The contribution of the voluntary sector to mental health crisis care: a mixed-methods study

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 15/70/73. The contractual start date was in November 2016. The final report began editorial review in April 2019 and was accepted for publication in November 2019. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of the authors

Karen Newbigging was a trustee of the Healthy Minds Board from 2012 to 2017 and a National Institute for Health Research (NIHR) Health Services and Delivery Research (HSDR) associate board member from 2016 to 2019. Doreen Joseph reports receiving personal fees during her time as a HSDR Researcher-Led Panel member (2018–20) during the conduct of the study. Benjamin Costello is a director and trustee of Bromsgrove and Redditch Network (BARN), a local council for voluntary services, which is also a volunteer centre; he is also a director and trustee of Redditch Nightstop.

Disclaimer

This report contains transcripts of interviews conducted in the course of the research and contains language that may offend some readers.

Copyright statement

© Queen’s Printer and Controller of HMSO 2020. This work was produced by Newbigging et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2020 Queen’s Printer and Controller of HMSO

Defining a mental health crisis

Defining a MH crisis is by no means easy and, as Rapoport5 observed over half a century ago, ‘the term “crisis” is generally used in a rather loose and indeterminate way, covering a variety of meanings and a wide range of experiences’. Common themes in the way the term is used are as follows: (1) a crisis is a time of heightened vulnerability, (2) a crisis is commonly conceptualised as an event, which poses a threat and leads to a sense of disequilibrium, (3) a crisis can be a negative or positive experience, such that a crisis is viewed as a ‘turning point’,6 with both risks and a constructive potential for change and personal transformation, and (4) the resources available to an individual, both their personal coping strategies and the availability and effectiveness of support, will influence their response to a crisis.

Two aspects of a crisis that are commonly identified are the temporal dimension (i.e. an intense, and sometimes sudden, experience with the urgency of the situation emphasised) and the severity of the crisis. For example, Boscarato et al. 7 state that:

Crises can occur when a person encounters an overwhelmingly stressful situation that might exceed their capacity to cope, resulting in feelings of helplessness and tension. Disorganization and confusion might be subsequently experienced, leading to a ‘breaking point’, characterized by psychological decompensation and disturbed or destructive behaviour.

Boscarato et al. 7

Paton et al. 8 distinguish the current definitions of a crisis in a MH context. These are a pragmatic service-oriented approach (i.e. a person coming to the attention of crisis services because of a relapse of an existing MH condition), self-definitions of crisis (i.e. the person defines their own experience and recovery), a risk-focused definition (i.e. the person is at risk of harming themselves or others) and negotiated definitions (i.e. negotiated collaboratively between service users, carers and staff). 8 Traditional descriptions of a crisis emphasise the behavioural and symptomatic elements of a crisis, reflecting a biomedical framing based on clinical assessments of health and risk. 9,10 These are widely contested for neglecting or negating the experiential aspects of a MH crisis11 and they potentially dismiss the agency of the individual and their family or carers in crisis management. This study, therefore, explores crisis experiences and their conceptualisation, as these will have influenced policy, system development and consequently the role of the VS. We began with an inclusive and relatively neutral conception of a crisis as a ‘turning point’, such that a MH crisis is personally disruptive but can provide opportunities to strengthen personal and social resources, and to anticipate and manage MH problems. This definition was subsequently critiqued by the Study Reference Group (SRG) as overly positive, as discussed in Chapter 4.

The policy and practice context for mental health crisis care

The voluntary sector

The VS has been conceptualised as a third ‘terrain’ of organisations between the state and market, comprising charities and community groups, underpinned by a sector ethos that typically values accessibility, self-organisation, service-user-defined outcomes, informality and relational-based approaches. 32,33 The VS makes a wide-ranging contribution to MH, including user-led organisations (ULOs), national specialist MH VSOs, VSOs concerned with a specific social issue (e.g. domestic violence or homelessness) or with a client group (e.g. ex-service personnel), and small community organisations, which are ‘under the radar’ by virtue of their size or informality. 34 Across this diverse range of organisations, there is a wide range of approaches and activity, from intensive support, including supported housing and support in a hospital setting, to advocacy, support groups and peer-led networks (e.g. the Hearing Voices Network), peer support, social and leisure activities, and befriending.

In exploring the roles of non-profit organisations in MH, Karlsson and Markström35 identified two broad (and overlapping) groups. One group is organisations providing services, seen as complementary to or alternatives to public sector services. They seek collaboration, are often dependent on state grants and become more like public or private sector organisations through the process of collaboration, but typically retain strong priorities of self-help and peer support. The second group is characterised as voice-giving rather than service-orientated. This group values experiential knowledge and work to bring about change through services and campaigning.

The VS is described as having a ‘comparative advantage’ and Dayson and Wells36 suggest that this comparative advantage derives from three elements, namely how VSOs do their work, who they do it with and the role they play in their community. 36 In particular, VSOs have a distinctive approach to governance, which is characterised by ‘stakeholder ambiguity’. 37 Stakeholder ambiguity occurs because stakeholders are likely to have hybrid and overlapping roles (e.g. managers may be the same as, or relatively equal to, those in ‘volunteer’ and ‘service user’ roles within the organisation). Such relatively ‘flat’ hierarchies are often associated with an ethos of non-judgementalism, encouraging nurture/care and a high degree of ‘relational skill’. 32

These characteristics mean that the VS may be particularly well placed to provide MH crisis support, offering alternative approaches to public sector provision for populations that are ‘seldom heard’ or find themselves excluded by various mechanisms,38 for example women who have offended or are at risk of offending,39 homeless people40 or older people experiencing anxiety and depression. 41 Thus, the VS plays a particular role in advancing equality by facilitating access to support for people from disadvantaged groups who may be reluctant to access public sector services.

Voluntary and public sector relationships

Since 1997, there has been a significant rise in the involvement of the third sector and civil society in delivering public services. 42 VSOs are now firmly embedded in the delivery of public services including health and MH services. This process has happened in an evolving political context including periods of significant government investment under New Labour, as well as periods characterised by austerity and short-lived agendas, such as the ‘Big Society’ agenda, under the coalition government from 2010 and subsequent Conservative governments from 2015. 32 Alongside this, the increasing marketisation of public services has opened up new opportunities for VSOs by way of competition for health contracts, both between VSOs and with public and private sector organisations. 43 Widespread concerns about this involvement in delivering public services have been expressed, potentially compromising some of the VS’s cherished attributes, especially its perceived trustworthiness, political independence and ability to act as an alternative or challenge to the state. 43 For many commentators, the VS’s enhanced role in the delivery of public sector services has come at the price of a drive towards ‘professionalisation’ and more competitive, even unethical, behaviour. 44 Regardless of the rights and wrongs – and there is no clear consensus across what is a very diverse VS – there is a trade-off between (1) aligning more closely with the values and approach of the public (or private) sector while remaining a challenge and providing an ‘alternative’ to them and (2) particularly in the case of MH, genuinely involving service users. This is often expressed in terms of threats to VSOs’ ‘independence’ from the state and market. 45

When VSOs work most closely in ‘partnership’ with the public sector, the relationship has been theorised as a collaborative or mutually dependent one arising from the inherent limitations of the two sectors in providing collective services – or, more formally, a system of services45 – suggesting there is some scope for synergy rather than a zero-sum game. This resonates with the CCC’s articulation of the crisis care pathway3 and Crisp et al. ’s16 reiteration of the importance of viewing the MH system as a whole, with synergy between the various elements necessary to provide a timely and effective response. Collaboration and synergistic relationships can have different meanings for the various stakeholders. We draw on the conceptualisation of collaboration by Gray46 as ‘a mechanism by which a new negotiated order emerges among a set of stakeholders’. Therefore, one hypothesis is that a more effective and efficient response to people experiencing a MH crisis will be achieved through effective collaboration between VSOs and public (and in some cases private) sector services. Our understanding of collaboration also draws on the work of Morrissey et al. 47 on MH service system change in a US context, which differentiates between collaboration at the service system level and at the individual client level. This underpins our research design in seeking to understand how different elements of the crisis service system are working together both as a system and for individual service users.

Commissioning the voluntary sector

An increasingly important factor in shaping the relationship between the VS and the public sector has been the rise of commissioning as the foremost mechanism for ‘purchasing’ services from the VS. Public sector commissioners [e.g. within local authorities and Clinical Commissioning Groups (CCGs)] are now required to shape and provide stewardship of local provider ‘markets’. 43 Commissioning was intended to enable a needs-based whole-cycle approach to purchasing services, thereby alleviating issues around fragmentation and allowing VSOs to have a greater influence on defining public services. However, commissioning remains ‘fragmented in policy and practice, between different localities and scales of government’. 48 Commissioning arrangements between the public sector and VSOs sit on a spectrum ranging from narrowly constituted ‘commissioning on price’, which resembles traditional procurement and tendering processes, to ‘intelligent/collaborative’ at the other end. 48 The integrity of commissioning – and the role and standing of commissioners – has also arguably been undermined by austerity and the widespread perception that it is one mechanism for enforcing ‘cuts’ to public services. Miller and Rees49 examined whether or not commissioning has created opportunities to improve the whole system of MH provision, finding that in reality commissioners felt they were ‘subjects’ rather than ‘masters’ of change. Apart from a few promising examples of individual service change, new commissioning arrangements were thought to be unable to bring about systemic change in MH services. This was attributed to a lack of personal expertise and knowledge of local services, limited influence on the whole system, poor communication, fragmented or inconsistent relationships between local authorities, VSOs and NHS services, and competitive tendering processes and contracts, which many VSOs felt limited their creativity or compromised the goals of their service provision. Some commentators have called for much more radical change to commissioning arrangements, including wholesale reform. 50,51 Therefore, linked to an examination of collaboration, understanding the extent to which current commissioning arrangements recognise and support the sustainability and contribution of VSOs to MH crisis care was also an important focus of this study.

This report

This report provides the context, aims, methodology and detailed findings of our study. This chapter has outlined the background for our study, covering the policy and practice context for the VS’s role in MH crisis care. Chapter 2 provides a literature review of relevant research to enable us to map the key concepts and develop the research tools. Chapter 3 describes the aims and methodology for undertaking our study, which involved four work packages (WPs), from outlining the landscape for the VS in MH crisis care to investigating the role at a system and individual level in four (anonymised) case study sites (sites A, B, C and D).

To address the research objectives, we have chosen to present the findings thematically, with each chapter synthesising the data from the different WPs. The Consolidated Criteria for Reporting Qualitative Studies (COREQ)52,53 and the Guidance for Reporting Involvement of Patients and the Public (GRIPP2)54 checklists have been used as guides to ensure comprehensiveness and rigour in reporting our findings. We start with individual experience and foregrounding needs in a MH crisis (see Chapter 4) to establish the reference point for crisis care provision. Chapter 5 describes the different types of VSOs and how they are relevant to meeting these needs. We present a typology of the different types of VSOs and the role they play in MH crisis care. Illustrative descriptions of these different types of organisations are available in the Report Supplementary Material 2. We then present the findings on how people have accessed support from the VS, the nature of the support provided, its quality and adequacy and the difference it has made to people’s lives, both service users and their families/carers (see Chapter 6). We use individual case studies to illustrate people’s experience of accessing help and the VS response. We then examine the relationship between the VS and public sector services, mainly those provided by the NHS, and how well these two sectors are working as elements of a system of MH crisis support to ensure an effective pathway for people needing support in a MH crisis (see Chapter 7).

Finally, we present the findings on the role of commissioning in shaping the contribution of the VS to MH crisis care (see Chapter 8). This includes the sources of funding for VS activity and the relationship with commissioning, including the contracting arrangements, monitoring and the quality of these relationships. We identify the implications for the sustainability of the VS in this area and the recommendations that participants made to strengthen the commissioning of the VS. Chapter 9 provides a synthesis of our findings on the contribution of the VS to MH crisis, the limitations our research and our contribution to addressing the identified knowledge gap. Chapter 10 summarises the implications for policy, practice and further research in this area.

Language and choice of terms

Some of the language used in this report will be contested, as it was during our study. We use the term ‘mental health problems’ to describe the wide range of emotional difficulties that people experience, and we have used the term ‘mental illness’ and diagnostic labels as they were used by participants. The term ‘service user’ is used to refer to people who are using or have accessed MH support; we are aware that, because the experience of engagement with MH services is often distressing, disempowering and unwanted, some people prefer the term ‘survivor’. We have used the term ‘black, Asian and minority ethnic’ to refer to people from a wide range of communities serving black or Asian, or people from other racialised, minorities. Finally, we have used the term ‘voluntary sector organisations’ to refer to charities, voluntary organisations and community groups.

Overview of the literature

Thirty papers relevant to the current study were identified (see Appendix 2 for a summary). These included papers from the UK, Canada, the USA, Norway and Australia. The papers fell into five main groups: experiences of a MH crisis and preferences for support (n = 9); evaluation and description of service models, including helplines and peer support (n = 9); alternatives to public sector provision, including comparisons of outcomes and cost-effectiveness, with the majority relating to alternatives to inpatient admission (n = 8); evaluation of new service models, including the VS (i.e. vanguards; n = 2); and the relationship between MH VS providers and MH public sector services (n = 2). The review identified significant gaps in the literature. The majority of the studies were qualitative studies, with five studies considering outcomes using rating scales55–59 and other studies analysing routinely collected data. 20,55,60–64

Conceptualising a mental health crisis

Many papers use the term ‘crisis’, often relying on traditional notions of a crisis. Several papers, however, identify different types of crises or describe important characteristics. The temporal dimensions of a crisis emerge as central, with a crisis as a process or condition and an emergency identified. 9,65 Bonynge et al. ,9 for example, distinguish between moderate (non-acute) crises, in which people are in need of urgent care, and severe crises, which are considered a MH emergency. The latter type of crisis was characterised by observing three or more of the following characteristics: (1) danger to self, (2) danger to others, (3) significant confusion, (4) significant depression and (5) significant functional decline. Sells et al. 66 explored the contexts and conditions for crisis and identified a recursive dynamic between a crisis and its consequences. For example, a chronic illness can lead to a loss of income, role disruption, and challenges to identity and routine, thus contributing to further crises. This suggests that a crisis is not necessarily sudden but can also be triggered by circumstances or life events. 1 Similarly, Gudde et al. 67 and Albert and Simpson68 describe the crisis experience as a process of ‘problem escalation’, with the lack of effective support creating an ‘emergency’, resulting in police intervention, or a cyclical process of short periods of hospitalisation then discharge until another crisis occurs.

Ball et al. 65 argue that there are significant differences between how crises should be understood for people who are living with a serious MH issue. 65 They propose that conceptualising crises in terms of ‘underlying vulnerability’ – traumatic life experiences, troublesome symptoms and ongoing circumstances – instead of a precipitating event leads to a better understanding of how broader conditions for crises are created. Reflecting the situated nature of a MH crisis, Thomas and Longden11 argue for a moral, emotional and contextual approach to understanding crises.

Exploring these dimensions of crises may enable an understanding to be gained of the function and nature of VSO interventions and support, in terms of which point of the crisis process these organisations intervene and what they are aiming to address (preventing readmission or breaking the cycle). It also raises the question of whether or not different services, organisations and individuals have a shared understanding of the crisis process.

Subjective experiences of crisis

Subjective accounts reveal the multifaceted nature of a MH crisis, situated in the context of people’s lives. Despite the inherently personal nature of crises, some common themes are evident: the feeling of ‘emotional darkness’, loneliness and a desire for togetherness, feeling scared and a sense of loss of control. 1,65,69 Hopelessness and seeing no end to the situation may lead to a suicide attempt. A service-user-led study of the experience of CRHTs frames a MH crisis as a journey. 70 Similarly, Gullslett et al. 69 describe MH crises as a ‘continuity of struggles in complex situations’. They identify two dimensions – existential/personal and contextual/social – and, depending on the individual and the situation, one of these might be more dominant. These themes were also identified by the Mind inquiry1 and Ball’s65 situation-specific theory. Other themes included the intervention of others, loss of identity and purpose, alienation, not coping or functioning, hopelessness, despair, self-blame and guilt. These themes were inter-related in complex ways and sometimes conflicting feelings were evident, for instance an awareness of the need for help and a desire to reach out to others, but limited emotional resources or capacity to do so.

Using a phenomenological approach in a study focused on carers’ experiences, Albert and Simpson68 identified that a MH crisis can also be a stressful time for carers. They suggest that they can experience a ‘double deprivation’, often unsupported by staff owing to different understandings of what constitutes a crisis, and not accessing support from their social network, preferring to limit the impact of the MH crisis. This highlights the wider impacts of a crisis and the importance of recognising carers’ knowledge and understanding.

These different experiences and understandings of a crisis indicated that it was important for our research to consider how the crisis experience is conceptualised.

Preferences and crisis responses

Given the intensely personal nature of a MH crisis and the conceptualisation of a MH crisis as a ‘turning point’,6 there is an opportunity for learning and building resilience if effectively supported. 71 Mind’s inquiry into crisis care1 identified four main themes for what people wanted from a crisis support service:

• to feel cared for, not abandoned

• choice and control, not coercion

• a personal caring response rather than a medical one and

• appreciating that one model does not fit all.

They recommended that there should be a greater range of options to meet different needs, including self-referral options, crisis houses, host families and services provided by peers. Similarly, a consultation exercise by Healthwatch Norfolk72 identified that the help and support provided by community organisations and VSOs, including telephone helplines, drop-ins, cafes, support groups, counselling and therapies, were highly valued and it recommended that their contribution to MH crisis care not be overlooked.

The personal response to a crisis varies from actively seeking help, to managing alone, to others stepping in to seek help. 65 Gudde et al. 67 explored the experiences of people with major mental disorders in a Norwegian context and identified a high threshold for contacting services as a result of previous negative experiences or inappropriate provision. Similar to other studies,1,67 service users wanted easy access to services to enable early intervention and to break a cycle of repeated hospitalisation. 67 Boscarato et al. 7 found that service users did not want a police intervention, with the majority preferring a more informal response. Hutchinson et al. 58 identified that men using a VS MH service were significantly more likely to be unemployed, have forensic histories, have less contact with other health services and have more unmet needs than those attending a service at a MH hospital in the same catchment area. Those attending the VS service cited wanting to escape ‘the system’, with the levels of dissatisfaction with public sector MH services particularly high among African Caribbean groups. These findings suggest that VSOs play an important role in enabling access for people from marginalised groups.

McGrath and Reavy73 underline the different needs of people in a crisis, to counter simplistic assumptions. They identified that people experiencing a MH crisis use space differently to maintain their sense of agency. Those experiencing a psychotic episode preferred outside space, as it ‘appears to open up new zones of fluid possibility, which potentially enables service users to de-centre, stretch out, and disperse some of the burgeoning intensity of experience’. 73 Other people preferred the privacy and the sense of safety afforded by being in an indoor safe space, which helped them restore feelings of agency and strength.

A key question, therefore, is the extent to which service users’ preferences and choices are heard, and the extent of their involvement in planning and defining their own support and recovery. Gudde et al. 67 concluded that service users identified active involvement, with dialogue-based care that placed equal value on their own coping mechanisms (acknowledging that these were not always ‘optimal’), as helpful. This included being understood as a ‘normal’ person, dealing with crises in an everyday context, and respectful, caring relationships.

Voluntary sector mental health crisis services

Systems, partnerships and processes

The importance of a whole-system approach to effective delivery of crisis care raises questions about how VSOs and the public sector, including the NHS, local authorities and the police, can best work together to ensure an effective and co-ordinated response. Bonynge et al. ,9 for example, scoped out the range of services offered by a US non-profit provider of a MH crisis care system in a rural setting, identifying a mixture of system components: urgent appointments, a crisis hotline, professional on-call services and five crisis beds (with a maximum stay of 72 hours). In examining how the system worked as a whole, they identified that distance was a challenge for mobile crisis services in rural settings, but that the combination of crisis services offered together reduced inpatient admissions by 11% and that many clients achieved stabilisation in the short period of time they used the crisis service. However, although people may use different services, the pathways to help are not always clear, with Healthwatch Norfolk72 identifying that approximately 50% of its respondents did not know who to contact if they needed help urgently.

A number of studies have considered the relationship between the VS and public sector services. The study by Johnson et al. 74 of alternatives to standard inpatient care found high levels of collaboration with NHS staff for non-clinical community-based alternatives, predominantly provided by the VS. Belling et al. 86 investigated the factors influencing the continuity of care by CMHTs through 113 semistructured interviews with MH staff, general practitioners (GPs), social workers and two VSOs. Alongside democratic and empowering leadership styles and decision-making, face-to-face communication facilitated cross-boundary working, including with the VS. Some poor communication between public sector and VS staff was noted, and was attributed to the high mobility of some people with MH issues resulting in highly complex networks of care and multiple interfaces at which communication breakdowns can happen. Information technology (IT) systems and information sharing between organisations was also cited as a significant problem.

Conclusion

The majority of papers identified in this literature review were concerned either with crisis houses or with the emotional or practical experiences of a MH crisis. Although the grey literature identified the particular role of the VS in MH in terms of longer-term, more holistic support, there are few academic studies that explore this. The dominant narrative in academic studies is focused on the VS and crisis houses and reducing admission to inpatient beds. Consequently, there is a gap in understanding the ‘whole system’ of crisis support, across the crisis journey described in the CCC. This includes sparse evidence on (1) a wide range of outcomes, (2) the collaboration between the VS and the public sector at the system and individual levels and (3) cost-effectiveness.

Aims and objectives

The primary aim of this research was to identify the contribution of the VS to MH crisis care and to identify the implications for policy and practice to strengthen the crisis care response. The specific objectives were to:

1. identify the different types of VS support being commissioned and/or provided to respond to the needs of people experiencing a MH crisis

2. develop a taxonomy of the different organisational types and forms of VS support available, service models (including characterising their relationships with public sector provision) and populations served

3. explore the configuration and the experience of a MH crisis system, including the factors and processes that facilitate the successful contribution of the VS to effective crisis care pathways

4. understand the crisis journey for individuals and their families and individual service user needs in a crisis, and how VSOs contribute to meeting their needs.

The scope of the study was MH crisis care in England. Assessments of clinical outcomes or cost-effectiveness, as well as comparisons with different types of service provision, were beyond the scope of this study.

Research design and methods

The design involved the use of multiple methods, both quantitative and qualitative, to provide a comprehensive and detailed analysis of the contribution of the VS to MH crisis care. The quantitative and qualitative methods complemented one another, with the quantitative methods providing an ‘extensive’ approach,87 to describe the landscape of VS provision, whereas the qualitative methods enabled an ‘intensive’87 investigation of meaning, experiences, relationships and processes. The study design ensured that the qualitative work was capable of being related to the wider picture through locating the qualitative data in a typology of VSOs derived from the quantitative data. To address the research objectives, the study was organised around four distinct but interconnecting WPs (Table 2).

The heart of the study was the comparative case study, at the system level (WP3) and at the level of individual service users and their families (WP4). The decision to use a case study design was threefold: (1) case study designs are particularly useful for enabling a real-time exploration of phenomena that are complex and dynamic;88 (2) it enabled an intensive examination of the VS contribution, contextualising both individual experience; and the VSOs within a system, to explore the relationships between VSOs and different system elements, and (3) the intensive examination had the potential to generate theoretical insights that could be applied in other contexts and provide the basis for subsequent evaluative work in relation to outcomes. The following section describes the four WPs, followed by data analysis and synthesis, methods adopted to ensure rigour, the research team composition, patient and public involvement (PPI) and ethics approval.

Work package 1: national scoping exercise

The focus for this WP was to identify the range of support that VSOs are providing to people experiencing a MH crisis. It involved reviewing the evidence and building a national picture of the contribution of the range of VS providers of MH crisis care in England. It comprised four elements: (1) a literature review (see Chapter 2), (2) assembling a database of candidate VSOs providing MH crisis care in England, (3) a national survey of VSOs to identify the type of crisis support being commissioned/provided and to whom, the type of organisation providing the support and the main methods of working, and (4) a purposive sample of interviews with national stakeholders (e.g. policy-makers, professional organisations and service user organisations) and national VSOs to provide further details on the different forms of VSOs, the type of crisis support they provide and how this contributes to the MH crisis care pathway.

Work package 2: regional mapping

Work packages 3 and 4: comparative case studies of the voluntary sector contribution

The heart of the study was the comparative case studies, which enabled a detailed investigation of the VSOs’ contribution to MH crisis care. It focused on investigating how the VS elements of the MH crisis care system work together with public sector provision, and identified the challenges and determinants of success from the perspective of commissioners, VS and public sector providers, volunteers, service users and carers. We investigated the contribution of VSOs to the MH crisis care system (WP3) and at an individual level for service users, their families and carers (WP4). Each site had an academic lead and three co-researchers, with all team members being involved in data collection in at least two sites.

Data saturation

Our sample size and sampling method were designed to enable us to explore variation, complexity and detail to provide a rich picture of the VS contribution to MH crisis care. 98 As it was evident fairly early on that similar themes from the service user and carer focus groups and interviews were emerging – particularly in relation to the crisis experience, views of public sector services and views of the helpful aspects of the VS – we actively sought data to disconfirm this and extend our understanding. However, saturation is a contested concept99 and, with more time and resources, it is possible that we could have sampled more widely to include people with a broader range of protected characteristics and smaller VSOs that go ‘under the radar’.

Data analysis

The findings from each stage of the study were integrated with the findings from each of the WPs, which informed subsequent WPs. WP1 informed the focus for the regional mapping and provided the basis for the development of a typology, refined as a result of WP2, which was used as a sampling frame for the case study site selection.

Data synthesis

The purpose of the data synthesis was twofold. First, the synthesis data provided by WP1 and WP2 were used to guide additional sampling and data collection. Second, the data from the case studies were used to clarify and elaborate on the data collected in the earlier stages of the study. We were able to locate the qualitative data on experiences and outcomes of VS MH crisis support within the typology derived from the quantitative data. Within each site, a combination of the analysis from the different methods enabled us to develop a holistic profile of that site and to triangulate our data. The integration of data across the sites enabled cross-case comparisons to be made. This was an iterative process focused on the research objectives and exploring the relationships and tensions between the following variables:

• the type of crisis needs

• the type of VS provision and activities

• individual respondent characteristics

• the interface between the VS and public sector services and

• organisational form and commissioning arrangements.

This report presents the major themes from our analysis and describes the range of experiences of the VS, including divergent and minor themes.

Rigour

The strategies employed to ensure the rigour of the study were:

• the adoption of a multimethod approach to provide a detailed examination of the contribution of the VS to MH crisis care

• comparing the candidate database with comparable databases

• the use of COREQ52,53 for reporting findings from the focus groups and interviews and the GRIPP254 checklist for reporting on PPI

• service user and carer involvement to strengthen the credibility and validity of the study

• development of the coding frame by the whole research team, and validation with the SRG

• double coding 10% of transcripts to identify discrepancies and interpretative differences

• an audit trail, through the use of NVivo.

Research team

The research team comprised 11 people: five academics (two female and three male), five co-researchers (four female and one male, all with a wide range of experience) and one advisor (a male carer). Further detail on the support arrangements for the co-researchers is provided in the sections below. The team met face to face, approximately every 6 weeks, depending on the WP. Training was provided for the whole research team and covered:

• collecting data through interviews and focus groups

• ethics considerations and good practice in research, recognising the vulnerability of the target population

• analysing data and the use of NVivo

• reporting findings and dissemination.

Nine members of the team (MA, SB, BC, CD, DJ, RI, BN, KN and JR) were involved in data collection. For every study site, there were four researchers (an academic and three co-researchers) and each person was allocated two sites. The focus groups were always undertaken by two researchers, namely an academic and a co-researcher, and this was also the case for the majority of the interviews. Following the focus groups and interviews, there was an opportunity to debrief and to reflect on participants’ accounts and on the interview process.

Service user, carer and public involvement

Approval by research ethics committees

Standards of good practice for research were followed114 and the project was undertaken in compliance with the Data Protection Act115 and University of Birmingham policies relating to the conduct of research. The University of Birmingham Humanities and Social Sciences Ethical Review Committee (RG16-153) granted ethics approval for WP1 and WP2. Ethical approval for WP3 was granted by West of Scotland Research Ethics Committee 4 (18/WS/0022) and approved by the Health Research Authority (IRAS 211953). Once these approvals were obtained, the research governance bodies for the relevant NHS trusts reviewed the application to confirm participation. Care was taken at the beginning of each interview to ensure that individuals had the capacity to consent to participate. As the study involved people with experience of a MH crisis, who were potentially vulnerable, we kept the well-being of participants under active review and made adjustments as necessary. During the early interviews in WP4, we identified several participants whose needs were not being met, and we subsequently contacted a health or social care professional, usually their GP, regarding our concerns. One participant took their own life during the course of the study. The question of whether or not the research had contributed was considered and there was no suggestion that it had. Appropriate action was taken, as advised by the SSG chair and clinical advisor, the sponsor, the Research Ethics Committee and the National Institute for Health Research (NIHR). This included an urgent amendment to the interview protocol and the participant information sheet to ensure the routine collection of a clinicians details, if we had concerns about a participant’s welfare.

Experiencing a mental health crisis

More than half of the service user participants reported a previous experience of having a MH crisis (n = 34), although a number of people were unsure whether this was their first crisis or not (Figure 1). There was a higher percentage of people in site C (36%) reporting it as their first crisis, reflecting recruitment mainly via the VS, than in the other sites, where participants were also recruited via the NHS. More than half of the sample (58%) had been accessing VS support for less than a year (Table 9). By contrast, two-thirds (67%) had been using MH services for more than 3 years, although this was particularly the case in sites B and D.

FIGURE 1.

Crisis experience of participants in the study sites.

Service user participants described a wide variety of crisis experiences across the sites. A distinction can be drawn between (1) ‘a situational crisis’, with service user participants describing their experience of crisis as a ‘one-off’ event or a response to a specific situation (e.g. severe work stress or relationship break-up), (2) ‘a traumatising crisis’, when the crisis was associated with previous trauma (e.g. abuse, assault or loss) and was triggered by a specific situation resonant of this (e.g. an abusive relationship), and (3) a crisis as an element of ongoing MH issues (e.g. depression and bipolar conditions were commonly mentioned). For some people, it was a combination of events or situations coupled with pre-existing trauma or MH issues. Some participants also said that they could not identify a particular trigger. The following sections outline aspects of the experience that were identified.

Factors implicated in the experience of a mental health crisis

A wide and complex range of factors were identified as influencing MH and resulting in a crisis, as summarised in Table 10. The three most commonly mentioned factors were family factors (breakdown, conflict or loss), issues related to MH, and housing.

Several participants dated their first experience of a crisis back to childhood, including parental loss and experiences of neglect and/or abuse, with subsequent events retriggering or resonating with this earlier experience. Racism and alienation was also identified as an explanation of the crisis presentation of black African and black Caribbean men and their disproportionate detention under MH legislation:

Racism is a factor, and it is not always blatant or overt. It comes subtly through your surroundings, through the media and so forth. When you’re struggling with feeling marginalised, low self-esteem, meeting racism everywhere you go, it impacts on you subconsciously, or consciously.

CVS7

The precarity of individual circumstances was also identified as having a bearing on MH. For example, an asylum seeker was experiencing a MH crisis because of the fear of deportation as a result of their immigration papers having not been sorted by the Home Office, and was subsequently sectioned. Similarly, housing was identified as a critical factor, particularly in site C, which had the highest rate of homelessness. The practice of ‘cuckooing’, where vulnerable people with MH problems are targeted by drug dealers who then take over their homes, was mentioned:

It starts off like friendship and they think oh god this is nice but then they start doing things to keep them under control like demeaning them; I’ve seen . . . where they’ve made them cut their toenails and stuff, to demean them and degrade them and to keep them in it.

CVS8

It was evident that, alongside complex social situations, several participants experienced complex difficulties, including experiences of MH problems co-occurring with substance use, a diagnosis of autism spectrum disorder and/or a diagnosis of personality disorder:

I’ve got multiple diagnoses; one of them is psychotic tendencies. I don’t realise when I am in a psychotic episode and I need help. The other thing is I have borderline personality disorder, with that I don’t know when it’s escalating but I do know when I am at the top and really stressed.

DCaFG

This could also serve to fuel negative stereotypes, intersecting with other forms of stigma (e.g. related to addiction or learning disabilities) and detract from people having their needs met.

Impact of the crisis

The impact of the crisis was often profound and, for some, the experience had shaped their lives:

The impact of recovering really from a crisis in a space of a few days has a knock on effect on people’s lives and for me it’s really stolen a lot of my life, you know; I’m 40 now and I’ve just got my mental health on track.

ACa3 (friend and service user)

From participants’ responses, it was possible to identify different types of impact, which interacted:

1. emotional impacts, undermining self-belief and self-worth

2. impacts on social networks and directly on family members and carers (as discussed later in this chapter)

3. changes in personal circumstances as a consequence of the MH crisis (e.g. relationship breakdown, unemployment and isolation)

4. changes arising from the service response (e.g. the sense of not being understood, being arrested by the police, being detained under the MHA in hospital, medication changes or access to different forms of treatment or therapy) and

5. changes in behaviour or perspectives.

These impacts could be negative but could also be positive, particularly when the experience led to an individual reappraising their circumstances or approach to life, on their own or with the support of informal networks or services. This was evident for those service users we re-interviewed who had reflected on the crisis experience and made changes as a consequence. These were sometimes attributed to the VSO response, as discussed in Chapter 6, but also reflected individual agency.

Service user needs in a mental health crisis

Reflecting the intensity of the experience and the sense of threat, the most commonly cited need was to feel safe – ‘to be in the safety zone’ or ‘a calm place where you could talk to people’:

You just want to be wrapped up. Safe-guarded if you like; know you’re in a safe place because perhaps you feel threatened.

ASUFG

It was evident that safety is relational – ‘building trust and confidence’, ‘being heard’, ‘reassured’, ‘accepted’ and ‘not being judged’:

I was really fed up because it was like a really vicious cycle I couldn’t escape and it was doing my head in, it was dragging me down, and I just wanted to talk to someone who would like help me reason it out and bring me thinking positively again to get me out of that deep, dark place.

CSUFG

‘Kindness’, ‘being listened to and not being dismissed’, ‘time and space to make sense of the experience’, ‘being treated with care’, ‘compassion’, ‘understanding’ and ‘humanity’ are how participants described what they needed:

When I’m in crisis or going into crisis I need people to be kind rather than kind of tough love approach, it doesn’t work with me.

BSU4

Listening and being able to share openly were important, but some participants also sought guidance – ‘a guru, someone to show me, guide me’:

Sometimes, it’s just being reminded of what I need to do and I know that sounds really silly because I know it and I should be able to do it myself, but when I can’t think because there’s too much going round in my head and I feel like I need to self-harm to be calm enough to be able to then distract myself so it’s safe to stop it going any further, but I feel like – and sometimes that phone call stops the self-harm, does that make any sense?

ASU13

It was evident that some people had ongoing, and sometimes highly complex, needs. For example, one man described having had difficulties since childhood following his mother’s death and an abusive relationship with his father. He identified as having learning difficulties and had been a regular user of crack cocaine. Living in a homeless hostel, he had been in three different prisons in the preceding 9 months, the most recent because he hit someone for spitting on him when he was homeless.

Family members’ and carers’ experiences

The definition of a carer is a family member, relative or friend who provides care for someone close to them who has physical and/or mental difficulties. Some participants were also caring for an elderly relative or had child-care responsibilities. Those that cared for someone with a MH problem did not necessarily consider themselves a carer, highlighting the reciprocal nature of caring and other roles as more important:

There’s certain connotations to it [identity as a carer] that I probably don’t really want to identify myself with. Because it’s not like that all the time; that isn’t how I would describe our relationship or what’s going on. Also I’m not infallible and I also have ups and downs or whatever, so sometimes she has to look after me. So it feels a bit kind of one-sided to call me a carer.

CCa1 (partner)

It was clear from the carers we interviewed that, in general, they were under strain, with some also experiencing their own MH difficulties. One carer had made a suicide attempt because ‘something tipped them over’, whereas another had self-harmed:

We . . . often get carers not only caring for somebody with a mental health problem, but they have their own mental health problem . . . I think stats say 80% of carers have some impact on their own mental health.

DVS4

Many of the carers had been providing support for many years. This included people who had been young carers (children or young adults) of parents or siblings who were suffering from mental distress. A participant’s father commented, ‘he’s witnessed the things from day 1, from 19, ‘cause it affected him. He had a breakdown himself . . . he was crying, when he saw me in bed’. Another participant had been a young carer for her mother and three of her siblings who were diagnosed with bipolar affective disorder, and one with paranoid schizophrenia:

Life has been strung out on managing, supporting to manage crises, but what the issue was that I didn’t really understand mental health, I didn’t understand what a crisis was, the language used in the field, to help me understand what was taking place with my siblings.

S2

There were also parents supporting their adult children who worried about the future in the event of their own death and were not confident that the services would care for them. In one situation, grandparents, with two teenage children, were supporting their daughter and were looking after her 4-year-old child while she was an inpatient. Multiple caring roles were not uncommon:

I’m happy to identify myself as a carer, which means as well as having a mum who’s very physically frail and has memory loss, most directly we’ve got three sons in their 20s and the middle one has Aspergers and the youngest, who’s 23, now has quite severe anxiety and depression.

ACFG1

All carers expressed a strong sense of responsibility, often associated with continual anxiety about the person they cared for:

Well, fear of her hurting herself, her killing herself, you know, that kind of thing. Fear of dangerous consequences or loss and that’s an understandable fear isn’t it, to have?

ACa2 (husband)

In several instances, they or another close friend or family member had intervened to prevent the person from harming or killing themselves:

It would be very frightening . . . ‘OK what do I do with this situation bar trying to wrestle him to the ground and restrain him’, because he would reach a point where sometimes you walk in and he’d be head butting the wall or he’d have taken a Stanley knife to himself and carved all over his stomach.

ASU2 (son)

The interventions to prevent a suicide generally involved calling services, usually the police. In other situations, a family member or carer had been contacted because of concern that the person was about to kill themselves. For example, the police contacted a man because they were worried that his father might be about to take his own life by jumping off a bridge. One carer (a mother) had been a victim of assault by her son:

I have another son – I had to get us out. So as soon as I could extricate myself, we ran out of the door and as I shut the door I heard a bang and he’s thrown the knife after us and it was embedded in the front door. Another time he was pushing the knife in here, oh he’s held various implements at me. He’s broken some teeth, my teeth, he got me in a headlock once.

ACaFG

Clearly, these experiences had an impact on their relationship with the person for whom they care and, indeed, on wider family members, including children. This was in a context of austerity and the reductions to public services and welfare benefits, which served to increase the stress for some carers or family members:

We’ve seen significant rise in our caseloads of carers from all walks of life having problems with housing and their mental health suffering as a result – attempted suicide, things like that. And people who are agoraphobic, who won’t go out . . . they can’t access the benefits, ‘cause they can’t get down to the job centre.

RN2

Conceptions of a mental health crisis

Stakeholders commented on the difficulty of defining a MH crisis. Nonetheless, there was a broad consensus that a crisis is marked by acute distress, an increasing inability to cope and the need for an immediate response:

This is quite hard to articulate. I would say if someone’s thoughts, feelings, compulsions, are having an immediate effect on their ability to carry on normal life – so at one extreme that could be very suicidal tendencies, at the other one it could be this sort of crippling fear of leaving the house. And somebody needs some help straight away, and it’s not always immediately obvious what the help is that they need and that’s part of the struggle.

ACa2 (husband)

For service users and carers, the urgency involved in needing an immediate response should be considered in the social and personal context of their lives, as they often described the crisis experience as a process that unfolds over time.

Crisis as a disruptive process

So it’s really hard to define crisis when it’s over a long term. I think for me it’s whether crisis is just when it’s perceived by the outside world to be a crisis because she’s nearly killed herself. That for me is quite a different definition from what I saw as somebody close to her, who was somebody ebbing towards it and away from it, towards it and away from it.

ACa3 (and service user)

Service users typically contextualised the crisis experience in what was happening in their life; relationship problems, historical and current abuse or trauma, racism, debt, and alcohol or substance use were common:

It was a series of minor crises all along the way really, and then coming more and more frequently. So it’s like about how many you’re getting, and how close together they’re all getting really. How many times a week I feel like I feel suicidal, or feel like I need to call the Samaritans. And when there’s no space between those experiences, I guess that’s a crisis.

CSU5

For some participants, crisis was described as an everyday occurrence, often reflecting fundamental existential doubts about the value of living, overwhelming impulses to self-harm, recurrent symptoms of voices or a persistent feeling of not being able to cope:

I have them every day. Well I’m a dramatic person, but I have them a lot of the time . . . where I feel sort [whispers] of suicidal or I feel like I hear voices and I just want it to stop. Like yesterday, I wanted it to stop and I was like well if I just kill myself, it didn’t matter.

ASU10

This negotiation with the self was common, with the person balancing various factors, including locating it in a spiritual context:

Well in the Quran it says . . . that if something is that severe that it is affecting your health or it’s going to put your health at risk, because we see suicidal as not halal. It’s a bad sin if you commit suicide. But if you feel like you have no other way out, you feel trapped and you feel forced, the only way you can end what’s going on is by ending your life.

DSU4

The factors that were considered in such self-negotiations reflected the resources available (including support and experience of previous responses), the potential for life changes, access to the means to kill themselves, and the meaning of suicide, including the anticipated impact of the act. This process of self-negotiation is portrayed in Figures 2 and 3 (produced by a member of our SRG), with how people think about self-harm (Figure 2) contrasted with the lived experience of self-harm (Figure 3).

FIGURE 2.

How people think self-harm works. Reproduced with permission from Rachel Rowan Olive (https://rachelrowanolive.co.uk), February 2019, personal communication.

Reproduced with permission from Rachel Rowan Olive (http://rachelrowanolive.co.uk), February 2019, personal communication

FIGURE 3.

The experience of self-harm. Reproduced with permission from Rachel Rowan Olive (https://rachelrowanolive.co.uk), February 2019, personal communication.

Reproduced with permission from Rachel Rowan Olive (http://rachelrowanolive.co.uk), February 2019, personal communication.

The distinction between the first experience and subsequent experiences of a MH crisis was identified by both the service user participants and SRG members. This was viewed as shaping sense-making, the capacity to identify triggers and, thus, self-management. By contrast, some service user participants reported that they were relatively unaware of what was happening and observed that it was those close to them who recognised the signs. This included instances in which a family member or friend, recognising the severity of the situation, had intervened to prevent the person from taking their own life.

Summary

The intensity of distress was described by service user participants, and the overwhelming nature of these feelings was associated with needing to be understood and to be treated with compassion and humanity. The narratives identified the experience of a MH crisis as a biographical disruption: an intense and extreme experience that disrupts everyday life and potentially has far-reaching consequences. A corollary of this is that the experience, and the response, cannot be disconnected from the personal and social context of living. This conception contrasts with a narrow definition of a MH crisis as an episode requiring an urgent response, which means that the underlying difficulties may not be addressed. We identified nuanced and important differences in the conceptions of a MH crisis that are enacted through the policy discourse, service configuration and professional behaviour, all of which may influence the contribution of VSOs and their relationship with public sector services. We explore this in more detail in subsequent chapters.

Organisational arrangements: charities, social enterprises or community groups?

Table 12 summarises the characteristics of the organisations that we surveyed and compares them with our sampling frame and with a wider population of organisations (covering six subsets of the ICNPO) from which the sampling frame was drawn.

The salient points of this are as follows:

1. Compared with the main ICNPO categories of interest, those that we identified for our sampling frame are likely to be larger (mean income of £3.28M) and are more likely to be charitable companies (the proportion that are companies is nearly twice as high in the sampling frame as in the ICNPO categories).

2. This is also true of the charities that responded to our survey. Although their mean income is lower than that of the organisations that formed the sampling frame, this is probably because our sampling frame included some very large organisations and survey response rates from such organisations are low. The median incomes of these two groups are almost identical (£152,771 and £154,020, respectively).

3. These results suggest that there are broad similarities between the survey respondents and the subset of charities that are of interest to our study.

We have not compared these results with the wider charity population – there seems little to be gained from comparisons with large numbers of Scout groups, village halls, Women’s Institutes, etc. – but, for charities as a whole, the median expenditure is approximately £16,000 and the proportion that are also companies is 27%. The majority of survey respondents were local in their focus (70%), with 12% describing themselves as regional and 18% as national, meaning that 30% of the organisations are larger than a typical (i.e. local) charity. Therefore, the VSOs in our sample are typically larger and more formalised than the charity population as a whole.

All of the VSOs in the sample were registered charities, but there were variations in organisations’ perceptions of themselves. First, some VSOs were keen to be seen as ‘more than’ a charity – emphasising their business-like approach. Other VSOs emphasised their grassroots origins, volunteer workforce, altruistic values and foundational ethos of user involvement. Some VSOs rejected the paternalistic connotations of ‘charity’:

We don’t want to be a charity; people feel it inhibits what people can do. I think there are arguments for and against that, but we are regulated as a company and of course you know that the financial regulations as a company is more tough than the regulation as a charity.

S24

Second, the degree of closeness to the public sector is far from simple (as discussed in Chapter 7). It can involve VSOs either opting to work closely ‘in partnership’ with the public sector (regardless of their exact sources of funding or ‘resource base’) or seeking direct funding for their work through grants or contracts from the public sector (typically in commissioning processes).

Often, VSOs are adept at blending a complex mixture of funding sources and ‘hiding the wiring’, but this can play out in many different ways in terms of the degree to which they seek to integrate themselves with statutory services, or indeed maintain a high degree of independence or autonomy. We will explore this further in Chapters 7 and 8.

Types of voluntary sector organisations providing mental health crisis care support

From the survey, VSOs that could be formally described as a ‘crisis service’ were in the minority. Just under one-third of respondents said that they actively promoted crisis support services and 13.5% of the total number of respondents characterised themselves as crisis services. A further 19% said that they provided some services to people in crisis. This suggests that we need to distinguish between ‘formal’ crisis VSOs and ‘informal’ crisis VSOs (i.e. those services explicitly established for crisis support vs. those VSOs set up for other purposes – such as dealing with a specific population or with general MH – that also provide crisis support). From the survey data, we identified five different types of VSOs that are contributing to MH crisis support. The different types of VSOs may overlap, but this distinction, as illustrated in Figure 4, was useful for mapping the different VSOs and their contribution to MH crisis care. They were:

1.  Type 1: VSOs explicitly set up to provide crisis support and that promote access to support in a crisis for people experiencing mental distress. There are three broad forms of type 1 VSOs: those providing accommodation (crisis houses); those providing a safe space, listening and social activities; and those providing telephone helplines for people who are feeling suicidal or in a MH crisis.

2.  Type 2: VSOs active in general MH that provide a wide range of services for people experiencing MH problems, including support in a crisis (officially and unofficially, for example branches of larger MH VSOs and ULOs).

3.  Type 3: VSOs set up to support a specific population that may be vulnerable to MH crisis [e.g. women, members of the lesbian, gay, bisexual, transgender and queer (LGBTQ) community, those who are deaf, BAME communities, refugees and ex-military personnel]. These organisations are particularly knowledgeable about the issues facing a particular group of people and, although they do not have a specific focus on MH, they often cover a wide range of health and welfare issues.

4.  Type 4: VSOs providing a response to a psychosocial or contextual crisis (e.g. bereavement, pregnancy, rape, domestic violence or homelessness), which means they are likely to encounter people experiencing a MH crisis.

5.  Type 5: community and social organisations used by the whole population or particular groups (e.g. churches and faith organisations, welfare and social support).

FIGURE 4.

Voluntary sector organisations providing support in a MH crisis.

Type 1 VSOs were most commonly identified by statutory services as contributing to crisis care.

Table 13 provides a description of the prime functions of the different types of VSOs illustrated in Figure 4.

Approach

Across the different types of VSOs, the following characteristics were identified as defining their approach:

• having staff and volunteers with lived experience

• blurring the boundary between being a service user and a peer or volunteer

• being responsive to community needs

• being flexible

• having a strengths-based approach

• involving service users and/or carers/families in the organisation and governance.

Many of these features reflected the VSO’s relationship with communities, whether this was a specific population or a geographical area, combined with a ‘can-do’ attitude:

We’ve got that absolute direct finger on the pulse out there working within community groups, picking up networking with other relevant VSOs, feeling the groundswell and thinking there’s a real need here; right we’ve got to do something about it.

S18

In some instances, this resulted in the initiative being taken to develop MH crisis-specific services, which had the following features in common:

• a positive stance on MH underpinned by a social model paying attention to the social context of people’s lives

• providing space and time for the individual to speak about their distress

• providing a safe, calm and welcoming environment and relational safety

• informality and providing a light touch in terms of assessment and notekeeping.

Frequently mentioned values underpinning the approach of VSOs included putting the person first, kindness, compassion, humanity and hope. The approach of VSOs was often contrasted with that of statutory services and the NHS, in particular in terms of their flexibility and their capacity to be more focused on an individual’s needs:

So for us not being tied rigidly to six sessions, not being tied rigidly to the entry criteria and not being tied rigidly to geographical criteria are extremely important.

CVS3

One participant attributed the more favourable assessment of VSOs to the fact that the expectations of these services are different from those of statutory service provision:

When something’s voluntary, I think people have . . . a different relation to it because when something is a state provision and you pay taxes . . . we have a right to it . . . You don’t really have that in the same way about a voluntary organisation, you don’t have that expectation, it’s something that is kind of benevolent and it’s there for you despite the fact that you haven’t done anything to sort of warrant that.

CCa1

More commonly, the key axis for comparison was the biomedical (often referred to as a clinical) approach of NHS services versus the social approach of the VS:

You know the biggest issue we have with people is loneliness and isolation. We know that. But loneliness and isolation I think could be dealt with in different ways. Third sector are far better at it than we are. We’re trained clinicians. We will diagnose a dead stick.

CMHP6

A clinical approach was characterised by diagnoses, formality, social distance, demand (as opposed to need) and bureaucracy, including thresholds for determining access. In contrast, a social approach was described in terms of the contextualisation of the crisis, ‘person-centredness’ and need, reduced social distance, open access and responsiveness:

Informal I’d say, because when you come in you’re not frightened of the procedures, the bureaucracy aspect is taken away and like there’s nobody bugging you, . . . you just come in.

ASU4

An important aspect of the VS approach was ‘normalising’ people’s MH crisis experience, which reflected the blurred boundaries between service users and staff, meaning that people could identify with and connect to each other more readily than the us/them approach experienced in encounters with NHS services:

Often they try to normalise the person’s recovery, . . . they support self-management . . . they’re very much part of their recovery in that way. And also when you’re working with other agencies, they aren’t medicalising the problem. You’re getting far more of a person-centred sort of social oriented view of the person, which I think is more normalising for people.

AMHP6

Participants also identified that the VS was better positioned to take a more holistic view of the crisis experience and, thus, was more responsive to the complexity of people’s lives:

I think the voluntary sector’s far more open to the . . . notion of complexity. [It] isn’t really an issue because they just appreciate that people come with all sorts and their very existence is based on seeing people and doing that work . . . They seem to exist a bit closer to the community they serve . . . and so I think they’re a bit more – it sounds terrible to say – person centric as opposed to diagnosis centric.

BCaFG

The social approach was consistently identified by service users as supportive and a helpful first step in enabling them to ‘recalibrate’ (i.e. to become calmer, recover their sense of self and to start to address their difficulties, as discussed in Chapter 6). This approach provides the foundation for a different kind of relationship, namely an accepting and non-judgemental relationship, which extended to the response to suicide and self-harm:

I get the feeling that a lot of people who work in the voluntary sector have gone through problems themselves and they understand more where you’re coming from. I’d quite often experience with the NHS, maybe because I wasn’t dealing with the problem very positively, but the NHS people would get annoyed with me and frustrated.

ASU6

Having more time was also identified as a distinctive aspect of the approach of VSOs in contrast with the NHS, as one peer support worker observed:

GPs only have 7 minutes, so no time to explore. It’s like they have a split personality; ask ‘what’s your symptoms, ‘cause it’s really awful you feel that way’, but they won’t say ‘we’re going to help you through that experience so you get stronger’.

CVS7

The VS is rich and diverse and there will obviously be differences in the extent to which these approaches and values are operationalised in responding to people in a crisis.

Service provision

The VSOs described in Table 13 offer a wide range of services, as illustrated in Table 14. The following sections describe, in more detail, these interventions.

Voluntary sector support across the crisis journey

In this and the following two chapters, we have provided examples of the contact that different participants made with services across their journeys. These were developed from the narrative interviews and in the repeat interviews; we invited participants to sketch out their crisis journey. We subsequently developed a schematic representation that also draws on their explanation of their journey. The importance of illustrating individual journeys is to demonstrate the ways in which the various different VSO types contributed to supporting people with different aspects of their crisis, using some of the different kinds of interventions identified. To ensure anonymity we have used non-binary description, unless gender was an important aspect of the narrative. Although all service user participants had some contact with public sector services, only some received support from a type 1 VSO across their whole journey, whereas others received support from a type 1 VSO in combination with the other types of VSOs. Some service users received no support from a type 1 VSO at all, but received valuable support from type 2 and 3 VSOs in combination with public sector services. Some of these variations are related to the availability and awareness of services between local areas (see Chapter 6 for more details) and some relate to differing personal contexts, needs, referral routes and relationships between services. However, what they all indicate is the complex nature of individual journeys and how active people often are in managing this for themselves. Figures 5 and 6 show the contacts that different participants made with services across their journeys. Statutory sector services are coloured light blue and VSOs are coloured orange. It should be noted that not all participants gave specific time scales for when services were contacted or for how long, but where possible an indication is given.

Figure 5 illustrates how one woman (DSU4) drew on different types of VSOs to address the trauma of domestic abuse, which was associated with depression and suicidal feelings. DSU4 had accessed a course run by a community organisation (type 5), support from a specialist sexual violence charity (type 4), cognitive–behavioural therapy from a type 2 VSO and counselling from a type 4 VSO. DSU4 accessed the same type 5 service on two occasions. The first course/programme that was offered by this service was not completed by DSU4, but accessing this type 5 service had a profound impact on her well-being and prevented potential loss of life; it enabled her to have a better understanding of their position (the course helped DSU4 to understand that the abuse ‘wasn’t my fault at all; in fact it was probably the opposite’) and gave her the confidence to leave their abusive relationship, which, they thought, saved their life. DSU4 revisited the same type 5 service, a type 4 service for domestic violence survivors and public sector services the following year. This was at a time when DSU4 had suicidal feelings and had hit ‘rock bottom’. Completing the type 5 course (which she had not completed the year before) helped to alleviate suicidal feelings and, she thought, had again saved their life: ‘I don’t think I’d be here if I hadn’t done this course’. DSU4 continued to receive support from this type 4 service and continued to have regular GP check-ups throughout 2018 and 2019. A growing pressure from family members to reconcile with DSU4’s abusive partner led DSU4 to seek cognitive–behavioural therapy from a type 2 VSO and counselling from a type 4 VSO; by accessing these services, DSU4 became more self-reliant, drawing on her personal resources and using self-help measures in preference to VS and public sector services.

FIGURE 5.

An illustration of the contribution of the VS across the crisis journey (site D).

Figure 6 illustrates the complexity of another participant’s (BSU7) situation and how they drew on various VSOs, as well as on the NHS, for support. The context of BSU7’s MH crisis is multifaceted and relates to adverse life events, religion and spirituality, and cultural identity. Following a breakdown related to childhood abuse and an abusive relationship in adulthood, BSU7 was told by fellow church-goers that they were ‘possessed by the devil’. BSU7 believed this and the ensuing spiritual angst and pressure from the church contributed to a heightened and ongoing crisis. The nature of the support that BSU7 relied on from the church as a type 5 service contributed to their subsequent crisis. This led BSU7 to seek support from other local groups and they found support from various type 2, 3 and 4 services. BSU7 did utilise – and in some cases was signposted to – NHS services, but BSU7 did not have a good experience with these public services and often returned to seeking help from VSOs. BSU7’s crisis was exacerbated by repeated questioning of their religion as a consequence of consulting different type 5 religious organisations, which espoused conflicting religious ideas and the nature of BSU7’s crisis. It was as a result of support from a type 3 organisation that BSU7 was able to reflect on how their experiences and religious questions were affecting their cultural identity; this enabled BSU7 to ‘feel new emotions’. However, although this helped BSU7 to see how the uncertainty of their religious views and changing cultural identity had contributed to their crisis, these new emotions ultimately led to an episodic crisis during which BSU7 turned to a national helpline for support.

FIGURE 6.

An illustration of the contribution of the VS across the crisis journey (site B).

These journeys illustrate the complex and multifaceted support mechanisms that are offered by VSOs. Services, both VS and public sector, are often used in tandem. Service users seek support from VSOs for a wide range of needs and the support they receive is often specific to their situation or circumstance, and often different types of VSOs offer different types of support that complement each other. It is also plain to see that VSOs are not a ‘one-stop-shop’, nor is a service user’s engagement with them transitory; service users can and do revisit VSOs, and their pathway through VSOs is often winding and non-linear.

Summary

Through the use of multiple methods, we have identified the breadth and range of the VS contribution to MH crisis care. Type 1 VSOs are most commonly identified as having a role to play in MH crisis care because they are (1) one of the elements providing an urgent response to someone in crisis and (2) formally commissioned by the public sector to do so and/or access to their crisis support is via the NHS. As well as an immediate response to a MH crisis provided by type 1 VSOs, type 2 VSOs offer preventative activities, support recovery and quality of life for people. Type 3 and 4 VSOs offer specific skills and knowledge in engaging with and responding to people who may not access statutory MH services or are experiencing a specific life event. Our findings, therefore, suggest that the nature of the VS is distinctive and, in comparison with public sector services, the VS is responsive to a wide range of MH needs.

The contribution of voluntary sector organisations in the case study sites

The typology described in Chapter 5 guided the selection of the case study sites used to investigate different types of contribution, particularly in relation to type 1 crisis services and their relationships with NHS services. Table 16 provides an overview of the VSOs in each site, identified by participants. All of the sites had a helpline with a local branch of a national VSO and two of the sites had user-led helplines, through which callers could access peer support (sites A and C). Two of the sites had a crisis house (sites B and D), both of which provided beds for people in a crisis, and the other two sites offered a safe space out of hours (sites A and C). In three of the sites, access to crisis-specific VSOs, notably the crisis houses in sites B and D and the safe space in site A, was determined by the NHS, whereas all of the helplines were open access. In each of the sites, there was a wide range of the other types of VSOs, reflecting the local political and organisational context for how the VS had evolved to respond to local needs.

Access to voluntary sector crisis support

Access to crisis support is predicated on identifying the need for support, by the person themselves; by a close relative, friend or carer; by a member of the public; or by public services, such as the police. Although many participants referred to several factors, the most commonly cited factor was the intensity of the experience, particularly the level of distress and the perceived risk of harm or to life. Most commonly, service users commented that they had accessed support from type 1 VSOs because they thought that their situation would escalate and possibly lead to self-harm or suicide. People may have made contact with the other types of VSOs (i.e. not type 1 services) when they were experiencing a crisis and two factors influenced this: first, the existence of an established relationship with the VSO or community organisation, thus providing an obvious point of contact, albeit limited by its availability out of hours, and, second, whether or not the crisis was intimately linked to the person’s social context or a specific life issue (e.g. sexual and/or domestic violence, homelessness or insecurity about leave to remain associated with seeking asylum).

The factors identified as influencing access in a crisis can be broadly split into system- and individual-level factors, as illustrated in Figure 7 and described below.

FIGURE 7.

Factors influencing the decision to contact crisis services.

System-level factors determining access

Location and availability of voluntary sector crisis services

Access to VS support in a crisis is dependent on the configuration of the crisis system and the range and availability of VS services. Figure 8 illustrates the distribution of type 1 VSO provision across England and distinguishes between availability in terms of 24-hour provision (e.g. crisis houses) and non-24-hour provision (e.g. safe spaces, crisis cafes and sanctuaries), including both VSO and hybrid models (i.e. NHS and VSO joint provision). This map does not provide a comprehensive picture, as new services are rapidly emerging, reflecting the current policy focus and investment in MH crisis care. 19 In addition to these VS services, there are a wide range of helplines, including both national [the most well-known of which are the Samaritans117 and the Campaign Against Living Miserably (CALM)]118 and local helplines that provide listening services and access to further support. These include those that are user led, providing a peer service; those targeted at specific groups, for example CALM focused on men; those that cover a specific area, for example Nightlink for Cornwall residents,119 and some that are both population and locality specific (e.g. Womankind in Bristol). 120

FIGURE 8.

Map of type 1 VSOs in England. © OpenStreetMap contributors. Data available under Open Database License.

© OpenStreetMap contributors. Data available under Open Database License.

Figure 8 highlights significant variation in the availability of VS provision and demonstrates that people living in more rural areas are underserved. VSOs are typically located in the main centres of populations and thus access is problematic for people in rural areas with limited public transport links and a limited income. One type 1 VSO would arrange taxis for people living in rural areas, but this arrangement did not appear to have been sustained and some people were unwilling to travel far. From the regional mapping in WP2, it was clear that even within the same region there were variations in provision that did not align with population density or deprivation (see Appendix 15). London-based services were reported as having something of an advantage because people were often able to access VSOs in other boroughs or VSO provision had developed to meet specific needs, reflecting greater population density. Access to VSOs was clearly challenging for participants who had moved from an area with provision to an area without provision, and we did not find evidence that there had been collaboration between VSOs in different areas to address this.

Of the national survey respondents, half identified that their services were open only on weekdays, with a further sixth open at weekends and one-third open in the evenings or at ‘other’ times (presumably outside usual day-time working hours). The out-of-hours provision was more likely to be type 1 services and had been introduced to address this identified gap in support. From the mapping, we identified that some type 1 services were available only one or two evenings a week, typically at the weekends, and this was more likely in rural areas. Some VSOs had experimented with both the location and the timing of their services to increase access.

The threats to the sustainability of the VSO and the contraction of public services also have an impact on service availability. One psychiatrist observed, for example, that the closure of a community drop-in service for people in crisis had adversely affected rapid access to support for African and Caribbean men. This appeared somewhat short-sighted given the disproportionate rates of detention for this population.

Eligibility criteria

The eligibility criteria for access also meant that certain groups were commonly excluded by VSOs and by public sector services. For VSOs, the exclusion criteria referred to by survey respondents were:

• people who use substances, particularly those under the influence of alcohol or drugs

• people under certain age limits, particularly under 16 or 18 years of age

• people with violent behaviour or with convictions for sexual offences, arson or violent behaviour

• people who could not engage with the service or who abused the service (e.g. abusive calls to a helpline)

• more rarely, people with a diagnosis of psychosis under the care of specialist MH services.

Other VSOs had criteria that reflected their objectives and, therefore, were targeted at a specific population, (e.g. women’s centres) or restricted access to a specific geographical patch. These criteria were by no means universal and it was evident that some VSOs were flexible in their interpretation, for example recognising that, for some people, substance use provided symptom relief.

Awareness and perceptions of voluntary sector crisis service provision

Overall, there was a lack of awareness of what the VS provided among MH staff and service users. Indeed, we found it difficult to find information about VS crisis services when we were developing Figure 8. Although this was largely because some of these services are new or yet to be established, a general lack of information about how to access support in a crisis and what the VS provides was evident:

I think more work needs to be done to promote mental well-being and awareness of crisis services, because even I had to go and look at a leaflet like this to find out what is being offered. How readily available is this to people with poor mental health . . ., so promotion and education can create an awareness about provision of these services, so that everybody knows what to do when they’re going through a mental health crisis.

BMHP1

Generally, people knew of the large VSOs, but were less likely to know about smaller organisations or were unaware that types 3 and 4 make an important contribution to crisis care through offering specialist tailored services. This is further compounded by the instability of funding for the VS, which leads to changes in the landscape of provision:

Finding out that information is quite hard and patchy and, in the meantime, if you then are going out to see somebody who you want to signpost, you don’t want to do them the disservice of signposting them to something that doesn’t exist.

AMHP3

Often, ULOs had established networks, and information about them was communicated by word of mouth. People were often given leaflets or signposted to other VSOs but, in some instances, they may not have had much understanding of what they were being signposted to or how these organisations could help. Knowing what was available was even more challenging for carers and family members. The one exception to this was the Samaritans:

I rang the Samaritans. When it gets really bad you end up thinking that everyone will be better off without you and I remember locking myself in a bathroom because it got really that bad that I was going to slit my wrists. I remember getting to the bathroom but I had my phone and I rang the Samaritans and I was crying down the phone to the Samaritans and they talked to me and calmed me down and things were getting okay.

ASU3

People who had used NHS services in a crisis were more likely to be knowledgeable about VS provision. This was often not the case for people experiencing a MH crisis for the first time: ‘I was thinking what’s the [safe space], what am I doing, where am I . . . is it a hospital, is it a group, is it a . . . what? Because they hadn’t explained to me what it was!’ (ASU5, repeat interview).

Once people had used a specific VSO, they found access easier and, in some instances, although the type 1 service was technically gatekept by the NHS service, some participants mentioned that they had rung the VS directly or known what to say to facilitate access:

But you can ask to go there, say things to make them kind of trigger something to make them suggest the [safe space], you can just say ‘can I go to the [safe space]’ and they’ll say ‘yeah’ or whatever. But no one’s mentioned [it], it’s almost like it’s a secret. You’ve got to be in this little club, like it’s some little secret place that no one’s meant to know about.

ASU5

The reasons given for the NHS gatekeeping direct access to type 1 VSOs included ensuring that people were directed to the right place and that people were not acutely unwell and, thus, did not require specialist NHS services (e.g. the CRHT). The effectiveness of the gatekeeping arrangement was contingent on a well-developed and accurate understanding of the VS offer, as well as on positive collaboration between the sector and the NHS service, as will be discussed in Chapter 7. It was clear that this gatekeeping role could serve as a barrier to access, with service users expressing a preference for open access. However, in site A, the introduction of an NHS crisis helpline was evidently serving to facilitate access, as illustrated by a woman with an experience of postnatal depression, who on the repeat interview described how much her situation had changed. As illustrated in Figure 9, ASU6’s journey began with postnatal depression, followed by an eating disorder. This led to hospital admission under the MHA and a year of treatment from an NHS community personality disorder service. ASU6 subsequently attended the local Recovery College, which contrasted positively with her experience of other NHS services. Following discharge from NHS community services, ASU6 was repeatedly overdosing, calling 999 and ending up in A&E. When an NHS helpline was introduced, linked to NHS 111 and promoted via crisis cards, ASU6 began calling this service and accessing the safe space as an alternative to overdose. The VS staff enabled access to counselling, which ASU6 identified as a major influence on subsequent recovery from both long-term difficulties and repeated crisis experiences.

FIGURE 9.

Access to VS crisis support (site A).

Social context for distress and availability of social support

As noted in Chapter 4, the social context and ready availability of support is intimately linked to the conception of a MH crisis. There was a reasonable range of VSOs providing support to people experiencing specific life events and VSOs that engaged with specific populations. These organisations would receive referrals from other VSOs that recognised their specific expertise and contribution. This was less reported by MH staff, with the exception of a specific VSO direct-access hostel for homeless people. Families and carers provide an important element of crisis care support, but, as noted earlier, many participants were estranged or living at a distance from their families. For those who had a supportive relationship, VSO crisis services (with the exception of carers’ organisations), like the public sector, were generally not engaging well with these support networks.

The role of community and the social context was explicitly mentioned by three VSOs, which were developing and running initiatives that recognised the importance of community and had initiatives targeted at building community capacity by, for example, creating spaces for social groups, such as a knitting group, to meet. The community was also identified as a barrier to access, as noted by a MH VSO focusing on the black community:

Within the black community as well I think mental health problems is a big kind of disgrace, kind of shame . . . It’s actually getting individuals to say ‘I have a mental health problem’.

BVS4

This stigma operates at an individual level and is not restricted to BAME communities, as discussed in the following section.

Signposting and referral routes

There are several potential routes through which people might access services and most VSOs had more than one. As Table 17 shows, there is a relatively high degree of self-referral, which does not vary by organisational size.

Both stakeholders and service user participants identified easy methods for self-referral as facilitating access:

We operate an online referral system or you pick the phone up to us and we get you in, you don’t have to fill out a complex form . . . We know from doing the online referrals that we’re getting more self-referrals because people are browsing the internet late at night, they can make a referral there and then and we’ll pick it up and follow that up with them.

DVS5

However, access to VS services that are crisis specific (type 1) and the other types of VS support differed in our study sites (see Table 18). Access to two crisis houses and one safe space was being gatekept by the NHS in three of the sites, although one was considering moving to open referral. By contrast, a wider range of VSOs provide open access, as was also the case for crisis-specific helplines and user-led services. This was highly valued by people in crisis needing support. After self-referral, the most common routes are via primary care and community MH services (see Table 17). GPs, MH staff and the police, however, were more likely to signpost than to refer to VSOs. This may have reflected their limited awareness of the VS, but governance concerns were also raised, meaning that some staff were more comfortable leaving it to the individual service user to pursue VSOs rather than make a direct referral:

If you’re referring someone on to a public sector service you tend to refer them, to voluntary services you tend to signpost, though some of them you would refer to, like a large established VSO but I think there is a danger that you might be signposting people to things that are inappropriate or possibly have changed their remit.

AMHP3

The perspective that the VSO was plugging the gap for people who were either unable to access public sector services or on a waiting list is supported by our data. Waiting lists for psychological therapies and specialist services (e.g. people identifying with a personality disorder or experience of abuse) were commonly referred to. It was not uncommon for people to self-refer to a VSO while on a waiting list, or to be signposted to a VSO by the public sector. For example, one participant had been simultaneously referred to IAPT and a VSO by her GP, who anticipated a waiting list for the NHS service. Participants also identified other gaps, as summarised in Table 18.

Quality of voluntary sector support

The quality of the VS response was widely praised, in particular the way in which people’s concerns were taken seriously with kindness, sensitivity and responsiveness – ‘a place where time did not matter, you’re number one’ (ASU3):

The staff here are absolutely amazing, you know. They’ve got such a way of explaining things, without hurting anyone’s feelings, without, with just . . . getting their point across, without offending anyone. And it might not be about a situation, it might just be an example you know.

DSU4

Although being able to see the same person was identified by some participants as important, for many it was the consistency of the approach and relational safety that was critical:

It’s somewhere where somebody is just one-to-one with a person; it’s confidential, very confidential, because I had problems with the confidentiality because my workplace was a place that they couldn’t keep anything safe and, you know, I lost trust in people. Here, I felt safe.

CSU11

Many of the participants indicated that they would use a named VSO in the event of a future crisis, with a sense of having a safety net:

The fact that I feel I can go back to them if there was something that was ever wrong, the fact that I know how to get help now and if you ask my husband I don’t think he would know how to get any help for me. They’ve been really, really helpful; if they weren’t there, I don’t think I would be sitting here right now, that’s how crucial they’ve been.

ASU3

The provision of the service by peers with similar experiences made a difference:

That initial conversation at the [safe space] made a huge difference because I . . . felt like for the first time there was an option where if you have a mental health crisis you can sort of learn to deal with it with somebody, not just yourself, because it makes it 10 times less stressful when you do it with somebody who knows exactly what you’re going through . . . It made a difference, it made me feel better and I did feel better.

ASU4

There was also a sense that having peer supporters involved reciprocity and the organisation being a collective effort. One participant had, however, been put off by the VS staff not being qualified MH professionals, although the manner and approach of the volunteer had helped her establish a trusting relationship. There was clearly a high degree of trust and the quality of relationships created a sense of safety, where it was possible to ‘talk about anything’. This included discussing suicidal feelings without a fear of being judged, which was often contrasted negatively with experiences of the NHS:

There’s something about the [type 1 safe space] . . . Everyone I . . . encountered there, and they are all volunteers, they were tremendously friendly and supportive in a way that I think is not necessarily characteristic of accessing the health-care facility. I felt like people really kind of cared about me [and] you can’t kind of underestimate how important that is to people in that situation.

CSU10

Increasing the size of VSOs and the formalisation of the service model through commissioner-led crisis models was identified as potentially posing a threat to this ethos and approach: ‘[T]he bigger VSOs become, the more restricted they become, the harder it is to engage people on a compassionate level’ (CVS7).

It was suggested by one VSO participant that there may be lessons from the formalisation of advocacy services through the introduction of public sector advocacy (i.e. independent MH advocacy): ‘a pushback to return to the “grassroots” of advocacy where they had more time for people; take more grassroots inspiration and action’ (BVS6).

Most of the dissatisfaction with the VSOs usually focused on access and lengthy waiting times for follow-on sessions for one-to-one support or therapeutic programmes. A small number of people found the informality and lack of privacy challenging:

The fact that it wasn’t like a GP’s office, it wasn’t a medical professional, is also kind of off-putting . . . I felt very awkward about meeting an entirely new person that I’d never seen before in my life and then just pouring everything out to them. And while there’s also a lot of other people just walking through this house and sometimes in the room you’re in potentially they’re just hearing snippets of the conversation.

ASU15 (repeat interview)

Nevertheless, this young man who described social anxiety had used the VSO on several occasions. Rarely, negative staff attitudes were mentioned and the highly positive evaluation was in stark contrast with that of NHS provision, as presented in the next chapter. The general theme, however, was that being listened to and being taken seriously is of great importance, whatever the service: ‘[M]an I did feel a lot worse after getting off that phone call [VS helpline], so much worse. They just make you feel like you’re just not important’ (DSUFG).

This raises questions about how to maintain a respectful and positive approach to people experiencing a MH crisis. Negative comments about VS and public sector staff suggest that responding well to people experiencing a crisis can challenge the emotional and psychological resources of staff. Similarly, maintaining an informal and friendly approach (as opposed to a technical and didactic approach) to courses offered by the VS was highlighted, alongside the individual skill of the course leaders in engaging course participants and maintaining an individualised approach.

Adequacy of voluntary sector provision

Impacts of voluntary sector support

As well as being highly valued, service users identified the difference that VS support had made to them, in terms of both the immediacy of the crisis experience and the longer-term impacts on their well-being. These impacts were consistent with meeting the needs that they had identified, as presented in Chapter 4.

For individuals, carers and their families

‘Rebooting my mind’

The support from the VS was identified as enabling people to better manage their MH. In the immediacy of the crisis, time and space away from the context of the crisis, provided by crisis houses and safe spaces, allowed the person to ‘take stock’:

Well [the crisis house] helped me out a lot ‘cause when I got there, that give me a good break for 3 weeks away from everything. It took a lot of stress off me, give me chance to reboot my mind and get me going again, and then work from there.

BSU5 (repeat interview)

Although the impact of immediate support on calming the situation was positively evaluated, the limitations, particularly of helplines, were acknowledged: ‘just calm you down a bit but they’re not going to fix you’ (BSU4, repeat interview).

Giving voice to experience and being listened to

Being able to give voice to the experience cannot be underestimated and many participants referred to the freedom offered by the VSO to ‘be me’, reflecting the sense of relational safety discussed previously. Being listened to, the support in ‘talking you down’ and ‘taking the pressure off my head’, and helping people to feel calmer led to the crisis being deescalated:

Personally, I think it’s been excellent. I was made to feel very, very welcome and it filled a need; I was under no pressure and it was having somebody who actually sit and listens to you, and doesn’t judge you anything and doesn’t put you under pressure to speak. She was always there so was always there for me to speak to, to speak questions. But she never put any pressure on me . . . and I found her voice very reassuring. She helped me a lot.

DSU5

Although listening is identified as one of the core activities of the VS response, it was evident, as implied above, that this was an active, not a passive, process:

It wasn’t just listening and being compassionate. It was sometimes suggesting where things maybe weren’t serving me very well, thought patterns. Or just useful images or strategies to deal with things. But it wasn’t formalised like that, it was just things that came from his life experience . . . My experience was that, as well as listening and keeping track of where I was, he would also try hard not to tell me what to do ever, but make suggestions sometimes.

CSU10

Participants also described how this process of active listening had conveyed hope and enabled them to feel that they could deal with the situation: ‘somebody was there listening to me and also saying you can do it, you can go through, you know’ (CSU11):

Finding that relationship where I felt I could open up to someone and I thought I could actually let someone in, which I’d never been able to do before, was a big eye opener for me; it gives you that sense of, well, actually, I can do this. She hasn’t come at it as the textbook, she’s coming at it as a human being . . . Someone that can actually relate to you that’s been through that type of trouble and crap and can actually say, well, you know, I get bad days too, it’s normal, you’re not getting someone going ‘oh my god, you have a hyper day or you’ve gone manic, let’s get you on the next medication’.

DSU2 (repeat interview)

The provision of support by peers facilitated a sense of solidarity and of being understood, and this was highlighted in relation to BAME VSOs:

I’ve learned a lot since I’ve been here [type 2 VSO] and the staff are like a family to us, you know; they treat us with respect . . . They’ll help you in any way but if you don’t help yourself you’re not going to get anywhere . . . So I need a place I come there for, so, I fancy, black communities it’s like we don’t get much help.

BSU3

Developing strategies for addressing challenges and future crises

Reflecting on the crisis experience and VSO support, several participants described how they learnt something about themselves and changed their perspective:

I kind of just accept it as ‘that’s my life’ really and I don’t really spiral on the negative things that happened anymore. When I think about bad things that happened in the past I stop myself and start thinking about positive things that have happened in the past, and try and relive those memories.

ASU3

For some, this was identifying specific triggers and, for others, it was a sense of what was missing in their life that they needed to address. The benefits of courses offered by the VS and specific VS therapeutic support were identified as enabling participants to develop a better understanding of themselves and to develop practical strategies to manage their MH:

My anxiety levels are just getting to the point now where they’re non-existent and it’s the same with the mental health; it’s just, like, the [VS] course has helped me that much; I would say it helps you control your overthinking, learns you how to deal with unresolved grief, definitely; helps you to like yourself more, as a person, and the ability to learn that everybody’s human and they make mistakes. It’s not hanging onto that, it’s like hanging onto the past and going round in a groundhog day, whereas I’ve learned to let go of it with the [VS] course . . . now I feel different about myself altogether.

DSU3 (repeat interview)

This course, run at a community centre, aimed to enable people to make sense of their experience, offered practical strategies and increased self-awareness and the potential for self-management. For this man, who had made a suicide attempt, the course proved more effective than counselling, which he had previously accessed via his GP, and he attributed this to meeting people encountering similar issues. While aiming to increase an individual’s repertoire for dealing with symptoms, such as panic attacks or suicidal thoughts, such courses also build a sense of solidarity. Furthermore, the value of signposting to other services, including programmes or therapeutic support provided by other VSOs or providing information and support in relation to wider issues, notably housing or welfare benefits, was highlighted: ‘[I]t makes a lot of difference and [she] gets the ball rolling quick, and more people getting help and seen to calms people down because somebody’s coming to listen to you’ (BCaFG).

Carers also highlighted the value of information and VS courses that had helped them develop a better understanding of MH and improved their strategies for coping with their situation:

I’ve attended quite a lot of different courses myself and had I not, I wouldn’t be where I am today because at least I have the understanding, i.e. when a crisis is approaching or what to do in a crisis . . . Well I can say it’s definitely helped me and it’s also helped me to cope well in my caring role.

CCaFG

Preventing suicide and self-harm

Several participants reported the difference that the VSO had made in terms of preventing suicide and self-harm:

As a gay you are not welcome . . . and then . . . every Wednesday I was, going there [type 1 safe space]. My life was without direction and it was so difficult for me. I’m telling you, without all this help I would have not survived.

CSU12

Figure 10 illustrates the crisis journey for this man, who sought asylum in the UK because of persecution in his home country owing to his sexuality. The VS featured in his journey through a range of services in combination, including, but not limited to, specific MH crisis support. He received support from a type 1 VSO via a referral from his hospital consultant, who also referred him for psychological therapy at the same time. Although he viewed the NHS psychological therapy very positively, he had to wait months for access. During this time, he was able to access the type 1 VSO within a week of being referred. Alongside this crisis-specific support, he also received support from multiple type 3 VSOs, which addressed specific issues in his personal context, relating to his sexuality, his status as a refugee at the time of the crisis and his distressing dealings with the Home Office (which had detained and questioned him about his reasons for seeking asylum). The legal support he received from a national asylum seeker VSO (type 3) assisted him in gaining asylum seeker status and being released from detention, which was a significant factor in his MH crisis. The ongoing support of a local refugee and asylum seeker VSO (type 3) helped meet some of his basic needs. In addition, he developed social connections and gained acceptance through attending a LGBTQ network (type 3).

FIGURE 10.

The impact of the VSO on a crisis journey (site C).

The participant who took their own life during the study had used two type 1 VSOs on several occasions, as well as NHS MH services, including inpatient admissions. They were on a waiting list for a programme offered by a type 2 VSO but possibly enabling them to address their complex difficulties would have required specialist psychotherapeutic support, which they did not appear to have been offered.

Increasing social connection and support

The input from VSOs had enabled some participants to evaluate their social support and to develop new connections through VSO activities and through peer support. The value of the opportunity to become a volunteer or peer supporter was identified by several participants and, for some, gave meaning to the difficult nature of the crisis experience. Several VSOs offered training to become a peer supporter, whereas others provided other volunteering roles or opportunities, which also provided structure and social connection.

Volunteering and employment

For some, volunteering could provide a path to employment:

My whole experience prior to that had been not functioning, not sleeping, just not really there to be honest. It was volunteering in [type 2 retail shop] that has just enabled me to have more of a life. It was when I was put behind the till in the shop that my mind started to work again.

DSU9

In addition, a small number of participants had used VSO support while still in work or off work because of MH difficulties, and this had enabled them to retain their job or change direction. Others had used their skills or developed new skills through the various activities offered (usually by type 2 and 3 VSOs). For example, one participant had developed their passion for art and now runs a local gallery.

Summary

Whether or not people experiencing a MH crisis are able to access the right support in a timely manner provides an indication of the capacity of the wider MH system and reflects the specific context for the evolution of the VSO. The access to type 1 VSOs tends to be restricted by NHS services. Although this may mean that people with higher needs or people presenting with greater risks are assessed by MH staff, self-referral, a rapid response and face-to-face support are clearly valued by service users. It is notable that some people preferred to use VSOs rather than the public sector. The VS services in our study were widely appreciated, evaluated positively and trusted by people in crisis. They offer specific expertise and peer support, and their distinctive contribution is their ethos and approach, which is highly relational and socially oriented. They play an important role in both prevention and recovery by enabling people to manage their MH better, facilitating access to a wider range of support and services, and by enabling people to develop their social networks.

There is work to do in ensuring that VSOs are engaging and providing services to diverse communities, and those that have skills and knowledge of specific life events are factored into the crisis response at a local level. Although this is primarily a descriptive study, we were able to identify a range of positive impacts through VS support, including enabling people to re-evaluate their lives, develop strategies for coping with distress and develop better support networks. The mechanisms by which the VS achieves these positive impacts were often interlinked and, in some instances, were delivered alongside public sector provision. There is a risk that this contribution may be overlooked by the public sector and/or that VSOs work in isolation from each other. This poses questions about how the different organisations can effectively collaborate, while recognising their individual contributions.

The wider crisis system in the study sites

Alongside families, communities and the VS, the crisis system includes a wide range of public sector services: NHS 111, GPs, ambulance services, A&E, psychiatric liaison, CRHTs, local authority services, the police and, where it exists, street triage, and social housing (provided by VSOs, housing association or local authorities). For people to be able to access timely support, policy-makers and commissioners proposed that these different elements needed to work as a system, maximising their different contributions through the crisis journey:

So if you have proper signposting information, advice, access for all the different age groups, you know, web tools, counselling services, so people can access easily, you’ll be able to support people earlier to access the right support at an earlier time. So if you have individuals that end up in a mental health crisis or any other crisis, you have the services that are able to respond in an efficient and timely manner . . . We’re talking about crisis resolution home treatment teams. Now we’re talking about an NHS crisis helpline, so we have that service able to meet people’s needs at the time of crisis. The [next] element is good quality care and treatment . . . and a good standard of care is at a similar level across the whole country. But what actually happens after crisis? How do all the systems work together to make sure that it’s effective and efficient so that individual doesn’t have to go back into crisis again, regardless of the time frame?

ACCG1

There was a highly varied notion of a ‘system’ across the sites. However, all of the study sites had a CRHT, locality community MH teams and psychiatric liaison services. It was clear that the CCC, together with additional investment, had created an opportunity for system development in identifying and bringing together different organisations. In site A, there has been an ambitious system redesign taking place over the last 3 years, with the remodelling of the crisis system in tandem with the introduction of an NHS helpline that provided a single point of access to MH crisis support and a redesign of primary care support and the VS support for recovery. Additional resources had been made available to support this and this included investment in a VS safe space, which would receive referrals via the NHS helpline team, which triaged callers based on need and the assessment of risk. The helpline and safe space worked in close collaboration, including joint meetings and supervision. There was also an out-of-hours VSO helpline run by a ULO, as well as a national suicide helpline. The feedback was generally positive:

I think we’ve got a lot more crisis care, I think it’s a lot better than it was . . . We are working much better together as different organisations; we have regular meetings, so that’s working well. So I think actually the crisis support that is available locally is quite good.

AULO1

Sites B and D had specific crisis pathways designed with the VS, but not an overall system:

I think we could do with more of an integrated crisis [system], definitely. At the moment all we’ve got are very overstretched staff trying to deal with people in crisis. Referrals to the crisis team who are also overstretched and if the beds at [the crisis house] are taken people are ending up in [hospital]; it is just trying to keep people safe.

BMHP3

Site B had a 24-hour crisis team and a well-established street triage service operating a ride-along model with a MH nurse and police officer. There was also psychiatric liaison at the local general hospital’s A&E department, from which the crisis team could refer people to the commissioned four-bed VS crisis house where they could stay for up to 3 weeks as an alternative to hospital admission. Service users had been heavily involved in co-producing the CCC and subsequently developed a specification for community safe spaces for people in crisis, and were awaiting the decision from the commissioners. In site D, the CCC had also facilitated the development of the system of crisis care. Funding had been made available through the CCC for an NHS crisis assessment suite and the CCC was attributed with leading to much-improved relationships between the MH trust and the police. There was an NHS walk-in face-to-face crisis service in one of the main urban centres and four CRHTs for different patches, with one gatekeeping access to the VS crisis house (two beds alongside supported housing) on behalf of the other CRHTs. There was also a street triage system operating across the area, a crisis assessment suite for those subject to a section 136 and an out-of-hours VS helpline. These developments were set within a broader context of an NHS and local authority ‘movement to involve the voluntary sector’, although it was unclear how these developments related to each other.

The CCC in site C related to a NHS trust, which covered three other CCC areas. The NHS trust in this site had a 24-hour MH crisis line with options for professionals and service users/carers. Callers to the NHS crisis line were referred to the local VS peer-led crisis line, and vice versa, depending on which service they would be better supported by. There was also a crisis assessment team that linked the police, ambulance service and MH teams, so that first responders encountering someone with a MH need could access advice from a MH specialist by telephone or in person if necessary. This was linked to a section 136 suite in the local acute MH hospital, and there was a psychiatric liaison suite available at the nearby general hospital A&E. Consultants and nurses in the psychiatric liaison suite, community teams and crisis assessment teams, and GPs all regularly referred people to the local VS appointment-based listening service, although it was not a commissioned service.

The overall context of underfunding was identified as impeding the effectiveness of the MH system. In particular, the austerity measures taken by local authorities and the NHS were specifically noted as adversely affecting thresholds for access to services and eligibility criteria for social care, the investment in the VS and the provision of wider support playing an important role in supporting a person’s recovery. In site C, for example, cuts were being made by the local authority to care packages and supported housing placements.

Adequacy of the crisis system

Relationship with public sector services

Collaboration between voluntary and public sector services at a system level

The quality of relationships is predicated on an awareness and mutual understanding of each other’s contribution. The close working relationship in site A was positively evaluated by a wide range of stakeholders, and there were regular meetings between the safe space manager and the relevant NHS staff: ‘we’ve come on leaps and bounds actually in the last few years’ (AVS3). There was some scepticism from a service user perspective as to the extent to which ‘warm words’ were being translated into practice. A risk that the type 1 VSO had become ‘part of the gang’ was identified and, thus, the contribution of other types of VSOs was potentially being overlooked. Positive relationships between the relevant NHS services (i.e. CRHTs) and the crisis houses were also described in sites B and D, although the formalisation of this relationship was restricted to referral arrangements. In site C, the landscape of crisis provision was dominated by the MH trust but the well-being hub run by a VSO was viewed as having increased access and reduced the number of people using social care services.

A range of ways of developing better relationships and mutual understanding were described:

We have twice yearly training days, the advance nurse practitioner sets those up and wrote out to all the voluntary sector and we have stalls, a marketplace that if there’s anything new in their area they can come and let us know about it, so that worked really well.

DMHP3

These clearly took time, and commitment, to mature to ensure that the VS was viewed as an equal partner:

They can be quite bolshy and when they become equal partners with us they start saying ‘well, what about if we did and what about if we did that?’. So I’ve never felt that we were dominant, we’re the commissioners so we could be quite dominant and bully, but in actual fact a lot of the time [it has] been really refreshing because they’ve reminded us of things that we ought to be doing . . . it’s a reminder of practices we’ve got into.

S17

In addition, VSOs were also working with primary care services; for example, a type 3 VSO in site A described working with a local GP surgery to support people who were recently discharged from hospital and at risk of isolation.

By contrast, some VSOs emphasised the importance of independence from public sector services, recognising that some people choose to use a VSO in preference to the NHS. Unease with the degree of closeness of the NHS was also expressed, with one participant describing one VSO with a close working relationship as ‘a tentacle of the NHS’ and another suggesting that ‘the VS now needed a VS!’. At the heart of this is concern that the values and ethos of the VS may be compromised. Some VSOs, reflecting their engagement with communities and their staffing by people with lived experience, also advocate, in the widest sense, for MH service users and/or carers. This includes offering a radical critique of public sector services, which may not be well received by the public sector and may challenge the development of collaborative relationships, inadvertently fuelling unhelpful stereotypes. For example, one VSO raised concerns about the failure to address negative attitudes and the apathy of NHS MH services to challenge the status quo in relation to their response to people from BAME communities:

[Racism is] like there being an elephant in the room, and it takes a dump, and everyone’s trying to talk about other [superficial] things, whilst trying to pretend they can’t smell it.

CVS7

In this instance, the VSO was trying to address this by being ‘proactive in making sure that we don’t allow ourselves to become part of the [apathetic] culture’ (CVS8) and actively supporting people from BAME communities.

The importance of maintaining this independent stance was emphasised by different types of VSOs, while recognising the need to keep the communication channels open: ‘we’re highly critical of them but we’ve got good relationships’ (BVS1). The extent of the closeness to the NHS, therefore, emerged as an important dimension to consider. Figure 11 depicts the degree of integration between the different VSOs and the NHS that we identified.

FIGURE 11.

The relationship between the VS and the public sector.

As well as funding arrangements, which are discussed in Chapter 8, the three main indicators of integration between the public sector and the VS at a system level were access arrangements (see also Chapter 6), the extent of information sharing and how risks were managed for individuals.

Access arrangements

In sites A, B and D, MH staff decided on appropriate referrals based, in part, on a risk assessment and gatekept access to type 1 VSOs:

If we’re going to refer people to them, we do the assessing bit, because we think that that’s the bit that we do, that we’re good at, but then they’re really good at being there with people, spending that time doing the de-escalation and then also talking about what next.

AMHP2

When the system was less developed, participants voiced their frustration with repeated assessments, which often failed to materialise into support, as discussed later.

Information sharing

In site A, decisions were judiciously made about the amount of information shared ‘because we don’t want the [safe space] to become a medical place’ (AMH1). Greater information sharing was identified as being useful for people who had complex situations and were using a wide range of services, when contact with services was construed as symptomatic of their difficulties:

I know that there are people that are touching lots of different services, but we don’t know what they’re touching unless they tell us. And it’s how can we make it more effective. I’m just thinking of a couple of ladies who are touching everything but they’re clearly not getting what they need to be able to move forward [reference to NHS trust services, VSO type 2 services, social care and occasional police and ambulance intervention], so getting a bit of what [they] need from everyone, but how can we join that up?

AMHP1

Thus, information sharing to agree ‘a treatment plan’ was seen as facilitating a more considered approach, and was referred to in sites A and C. Similarly, in site B, there was joint working between the NHS and the VSO for people in the crisis house, with joint planning and joint reviews. Furthermore, the importance of shared learning following serious incidents relied on both trust and sharing information. The introduction of the General Data Protection Regulation was identified as affecting information sharing arrangements, although this was yet to be worked through.

Risk management

At a strategic level, VSOs were involved in suicide prevention: ‘[I]t’s an area where people are trying to work together to look for solutions in areas that have caused problems before and just been kind of never addressed in a cross-group sort of way’ (AVS13).

The VSOs had various systems and policies in place to manage risk, including risk registers and lone worker policies, which involved liaison with public sector services:

On an individual level when we’re working with clients, we have really robust systems, so things like risk assessments are conducted as a matter of course. If we visit them in the home, for example, we have really clear processes around making sure the environments are risk assessed and in the mental health units as well, we’re linking with staff to check that the person’s safe to meet with. Often if you’re under a Section you could be a risk to yourself and others.

BVS6

In site A, as MH professionals decided on referrals to the type 1 VSO, the NHS MH service continued ‘to hold the risk’. Risks associated with suicide and self-harm could lead to referral to public sector services, and this was often the case if the VSOs felt that they did not have the relevant skills or expertise:

So if we have clients that would need 15-minute observations, that would be a high risk for us, because we can’t keep that person safe. They would either go to hospital or the crisis team would find an alternative placement for them, dependent on their needs. So for us it is more a lower risk client group because we aren’t clinically trained. We are housing and support workers.

BVS5

Other VSOs explicitly engaged with risk:

Running crisis houses, you are going to inevitably have more people that at least try to take their own lives even if they don’t actually manage to and so we had to sort of educate trustees to say this will happen. It’s a high risk . . . or we can be in it because we believe that we can provide a better experience and we have to try and manage the risk.

S10

Risk management was also framed as ‘a dynamic process’ and one VSO in site D was developing a harm minimisation approach: ‘embedding the recovery approach within our services, which has a focus upon harm minimisation and being far more informed than we were previously’ (DMH1). VSOs had a more comprehensive conception of risk than public sector services and referred to risks to individual welfare, of homelessness, of domestic violence, of substance abuse and of deteriorating MH that VSOs were often managing. This included assertively following individuals up if there was evidence of self-neglect or if they did not turn up as expected, and liaising with NHS services to access appropriate support:

We have been working with [a young woman] and her mood has been progressively worsening. She’s been really struggling and her protective factors have been reduced over the last few weeks, so we started to raise concerns last week with the GP. Today her mum took her to A&E after ringing the NHS helpline, but they had just suggested they should wait until the evening when they might be able to see her. Her mum took her to A&E, A&E tried to send her back to the NHS. I had to liaise with A&E and say ‘look, we’re really concerned about this girl because she’s extremely vulnerable if she’s there and she’s presenting in this distress after isolating herself for the last couple of weeks and not eating, not drinking, she is a serious risk and should be assessed’. So I had to have a long conversation with the psychiatric liaison team just so that they would do an assessment and they’ve finally conceded to do that today.

AVS6

This illustrates the ‘responsibility tennis’ between NHS organisations that we referred to earlier. Indeed, we identified a number of people who were under specialist MH services and situations in which the risks were known but not being managed. This included one woman with psychotic symptoms who had not turned up to a safeguarding meeting and, as far as we could gather, there had been no follow-up. Generally, however, communication about risks was shared when type 1 services were being gatekept:

If there’s something about risk we want to share, we’d pick up the phone as well, we’d send the referral form or we’ll pick up the phone and let them know if there’s something that doesn’t come across on paper really or that is of high enough risk that we’re concerned about it.

DVS3

There was also the view that the VS may not be equipped to assess the level of risk to the individual and others in the crisis house unless MH practitioners were part of the team.

Collaboration between voluntary and public sector services at an individual level

Policy-makers and commissioners often referred to crisis care pathways but we found little evidence of effective pathways across the crisis experience, outlined in the CCC (see Chapter 1). In site A, despite a clear pathway between the NHS helpline and the type 1 crisis service, the complexity of the crisis journey was evident:

Working out all those pathways, different systems you know, different services, trying to work together is difficult for staff – how difficult it must be for actual service users, trying to go through that pathway.

ACCG1

The pathways across the sites were compromised by the difficulties in accessing NHS services that have been discussed. A number of themes emerged for collaboration at an individual level. First, the extent to which needs were being appropriately met in the absence of an articulation of a coherent system and the restricted conception of a crisis as an episode. Service user participants described going round in circles and being repeatedly assessed by NHS services, and to a lesser extent VS services, without this seeming to lead anywhere:

The NHS side of things was just like repeated assessments and she felt like she was continually going back and saying the same stuff and then she just wouldn’t hear anything for ages; she didn’t know whether she was on a waiting list or not . . . it’s harder to cope with stuff like that when you’re depressed and it’s easier to accept stuff like that when you’re not depressed, so she did feel quite abandoned by the NHS.

CCa1

Figure 12 illustrates the journey of a participant, ASU14, who used both NHS and VSO services extensively and had contact with two VSOs out of their area. ASU14 repeatedly self-harmed and their journey dramatically illustrates the lack of resolution of their difficulties, despite the contribution of the various VSOs being appreciated for their supportive and empathic approach.

FIGURE 12.

An illustration of a crisis journey using both NHS and VS support (site A).

The second theme was the agency of service users in accessing support and ‘project managing’ their crisis. The degree to which this was understood and formalised into a crisis plan was unclear, as few participants referred to a crisis plan.

Third, when the NHS was gatekeeping access to type 1 VSOs, access had improved, but this provision was short term and the VS often had limited capacity for ongoing support. There were clear exceptions to this, for example a VSO for homeless people and a CRHT working together to address the complex array of presenting difficulties for their mutual clients.

The general picture, however, is that the VS is contributing to a patchwork of different types of support, at different points in people’s individual journeys through services, in combination with other VSOs, as well as in combination with public sector services. Figure 13 illustrates this for a participant, BSU4, who had repeated MH crises and had made extensive use of the VSO crisis house, to which they could self-refer. BSU4 also frequently presented at A&E and accessed the CRHT. Despite collaboration between the CRHT, the crisis house and acute admission wards, this pattern was repeated. At the repeat interview, aside from getting a dog, BSU4 described their situation as having changed dramatically because of a change of psychiatrist who reviewed their diagnosis, reduced their medication and referred them for specialist psychotherapy. For BSU4, their involvement with type 1 VSOs was interspersed between frequent public sector service provision/support. This journey reflects how the VS and public sector services can complement each other; for BSU4, type 1 services went hand-in-hand with various public sector services to support their individual crisis needs, but their use of these VSOs was limited by the time limits operating for these services.

FIGURE 13.

An illustration of a crisis journey using both NHS and VS support (site B).

Recommendations for improving the crisis system

As well as commissioning, discussed in the next chapter, participants were able to identify what was needed to improve the crisis system and to better realise the contribution of the VS within this. Some of these have been picked up elsewhere and cover many of the gaps summarised in Table 18. Overall, participants wanted to see a broader range of services, not only those providing an accessible and flexible response to the immediate MH crisis, but also those that enabled people to anticipate and prevent a crisis and to address the underlying issues; abuse, previous trauma, substance use and housing were specifically identified. The crisis event should, therefore, lead to something better:

I think it’s about providing more support, preventative and post-support treatments and exploring more opportunities and giving more flexibility to the types of solutions available; don’t always use the same things. Listen to people, listen to the clients that are actually impacted . . . and more emphasis on supporting people with mental health issues with those two or three key areas of life, empowerment, housing and employment.

BVS6

The importance of this support being needs-led face-to-face support was stressed and participants wanted responsive flexible services: ‘to have an agency just simply called “Help”’. This included readily available peer support:

To have a group where even people who feel like they’ve come out of it or people are still in it or just people could exchange their feelings about it and make everybody feel there’s no shame there, there’s no . . . you know, so many people go through things and so many people are still going through things that, you know, there’s got to be a much more open approach to it.

CSU8 (repeat interview)

The value of the VS was clearly recognised and many participants recommended a better appreciation of this contribution, which would entail upskilling staff, effective collaboration between the VS and the public sector and greater investment in the VS:

The VCS I think should be a key part. I always think when you’re planning MH services this is where we get it wrong. When we plan mental health services we say ‘we’re going to give another 2 billion to the NHS’ and actually I think that’s wrong. What we should say is ‘we’re going to give 1 billion to the NHS and 500,000 to the local authority and 500,000 to the VCS, and we’re going to make them all work together’ and plan the services around the service user.

S17

The potential cost benefits of investment in the VS were also noted:

I have been sectioned three times in the 1 year. My first admission was a bereavement, well, a potential bereavement of my mother. The key thing is to avoid admission, isn’t it? The cost of admission when they cost it out is horrendous. All the money could be saved elsewhere if you didn’t have to go through all this bureaucracy. There’s a lot of money to be saved that could be used for the crisis.

ASUG

Overall, these recommendations were envisaging a crisis system with effective collaboration between all of the different elements, including between VSOs. There was the suggestion that there should be clear standards for crisis support, so that people knew what support they could expect. These would necessarily be underpinned by a commitment to equality: ‘[I]f someone’s going through a crisis, they’re treated equally, doesn’t matter what their cultural background is, don’t matter about their status in society, they’re all treated equally and with the best practice that’s available’ (CCaFG).

This principle of equality was referring not only to people with protected characteristics but also to people with different kinds of MH difficulties, and participants wanted a better response to people who self-harm, people who use alcohol and/or drugs, people who are diagnosed with a ‘personality disorder’ and people who do not easily engage with a standard model of provision.

Summary

The crisis system in the different sites was generally underdeveloped, although the CCC had stimulated some redesign. This was most advanced in site A, where an NHS helpline had been introduced with a first response service attached and a route through to a safe space. Nonetheless, across the sites, there was evidence of a wide range of unmet needs, including for people from BAME communities, young people and people with complex needs related to substance use, learning disabilities or homelessness. The closeness of the relationship with public sector services varies, from VSOs that are committed to maintaining their independence to VSOs that are closely aligned with NHS crisis services and that determine who will access the VSO. Some VSOs provide a radical critique of public sector provision, and maintaining this in a context of competitive tendering may prove challenging.

The relationship between type 1 VSOs and NHS services was most developed and where there was evidence of a mutual understanding of each other’s roles. The awareness and appreciation of other types of VSOs was less developed and there was a general lack of up to date information about what was available. GPs and MH staff would, therefore, signpost rather than refer to these services because of concerns over governance.

Effective collaboration at the level of the individual service user is focused around providing an urgent and immediate response and there was little evidence of a coherent pathway, although VSOs and NHS services would refer to each other. Both the absence of a preventative approach and a lack of continuity to enable people to address the relevant contextual factors were evident. Thus, some people go from crisis to crisis, without adequate support or resolution. The understanding that a crisis represents a window of opportunity for longer-term change appears to be being missed across the crisis system, although is being addressed to some extent by the VS.

Despite this, the VS contribution was widely appreciated and this was evident even for those participants whose difficulties had not been resolved. Participants were often critical of their experience of NHS services and identified the lack of responsiveness of CRHTs, thresholds to accessing services and waiting lists as compromising their access to crisis support. They were also critical of dismissive and insensitive attitudes, and referred to a mistaken view of agency as shifting responsibility back to the person experiencing a crisis. Participants agreed about the need to develop the crisis care system, which would better recognise the contribution of the VS.

The important role of commissioning of the voluntary sector

Funding sources, relationships with other ‘fields’ and sectors

The funding context: from ‘feast to famine’ – declining funding and increasing demand

This section first examines the wider funding context in which commissioning arrangements sit, before moving on to consider specific criticisms of commissioning and its influence on crisis services. It was very clear from interviews at all levels – from national stakeholders to regional commentators and case study respondents – that a major overarching feature affecting MH services (and indeed all related policy fields) has been declining resources, while at the same time needs and demand are perceived to have been increasing:

In the 16 and a half years that I’ve been a consultant, I’ve been here for that time just in this borough, we had a huge provision back in the day of feast and the years of famine have led to a constriction of third sector provision because it’s been decommissioned.

CMHP1

There is also a sense that resources are being spread very thin and that often the VS is seen as an afterthought or receives only the ‘crumbs’; for instance:

[H]ere, as happens in lots of other places, there’s been less funding for mental health in the last few years and, as you’d expect, it’s split between the acute trust and the mental health trust

ACaFG

A strong narrative emerged that funding has declined as a result of public sector austerity, and respondents were clear that, where once public funders and commissioners were almost ‘throwing’ money at providers, including those from the VS, now the landscape is completely transformed:

Well we’ve had a tremendous amount of money taken out the system, you know, both in local authority and in health . . . and we don’t have parity. I think this council spends about 15% of its budget on mental health and I don’t think the CCG spends more than that. Well that’s not good enough, you know, when the demand’s increasing.

CVS5

A number of respondents from different vantage points echoed the idea of falling funding in tandem with the identification of greater need in the ‘system’:

Increased demand for the services and I think the services are geared to be able to meet the demand, that’s a huge, huge issue that’s likely to stretch the services further. At the moment, every service in the country is now running into financial trouble; we’re having staffing cuts, we’re having increasing demand for the services . . . I don’t see any positive new developments happening, everything seems to be shrinking.

BMHP1

This potentially compromised the effectiveness of commissioning to deal with variability in access and quality across the areas, as noted in Chapter 6:

I don’t think the mental health commissioning in Middletown was very effective. I didn’t get a chance to look at that because they all needed to make savings. Middletown’s been even worse hit than Centreville, mainly because they’re so small so the economies of scale aren’t there.

ALA1

Furthermore, it was argued that this systemic austerity was affecting the ability of services to experiment and innovate:

Things have changed so much, that actually people are being so cautious. And it means that you can’t, whenever you’re trying to kind of think of ways of evidence in what we want to do, we’d have to do it in such small ways that it wouldn’t be a good example of what our idea would be.

CMHP2

This, it would appear, is affecting all public sector services, and thus having an impact on relationships across sectors, whether or not they are directly implicated in crisis services or wider MH, including other public services such as the police: ‘[B]ecause to say everything is stretched is a real understatement. It’s at breaking point. It’s at breaking point’ (BPo1).

By contrast, some participants pointed out that the increased emphasis on MH policy, and ministerial statements, have meant that some now perceive that more money is going into MH and this has caused some problems:

What’s a bit of a challenge is balancing people’s perceptions, because of the media, everybody thinks that money’s just been thrown at mental health now and we’re actually finding it harder now than ever to get money because even the grant givers, like the Lottery and people like that, it’s harder to get them because more people are competing. They don’t open the grant giving as much as they used to, so it is harder.

DVS2

Alternatively, more money is being made available but is not reaching VSOs or front-line services:

I think as well recently there has been some political statements about extra money going into mental health for example. So say if x money did go into mental health, where’s it going, is it going towards the trust or is it going towards the actual providers that are delivering face to face?

DVS5

This broader picture, which was consistent across the national, regional and case study data, sets the tone for participants’ understanding of the commissioning landscape. However, it does at times make it difficult for people to disentangle the effects that ‘cuts/austerity’ are having on available resources and relationships between public sector services and VS services, and between VSOs themselves. For instance, it is not surprising that VSOs themselves report an increase in the sense that they are in competition with each other and that they are less likely to share information through a spirit of collaboration, but it is not always clear that commissioning and individual commissioners are necessarily to blame for this.

Navigating complexity: failure to divert funding towards prevention and to co-ordinate services across different service fields

Both public sector and VSO respondents expressed considerable frustration about the seeming inability of public sector commissioners to ‘bend’ resources towards preventative services, which is argued to be an area in which VSOs excel in providing services and in which it is understood that there would be system-wide benefits resulting from an expansion in services:

Continuing to build on that conversation between the trust and NHS and voluntary and community sector . . . and working with the likes of the CCG to get them to put some money where their mouth is because everyone says prevention is massively important but, when push comes to shove in a financially constrained world, the money for the prevention gets used up by the delivery of the actual crisis service.

AVS1

Next, there seem to be very specific issues that affect specialist services, which, in many cases, overlap with or have an impact on crisis services and thus the quality of crisis pathways. For instance, in site D, we considered specialist sexual and domestic violence services. After describing the complex funding arrangements that the VSO had in place, including a mix of central and local public sector contracts, Lottery funding and long-running grants, the respondents felt strongly that the nature of the service was not always well understood by commissioners:

For me, I think it’s a massive issue, the fact that the CCG, apart from the IAPT service, don’t seem to recognise the value and the impact that [type 4 VSO] has on the survivors of sexual violence. So [type 4 VSO] having to go searching for funding everywhere that you can find it, when really I think there should be a CCG commitment to support the specialist sexual violence services.

DVS5

Furthermore, like in other areas, the argument here is that ‘generic’ IAPT services, on the ground, are not specialist enough to understand the particular needs of victims of sexual violence – some of whom experience a MH crisis – who therefore risk not having their needs met. There is a strong sense that CCGs do not adequately recognise the role of specialist VSOs – whether through financial stringency or lack of knowledge – and that includes the range of local VS domestic violence organisations. So neither the specialist issue(s) nor the role of the VS in addressing or tackling it is recognised:

I don’t think necessarily the commissioners have a good idea of the needs of sexual abuse within that bigger broader picture of domestic abuse. I think they’re probably getting the outcomes and the outputs, but they’re not distinguishing well what were the needs, so how many of those clients did you counsel for domestic abuse, or how many were childhood. I don’t think they’re getting that level of detail. I think, to them, as long as they’ve got that service in place, they’ve got somewhere they can signpost people.

DVS5

A further factor in site D is that IAPT services were being recommissioned as a single service across a wider geographical area, so there was uncertainty about what future services will look like. The point was echoed by national stakeholders, with one participant reporting that their domestic violence/rape services received no CCG funding and relied on multiple funding sources to survive, in a context of increasing waiting lists. However, it is important to note that this issue of whether or not commissioning agencies sufficiently recognise and value ‘specialisms’ varies between sites. For instance, in site B, where there appears to be a recognition of some but not all specialist services, respondents spoke highly of commissioned drug and alcohol services. They also supported the BAME-specific services provided, which even extended to BAME-specific domestic violence services, but conversely services for the LGBTQ community were said to be ‘non-existent’ and public sector services had nowhere to signpost or refer people to who were experiencing a crisis related to their sexuality/gender identity.

Commissioner–voluntary sector organisation relationships: towards better integrated and ‘collaborative’ commissioning

A deeper issue underlying the themes outlined earlier is the sense that commissioners and VSOs can view each other with a mixture of incomprehension and a lack of trust – the relationship is quite fraught – and this clearly bodes ill in terms of improving the quality of commissioned services, service outcomes and integration between public sector and VSO-provided services. A central issue is a fundamental mismatch between the understandings of the sector held by commissioners and VSOs:

Integration I think between the [place of safety] and, you know, it’s the same old chestnut, between the [place of safety] and [the NHS helpline], which is provided by our mental health trust, it’s just an ongoing battle for people to work together and for public sector service not to see third sector as inferior and a little bit vice versa. [The] third sector sort of think ‘oh well they don’t care about us’.

ACCG2

These issues are clearly interlinked: VSOs often feel that commissioners do not understand the complexity of the issues in the front-line day-to-day service arena, but more problematic is the fact that they also do not understand the distinctive and potentially unique offer of local VSOs. In addition, the behaviour and decisions of individual commissioners or teams cannot be entirely disentangled from more structural constraints on commissioning, particularly the trend discussed earlier towards competitive tendering and upscaling of contracts:

I think that what’s happened in the system is that the VS’s contribution isn’t necessarily appreciated . . . Commissioners tend to focus their energies on the big contracts and when you’re talking about the voluntary sector, you’re talking about small amounts of money; they don’t actually invest in them to the degree that they should invest in them, considering that they’ve got the potential to take up quite a lot of slack at quite a lot less cost than these big institutions have.

S2

What VSOs are often calling for from commissioners is a recognition that VSOs can be professional, when required, but also operate in ways that are different from public sector organisations, and that includes combining mission, ethos and the very varied approaches described in Chapter 5. VSOs require commissioners to recognise this distinctive offer while commissioning in ways that are appropriate and proportional, that do not ‘kill the golden goose’, and that allow the VS to operate in ways that are complementary to, rather than competing with, the public sector. There was some sympathy for the constraints that commissioners face:

I think it’s such an awful place to be at the moment, commissioning. I mean, I’ve had very extreme experiences of commissioning. I’ve had really supportive commissioners that are so apologetic for what they’re putting you through because the process is awful.

S18

Key recommendations to improve commissioning included more resources on a longer-term basis; more integrated commissioning and, consequently, joined up services; greater recognition of what the VS offers and how it’s role in commissioned services can be sustained (rather than gradually run down); and, finally, greater involvement of potential beneficiaries (i.e. service users and carers), the VS and communities (including specialist health disorder and protected characteristic communities) in the commissioning cycle.

Summary

As this chapter has shown, it is widely recognised that commissioners are operating in a particularly difficult contemporary context – and some sympathy with them was expressed – given continued public sector austerity and the constraints that the commissioning process places on individual commissioners. Participants recognised the centrality of commissioning in regulating and delivering funding and the sense was that it must be improved, with genuine co-commissioning with people with relevant experience. However, a bigger challenge comes from some of the participants who suggested that the commissioning approach is fundamentally flawed, in particular that commissioning is actively inhibiting or damaging the quality of services delivered in the VS, by adopting a business model.

A mental health crisis as biographical disruption

From the accounts of people who have experienced a MH crisis, it is clear that this is rarely experienced as a one-off event. The theoretical origins of crisis started with Lindeman and the Coconut Grove Fire. 124 This approach relates to an identifiable catastrophic event in people’s lives (e.g. floods, fires, redundancy and loss), but is not necessarily appropriate for people experiencing MH problems, when an individual’s context sets the stage for the MH crisis. 65 Our findings indicate that a MH crisis has meaning in the context of an individual’s life and is a process, often unfolding over time. Indeed, some service users viewed their lives as an ongoing crisis, often accompanied by profound existential doubts, reflecting the findings of Gudde et al. 67 and Gullslett et al. 69

This conception of a MH crisis as a process resonates with the concept of biographical disruption that has emerged from sociological approaches to illness. 125 Drawing on Giddens’ description of a ‘critical situation’ as ‘a disruption of taken-for-granted assumptions and behaviours’,126 Bury125 locates the experience of a chronic illness in an individual’s biography. This is not to imply that a MH crisis heralds long-standing difficulties; instead, the elements identified by Bury as characterising a ‘biographical disruption’ are relevant here: a recognition of pain and suffering and a possible awareness of death; disruption to everyday life and the forms of knowledge that underpin them; and affecting social relationships, potentially disrupting reciprocity and mutual support. 125 We identified four important elements of the crisis experience: the intensity of the distress, including suicidal feelings and self-harm; the meaning of that experience; the availability and use of support, both social and service support; and the personal and social context of the experience. Locating these elements in a biographical frame strongly supports the contention that a MH crisis is a uniquely personal experience1 and that self-definition is critical, as promoted by many of our participants. It potentially goes further, as argued by Williams (p. 62),127 in providing a bridge between the ‘personal troubles of illness and broader public issues of social structure’,125,127,128 which in the case of MH include stigma and discrimination.

Recasting a MH crisis as a ‘biographical disruption’ crisis contrasts with a narrow biomedical discourse, which has driven policy and practice developments until more recently. Such a discourse has far-reaching implications and risks not only decontextualising experience, but also rendering it unknowable. The struggle by participants to define a MH crisis hints at an ambivalence and, in some instances, rejection of such a narrow understanding of the crisis experience. Nonetheless, a MH crisis as an episode requiring an urgent and emergency response currently underpins the development of the MH crisis system. Our data, therefore, support advocacy of a crisis response that takes a broad view of MH and distress, is person centred, and is responsive to individual needs and wishes (see, for example, the CCC3 and MHA review recommendations26).

The distinctive value of the voluntary sector

Many of the participants in our study had complex difficulties across the MH spectrum, from psychotic symptoms to depression, anxiety and substance use, with several identifying as having a personality disorder. Many reported strong suicidal feelings and a smaller number self-harmed on a regular basis, with one person killing themselves during the course of the study. Although there was no formal assessment of need or diagnosis, our sense was that the participants had significant levels of need that were not being addressed by MH services, which had, in some instances, led them to seek support from a VSO.

It is clear that the VSO offer is distinctive and potentially unique. It is characterised by its relational qualities and attributes, including kindness, the capacity to listen and compassion. This is combined with the blurring of the boundary between service users, peers and staff to facilitate responsiveness to need and community engagement. This emphasis on relationships is typical of a socially oriented approach that contextualises the MH crisis. It is distinct from the approach found in the public sector, which individualises MH problems and pays scant attention to the factors that have contributed to the crisis or to strengthening social networks. Being accepted ‘for the person I am’ and creating the space and time to work through the issues and challenges raised by a MH crisis means that the VS contribution is widely valued. The capacity to engage, particularly with people who have lost faith in public sector provision, is important, particularly in the context of the use of the MHA and the suicide rates for people who missed their last appointment with MH services. 29 Both the commissioning and the organisation of the specific VS contribution were identified as important influences on the ethos and approach, with the suggestion that the value of this could be compromised by greater alignment with a more commercial model.

Framing a MH crisis as a biographical disruption provides a theoretical basis for explaining why the VS contribution is valued; it locates the crisis experience in a social and biographical context, creating the conditions for people to hold uncertainty and explore the meaning of the experience. Indeed, Bury125 argues that a fundamental feature of a biographical disruption is that it entails a fundamental rethinking of the person’s biography and self-concept, as well as decisions about seeking help and mobilising resources. Williams, building on Bury’s theoretical contribution, identifies ‘narrative’ reconstruction128 as a core task in making sense of the illness experience, in this case a MH crisis, and the changing relationship between the self and the social world. This resonates with theoretical constructions of a MH crisis as ‘a turning point’ with opportunities for narrative reconstruction, which may or may not be facilitated by engagement with MH support.

Indeed, the people we spoke to were not passive bystanders in their experience, but were actively searching for meaning and support in an intense and potentially overwhelming experience. We have illustrated how people will actively seek out different sources of support, through the VS and the NHS, if they feel they are not getting the support they need. Appreciating the agency of people in a MH crisis is a clear feature of the VS. This includes agency in relation to suicide, which was valued by participants and contrasted with their perceptions of the risk-averse nature of public sector MH services. The conception of agency was, however, nuanced, with a recognition that, for some people, agency is constrained and that extra efforts are needed to engage with and support them. Another dimension of the VS contribution, consistent with Bury’s exposition of a biographical disruption,125 is that it provides opportunities for social connection and leads to the possibility for mutuality, reciprocity and solidarity through the provision of peer support and/or user-led services.

The contribution of the voluntary sector to crisis care

Given the nature of the crisis experience, the service response is critical. We found that VS support was generally highly valued, regardless of the outcome. This is consistent with other studies that have identified respectful, flexible and consistent support with people in crisis at the centre of decision-making is highly valued. 129 Our findings illustrate the breadth and depth of the VS contribution to supporting people in a MH crisis. There is a wide range of activity, from ULOs to large charities, such as St Andrews Healthcare, which employs 4500 staff and provides services in a similar manner to the NHS.

The VS offers not only a distinctive approach but also a wide range of support across the five types of VSOs that we have distinguished. They appear better equipped than public sector services to support particular groups of people and we identified three groups for whom this may be the case: (1) people, predominantly women, who identified as having a personality disorder or complex post-traumatic stress disorder (Dial House in Leeds130 is recognised for its expertise in working with trauma, which is generally lacking in public sector services);131 (2) groups that are reluctant or fearful of engagement with public sector services, notably people from BAME communities and specifically from African Caribbean communities (the African Caribbean Community Initiative provides an example of culturally appropriate support, underpinned by an African ethic of care);132 and (3) people from specific communities or who have experienced a life event for whom a wide range of skills, knowledge and expertise are required to provide support, for example victims of domestic abuse (e.g. the support provided by Women’s Aid133) and asylum seekers and refugees (e.g. Freedom from Torture134). The unifying themes across these different types of organisations is the importance of peer support and the relatively flat hierarchies, with role boundaries blurred. Indeed, some of the VSOs avoided the term ‘service user’, preferring visitor, volunteer or peer, conveying a sense of communal effort.

Despite this, the contribution of VSOs is often narrowly understood in policy and by the public sector, and in relation to crisis care it is limited to those VSOs that we have characterised as type 1 (crisis specific) or type 2 VSOs (general MH), which make an important contribution to other aspects of the crisis journey, namely prevention and recovery. Types 3 (population specific) and 4 (life event focused) provide specialist support, peer support and engagement with communities that are, often inaccurately, described as ‘hard to reach’ and this type of support is generally not available in the NHS. The skills and capacity evident in these types of VSOs challenge stereotyped assumptions of the VS as ‘a poor relation’. Furthermore, constraining the public sector focus to types 1 and 2 VSOs in crisis support risks increasing inequalities by skewing the funding towards these VSOs at the expense of VSOs serving marginalised and/or racialised communities.

The ability of the VSOs to respond to needs will reflect the legacy of specific VS activity, current capacity and specialist skills. Indeed, we have identified variation in the availability of VS support, not only on the urban–rural axis, but also in terms of particular groups, whose needs are not being well met by the public sector and may also be missing out on VS provision. This demands that greater attention be paid to population diversity, the experience, manifestation and interpretation of distress, and help-seeking preferences. Although, it is argued that the VS has a comparative advantage37 in engaging and responding to the needs of otherwise marginalised groups, there is some evidence from our study that the development of mainstream VS provision crisis care may not be particularly accessible or attractive for particular groups. This requires further investigation and needs to consider ‘under the radar’ organisations34 that are not being commissioned, as well as other forms of VSOs: social enterprises and community interest companies, for instance. Indeed, the quality of commissioning was identified as having a significant impact on the VS provision of crisis support. A better understanding of how population diversity can drive the commissioning of crisis support (both VS and public sector) and wider MH services is needed.

The sustainability of the VS has long been an issue and the rapid expansion of the VS provision of MH crisis care needs to be underpinned by realistic expectations and to support sustainability, as well as potentially innovation and growth. A factor that is relevant to sustainability that emerged partly from the data but also from our experience of undertaking the research was the ‘emotional labour’ of supporting people in a crisis. Recently popularised, the concept of ‘emotional labour’ was originally described by James135 as ‘the labour involved in dealing with other peoples’ feelings, a core component of which is the regulation of emotions’. The intensity of the experiences that participants described to us was troubling. Maintaining the VS’s collaborative advantage (i.e. the capacity to provide a consistent, kind and non-judgemental flexible response) demands that the well-being of staff and volunteers is a priority. This means ensuring that adequate arrangements for support and supervision are in place, which need to be factored into bids and properly recognised by commissioners. The negative evaluations of NHS services, in particular the behaviour and dismissive attitudes of some staff, suggest that this needs to be a priority for these services too.

The voluntary sector as a key element of a crisis care system

Although it focused on the VS contribution, our study has identified that this is contingent on the organisation of the rest of the crisis system. The framing of a MH crisis as an episode emerged as problematic because it compromises ongoing support and the opportunity to develop strategies for preventing crises in the future by addressing the underlying issues, such as trauma, and strengthening social resources. A limited reliance on an urgent and emergency response means that re-presentation, particularly through A&E and section 136 of the MHA, is probably inevitable, costly and an indicator of an ineffective system. 136 Our findings reinforce the systemic problems previously identified by the Audit Commission,15 Mind,1 the CQC4 and Crisp et al. 16 among others. They are a source of frustration for people in crisis, their families/carers and the relevant staff, and are not a good use of resources, personal or public. Indeed, comparing our data with the domains from the CCC (see Box 1), it is clear that there are unmet needs and substantial gaps in support to address underlying difficulties, early intervention and recovery to stay well. Although the VS does contribute here – ‘plugging the gap’ – it was also evident that there was ‘a cliff edge’ for some participants, notably those people with persistent suicidal feelings or self-harm. This was exacerbated by thresholds for access to support for CRHTs, suggesting that the emphasis on fidelity to the model137 should be examined further in the context of a systemic crisis response. Lengthy waiting lists for therapy and a restricted number of sessions also raise questions about the capacity of both the VS and the NHS to respond. The framing of a crisis as an episode underpinning system design also meant that people were often signposted or referred from one service to another without a sense of a journey or a thoughtful pathway for them, and we have provided illustrations of this.

The wider context for these systemic difficulties, including austerity, welfare benefit reform, racism, violence and abuse, were identified by participants. The relationship between inequalities, socioeconomic deprivation and poor MH is inescapable,138–140 with an association between social adversity and suicide. Indeed, our SRG observed that there needs to be a fundamental shift in thinking from seeing services as ‘a safety net’ – albeit one that has an increasing number of holes leading to increased need – to creating firm and stable ‘building blocks’ (e.g. employment and housing). This resonated with the location of a MH crisis in the life course and supports the argument for a robust preventative approach, as others have called for. 138,141,142

The system redesign in one of our sites showed promise, particularly because this redesign went hand in hand with investment in primary care MH and investment in the VS to provide recovery and social support, as well as a type 1 VSO. Nonetheless, there were still issues to address for people who were presenting in crisis. The rationale for gatekeeping access to type 1 VSOs is that people with a diagnosable mental illness and higher levels of risk will be triaged and referred to a CRHT or an equivalent. However, the definitions of need and risk require some examination, as a significant proportion of people who kill themselves have been thought to need less intensive service support after the acute episode has subsided, although many of their risk factors may be unchanged. 143 This raises questions about access to VSOs and the extent to which they should be gatekept via the NHS. Service users value open access and self-referral, and it is likely that some people will be disadvantaged in the moves to make access to crisis support easier if a single point of access is introduced.

Addressing inequalities is a focus for some VSOs and they make a contribution to supporting people in a crisis that needs to be better recognised. Those VSOs that are crisis specific have generally not been designed with equalities in mind. We have, therefore, identified clear inequalities in access along a number of dimensions: (1) the urban–rural axis, (2) ethnicity, (3) substance use, (4) age (both younger and older people) and (5) people with a learning disability and/or diagnosis of autistic spectrum disorder, as well as a lack of support for carers. The proposed transformation of community and crisis services, and the MHA review’s promotion of alternatives to detention and interventions to prevent crisis or the escalation of crisis provides the opportunity to address these inequalities, through investment and collaboration with VSOs that are designed to respond to the needs of these groups.

The shifting shape of the voluntary–public sector relationship

The extent to which the VS works closely and collaboratively with public sector services varies considerably and reflects a complex set of factors including specific organisations’ strategic objectives, ethos and mission, and, crucially, their funding mix. For instance, an organisation that receives little or no public funding has a strong emphasis in its mission on campaigning and/or advocacy, or has governance features such as service-user leadership, and may have good reasons for holding the public sector at ‘arm’s length’. At the other end of the spectrum, some receive a high proportion of their income from the public sector and see it as important to deliver crisis services in partnership with the public sector and to contribute to system integration, innovation and improvement. Nevertheless, our data indicate that it is important to recognise the diversity of views on offer. For some, in advocating for a more coherent and ‘seamless’ crisis system that involves a diversity of providers, there is a risk that the pluralistic nature of the VS will be diluted in a move towards more ‘providers’ under the control of public funders. Allied with this is the fear that a move towards integration risks the creeping control of the more bureaucratic and risk-averse NHS extending into the ‘independent’ VS, reflecting long-standing fears in the academic VS literature. 43,48 Indeed, we identified that, through commissioning, the public sector was influencing the VS methods of operation, potentially compromising VSOs’ values and ethos. An example of this was VSOs shifting from open access to thresholds or waiting times for access or limiting the time that people in crisis were allocated.

Gadja’s144 continuum of integration provides a framework for both understanding this diversity of perspectives within the VS and assessing the strength of partnerships, and is potentially useful in exploring the shifts in the VS–public sector relationship. As illustrated in Figure 14, the degree of integration ranges from co-operation to co-adunation (i.e. a single structure combining the VS and the public sector). Building on this, Figure 15 provides a heuristic to illustrate the VS contribution along the elements of a crisis response, identified by the CCC, and the extent of integration between the different types of the VS and the public sector. In mapping the different VSOs, we noted the emergence of hybrid models of crisis services (usually safe spaces) being introduced by NHS trusts in partnership with a VSO, which are close to the definition of collaboration in Gadja’s model. It was also evident that NHS trusts can develop successful alternatives to inpatient admission, as has been the case with the Drayton Park Crisis House for women in Islington. 145

FIGURE 14.

Gadja’s continuum of integration. Reproduced with permission from Gadja. 144

Reproduced with permission from Gadja. 144

FIGURE 15.

Typology for the relationship with public sector services.

The growing evidence base for alternatives to inpatient admission emphasise the importance of collaboration between crisis house staff and other MH services. 146 In our examination of the VS’s role, we note in particular that such successful examples rest on a recognition of the distinctive contribution of the VS to the collaboration, and a determination that these contributions are not stifled. In particular, as Chapter 8 makes clear, commissioners need to be adept at understanding the VS and recognising and actively supporting the VS contribution (most obviously financially, but also in terms of requirements and appropriate monitoring). From other research, in cases in which this has worked particularly well there is a ‘mutual dependence’ between the public sector and the VS in the delivery of a service (or set of services), and their associated outcomes. 49 Concern was voiced that the radical critique that some VSOs offer in advocating for their client group would also be compromised, thus representing a loss to the crisis system as a whole, was reflected in the observation that ‘the VS now needs a VS’. Thus, there are tensions that need to be recognised and worked through by the VS and the public sector in a way that is respectful of and safeguards the distinctive and diverse contributions of the VS. Potential issues that need to be addressed include developing satisfactory governance arrangements, good commissioning models, such as alliance contracting, and arrangements for information sharing and risk management.

Limitations/reflexive account

Critical perspective on patient and public involvement

As noted earlier, the independent evaluation of service user and carer involvement in the study (see Supplementary Material 4) commended the approach and breadth of involvement. Nonetheless, a number of areas were identified in which this could be strengthened. These included:

• an explicit discussion about the principles of involvement as a useful starting point in team building

• greater clarity about the roles and expectations, balanced against the requirement for flexibility and adaptation to emerging findings and learning during the research process

• greater recognition of the administration role in supporting people with lived experience with the practical aspects of involvement.

Importantly, the evaluation commented on the emotional labour involved given the focus of the study. Guidance for academic researchers in supporting co-researchers and clarity about arrangements for people to take time off from the project were recommended. The evaluation also raised interesting questions about the nature of leadership, which was understood as an inverted model of leadership, with the chief investigator role providing sufficient resources, communication and boundaries to enable others to take on the work. Finally, the scope to strengthen this to enable greater co-production with the ultimate aim of work led by service users and carers was highlighted.

Contribution

Our study gathered rich data on the crisis experience and response. It documents, and provides evidence for, perspectives and perceptions of the VS in MH services that, although well established, have not been documented and evidenced fully. A key contribution of this study is to address this knowledge gap to address the questions of what is being provided by the VS to those experiencing a MH crisis, where it is being provided and to whom. We have developed a number of resources that will provide the basis for further research and practice development, namely (1) a database of organisations that potentially provide support to people in a MH crisis, (2) a typology for identifying the diversity of VSOs supporting people in a MH crisis, (3) a map of the current provision of formal crisis services and (4) our original mapping of individual service user journeys, which illustrates not only how the VS complements and addresses gaps in provision but also the exercise of service user agency. Finally, we have made a theoretical contribution to the conceptualisation of a MH crisis, finding evidence for a shift from a narrow biomedical framing of a crisis as an urgent event to a more contextual understanding that locates the crisis experience in a personal and social context, as a ‘biographical disruption’.

Summary

Our study has explored the value of VSOs in supporting people in a crisis and has identified the wide range of activities that not only provide an immediate response but also contribute to prevention and recovery. It has shown the VS to be attractive and acceptable to people in a crisis, that the VS has social value and that the VS can potentially address the complex interactions between MH, inequality and socioeconomic conditions. There is also evidence that the VS can provide a cost-effective alternative to public sector provision, particularly inpatient care. However, the understanding and awareness of the VS contribution is not fully realised and the VS can be viewed as ‘a bit player’ in the provision of crisis care.

Although our study focused on the contribution of the VS to MH crisis care, it has thrown the adequacy and quality of crisis care into sharp relief. In doing so, it has identified significant gaps, with crisis provision often a patchwork of services rather than a pathway or coherent system. The need to address this is recognised by the NHS LTP, which proposes the expansion of community crisis services to be accessed via NHS 111 and additional resourcing to enable a 24/7 community-based MH crisis response offering intensive home treatment and alternatives to acute inpatient admission. Recognition of the VS contribution and the routine involvement of the VS in NHS care pathways could help to translate this aspiration into reality. Indeed, the NHS LTP could potentially use the VS as a fulcrum for localised community support, as opposed to complementing or providing an alternative to public sector provision. At a strategic level, this suggests that increasing investment for community and crisis services, identified in the LTP, could be effectively deployed to increase investment and expand VS provision in MH crisis care.

To conclude, our study was a descriptive study and, thus, it provides a platform for further research to contribute to addressing the identified gaps in MH crisis research. 8 The VS provision for children and young people, older adults and specific communities, particularly BAME communities, as well as people who use substances, requires further investigation. The expansion of VSOs in MH crisis care provides a good opportunity to evaluate the different models of VSO provision, including the degree of integration with the public sector, and their outcomes – short- and long-term – including the cost-effectiveness and impact on advancing equalities. Finally, ethnographic studies would enhance our understanding of people’s crisis journeys and the role of VS and public sector service support in promoting the capacity of individuals, families and their social networks to respond to the range of MH crises.

Implications

From our findings, we identified the following implications, taking account of the CCC’s commitment to an inclusive definition of a MH crisis and the NHS LTP commitment to increasing alternative forms of provision for those in a crisis: Department of Health and Social Care, NHS England, Public Health England, Sustainability and Transformation Partnerships/Integrated Care systems/commissioners, local NHS mental health and local authority providers, and their partners.

Contributions of authors

Karen Newbigging (https://orcid.org/0000-0001-8764-528X) was the chief investigator for the study and was responsible for co-ordinating the research and providing intellectual oversight. She co-designed the study with Alex Davis, John Mohan and James Rees. Karen was responsible for the ethical conduct of the study and was the lead in the case study element, undertaking fieldwork in three of the four sites. She contributed to coding and synthesis, and led the drafting of the final report.

James Rees (https://orcid.org/0000-0003-0545-782X) contributed to the study design in relation to the VS. He co-ordinated and undertook fieldwork in one of the regional sites in WP2 and in one of the four case study sites. He contributed to coding, synthesis of the findings and the drafting of Chapters 3, 5 and 8 of the report.

Rebecca Ince (https://orcid.org/0000-0002-0725-7912) undertook the literature review and developed the national survey and topic guides for the focus groups and interviews. She analysed the databases and, with Karen Newbigging, developed the typology of VSOs. Rebecca undertook fieldwork in one of the regional sites in WP2 and in two of the four case study sites. She contributed to coding, synthesis of the findings and drafted Chapter 2 of the report.

John Mohan (https://orcid.org/0000-0002-6063-3454) contributed to the study design in relation to literature on the VS. He constructed the database of candidate organisations for the national survey in WP1 and he contributed to relevant sections of the final report.

Doreen Joseph (https://orcid.org/0000-0003-0405-0067) contributed to the development of the research tools and undertook fieldwork in two of the four case study sites. She contributed to coding, synthesis of the findings and drafting of sections for the report.

Michael Ashman (https://orcid.org/0000-0003-4195-0208) contributed to the development of the research tools and undertook fieldwork in three of the four case study sites. He contributed to coding, synthesis of the findings and drafting of sections for the report.

Barbara Norden (https://orcid.org/0000-0002-8455-5702) contributed to the development of the research tools and undertook fieldwork in two of the four case study sites. She contributed to coding, synthesis of the findings and the drafting of the service profiles.

Ceri Dare (https://orcid.org/0000-0002-6762-506X) contributed to the development of the research tools and undertook fieldwork in two of the four case study sites. She contributed to coding and synthesis of the findings.

Suzanne Bourke (https://orcid.org/0000-0002-5581-8622) contributed to the development of the research tools and undertook fieldwork in two of the four case study sites. She contributed to the drafting of the service profiles.

Benjamin Costello (https://orcid.org/0000-0003-4744-5659) undertook fieldwork in one of the case study sites. He contributed to coding, synthesis of the findings and developing the crisis journey diagrams.

Publications

Newbigging K, Mohan J, Rees J, Harlock J, Davis A. Contribution of the voluntary sector to mental health crisis care in England: protocol for a multimethod study. BMJ Open 2017;7:e019238.

Data-sharing statement

All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review. However, owing to the sensitivity of the data and the possibility that the location of the participants may be identified, there may be limitations on the data that can be shared.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care.

Review question

The review question was ‘how does the VS contribute to MH crisis care?’. This covered evidence relating to service user experience and outcomes, the relationship with public sector services and the cost-effectiveness of VSOs.

Search strategy

A comprehensive search strategy was adopted to identify the breadth of literature in this area, including grey literature and journal articles. The Health Services Management Centre Knowledge and Evidence Service undertook the search. The review was conducted between May and August 2017 and was updated between November 2018 and January 2019.

Sources

The following bibliographic databases were searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, EMBASE, Health Management Information Consortium (HMIC), MEDLINE, Social Care Online Sociological Abstracts and Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA). Searches were restricted to English-language papers and limited to 2000 onwards, following the focus of the National Service Framework for Mental Health12 on crisis provision. A Google search was undertaken, limited to papers from 2000 onwards using the terms ‘mental health crisis’ and ‘voluntary sector’. Citation tracking was also used – references of or from relevant papers identified through the database searches were followed through to find more recent or other relevant papers. Survey respondents were also invited to send relevant evaluation reports.

Search terms

The search terms used were as follows:

(“mental health” OR “mental illness” OR “psychiat*”) AND (“crisis” OR “emergency” OR “urgen*”) AND (“charit*” OR “voluntary sector” OR “third sector”)

Inclusion and exclusion criteria

Quality appraisal

A systematic quality appraisal was not undertaken, as this was a scoping review including diverse types of material. However, observations about the relevance to the current study and factors influencing the robustness of the findings were noted.

Database of candidate voluntary sector organisations

This section outlines the decisions we made to develop the database for the survey.

There are over 200,000 non-profit organisations (registered charities, companies limited by guarantee, community interest companies, industrial and provident societies, etc.) in England and Wales. Although organisations will supply some information about their activities at the point of registration (e.g. with Companies House), this is often in the form of very general categories, such as the Standard Industrial Classification (SIC) and, therefore, is not very informative about specific fields of activity such as MH. We focused in this project on registered charities, which account for by far the majority of third sector organisations, supplemented by other data provided by bodies that represent and support third sector organisations working in particular fields of activity.

Charity Commission register data

We use a combined version of the registers of charities for England and Wales and for Scotland supplied by the Third Sector Research Centre’s research partners the National Council of Voluntary Organisations (NCVO). The NCVO augments the data captured for regulatory purposes with other fields including a classification of organisations and geographical information, both of which are relevant for this study. The regulatory data are open and publicly available. 155

At the time we commenced the project, there were around 190,000 charities on the registers of the various regulators of charities in the UK (the Charity Commission for England and Wales, the Office of the Scottish Charity Regulator and the Charity Commission for Northern Ireland). Our exclusion criteria for the database were as follows:

• Charities not based in England, using the information supplied in their governing documents or in regulatory returns. There are small numbers of organisations that appear on more than one of these registers, but it is almost unheard of for a social service or health charity to be registered in Scotland or Northern Ireland and to be operating in England. This gave 158,426 organisations.

• Not currently active [defined as having submitted no non-zero financial returns in the past 5 years (2011–15) prior to the start of the study in 2016]; this left 156,177 organisations. 156

• Charities that are directly controlled by the NHS (which usually have a fundraising purpose, such as the endowments of teaching hospitals), that provide benefits only to restricted sets of the population (which are known as benevolent organisations, providing support to members of a specific occupational group, e.g. Aged Mineworkers’ Homes) or that are independent schools. This left 152,741 organisations. 157

For the remaining organisations, we searched through their charitable objects – a document, usually created at the time of initial registration with the relevant regulator, which specifies the purposes for which an organisation has been established – for those operating in the area of MH. This involved text searches for key words or phrases including ‘mental’. This reduced the numbers to 9262 charities.

This figure is much larger than estimates from large national surveys that asked third sector organisations to rank the areas of activity that best characterised what they did (see National survey data: what organisations think). 89 The discrepancy arises for two reasons:

• Some will be false positives – text descriptions of charitable objects will include phrases or words such as ‘regimental’ and ‘environmental’; these satisfy search criteria in that they encompass the text string ‘mental’ but we are unlikely to be interested in them unless other ancillary information suggests that we would. For example, a regimental charity supporting ex-service personnel might well be relevant, given the increased prevalence of mental illness in this group of the population.

• Some potential candidate organisations were identified because of the way in which charitable objects are constructed. Many charities use, in their objects, standard phrases such as ‘promotion of physical and mental well-being’, ‘develop emotionally, mentally, physically’ and ‘purposes of physical and mental recreation’. Such phrases often occur in the governing documents of generic organisations providing premises and a social focus, such as community centres and village halls, or in those of sports organisations that wish to demonstrate that they have a wider public purpose. However, we judged that it was unlikely that the primary purpose of this provision was support for those experiencing MH crises.

We therefore refined our selections by considering only those entities whose objects included the word ‘mental ‘ or ‘ mentally’, either independently or in combination (e.g. ‘mental health’, ‘mental sickness’, ‘mental well-being’, ‘mental distress’ and ‘mental illness’). However, it was not possible to envisage all of the possible ways in which a reference might be made to mental illness in the objects of charities. The suggested text strings would miss organisations such as the Samaritans, whose objects (which are fairly standard across branches) refer to working to assist ‘persons who are suicidal, despairing or in distress’. Therefore, we included some such organisations on the basis of the team’s prior knowledge of entities that were likely to be delivering crisis support.

We were also able to use the ICNPO, developed by Salamon and Anheier,158 which is now widely accepted as authoritative. This breaks down the fields in which non-profits work into subsectors (e.g. health-related organisations are subclassified as hospitals and rehabilitation centres, nursing homes, MH and crisis intervention centres or medical research or in a residual ‘other’ field). The ICNPO schema has been applied to the population of charities by NCVO, using text data from the Charity Commission to match organisations to this classification. 90 This is a largely automated process with an element of machine learning so that it is refined over time and they have been doing it for over 10 years. Because it is automated, it does mean that its usage needs to be combined with further primary research to avoid the risk of leaving out organisations of substantive interest. The main area in which we were interested was ICNPO 3300, ‘mental health and crisis intervention’. By combining NCVO’s classification with our own searches based on combinations of the foregoing phrases or words, we found around 7000 charities that contained some reference to mental illness in their governing documents. These were distributed quite broadly across the ICNPO, suggesting that many were organisations that had only incidental connections with MH. We therefore excluded organisations in all those ICNPO categories in which the proportion of charitable objects that make reference to MH was under 10%, leaving 3125 charities, with two additional ICNPO categories represented: nursing homes and social services.

We further removed those charities that were not also a charitable company, as, without the protections offered by company status, such organisations cannot legally enter into contracts or employ people, and the trustees can be personally liable for anything that goes wrong. 159 We judged that charities operating in this area would not be willing to take such risks if they wanted to recruit and retain volunteer trustees and, therefore, exclusions on this basis left 1551 charities.

In short, our starting point was as follows:

1. all charities either in the ICNPO class 3300 (‘mental health and crisis intervention’) or that include variants of terms relating directly to MH in their objects: 7371 organisations

2. the above, but restricted to only those subsets of the ICNPO in which at least 10% of charities have such references in their objects: 3125 charities

3. the above, but restricted further, to organisations that were registered as companies: 1551 charities.

However, as this was a largely automated approach, there was a risk that we would be missing potential candidate organisations. Therefore, we supplemented this with further inquiries. These focused on six subsets of the ICNPO, which we believed to be substantively relevant to our work because of concerns with housing, advocacy, other health services, hospitals, social services and MH. Searching through these criteria, our exclusion criteria involved the following:

1. Organisations were removed for which there was anything indicating that they were specifically set up to serve causes that were not being explored by the present project. This covered:

   • specific illnesses or disabilities (e.g. cancer and diabetes)

   • children’s services

   • charities identified as medical or social care facilities (e.g. hospices and nursing homes), friends of medical practices (e.g. Leagues of Friends) or medical equipment funds (e.g. appeals for scanners)

   • sports organisations

   • horticulture (this term often appears connected to ‘mental well-being’ in objects).

2. Further clarification was sought by analysis of the information available on the Charity Commission website and/or by using information from the websites of individual organisations. This led us to exclude charities whose sole or principal focus was on leisure and recreation (e.g. maintaining a building, a youth club or specific sports), transport or furniture; charities whose principal purpose was to provide grants as opposed to service provision; and organisations whose primary objectives appeared to be environmental.

We scrutinised the social service category in more depth because of the numbers of organisations in this field – with over 12,000 charities involved – and the likelihood that many of these would at least touch on MH issues in their activities. Within the social services category, a text search of the objects of charities for the string ‘mental’ resulted in 2787 organisations. We filtered out the types that we definitely wanted to exclude under steps (1) and (2) as above. We also searched for other relevant terms such as ‘addiction’, ‘homeless’, ‘abuse’ and ‘substance’ in the objects and checked through these to assign relevance. This left 2383 social care organisations to check through. In this heterogeneous field, it can be difficult to rule organisations out on the basis that they have no connection with MH care, but we removed organisations that had reported no income and entities that appeared to be specifically about child or early-years support (e.g. Home Start). We left in a number of organisations that were recognisable as charities that dealt with vulnerable people, and we also included charities serving elderly people or providing personal care as, after checking a sample, they appeared to provide services to other groups with support needs. For broadly similar reasons, we included organisations that appeared to provide general support and advice to specific groups in which the incidence of mental illness was likely to be higher than in the general population (e.g. the LGBTQ community, people with visual or hearing impairment and ethnic minority groups).

Having approached the challenge of identifying candidate organisations in two slightly different ways, we produced, from the more focused exploration of specific subsets of the Charity Commission data, a core list of 1982 charities. The ICNPO breakdown was as follows:

• 3300: ‘mental health and crisis intervention’ (682 organisations)

• 3400: ‘other health’ (215 organisations)

• 3100: ‘hospitals and rehabilitation’ (51 organisations)

• 6200: ‘housing’ (337 organisations)

• 7100: ‘civic and advocacy organisations’ (85 organisations)

• 4100: ‘social services’ (612 organisations).

Region 1

This region comprised four distinct areas of local government: three largely rural counties and one unitary authority. These were covered by two NHS partnership trusts. The areas were geographically diverse, including coastal areas, small cities and large towns (but no major urban centre), and rural and agricultural areas. Socioeconomically, region 1 is commonly assumed to be wealthy, but interview participants noted specific pockets of deprivation and high need. These were found particularly in coastal and inland towns, each with specific issues such as high rates of substance abuse, a local suicide hotspot or a large proportion of residents from the armed forces. Some of these areas were targeted for pilot studies of VS crisis services, some of which did not extend beyond the pilot phase.

There was significant variation in the availability of VS crisis services both across the region and within the four areas it was made up of. One area housed a number of crisis cafes open out of hours on different days, as well as a VS crisis telephone line. Another area had a residential crisis house that was gatekept by the local CRHT and an out-of-hours safe space (notably, these were both located in the same town, whereas other towns in the area with particular needs had no face-to-face crisis services), while another area had an integrated ‘hardship’ crisis service. There had also previously been a service-user-led pilot of an out-of-hours crisis cafe-style safe space in one of the areas identified as having a high level of need, which did not last beyond the initial 6-month pilot, largely because of underuse. It was noted by a local peer support organisation that the short-term nature of pilot projects such as this one made it difficult to confidently signpost people to crisis services. The fourth area – a largely rural county – had no VS crisis services at all apart from voluntary peer support for people in distress. The sparsest provision was in the most rural areas, in which both VS services such as safe spaces and statutory services such as A&E departments with psychiatric liaison involved long drives or were very difficult to access without a car owing to a lack of reliable public transport infrastructure. There were, however, a number of long-standing VS providers of type 2 services across the region in all areas.

Region 2

This region was made up of 12 local authority areas, including two major urban areas that were considered city regions (both forming combined authorities). The region contained two predominantly rural county council areas and 10 unitary authorities of varying levels of urbanity and scale. In short, there were two large conurbations and two large rural areas, and the region had a significant coastline, which all presented challenges in terms of access and providing services across a very diverse area. The region was covered by two NHS foundation trusts. Overall, the region had a post-industrial character and contained large areas in which communities faced significant deprivation. As can be expected from this brief description, the area was socioeconomically mixed, with deprivation often concentrated in neighbourhoods in urban areas and also somewhat in isolated coastal and rural towns and, owing to distance and relatively fragmented public transport, it could be difficult to travel around the area. The region was noted for high rates of suicide and this was reflected in local MH priorities, including those of some of the VSOs that we spoke to. For instance, some of the smaller VSOs focused on male MH concerns and suicide reduction, including in the rural areas.

One conurbation had a relatively high-profile ‘complex needs’ programme that was led by a VSO and funded by a large national grant maker, reflecting the prevalence of substance abuse and rough sleeping, often closely linked to MH problems. In this area there also appeared to be a relatively active VS role in terms of safe spaces and a Recovery College. In the other conurbation, the local crisis ‘system’ appeared to be closely shaped by statutory organisations (including the provision of various interventions to improve access and response to those in a crisis) and the VS, although the part played by the VS in this was often seen as supplementary and somewhat peripheral: people were ‘signposted’ to VS services as necessary. This latter area also had a VS-delivered crisis house, but this provision was small and not widely known about, and access was gatekept by the area’s crisis teams. Like region 1, region 2 was very diverse and VS provision was much sparser in the rural areas.