Barker et al's examination of the introduction of a crisis resolution and home treatment (CRHT) service to Edinburgh 1 was of great interest to us in the North-East of Scotland. However, we have significant concerns as to the widespread reproducibility of their findings. The authors conclude that this service reduced admissions by 24%, but we believe that they paid scant attention to the planned, concurrent closure of 30% of adult beds. They made little attempt to account for this and consequent effects on admission rates and bed pressure, leading us to question the suggestion that CRHT may catalyse more efficient use of in-patient beds.
Owing to the paucity of demographic data, we found it difficult to assess the applicability of the results. The study population described had a high proportion of people with major mental illnesses, with a striking lack of dual diagnoses and adjustment disorders. We can only hypothesise on the effect of other nearby emergency psychiatric services on the CRHT case-load, and were surprised that the provision of overnight stay, from March 2009, at the Edinburgh Crisis Centre was not considered a confounding variable. 2
We would question the outcome of high user satisfaction, given the 29% response rate to the questionnaire, with possible selection bias. We would also have been interested to hear how patients rated the CRHT in comparison to hospital admission, and how allied services, within Edinburgh and beyond, including adjacent health board areas, rate their satisfaction with this novel team.
We struggle with comparisons made to admission rates in Scottish health board areas without CRHTs - for example, the reported 9% reduction in Grampian admissions. Grampian is a diverse area of 3400 square miles, with a mixed rural and urban population, yet comparisons have been offered to the 100 square mile City of Edinburgh, which is but one part of the Lothian Health Service.
Using Information Services Divisions (ISD) Scotland data for general psychiatry adult admissions in 2009-2010, adjusted for the 2008 NHS Scotland Resource Allocation Committee (NRAC) population formula, we calculate an admission rate of 3.39 per 1000 adult population for Grampian, compared with 3.77 for Lothian, with a reported mean stay for Grampian of 35.1 days per episode, compared with 40.4 days for Lothian (further details available from the authors).
In addition, the 2009-2010 Mental Welfare Commission report confirms a lower rate of immediate detention in Grampian, with emergency detention rates of 15 per 100 000 in Grampian against 31 per 100 000 in Lothian, and short-term detention rates of 70 per 100 000 in Aberdeen city compared with 78 per 100 000 in Edinburgh. 3
In our opinion, despite the conclusions of the Barker et al paper (including comparisons with other health board areas), we remain concerned that similar services, with the obvious attraction to managers of potential bed closures, will be prematurely implemented across Scotland, and we question whether a CRHT service would provide any additional benefits to the population of Grampian, where continuity of care based on primary care and local authority aligned services remains the cornerstone of practice.