying reason for the symptoms they are feeling, that then end up resulting in them reaching crisis. Often it feels as though they may need some more intensive and in-depth, long-term therapy to deal with the underlying issue, rather than the surface level issues.” (Participant 41, Safe Zones)

This poses an issue for crisis services, as if access to step down, long-term mental health services is problematic, then professionals may feel uncomfortable offering short-term support, creating a perceived need for crisis services to extend their length of support.

2.11 How to improve integration

There were many responses which related to the super-ordinate theme of how to improve integration, with many responses to the qualitative part of the survey highlighting the demand for different services to work together more effectively. This need is echoed in participants responses to the Likert scale questions in the survey, with the statement about effectively working together receiving a 19.23% negative response rate (see Fig. 1i) and the integration statement receiving a 26% negative response rate (see Fig. 1n). Not only did these statements receive high negative responses, but also high neutral responses. 19.23% of participants reported to “neither agree or disagree” to the statement about working together effectively (see Fig. 1i), and a further 32% of participants responded as “neither agree or disagree” for the statement about service integration (see Fig. 1n). This may be in part be due to the lack of knowledge of crisis services, which is demonstrated in participants’ self-assessment of crisis services displayed in Table 2. With 85% of participants reporting to not have a full understanding of crisis services, it is understandable why the number of neural responses for these two statements were particularly high. The following sub-ordinate themes explore how crisis services can work together more effectively to become better integrated.

2.11.1 Crisis and community care

Many responses to the survey requested there to be more integration between existing crisis services, such as, “For CAMHS HITT and RRT to be more integrated.” (Participant 19, CAMHS Home Treatment Team). But there appeared to be a particular demand for the Rapid Response Team and CAMHS Home Treatment Teams (HITT) to be better integrated, especially from participants associated with these services.

“I think it makes more sense to have the RRT and HITT teams work together.” (Participant 33, Rapid Response Team)

“I feel that an integration of crisis teams and home treatment functions could work really well, and provide individuals with holistic and person-centered care.” (Participant 5, Rapid Response Team)

One response highlighted that the services the Rapid Response Team and Home Treatment Team provide have some overlap, which is why integration between these two services would be so desirable.

“I think Mental Health crisis services can be improved by considering a model that integrates RRT and the new HITT. Currently, RRT and HITT duplicate the initial intensive support needed and they run as two separate teams.” (Participant 60, Rapid Response Team)

However, it was not just services which offered similar care or crisis support which were requested to be better integrated. Survey responses also demonstrated the need for crisis services to be better integrated with broader services in the community.

“There needs to be more integration with GP's surgeries and other locations within local communities which practitioners can base and support from.” (Participant 23, Safe Zones)

“Being more integrated with social care so that those cases don't get confused with mental health services.” (Participant 6, Rapid Response Team)

There was a clear wish for a holistic integration of services, both community based and crisis specialist, to better support young people along their journey of mental wellness.

2.11.2 Communication

However, to achieve better integration of services, communication needs to be improved. With so many services involved in the care of young people experiencing mental health crisis, it is important that communication routes are “watertight,” with current communication methods between services being perceived by some respondents as inefficient.

“Bearing in mind how many other services crisis mental health services work with and are in contact with, communication methods must be watertight. A universal way of communicating the same information to a number of different services and agencies would be much more efficient. A lot of time is spent disseminating the same information to a number of different staff and services.” (Participant 25, CAMHS Home Treatment Team)

Participants recommended communication could be improved by, “being part of at least 1 huddle per day to exchange information”, (Participant 6, Rapid Response Team) or “to join all the crisis teams together (RRT, HTT, GMAC), working from a central office and having more streamlined management in place to feel better supported”, (Participant 3, Rapid Response Team) or through a “central hub” (Participant 15, Other).

2.11.3 Shared systems

However, the most popular recommendation that was made to better integrate services and enhance communication through improved information sharing, was through a shared system.

“I think crisis mental health services for young people could be improved by having more cohesive methods of communicating the same information to multiple agencies, services, and professionals. A lot of time and work goes into communicating and disseminating important information, which is paramount. However this could be done more efficiently to avoid repetition and costing time, which could be spent on other important aspects of care and treatment. Perhaps one of the barriers is different services having their own different computer systems.” (Participant 59, CAMHS Home Treatment Team)

Within current practice, services use different systems to record information, making the process of sharing this information onwards more challenging. A shared system may ensure that all services have access to the same information, and reduce time spent disseminating information to other services. In turn, this would enhance the feasibility of integration across services.

2.11.4 Training and awareness

Finally, training persisted throughout survey responses as a key recommendation to enhance crisis service provision. More training was requested in general terms, with numerous forms of training being recommended. Training suggested ranged from basics, such as, “Baseline training for staff working with YP in metal health crisis situation,” (Participant 48, Safe Zones) to more specialised training, such as, “Training and awareness for young people presenting with complex trauma related symptoms as well as neurodevelopmental difficulties.” (Participant 21, Other). Regardless of the type, training was viewed as a way of enhancing crisis support provided to young people in crisis; “further access to training options for staff within crisis teams so they can better support YP.” (Participant 53, CAMHS Home Treatment Team).

However, whilst training offers a route to enhance how to support young people in crisis, it can also be utilised to enhance integration, by developing an awareness and shared understanding of crisis services available, and how they can work together effectively. An “Increased understanding of everyone's role in supporting the young people and knowing which service provision suits the young person's needs the best,” (Participant 48, Safe Zones) could be achieved through training. Furthermore, the request for a better understanding goes beyond crisis services, with a desire for “More understanding of the community services we can refer to.” (Participant 38, Mental Health Liaison). Training that enhances staff’s understanding about how crisis services work together and with wider community services to provide support for young people could lead towards better integration of services, enhancing the accessibility and navigational challenges currently faced in practice.

3 Discussion

Undoubtedly, crisis mental health services for young people in Greater Manchester have been enhanced through investment in the Crisis Care Pathway. It has provided young people in Greater Manchester with new and improved services, which did not previously exist, providing more choice and support for those living in the city region. Nevertheless, the findings from this research indicate several areas of improvement for crisis services as identified by professionals working within them.

How do professionals believe crisis services can be improved for young people in Greater Manchester, and what actions can crisis services take to improve their service provision?

Analysis of the quantitative data found 6 clear areas for improvement from the evaluative indicators. Likert scale questions that returned over the required threshold of negative participant responses were: services delivering support at a time that worked for young people; delivering the right amount of help for the right length of time; providing services which are quickly available; services and agencies working together effectively; movement between services is clear and well planned; services are fully integrated. A further 3 super-ordinate themes were established through thematic analysis of the qualitative data that indicate a need for the further development of crisis services: the challenges of navigation, issues of accessibility into and between services, and the need to improve integration. Deeper analysis of those three themes explored the links between the quantitative and qualitative findings and suggested solutions to the issues identified with current crisis service provision as identified by professionals taking part in this survey.

This study found that navigation of crisis services was a challenge for both service users and professionals, with a lack of understanding of crisis services reported by professionals in the qualitative and quantitative data (see Table 3 and Fig. 1). This issue was not helped by the inconsistency in offer of crisis services across Greater Manchester. However, this is not an isolated issue. Inconsistency in crisis service provision is widely reported [7], with an individual’s postcode being a crucial factor determining what care is available to them [23].

As A&E is a well-known, dependable emergency service which is offered 24 h a day, it is unsurprising that participants report an overreliance on A&E by young people in crisis. Other crisis service research has indicated that long wait times for specialist mental health support and insufficient information regarding where to go when in crisis, has resulted in emergency departments becoming the default option for CYP in crisis [13]. This is despite a reduction in avoidable mental health A&E attendances being a key policy goal for mental health services [10, 24].

However, as exemplified in this context of this study, alternative specialist crisis services for young people do exist, the issue identified in this study is how to enable young people in crisis to access these services, rather than needing to rely on A&E. From the challenges young people and their families face when navigating crisis services, it is easy to see why they turn to A&E when in crisis, as it is a consistent 24 h service, acting as the first point of emergency contact to everyone across the UK. Although not the preferred environment for CYP’s crisis care, the review of crisis service literature conducted by Edwards et al. demonstrates positive outcomes of crisis services initiated in Emergency Departments [13]. Therefore, it is important that crisis care for CYP in A&E is not ignored in future research, and that this route within crisis care pathways is developed rather than completely cast aside for community and home treatment services.

Although Emergency Department initiated crisis care can have positive outcomes, there is still an overwhelming push within policy and literature to provide crisis care services in the community. To be able to achieve this and avoid crisis mental health related A&E attendances, participants suggested that specialist CYP crisis services be provided on a 24 h basis. Although 24 h crisis service provision is already an aim set forth in the NHS’s Long Term Plan, results from this research echo the dissatisfaction reported with out-of-hours care and the need for accessible 24/7 care in other literature [13]. Participants in this research articulated the need to increase resources in this area of service provision to make 24/7 crisis care a viable option.

Barriers and facilitators for CYP accessing crisis services has been explored in the research literature [13], but less emphasis has been put on the accessibility between crisis services. Accessibility between crisis services proved to be a challenge in the context of this research, contributing to issues of navigation into and between crisis services. Previous literature has illustrated the negative impact of poor transition between services on adherence to future treatment and health outcomes for young people [25]. Yet, movement between services was identified as key area for improvement from analysis of the quantitative data (Fig. 1). Through analysis of qualitative responses, a deeper understanding of this issue was identified.

First, participants expressed their frustrations with crisis services limiting their care to young people aged 16, leaving a gap in crisis provision for young people aged 16–18. Conclusions drawn from the IMPACT study, a body of research which investigated mental health pathways and care for adolescents in transition to adult services, promote standardised and robust policies and guidelines to ensure ideal transition between adolescent and adult mental health services [26], once again highlighting the need for consistency in service provision.

The second issue professionals faced in relation to the movement between services was referrals. Challenges of referring into CAMHS has been explored in depth [27], particularly the impact on wait times and inequalities faced in this process [28, 29]. However, little is known about the referral process between services. This study has illustrated the importance of referral procedures between crisis mental health services, highlighting the complexities professionals face when trying to support young people in crisis, exhibiting limits on professional freedoms to refer young people into other mental health and community services. It has been highlighted in other literature that poor communication and collaboration between services has caused CYP to fall between the gaps, acting as a barrier to receiving the right help and support [13]. This research argues that the findings from the IMPACT study regarding the promotion of robust and standardised policies and guidelines when transitioning to adult mental health services [26], be expanded to the movement between all services providing crisis and step-down crisis care.

Improving consistency in service provision, policies, and guidelines would not only help professionals when navigating access between services, but also for CYP accessing them. Lack of information for CYP has been identified as a barrier for accessing crisis mental health services, as they do not know where to go when experiencing crisis [13], which is most likely not helped by the current inconsistencies in service provision. The successful dissemination of appropriate information about crisis services to staff and CYP would be much more probable if it were less haphazard.

The survey results highlighted a single point of access as another way of improving accessibility into and between services. A single point of access is recommended elsewhere as a general characteristic that crisis services should share [13]. Some participants specifically suggested that the NHS 111 telephone line could be utilised for this purpose. The use of 111 as a point of access to crisis care services is currently in the process of being implemented across the UK [30]. Although studies have demonstrated the effectiveness of telephony crisis services for CYP [13], the success of this working as a referral route used by professionals between services is less likely. Therefore, the development of a professional version of a 111 phone-line for movement between services, or another standardised process which streamlines the referral process between all services involved in crisis care is necessary to remediate current issues experienced by service users and professionals in the movement between services.

Better referral routes would not only enhance the movement between services but may also impact professionals’ attitudes towards the length of service provision. This research unearthed discrepancies within professional attitudes towards the length of crisis support. Some of whom believe current crisis service provision is too short, and more flexibility to extent the length of care should be given. Contrary to this position, other professionals expressed the belief that crisis services should remain short term, and that professionals need to be more confident in ending care with service users. As the findings in this study demonstrate, the movement between services was perceived to be in most need of improvement. Therefore, it is foreseeable that professionals would be reluctant to end care if apprehensive about the future quality of care for service users who need it. However, this raises a conceptual issue of crisis within crisis care (i.e., when do crisis services end and long-term support begin?).

Finally, results demonstrated that the way in which services work together effectively and provide integrated care was unclear to professionals. Quantitative findings found that not only did a significant percentage of participants disagree that working together, and integration was done well, but the number of participants who reported to have no opinion on this was higher than any of the other evaluative Likert scale statements. This, alongside most of the participants self-reporting to not have a full understanding of crisis services available, clearly demonstrates the need to improve how crisis services work together and integrate. Research into collaboration to provide mental health services has proved to elicit many benefits [18], with NHS England encouraging integration and collaboration through “building positive trusted, and enduring relationships with communities to improve service, support and outcomes for all.” [31]. This research illustrates a similar demand amongst professionals, with participants in this study expressing a desire to be better integrated not only with other crisis and mental health services, but also wider services available in the community.

As it currently stands, there is a lack of understanding of crisis services and long-term support after crisis, which could be enhanced through training. Training was requested by participants, to not only improve their skills in service delivery, but also in better understanding the range of services that support young people in crisis and after de-escalation. However, training to enhance the understanding of other services will not create fully integrated services without the ability to improve communication between these services. The creation of a shared system, to communicate and share information between the many services that provide care and step-down care for people in crisis was highly recommended by professionals.

4 Limitations and future research

This study contributes to current understanding of crisis mental health service provision for young people by developing clear actions for the NHS to enhance current provision. However, the scale of this research makes generalisability of findings difficult. The sample of participants, although representative of some of the crisis services in Greater Manchester (Safe Zone, the Rapid Response Team, Mental Health Liaison, and CAMHS Home Treatment Team), it does not represent all professionals working with children and young people in crisis services across Greater Manchester (in-patient facilities, A&E, crisis phone lines, police and ambulance etc.). Therefore, this is only a snapshot of the wider picture available. That said, providers organising crisis services may be able to transfer relevant conclusions drawn from this small-scale study to their own context.

Furthermore, we implore providers within other contexts to use this research in assistance to evaluate their own provision of crisis services, to act as a benchmark and foundation to draw from. Whilst this survey sufficiently answered our research questions, we recommend that crisis services have a clear and transparent evaluative process structured into their policies and practices, so that relevant data can be collected consistently for evaluative purposes. A cross-sectional survey, such as this one, is helpful for planning on retrospect, however, having access to detailed, longitudinal data would enable a deeper analysis of the different impacts of crisis services over time and determine what services and strategies work.

Future research focused on the practical enhancement of crisis service provision should include a wider range of crisis services, beyond the bounds of the NHS, to explore the wider field of crisis services available to young people. Additionally, the comparison of professional perspectives with service users would elicit an even deeper understanding of current crisis services and how providers may enhance them.

5 Conclusion

This research found 7 clear actions to enhance the provision of crisis mental health services for young people in Greater Manchester: (1) 24/7 specialist crisis service provision for young people; (2) consistency in offer across locality; (3) extension of crisis services to 16–18 year olds; (4) clear and standardised referral routes between services; (5) a single point of access for young people, and for professionals making referrals; (6) enhance integration between crisis services, and between crisis services and step-down services, through service awareness training (specialist and community); (7) enhanced integration through developing a shared system for professionals working across services that offer support to young people in crisis, and post crisis, to share information and communicate better. Some of those points support current initiatives taken by the NHS to improve crisis services across the UK; others offer a novel perspective from professionals which may influence providers in their organisation of crisis services.