Alternative approaches to standard inpatient mental health care: development of a typology of service models

Background Inpatient mental health care is a challenging component of the mental health services system, with frequent reports of negative and coercive experiences and doubts about its therapeutic value. As such, alternative approaches for individuals experiencing a mental health crisis are highly desirable. This research aimed to identify models which offer an alternative to standard inpatient mental health care across all age groups, both nationally and internationally, and to develop a typology for these alternative models. Methods A dual literature search and expert consultation research methodology was adopted to identify relevant models. Three typologies of models were developed according to age group and acuity, including: alternatives to standard acute inpatient services for adults; alternatives to longer-stay inpatient services for adults, including rehabilitation and forensic inpatient services; and alternatives to standard inpatient services for children and young people. Results We identified an array of service models in each typology, some in community settings, some hospital-based and some working across settings. Models varied greatly in characteristics, extent of implementation and supporting evidence. Conclusions Through this mapping exercise, we have developed three novel typologies of alternatives to standard inpatient care. A range of community-based, hospital-based and cross-setting approaches were identified. The identification of services providing inpatient care in a substantially different way to the standard suggests that some improvements could be provided within existing structures. Potential inequities in access to alternatives were identified for certain groups, such as people who are compulsorily detained, younger children and young people transitioning between children’s and adult services. These typologies can inform future description, evaluation and comparison of different service models. This research also yields some key considerations for the design, development and implementation of alternative mental health service models and service arrays. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant no. PR-PRU-0916-22003). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The College Research Ethics Committee of King's College London gave ethical approval for this work (Minimal Risk Registration Number: MRA-22/23-34963). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The Excel dataset generated via expert consultation and literature searching is available within this manuscript’s additional materials. Unpublished data and identifiable information from expert responses have not been made publicly available to protect participants’ confidentiality. * ACT : Assertive Community Treatment BA : Brief Admission CCM : Crisis Case Management CMHT : Community Mental Health Team CRHTT : Crisis Resolution and Home Treatment Team CYP : Children and Young People DTC : Democratic Therapeutic Communities EIP : Early Intervention in Psychosis FACT : Flexible Assertive Community Treatment FREED : First episode and Rapid Early intervention for Eating Disorders HASS Housing and Accommodation Support Services ICM : Intensive Case Management IIRMS : Intensive Intervention and Risk Management Services LEWG : Lived Experience Working Group NHS : National Health Service NICE : National Institute for Care Excellence OPD : Offender Personality Disorder PA : Preventative Admission PIPEs : Psychologically Informed Planned Environments REMS : Residences for the Execution of Security Measures STC : Secure Training Centre TBS : Ter Beschikking Stelling UK : United Kingdom USA : United States of America