Global Healthcare Management (MSc)

M05SOH

MANAGEMENT PROJECT (GENERAL)

AL

August

2018

The work contained within this document has been submitted by

the student in partial fulfilment of the requirement of their course
and award

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 Coventry University

Faculty of Health and Life Sciences

A business proposal to introduce the Implementation of a ‘Crisis House’ for patients

living with Bipolar Disorder in Coventry.

Module Leader: Rob Wilson

Student Name: AL

Student Number: XXXXXXX

Word count: 9533

Date of Submission: 20/08/2018

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 1. Proposal Title
A business proposal to introduce the Implementation of a ‘Crisis House’ for patients
living with Bipolar Disorder in Coventry.

2. Executive summary
A systematised review was conducted to understand the experience of patients with
Bipolar Disorder (BD). The literature review identified that patients preferred
community-based mental health services in comparison to hospitals. This was directly
related to stigmatisation and lack of therapeutic communication given to patients once
hospitalised. Due to the prevalence of BD, lack of resources within acute psychiatric
wards and Crisis resolution teams (CRT), this business proposal aims to introduce a
Crisis House for patients diagnosed with BD who need help but do not require
hospitalisation. The proposed business plan offers 1-week stay for up to 5 patients.
The Crisis House is estimated to cost £181 per bed day and could save mental health
services up to £173/ bed day.

3. Acknowledgements
Most importantly I would first like to thank God, for supporting and giving me strength
throughout my MSc degree.

I am grateful for my family’s abundant prayers, love, support and motivation every step
of the way.

I would like to thank my best friend and sister, H for the support, guidance and all the
late nights we spent making sure we met our deadlines.

I am thankful for all my friends who supported me along the way, by motivating and
listening to me.

To my Dissertation Supervisor, Jill Barr, your guidance, positivity, laughter and

encouragement throughout this dissertation was truly appreciated, thank you so much.

To all the lecturers in Coventry University who has helped me along the way, thank
you all for your support and guidance in educating the future healthcare leaders of
tomorrow.

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 4. Table of Contents

Contents
1. Proposal Title ................................................................................................................................ 3
2. Executive summary ...................................................................................................................... 3
3. Acknowledgements ...................................................................................................................... 3
4. Table of Contents ......................................................................................................................... 4
5. Glossary of Terms ........................................................................................................................ 5
6. Introduction.................................................................................................................................... 6
7. Literature review ........................................................................................................................... 9
8. Project Aim, objectives .............................................................................................................. 15
9. Project Plan/ Project Milestones .............................................................................................. 16
10. Financial Costs ....................................................................................................................... 26
11. Evaluation Plan ....................................................................................................................... 30
12. Mainstreaming of the Crisis House...................................................................................... 31
13. Reflexivity ................................................................................................................................ 34
14. Reference List ......................................................................................................................... 38
15. Appendix .................................................................................................................................. 54
Appendix 1: PEST Analysis .......................................................................................................... 54
Appendix 2: SWOT analysis of mental health services........................................................... 55
Appendix 3: Crisis House capacity .............................................................................................. 56
Appendix 4: Database search ...................................................................................................... 57
Appendix 5: CASP (2018) ............................................................................................................. 60
Appendix 6: McMaster (Law et al. 1998) .................................................................................... 61
Appendix 7: SWOT analysis of Crisis House ............................................................................. 64
Appendix 8: Ethics approval ......................................................................................................... 65
Appendix 9: Stakeholder assessment........................................................................................ 66
Appendix 10: Critical Path Analysis ............................................................................................. 68
Appendix 11: Gantt Chart ............................................................................................................. 69
Appendix 12: Questionnaire ......................................................................................................... 70

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5. Glossary of Terms
List of Abbreviations:

BD- Bipolar Disorder

CQC- Care Quality Commission
CRHT- Crisis resolution and home treatment
CRT- Crisis resolution teams
MHS- Mental health services
NHS- National Health Service
NICE- National Institute of Clinical Excellence
PEST- Political, economic, social, technological
PM- Project management
PMT- Project management team
QOL- Quality of life
STP - Sustainability and transformation plans
SWOT- Strength, weakness, opportunity, technological
WHO- World Health Organisation

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 6. Introduction

Mental health has been at the forefront of global agendas for many years. This has
encouraged global leaders to work together to transform and improve the leadership
and governance of mental health services, through the integration of social and mental
health services into community-based settings (WHO 2013). With the World Health
Organisation (WHO) acting as the main driver. In 2013, the World Health Assembly
commissioned WHO’s Mental Health Action Plan 2013-2020, which stated that
everyone should have access to effective mental health services (WHO 2013). In
addition to this, NHS England (2018a) have initiated the NHS Five Year Forward View,
this will also have an impact on reaching global goals. This policy involves local
authorities working together and achieving sustainability and transformation plans
(STP) (NHS England 2018b). With the budget allocation of £1.4 billion to develop
mental health services (NHS England 2018a). The NHS Five year forward aims to
increase accessibility to mental health services for an additional 200, 000 people,
increase psychological therapies and provide better psychiatric health services for new
mothers (NHS England 2018b). It was identified that mental health cost England up to
22.5 billion (McCrone et al. 2008), with an average bed cost between £259- 354 per
day (Smith and Chakraborty 2012; and CQC 2018). The NHS has made efforts to
allocate £2.1 billion to fund STP’s in 2016-2017, promising to increase the budget
yearly until 2021 (Ham, Buckley and Baylis 2016). However, local authorities are
facing many challenges due to lack of resources, beds, accessibility to crisis services,
staff retention and training, which is further affecting the quality of services (BMA
2017). Nevertheless, due to the prevalence of patients requiring this service, it is
important services work together to ensure services provided are safe, effective and
efficient.

This business proposal will focus on Bipolar Disorder (BD), a mental health condition
that causes changes in a person’s mood, regulating from high to low mood states
known as episodes (Mind 2015). Patients with BD can be diagnosed with either Bipolar
1 or Bipolar 2 disorder depending on their symptoms (Thomas 2004). Bipolar type 1
is where patients experience manic episodes with or absent of depressive episodes.
Patients with type 1 are more likely to be hospitalized during manic episodes (Miller,
Johnson, and Eisner 2009). While type 2 involves having one hypomanic episode with

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severe depressive episodes (Datto et al. 2016). Manic episodes include symptoms
such as feeling irritable, increased self-esteem, inability to sleep, flooded with ideas,
unable to focus and excessive talking (Lankeren 2016). The diagnosis of BD can
impact patients social, educational and work lifestyles and although the psychosis is
not relatively new, stigmatisation of BD still exists, rendering patients less likely to
request help from mental health services (Clement et al. 2015).

WHO (2017), identified that BD affects 60 million people worldwide and 1 in 100 men
and women in the United Kingdom (UK) (Goodwin and Jamison 2007). BD has also
been labelled as one of the most expensive behavioural disorders (Walsh 2016).
According to McCrone et al. (2008), between the years of 2007-2026, the NHS will
see an increase in BD cost from £1.6- £2.63 billion. The Mental Health Network (MHN)
team identified that mental health resources are limited and the majority of acute
psychiatric hospitals in England experience bed shortages (MHN 2016). It is estimated
that 40% - 73% of people with BD relapse and need hospital care within the first 5
years of their diagnosis (Colom et al. 2003). Tondo et al. (2016), identified suicidal
rates of 31.1% in BD patients, with patients having an increased risk of alcohol or drug
abuse. Researchers have also found patients to have a reduced life expectancy of 15-
20 years (Green et al. 2018).

A Care Quality Commission (CQC) report on a local mental health trust found that
services had appropriate staffing levels and the National Institute of Clinical Excellence
(NICE) guidelines were being followed (CQC 2017). However, a limited number of
employees had training on the Mental Health Act 2007, ligature points were not
minimised, and bed occupancy exceeded 100%. The lack of beds resulted in patient
sleepovers on other wards, or patients left without beds for short periods (CQC 2017).
Minimising the ligature points in rooms allows the psychiatric ward to reduce the risks
of suicide (CQC 2015). Although, the mental health crisis services required service
improvement in some areas the service was efficient, and patients found employees
caring. A crisis in mental health services is referred to as the point at which a patient
feels their mental state is in jeopardy (Mind 2015). This is known as a psychiatric
emergency and can be triggered by external stress but can also occur in absence of
stress (Heath 2004). Subsequently, lack of resources has resulted in crisis teams
having to manoeuvre appointments to meet service demands (CQC 2017). The
community-based mental health services for adults was rated good overall, however,

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services lack resources and adequate documentation of complaints (CQC 2017).
Nevertheless, patients are more susceptible to the community- based mental health
services over hospitalisation (Rose 2001). Moreover, for service improvement, the
NHS mental health trust needs more collaborative leadership, governance and further
training for employees (CQC 2017).

Additionally, the strategic management tools; Political, economic, social, technological

(PEST) and strength, weakness, opportunity, technological (SWOT) analysis were
used to further identify the existing management problems in mental health services
to propose a solution (see appendix 1-2). PEST analysis was used to identify the
external factors that influence the mental health services. PEST analysis is useful for
forecasting potential threats (Phast 2017). However, due to the organisation changes
PEST analysis needs to be updated regularly. This can be time-consuming; however,
PEST is easy to use, cost-effective and identifies opportunities for business growth
(Latest Quality 2017). The SWOT analysis was used alongside the PEST to identify
the internal (strengths and weaknesses) and external factors (opportunities and
threats) of mental health services. This is an effective strategic tool that is used in
project planning to make decisions (Mullerbeck 2015). Through, the use of these tools
a Crisis House was identified as a better hospital alternative. A Crisis House is a
residential service provided to mental health patients for a brief period to help patients
manage a crisis (MIND 2015). A Crisis House could potentially reduce bed occupancy
in hospitals, reduce the strain on crisis and community-based services (Morgan 2007).
Although, the concept of Crisis Houses is relatively new, service is safe and effective
at providing accommodation to mental health patients experiencing a crisis (MIND
2015). The current Crisis Houses in the UK facilitates up to 10 patients with a duration
of stay is between 1- 4 weeks (appendix 3). Crisis Houses have also been seen to
reduce bed day costs when compared to NHS acute inpatient care, by more than £100
(Mcdaid and Park 2016). Crisis Houses do not support mixed-sex accommodation
(MSA), which is compliant with the NHS Operating framework policy 2011/12 (NHS
2010). MSA can occur only if it is best for the patients. Furthermore, MSA breaches
must be reported to prevent services from being penalised. Subsequently, due to the
demand, the evidence obtained from the CQC (2017) report and the information
obtained from the management tools, it will be beneficial to implement an alternative
mental health service such as a Crisis House. Subsequently, this proposal will critically

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analyse existing mental health services by analysing literature available on BD whilst
discussing the Crisis House benefits and the implementation process required.
Additionally, this proposal will demonstrate the financial breakdown, evaluation of the
project and identify how this project can be mainstreamed.

7. Literature review

7.1 Search strategy

The quality of research is reliant on the reliability of the chosen methodology;

therefore, the methodology was established once the research topic was identified to
determine rigour (USC 2018). Rigour in research refers to the validity and reliability of
research which is important for quality (Seale and Silverman 1997). Rigour is a
fundamental part of science, consequently, if this cannot be established in research,
the study should not be funded or published (Cypress 2017). A literature review was
carried out to critically analyse gaps in research and to justify why a Crisis House is
needed (CQUniversity Library 2018). The keywords and search strategy used can be
seen in appendix 4. Qualitative and quantitative literature was obtained using
databases such as PubMed, Google Scholar and Ovid. The Critical Appraisal Skills
Programme (CASP 2018) tool was used to appraise the qualitative research obtained
from the database search (appendix 5). McMaster was then used to appraise
quantitative literature by analysing usefulness and trustworthiness (Law et al. 1988)
(appendix 6). As discussed in the introduction an alternative mental health service is
required for BD patients, subsequently, a systematised literature review was
conducted as it provides researchers with the direction for future research (Aromataris
and Riitano 2014). PubMed provided a range of healthcare publications and is one of
the largest databases. Additionally, Pubmed ccontains Medline citations, journals on
life science and books, therefore, was useful for locating literature on BD management
strategies and the current services available (Grewal, Kataria and Dhawan 2016).
However, unlike PubMed and Ovid, Google Scholar does not have an advanced
feature that allows the researcher to filter the search strategy to match the researcher
inclusion criteria e.g. only literature in English was selected, and papers between
2008- present to ensure research is up to date (Shultz 2007). For further information
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on exclusion and inclusion criteria please see appendix 4.3. Google scholar was a
quick and efficient database for locating a wide range of publications, such as peer-
reviewed papers, books and articles from organisations which were used in this
proposal (Shultz 2007).

7.2 Management of acute psychiatric wards

According to Moreno- Poyato et al. (2016), therapeutic relationship is crucial in quality

psychiatric nursing, this involves developing effective communication skills through
talking, listening and showing empathy towards patients (McAndrew et al. 2014). A
systematic review by Bee et al. (2008), agrees with this and suggests that nurses need
to develop communication skills, build relationships and engage with patients to
improve service user experience. A thematic analysis was conducted by Gilburt, Rose
and Slade (2008) on 19 patients previously admitted to 10 different hospitals. The
participants advised that communication with clinicians was a vital part of their hospital
stay, in addition some participants found health workers lacked the ability to listen and
communicate. However, when the staff listened and communicated effectively patients
found the information provided was useful (Gilburt, Rose and Slade 2008).
Subsequently, as the largest population of mental health employees in the NHS are
nurses, therapeutic communication should be a vital aspect of their role (Bee et al.
2008). A huge barrier of communication in acute psychiatric wards is caused by
nurse’s excessive workloads and lack of time. A quantitative study carried out by
Lasalvia et al. (2009), on 2000 employees in mental health services identified that
psychiatrists and nurses were the least motivated amongst other health workers within
the mental health sector. Additionally, a direct relationship between the duration of
working in mental health services and exhaustion was found, indicating staff employed
more than a year showed more signs of exhaustion (Lasalvia et al. 2009).

7.3 Stigmatisation and hospital admissions: patient experience

According to Szmukler and Holloway (2001), there is not enough literature available
on patients in relation to the effectiveness, process and the level of risks associated
with acute wards. However, there are more publications available on the experiences

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of hospitalisation, and more interest in the stigma linked to mental health.
Stigmatisation is a major challenge faced by patients with BD (WHO 2001). According
to Freedberg (2011), mental health patients are left feeling unvalued and physically
weak after hospitalisation, which can lead to self- stigmatisation and resentment
towards hospitals. Brohan et al. (2011) study discusses three types of stigma
experienced by patients with mental health illnesses; internalising people’s negative
response towards the disorder (self-stigma), fear of how people may act (perceived
stigma) and experience of receiving unjust treatment (experienced stigma). Stigma
can significantly influence the wellbeing of patients (Brohan et al. 2011). Hawke,
Parikh and Michalak (2013) qualitative study on patients with BD expressed that
patients experience stigma at work and within healthcare environments, subsequently,
affecting the quality of life (QOL). Self-stigmatization is a major issue which prevents
patients from seeking health advice or help (Hawke, Parikh and Michalak 2013).
According to studies by Patten et al. (2016) and Clement et al. (2015) stigmatisation
within society has resulted in patient’s reluctance towards seeking help from mental
health services. Moreover, Lee Mortensen et al. (2014) further supports that QOL of
patients with BD is negatively impacted by Internal and external stigma, with BD
patients accounting for a lower level of QOL in comparison to other mental health
illnesses (De la Cruz et al. 2013). Furthermore, De la Cruz et al. (2013) study identified
that health-related QOL of women with BD was more significantly impacted than men.
However, the study was limited as the study only consisted of 30% males, to avoid
bias further studies will need to be conducted with equal applicants of both genders.
A study by Wittkowski, McGrath and Peters (2014) suggests that women avail of more
mental health services than men due to women being more open to alternative
treatment options. This suggests that there is more demand for mental health services
in women than in men. It will be of importance for researchers when conducting future
studies to closely analyse why some men are reluctant to use mental health services,
this could be due to further stigmatisation. Subsequently, hospital stigmatisation and
the community may play a huge part in this. Although global efforts have been made
to reduce the stigma of hospitalisation by focusing on deinstitutionalisation and moving
to more community based mental health services, stigmatisation has increased in
some studies and has had positive effects in others (Loch 2012). Furthermore,
according to Corbiere et al. (2012), stigmatisation can be addressed by educating the

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public on mental health disorders and mental health needs, so it can be normalised
within society.

7.4. Alternatives to hospitalisation

A study was carried out by Rose (2001) on mental health services (MHS), which
involved training 60 mental health users to enable them to conduct interviews on 500
other MHS users. This study was an effective approach for using feedback from
service users that could be potentially used for service improvement. According to
Omeni et al. (2014), the involvement and agreeance of service users in relation to the
services provided to them is a highly favoured method and policy used to improve the
quality of services. Furthermore, Rose (2001), identified that patients preferred
community-based MHS in comparison to the hospital. This was due to patients not
receiving enough information in hospital settings, most patients either did not have
access to their care plans or were unaware of its existence. While mental health
patients were satisfied with community MHS as more information was provided to
them (Rose 2001). This indicates that there is a clear demand for more MHS within
the community. Services such as the Crisis resolution team (CRT), which can often be
referred to as the Crisis resolution and home treatment (CRHT) have been used in
England as an alternative to hospitalisation for mental health patients. CRHT offers
mental health patient centred approach towards recovery. However, researchers have
controversial opinions on whether CRT’s are required. Burns (2000), indicates that
when a patient with a mental illness is experiencing a crisis, hospitals are highly
experienced to care for the patient’s needs, therefore a crisis team is not useful nor
efficient. Burns (2000), concludes that crisis teams in the UK need to be more effective
and sustainable to prove services are required and are better than inpatient care.
However, through this literature search evidence suggests that there are more studies
available discussing the effectiveness of CRT. In addition, a quasi-experimental study
evaluated the outcomes of mental health patients in a crisis. The study found that
hospital admission decreased from 71%- 49% within 6 weeks of CRT intervention
(Johnson et al. 2005). Subsequently, a systematic review conducted by Wheeler et al.
(2015) further supported the CRT model, CRT provides better service user satisfaction
rates, reduces hospital costs and admissions. With a further reduction of 40% in
hospital admission when CRT have psychiatrists within their team (Wheeler et al.

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2015). According to a research project carried out by McCrone, Knapp and Hudson
(2007), every 28 days £600 could be saved on healthcare costs if CRHT were used
for a patient instead of hospitalisation. On average patients with BD require up to 33
days in the hospital while the crisis team manage crisis within 28 days (McCrone,
Knapp and Hudson 2007). Subsequently, although CRT offers many benefits, barriers
still exist. The main challenge faced by CRT is integrating with other mental health
services (Johnson 2013). These barriers can be due to services coming from different
training backgrounds, attitude towards change, accountability, political stability,
management and leadership (Wakida et al. 2017). Furthermore, for the continuous
improvement of CRT services, research indicates that crisis teams need to effectively
liaise and communicate with services and maintain rapport with patients through
therapeutic communication (Johnson 2013). Another issue identified in the literature
was the risk management of suicide rates in CRT (Wheeler et al. 2015). The CRT
need to optimise the quality of services and improve implementation strategies to
ensure CRT meets policy requirements and crisis resolution aims of providing an
effective and safe alternative to hospitalisation (Wheeler et al. 2015). Additionally,
there were more CRT guidelines and qualitative research on how to improve CRT
services than quantitative research. Furthermore, Morgan (2007) conducted
interviews with managers from CRT services and 25 hospitals across England, the
managers advised that hospital occupancy could be further reduced by 23% if CRT
had the capacity. In absence of CRT services managers predicted that this would
result in 74% of CRT patients being admitted into hospital (Morgan 2007).
Subsequently, the managers expressed that to reduce the strain on the CRT more
staff and psychiatrists will be required, better access to acute day hospitals and lastly
the implementation of more Crisis Houses to meet service demands (Morgan 2007).
Furthermore, Sweeney et al. (2014) found that the Crisis Houses were limited but
offered better service user experience when compared to hospitals, as patients
reported lack of therapeutic relationship was built in hospitals. According to Gofal
CYMRU (2018), 88% of patients that used the Crisis House in Wales were able to
avoid hospitalisation. Furthermore, the Crisis House provides help and support to
mental health patients within a safe environment (Department of Health and Concordat
signatories 2014). Predominantly, most literature obtained identified the success rates
of Crisis Houses. However, the literature failed to explore the community’s response
to having a Crisis House in local areas due to the possible threat of stigmatisation.
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This would be a useful research topic to further develop information currently available
on Crisis Houses. Sweeney et al. (2014) identified variations in Crisis Houses, some
are largely managed by the voluntary sector (social care workers) while others are
managed by the NHS (mental health employees). Furthermore, this could be a
potential area of study for researchers, to further explore whether the Crisis House
under either management makes a significant difference. This could provide
stakeholders with more information that may be vital for improving the service user
experience for mental health patients. Moreover, the study provided more information
on the type of patients residing in Crisis Houses, which was difficult to obtain in other
papers (Sweeney et al. 2014). The study found that patients in Crisis Houses were
previously known users of other mental health services and their likelihood of violence
was slim, with 31% of patients requesting help on their own terms, however, more
often help-seeking was requested by family or health workers (Sweeney et al. 2014).
A randomised study by Killaspy et al. (2000) found that Crisis Houses in the UK
consisted of 33% of BD patients. While, according to Gofal CYMRU (2018), the Crisis
House in Wales identified that 69% of patients had either BD or a depressive episode.
However, the figures were not further broken down to see the actual amount of BD
patients. Lastly, grey literature by Rethink Mental illness (2018), provides information
on alternatives to hospitalisation. Patients are referred to Crisis Houses from CRHT
and mental health wards. The clinical team of Crisis Houses are required to help
patients develop self-management plans, promote healthy living and relaxation
techniques for the prevention of future crisis. Furthermore, Crisis Houses are
predominately managed by an experienced mental health workers. For safety
purposes, one nurse or support worker is assigned to every three residents (Rethink
Mental illness 2018). The sociodemographic of Crisis houses identified that 57% of
service users were women (Rethink Mental illness 2018). Gofal CYMRU (2018),
acknowledged that most service users were females which accounted for 64%.
Although the male and female usage of Crisis houses are relatively similar, both Gofal
CYMRU (2018) and Rethink Mental illness (2018) values indicate that women avail of
Crisis Houses more than men. This further supports Wittkowski, McGrath and Peters
(2014) study, which indicated that women are more susceptible to try different health
services and treatments available.

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 8. Project Aim, objectives

Project Aims

The aim of the business proposal is to introduce a Crisis House for patients diagnosed
with BD who need help but do not require hospitalisation.

This will include:

1. To provide knowledge to patients with BD, aged between 18-45 of

alternative mental health services in Coventry.
2. To create a service that is safe, efficient and effective for patients.
3. To combat the stigma associated with hospitalisation and mental health
services.
4. To reduce costs and strain associated with BD on acute psychiatric wards
and CRT services.

Project Objectives
Objectives were formulated using the Specific, Measurable, Achievable, Realistic and
Timely (SMART) model (CMI 2011). SMART objectives will establish specific targets
that the project manager (PM) of the Crisis House will require to achieve the project
aims. Objectives can be used as goals and can be relayed by the Crisis House PM to
key stakeholders to create a shared purpose.

1. To significantly reduce the acute bed occupancy and readmission of BD

patients by 25% within the first 12 months of implementation.
2. To reduce the number of BD patients requiring CRT services by 20-30%
through a clinical audit within the first year of the Crisis House project.
3. To provide a Crisis House that will increase patient and family satisfaction by
the end of the year.
4. To improve the confidence and satisfaction level of the employees with their
skills of caring for BD patients through training in Safeguarding, First Aid
training, Mental Health Act 2007 and therapeutic communication within 3
months of employment.

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 9. Project Plan/ Project Milestones

This proposal is intended for the West Midlands mental health trust. The
implementation of a Crisis House will bring local policymakers and stakeholders closer
to the goals of achieving national Sustainability and Transformation Plans (STP) and
the NHS five year forward plan (NHS UHCW 2018). To meet the operational
framework requirements, it is advised MSA is not tolerated (NHS 2010). Therefore, it
is recommended that the proposed Crisis House focuses on facilitating women only
for the meantime. Although BD affects men and women both equally, according to the
information obtained from the above literature review, women are more open to using
new services. The Crisis House should encourage family and friends of BD patients
to visit to further facilitate recovery. It is recommended that the PM should consider
allowing 2-3 visitors per visit, with visiting times held during the day before 6 pm. In
addition, a SWOT analysis was carried out to identify internal and external factors that
can hinder the implementation of the proposed Crisis House (appendix 7). The
proposed Crisis House PM can work on developing strengths, removing weaknesses,
exploiting potential opportunities and combatting threats that may occur (Salar and
Salar 2014). One of the strengths and opportunities identified from the proposed Crisis
House is that it would integrate with CRT and further build on relationships between
CRT services and acute psychiatric wards. This will help reduce the demand on
hospitals and CRT services and subsequently, provide better service user
experiences. However, the potential threats exist within budget constraints and the
potential resistance the community may have towards having a Crisis House in their
area. Additionally, this project plan will analyse the following; ethics, stakeholder
analysis, Crisis House barriers, leadership techniques and the project milestones
using a Critical path analysis (CPA) and Gantt Chart. This information will be of value
to the proposed PM.

Ethical Approval

A low-risk ethical approval was gained to carry out this proposal from Coventry
University Research Ethics committee (Reference: P71768) (appendix 8). Ethical

16
approval is an essential part of the research, it is used to ensure participants i.e. BD
patients’ rights are met and are free from harm (Orb, Eisenhauer and Wynaden 2001).

Stakeholder assessment

Stakeholders are defined as participants, individuals or organisations who have a

stake in a project, organisation or policy (Brugha and Varvasovszky 2000). These
stakeholders can influence and be influenced by an issue, i.e. prevalence of BD
(Schiller et al. 2013). By identifying the stakeholders of this business proposal, the
proposed project team will be able to prioritize stakeholders, build relationships and
spend time understanding the needs of BD patients for a successful project (Schiller
et al. 2013). The Crisis House stakeholders were identified as follows; BD patients,
family members of patients, CRT services, acute psychiatric wards, policymakers,
NHS, community, employees of Crisis House, researchers, mental health charities,
and CQC as seen in figure 1. The stakeholders are a diverse group of people, which
will be a great attribute for the development of the Crisis House project. Diverse groups
offer insight into different perspectives, years of expertise which will be required for
solving problems that may arise during project planning (Phillips 2014).

17
Project plan

A CPA was used for this proposal to identify the tasks needed for the proposed Crisis
House (appendix 10). CPA is a useful tool used in project management to outline high-
risk tasks, develop schedules and feasible timescales. In turn, CPA increases project
efficiency and identifies areas where project development opportunities may arise
(Sharma 2015). The important tasks represented on the CPA can be translated on to
a Gantt chart (appendix 11). A Gantt chart is more visually appealing and will be easier
for the proposed PM to present the Gantt chart to stakeholders. This allows the
interested participants to view the start and competition dates of the tasks needed for
the Crisis House. A project can consist of variables, such as tasks running
simultaneously, therefore, a Gantt chart can also connect tasks to individuals.
However, this can be time-consuming as PM may need to update chart due to
unforeseen circumstances, such as an employee leaving (Grover 2002). However, this
can be easily amended electronically and sent to the proposed project team. The tasks
needed to implement this Crisis House are as follows; develop project management
team (PMT), schedule meetings with acute psychiatric hospitals and CRT, conduct a
BD survey, schedule stakeholder meetings, secure budget, budget allocation,
recruitment of Crisis House employees, staff training, rent a house, signposting of
Crisis House, and conduct a service user questionnaire. The process identified in the
CPA and Gantt chart is estimated to take up to 2 years. After 2 years the PM hired can
discuss how the Crisis House project can be mainstreamed.

Task 1: Developing the Crisis House PMT

Characteristics of the PM:

 Impartial governance: hired externally by the local CRT and acute psychiatric
hospital to ensure unbiased decisions are made that are best for the Crisis
House.

 Management Skills: due to complex nature of the healthcare sector, the PM

must have the following; experience within the healthcare sector, business
management skills, ability to build relationships, inspire employees, resolve

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 conflict, understand the culture of the organisation and hold change
management skills (Slipicevic and Masic 2012). Change management is a
process required to take an organisation or service from one state to another
(Ryerson University 2011).

 Have a clear understanding of the NHS leadership academy (2013) model;

communicate a shared purpose, motivate teams, and have a clear focus on
improving services and performances (Storey and Holti 2013).

Advantages: NHS leadership model is relatable and offers a continuous

improvement to meet demands of the evolving healthcare sector.

Limitations: Only 50 managers involved in producing the NHS model and most
of the information used in management theories were secondary resources
(NHS Leadership Academy 2018).

 A transformational leader: inspire stakeholders, meet project objectives,

change/ develop a system, utilise resources and teams and problem solver (St.
Thomas University 2018).

 Facilitate teamwork: trustworthiness, accountability and communicate the

shared vision effectively to employees, this will boost the morale of the Crisis
House team and integrated services (Ngambi 2011). Organisations that
encourage team building will result in increased outcomes, performance and
productivity (Gaskell 2017). The PM can further improve morale by arranging
brief meetings once every week and by arranging activities for employees and
the project team every 6months to further motivate the team.

The responsibility of Crisis House PMT:

 Financial advisor: accounting, allocating budget and ensuring project feasibility.

 Personal Assistant: administration work, scheduling project meetings,

documenting meetings, answering phone calls, sending emails, logging records
for reporting and ordering supplies.

 Contracted training consultant. ensuring all staff employed are kept up to date
with training.

19
Task 2: meetings every 6 months with CRT and acute psychiatric hospital
managers (Key stakeholders)

 Liaise: teams should discuss expectations of the Crisis House and create a
shared purpose. A close relationship will be needed between all mental health
services, this will require integration of teams. Integrated care is the ability of
healthcare services to effectively work together to manage an organisation and
to provide a user-friendly environment and valued service for all service users
(WHO 2008).
 CRT and the acute psychiatric hospital will undergo a Clinical audit before and
after a year of the Crisis House implementation. This will identify whether a
reduction of BD patients is seen in either service.
 Develop an assessment plan to guarantee only BD patients who meet the Crisis
House criteria are referred appropriately. The number of referrals to the
proposed Crisis House can also be used to quantify the reduction of BD patients
using the alternative mental health services.
 Challenges and opportunities: discuss how to exploit opportunities identified in
SWOT analysis, develop policies and create a complaints procedure. Crisis
House will be a safe environment for BD patient, therefore, policy should state
that no alcohol, drugs, violence and theft should be tolerated in the proposed
Crisis House (MIND 2015).
 Allocation and pooling of resources for further integration e.g. the existing
training and financial advisors from the hospital or CRT could also be
contracted for the Crisis House project. However, as previously discussed the
CRT require more resources, therefore, this may not be ideal. The PM should
avail of CRT best contacts and could consider hiring health consultants from
the same agencies used by the CRT as rapport will already be built with the
agencies. It will be ideal to use nurses that have similar training to nurses in the
CRT as patients have advised community-based health workers communicate
more effectively with them.

20
Task 3: Conduct a survey on BD patients aged 18-45

 To encourage service user involvement: improves the quality of healthcare

services (Omeni et al. 2014).
 Distribute survey amongst BD patients familiar with local CRT, psychiatric
hospital, and mental health charities.
 Ethics: The PM will need to gain NHS Research Ethics Committee approval to
ensure patients safety, rights and dignity are protected when conducting
surveys (NHS HRA 2017). A reflexive approach must be taken by the PM to
avoid bias in research, prevent maleficence and to ensure the integrity of the
Crisis House project (Sanjari et al. 2014). The PM will need to state their
position/ relationship towards participants of the survey and proposed Crisis
House service when gaining ethical approval (Sanjari et al. 2014).

Details of the survey will be discussed in the evaluation section.

Task 4: Schedule stakeholder meetings every 6 months

 The PMT should consult with stakeholders: discuss project plan, timescale,
address stakeholder concerns, discuss potential opportunities and threats
identified through clinical audits and management tools.
 Stigmatisation: the PM must address community concerns, educate
stakeholders and normalise mental health by ensuring BD patients and other
stakeholders all attend meetings (Corbiere et al. 2012).
 Social capital: develop a relationship with the Crisis House stakeholders/ social
groups to increase the efficiency of the project (Martikke 2017).
 Reports on Crisis House progression can be distributed electronically to
stakeholders, to ensure stakeholders who are unable to attend are kept
updated.

Task 5: Secure Crisis House budget

Due to global, national and local drivers towards improved MHS and the NHS five year
forward view, the Crisis House project is of interest of the local NHS trust. NHS
England (2018b) promises to invest up to £1.4 billion to develop MHS.

21
Local NHS Trust:

 The PMT, CRT and acute psychiatric hospital advocates should schedule
meetings with the local NHS commissioning board to discuss funding.

 Purpose of meeting: to discuss a business proposal, evidence-based research

of success rates of current Crisis Houses, data obtained from strategic tools,
and stakeholder analysis.

Stakeholders:

 It will be ideal for the PM to appeal to the stakeholders for funding also, i.e. local
charities could assist with providing essentials to Crisis House such as food and
household supplies. For BD patient’s continual development some mental
health charities may have voluntary workers that may be willing to help with the
Crisis House. Charities can further help patients within the community once
they leave the Crisis House.

Task 6: budget allocation

Financial advisor:

 For better control over the project outcomes, the PMT and other employees
should be involved (Walsh 2016).
 The budget will be allocated towards employing health experts, training staff,
house rent, cost of living, maintenance of house and food.

The breakdown of financial costs will be discussed further in section 10.

Task 7: Recruitment of Crisis House employees

It is important that the Crisis House has enough staff capacity for a safe, efficient and
effective 24/7 service.

 All employees require a Disclosure and Barring Service (DBS): a criminal

record evaluation that is needed when dealing with vulnerable people, for

22
 example, BD patients. An organisation or an individual can be legally liable if a
safeguarding incident occurred and DBS was not obtained (Silver Swan
recruitment 2018).
 Psychiatrists: literature review identifies that the Crisis model is more efficient
when a psychiatrist is part of the team.
 Lead nurses and support worker roles: promote roles within the community to
encourage community involvement. This will be part of reducing stigmatisation
of mental health services and eradicating threats identified in SWOT.
 The health workers employed should be responsible for developing an action
plan for BD patients to prevent and manage future crisis (Bristol CCG 2013).
 A Cleaner is required to clean the communal areas twice a week. BD patients
are required to clean their own rooms and do their own laundry to encourage
self-management (NHS Bristol 2011).

Task 8: Training employees

Training consultant:

Risk management: it is important that the contracted training consultant ensures all
employees are sufficiently trained.

 Mental Health Act 2007 (Legislation.gov.uk 2007).

 Mental Capacity Act 2005.
 Safeguarding: to keep vulnerable adults safe, free from neglect and abuse
(Merton Council 2015). Safeguarding training can be carried out online, and
employees can print the certificate once completed (HL online training 2018).
 First aid training.
 Inspire a shared purpose and to adhere to national policies, the Crisis House
employees and project team need to familiarise themselves with WHO’s
Mental Health Action Plan 2013-2020 (WHO 2013), STP (NHS UHCW 2018),
the Operating framework policy 2011/12 (NHS 2010), and NICE guidelines.
 Therapeutic communication skills: to develop a better relationship with
patients, staff members and supporting services.

23
  Enrol staff in food hygiene course: to save service costs, promote healthy living
and inspire self- management, BD patients will be expected to help staff with
food preparations.

Task 9: Purchasing and development of Crisis House

The PM should consider the Crisis Houses available when deciding on size (appendix
3).

Crisis House recommendations for project feasibility:

 5 bedrooms.
 1week duration of stay. The duration can be evaluated by health workers as
some patients may require a longer duration of stay depending on the crisis.
 Location: It will be beneficial for Crisis House to be situated in a town, close to
local amenities i.e. shops, recreational facilities, GP’s, and local hospitals in
case of emergencies, this will help mitigate risks and prevent patients from
being secluded from the community. For feasibility, PMT should consider
renting a relatively cheap house or an abandoned healthcare property that can
be renovated. This may need to be further discussed with Coventry’s council
and landlords.
 Crisis House design: can be developed based on recommendations obtained
from the survey conducted in task 3.
 Ligature risks: the PM needs to minimise ligature risks when selecting a house
to rent as a suicide preventative measure (CQC 2015).

Task 10: Signposting of Crisis House

CRT and acute psychiatric hospital

 Using the Crisis House assessment criteria that would have been produced in
task 2, BD patients can be referred appropriately to Crisis House. In some
cases, BD patients can self-refer, however, most patients should be referred by
mental health professionals to evaluate if the patient meets the requirements
(Mind 2015).

24
Task 11: Conduct a service user and family questionnaire

 Satisfactory questionnaire survey: the PMT will be required to give

questionnaires to BD patients and their family members at the end of their stay.
Results will be reviewed by the PM to analyse the progression of the Crisis
House.

This will be discussed further in the evaluation plan.

Task 12: Present data obtained from the final report

 Results from the audits and questionnaires/surveys will be presented to all

stakeholders after a year.

25
 10. Financial Costs
As discussed in the project plan, the PMT will schedule a meeting with the local NHS
Trust to discuss funding. The below table is for the attention of the NHS trust and the
financial advisor. The Crisis House in Tower Hamlet in 2012/13 cost £220 per bed day
(Mcdaid and Park 2016). While the proposed Coventry women’s Crisis House bed per
day estimated cost is £181 as seen on the below table. Although there are no records
of the financial breakdown of the Tower Hamlet Crisis House, it is expected that the
proposed Crisis House will cost less as it will accommodate 5 fewer patients. It was
previously identified that it costs the NHS mental services £259- 354 per bed day.
Therefore, the proposed Crisis House could potentially save the NHS acute psychiatric
wards up to £78- 173 per bed day. More details of the financial breakdown can be
seen below:

Table 1: Budget allocation of the Crisis House

Coventry Women's Crisis House Expenditure 2019-2020

Expenses Amount (£) Justification

Project manager 26250 Maximum 30-hour contract: A

(Glassdoor 2010). lead nurse will always be present
to ensure Crisis House is
managed efficiently when the PM
is not there, this will save money.

Financial advisor 13000 Can be contracted from the CRT

(Graduate and psychiatric hospital or hired
Prospects Ltd externally for 20 hours a week.
2018a)
Personal assistant 25217 Required maximum 40 hours to
(PayScale 2018). assist PM and to schedule
meetings when the manager is
out of office.

26
Psychiatrist 21881 Total: 12.5 hours/per week.
(Graduate Each patient will receive 2 hours
Prospects Ltd sessions for the week.
2018b) Developing management plans
for patients: 2.5 hours/week.

Lead nurse 127890 One healthcare worker is needed

(Glassdoor 2018).
per every 3 patients; therefore, a
clinical lead is always required for
medication and safety. 168 hours
required for the week due to 24/7
service, this can be split amongst
6 lead nurses, working an
average of 28 hours a week. Total
Salary is based on 28 hours shifts
for 6 clinical lead. (6 lead nurse x
21315 salaries per annum for 28
hours per week)

Support worker 78840.216 A support worker is needed per

(Indeed 2018). shift to work alongside a lead
nurse. Average pay is £9/ hour x
28-hour shifts each x 6 support
workers x 52.143 weeks in a year.

Core skills support 2320 The trainer will be required to

trainer (NHS ensure all employees complete
Professionals online training courses. Lead
2018) communication training classes
for employees. Required for 2
sessions each running for a
month. This will ensure all staff
are kept update to date with

27
 training. £11.60/ hour x 2
sessions x 25 hours a week x 4
weeks.

House rent (Zoopla 27432  1year contract

2018)  furnished
 6 bedrooms: one room can
be turned into an office for
staff
 2 bathrooms
 Reception room can be
used for occupants to
watch TV and
communicate with staff
and other occupants.
 Close location to town,
bus, train and amenities
 Zoopla total: cost includes
estimates of rent, council
tax, water, electric and gas
bills for the year. Deposit of
£1800 was further added.

Internet and 648 Internet will be required for office

landline (Virgin (CRT and psychiatric ward may
Media 2018) need to fax referral details of
patients) and patients to connect
their devices. Two devices
needed as broadband only
connects to 4 devices.

TV and tv license 271.96 A TV should be added to the

(GOV.UK 2018) communal reception room for

28
 interaction between all the
patients and employees. This will
ensure patients feel more at home
and recover faster.

Insurance BD patient’s health care and the

(covered by NHS) ______ house insurance should be
covered by the NHS.

Computer (DELL A desktop computer will be

2018) needed for administration
500.1 purposes.

Cleaning service 2392 To clean communal areas, 4

(Maid2Clean hours a week. locally employed
Warwick Ltd 2018). for further integration of the Crisis
House project with the
community.

office supplies 500 Pens, pencils, papers, eraser,

(turn one room into notebooks can be used by
an office) employees and BD patients. For
recreational and therapeutic
purposes

house 2400 £200 estimated for repairs of the

maintenance twice house, however, the house may
a month x12 not require repairs every month.

sundries PM can discuss during

(sponsors) stakeholder meetings; local
______
charities may assist with funding
towards sundries.

29
 user participation 1000 For recreational activities, for BD
patients and employees: an
appraisal for excellent work.

TOTAL £330542.276
EXPENSES FOR
THE YEAR

TOTAL £181.12
EXPENSES PER
BED PER DAY

11. Evaluation Plan

To identify whether the implementation of the CH has been successful, the PMT will
need to analyse project findings to determine whether the SMART objectives 1-4 have
been achieved. The method of systematically assessing project outcomes is known
as the evaluation process (Zidane, Johansen and Ekambaram 2015). The process of
evaluation is as follows; review the problem, obtain evidence, analyse the evidence,
implement these findings and share results with stakeholders (Taylor et al. 2005).
Subsequently, an evaluative plan is required to provide stakeholders with the relevant
information that stakeholders need to know, and it determines the progress of the
project (Parry et al. 2018). Quality of care is mostly evaluated through healthcare
performance, which will be required when determining the feasibility of the Crisis
House (Groenewegen et al. 2005).

1) To significantly reduce the acute bed occupancy and readmission of BD patients by

25% within the first 12 months of implementation and 2) To reduce the number of BD
patients requiring CRT services by 20-30% through a clinical audit within the first year
of the Crisis House project: The clinical audits will be conducted before and after the
implementation of the Crisis House. An audit in a healthcare sector helps improve the
quality of healthcare services through policy and financial planning (Esposito and Dal

30
Canton 2014). Successful outcomes will inspire stakeholders to increase funding, help
with better budget allocation, reduce strain on acute psychiatric wards and CRT.

3) To provide a Crisis House that will increase patient and family satisfaction by the
end of the year: Two service user feedback survey/questionnaires will be conducted
on BD patients before and after the implementation of the Crisis House. The first
questionnaire will be used to gain insight into BD patients experience with psychiatric
wards and CRT. The questionnaire will include a recommendation section that will be
utilised when developing the Crisis House (appendix 12). After a year of
implementation of the Crisis House, all the findings obtained from the questionnaires
of patients and family members that used the Crisis House will be collated into a final
report. This will be evaluated and presented to all stakeholders. Service user feedback
is a crucial tool for critical reflection (Allen et al. 2016). Feedback can identify areas in
need of development, subsequently improving the service user experiences and the
quality of services (Allen et al. 2016).

4) To improve the confidence and satisfaction level of the employees with their skills
of caring for BD patients through training in Safeguarding, First Aid training, Mental
Health Act 2007 and therapeutic communication within 3 months of employment: The
PMT will evaluate this during weekly progression meetings with employees. All Crisis
House employees can provide recommendations, discuss issues and suggest any
further training that is required to increase confidence levels when caring for patients.
The employees will also receive certifications when each training session is
completed.

Furthermore, the evaluation stage of a business proposal can identify how the project
can be mainstreamed i.e. opportunities for organisation growth. The mainstreaming of
this project will be discussed further in the next section.

12. Mainstreaming of the Crisis House

The progress reports produced from all questionnaires and clinical audits will
demonstrate the effectiveness of the Crisis House. The Crisis House project can be
mainstreamed based on how successful the outcomes are. Subsequently, the

31
implementation of a Crisis House will reduce bed occupancy in acute psychiatric
wards, prevent hospital sleepovers on other wards for Mental Health patients, reduce
strain on CRT, integrate community and primary services together along with charities
to provide a safe and effective service for patients. The mainstreaming of the Crisis
House project will entail conducting more surveys on BD patients throughout the UK
to analyse what is best suited for the BD population. Success rates should generate
more facilitated funding, therefore, more Crisis Houses for both men and women can
be established. The more Crisis Houses are normalised, and stakeholders are kept
involved with the process the more Crisis Houses and patients with Mental health
disorders will be normalised within the community. In turn, this could potentially reduce
the stigmatisation towards patients with BD. This will further help combat threats
identified in SWOT analysis. Furthermore, recommendations for the West Midlands
NHS Trust, the Crisis House PM and other stakeholders on how Crisis House may be
mainstreamed can be seen below.

1. Develop the Crisis House for two more years for a clearer understanding/
development of process and outcomes to ensure feasibility and sustainability.
2. A larger scale i.e. Crisis House could contain 10+ bedrooms instead of 5.
3. Crisis House can be developed in other West Midland towns in need of this
service.
4. Crisis House in Coventry can cater to other mental health disorders in Crisis to
analyse if this further reduces bed occupancy in psychiatric wards, NHS costs
and reduces strain on CRT.
5. Develop a Crisis House for men: analyse whether this service is used more and
preferred in comparison to other mental health services.
6. Build partnerships with other NHS Trusts: Crisis House progress reports can
be shared with other NHS Trusts who are in severe need of hospital alternatives
for mental health patients. Results obtained from Coventry’s Crisis House can
be compared with other NHS trusts who already have Crisis Houses to identify
what works best. This will help with the national policy goals of providing safe,
effective, efficient and equitable MHS for all.
7. Research development: researchers in the UK and other international countries
will be able to develop more research on the effectiveness of Crisis Houses.

32
 Researchers can further investigate if Crisis Houses reduces the number of
mental health crisis yearly.
8. NHS England could liaise with other countries who have similar services for
mental health patients to pools ideas together to identify the best methods for
patients. This would be a key policy driver.
9. Stakeholders could integrate more communities in the process and
development of Crisis House, this will further educate and reduce stigmatisation
associated with BD and other mental health disorders.

33
 13. Reflexivity
In the healthcare sector, reflective writing is a useful strategic tool used to analyse
experiences, problems, systems or organisations by using theoretic knowledge to
develop a solution or action plan for future purposes (Reid 1993). Reflection is a
learning tool, that develops self-growth, adds value and skill to an area of expertise
(Syed, Scoular and Reaney 2012). The process of reflection allows you to analyse
positive and negative experiences to gain further insight into a situation, to discover
what can be improved or repeated (Koshy et al. 2017). This ensures a successful
outcome if the situation was to happen again (Koshy et al. 2017). Reflection is
important in my professional development as a future healthcare manager.
Furthermore, I will be using Rolfe, Freshwater and Jasper (2001) reflective model to
discuss what I learned from carrying out this dissertation on proposing a Crisis House
for BD patients, the issues I found and areas where I loved and was passionate about.

Figure 2: Rolfe, Freshwater and Jasper (2001) reflective model consist of three
questions, what? Now what? and So what?

34
What?

During my journey of writing this dissertation, I started a new role as a healthcare

coordinator as I wanted to gain professional experience within the healthcare sector.
Although this job was a wonderful opportunity, I struggled with time management. I
found it quite challenging balancing university, work and social life and was tired most
days. Within the month of gaining ethical approval, I had to start developing my
business proposal, create a search strategy, appraise literature, critique papers to
ensure I had viable information, set up regular meetings with my supervisor and attend
work. I am passionate about proposing a service that will cater to the needs of patients,
help the NHS with strategic planning, save resources and subsequently, improve the
services provided. However, to do this I needed to strategically manage my time.
Furthermore, I decided I had to reduce my hours at work for the meantime as I feared
that my dissertation would be in jeopardy if I did not act sooner, I knew my dissertation
was more important.

So what?

Time management can be achieved in 10 steps; allocate your time wisely, set tasks,
use planning tools, be organised, schedule, delegate, avoid procrastination, manage
external factors that could waste your time, limit multitasking and keep active
(Chapman and Rupured 2008). However, Jackson (2009) further disseminated time
management process in 5 steps as the researcher felt that the resources available on
time management leave the reader feeling overwhelmed. The 5 steps included; set
goals, organisation, delegate tasks, relax and stop feeling guilty. I felt this helped me
a lot throughout my dissertation, I knew I needed to prioritise my tasks, create realistic
deadlines for myself and try not to get overwhelmed. I did this by delegating my
dissertation into sections, if I found a section difficult, I would leave it for a period and
focus on another segment. Therefore, when reattempting the section, I had a fresh
perspective, which I felt helped with further progression. Moreover, the most
challenging aspect of this project was locating literature on the databases. I found that
my search strategy worked best on PubMed and Google scholar when compared to
Ovid. According to Koffel (2015), it is beneficial to gain help from the universities
librarian when developing search strategies, which, I wish I did at an earlier stage. I
did, however, attend the library’s academic writing session which I felt was very
35
informative. Furthermore, through my research, I felt that changes in healthcare are
more efficient when all stakeholders are involved. I feel, that the healthcare sector
should consider implementing more services that involve the participation of more
service users to further improve services. I tried to be creative and demonstrate
originality in my proposal by proposing a Crisis House based on the input of BD
patients which I felt will provide them with a sense of user empowerment and social
capital. I used the information gathered on the strengths of current crisis services,
networking, integration of all stakeholders and charities to develop this business
proposal for better outcomes.

Now what?

I now know time management is a vital part of self-progression, therefore, I will need
to develop this more. I am extremely proud of what I was able to achieve, and I feel
this dissertation has steered me in the direction of my career path. My next steps will
be to look at roles which deal with change or project management roles. I really
enjoyed reading literature on patients and healthcare services available. I now feel a
sense of confidence that I could present this business proposal to a local NHS trust
as I feel a Crisis House will significantly help. I now know the importance of time
management. Overall, I found that my MSc in global healthcare management taught
me the importance of reflection. Now when I see a problem, I try to identify the root
cause by asking; who, what, why, when and how? I have found this is the simplest
way of finding answers. Subsequently, through learning about diverse types of
leadership required to lead and implement change, I believe a leader needs to have
many leadership techniques and traits as all problems, organisations and situations
may vary.

Action Plan

1. For future projects, self-progression and time management purposes I plan to

always have the concept of Gantt charts and CPA’s on the forefront of my mind when
scheduling tasks.

2. Send a copy of this business proposal to the local NHS Trust, so it can be
discussed with the local CRT and acute psychiatric wards.

36
3. Interact with a skilled librarian for further insights on best methods for future
research.

37
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 15. Appendix

Appendix 1: PEST Analysis

Political Economical

1. Mental Health Act 2007. 1. Budget allocation

2. Mental Capacity Act 2005 2. Lack of training
3. WHO’s Mental Health Action 3. Bed shortages
Plan 2013-2020 (WHO 2013). 4. Shortage of healthcare
4. Sustainability and Transformation professionals
Plan (STP) (UHCW 2018).
5. Operating framework policy
2011/12 (NHS 2010).
6. NICE guidelines
Same-sex wards policy (Gilburt,
Rose and Slade 2008).
Social Technological

1. Stigmatisation 1. Online training courses

2. Education level 2. More online resources needed on
3. Mental health charities need to hospital alternatives
provide more awareness of
mental health services available

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Appendix 2: SWOT analysis of mental health services

Strengths Weakness

 Adherence to all policies  Increase suicide rates in BD

mentioned in PEST to ensure all patients
patients receive safe, efficient and  Not enough beds on wards
equitable care.  Lack of resources
 The NHS offers a free range of  Prevalence of BD
training courses for NHS  Lack of relationship building and
employees. communication between patients
 Good staffing retention and staff

Opportunities Threats

 Integration with other innovative  Patients not wanting help from

mental health services. health services
 Stigmatisation
 High workload

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Appendix 3: Crisis House capacity

Crisis House Bedrooms Duration of stay

(weeks)

Bristol Men’s Crisis house:

St Mungos (Bristol CCG
2013)
10 4
Bristol Women’s Crisis
House: Missing Link
(Bristol CCG 2013)

Drayton park women’s 12 1- 4

crisis house (Camden and
Islington NHS Foundation
Trust 2018)

Coed Arian Community 4 1

Crisis House (Gofal
CYMRU 2018)

Tower Hamlett Crisis 10 Not specified

House (Bhattacharya
2017)

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Appendix 4: Database search

4.1. Keywords

Search Keywords

1 Experience, living, lived experience,

patient experience

2 Bipolar, bipolar disorder, psychiatric,

mental health disorder

3 management, crisis, crisis house,

hospitalisation, hospital admission,
admitted, admission, psychiatric wards,
mental health, services, acute
rehabilitation, community.

4 Stigma

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4.2. Search strategy

Search Database Hits

1. Acute* OR Pubmed 51,676

psychiatric* ward*
Ovid 6,079
OR service* OR
bed* AND bipolar* Google scholar 143,000
OR Mental* health*
AND staff* OR
employees* OR
nurses* OR
clinicians* OR
management*

2. Stigma* OR Pubmed 22,303

experience* AND
Ovid 6,170
bipolar* OR
mental* health* Google scholar 18,400

3. Alternatives* AND Pubmed 118,401

hospital* OR acute*
Ovid (don’t use) 4,680
OR psychiatric*
AND community* Google scholar 8,610
AND bipolar* OR
mental* health*
AND crisis* OR
Crises* or
rehabilitation* AND
house* OR home*
OR model*

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4.3. Inclusion and exclusion Criteria for Literature review

Inclusion Exclusion

 Papers written in the English  Literature in languages other than

language English, as translator would be
 Age group: 18- 45. needed, which is time consuming
 BD 1 and 2 and not cost effective.
 mental health services  Patients with BD diagnosed
 Date range: 2008- 2018 before the age of 18, as younger

 Peer- reviewed patients will need consent before

 Grey literature staying in Crisis House and

 Qualitative and Quantitative services is for adults.

literature  Literature that refers to BD as

manic depression as this was an
old term used.

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Appendix 5: CASP (2018)

CASP (2018) tool used to appraise: Hawke, L. D., Parikh, S. V., and Michalak, E. E.
(2013). ‘Stigma and bipolar disorder: A review of the literature’. Journal of Affective
Disorders 150 (2), 181-191.

1. Was there a clear statement of the aims of the research? Yes. Researcher
aimed to conduct a literature review on the stigma experienced by BD patients.
However, could have been stated more clearly by having an aims section.
2. Is a qualitative methodology appropriate? Yes. Stigma is based on experience;
therefore, qualitative methodology is appropriate. Qualitative analysis
discusses behavioural and social aspect.
3. Was the research design appropriate to address the aims of the research? Yes,
researcher used databases such as Psychinfo and Medline, papers were peer
reviewed.
4. Was the recruitment strategy appropriate to the aims of the research? Yes.
Desk based research.
5. Was the data collected in a way that addressed the research issue? Yes aims
were used to critically discuss literature available.
6. Has the relationship between researcher and participants been adequately
considered? Yes. Researcher states there is no conflict of interest.
7. Have ethical issues been taken into consideration? Yes, ethics briefly
discussed in one of the themes. It is low risk ethics; however, this was not
stated.
8. Was the data analysis sufficiently rigorous? Yes. Thematic analysis used and
is clearly structured.
9. Is there a clear statement of findings? Yes. There is a method section and table.
10. How valuable is the research? Research is valuable as it systematically
addresses problems encountered by stigmatisation of patients with BD.
Researcher provides useful insights on stigma and experiences and advises
this should be on the forefront of international agendas.

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Appendix 6: McMaster (Law et al. 1998)

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Appendix 7: SWOT analysis of Crisis House

Strengths Weakness

 Alternative to hospitalisation  House occupancy limited to 5

 Reduce bed costs patients a week
 Integration of community, social  MSA: can only facilitate one sex
care and public services. group. i.e. woman

Opportunities Threats

 Better integration of health and  Safety

social care  budget
 Reduction of bed occupancy in  Stigmatisation- self- stigma and
psychiatric wards community response to Crisis
 Potential job opportunities for the House proposal
community, nurses and
psychiatrists
 Partnership with charities such as
MIND and Rethink Mental illness
 Training

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Appendix 8: Ethics approval

65
Appendix 9: Stakeholder assessment

Stakeholders Stake in Crisis Requirement of Level of

house stakeholder importance

BD patients Service users To avail of Crisis high

house
Family members Family members of To encourage and medium
of BD patients service users support BD
patients
CRT Improved care for Integrated care high
BD patients and and signposting of
ability to facilitate Crisis house
patients with other
mental health d

Acute psychiatric Improved care for Integrated care high

wards patients and and signposting of
reduction in bed Crisis house
occupancy and
costs
Mental health Improved care for Patient referral and medium
charities patients offer voluntary
support to Crisis
house project
Community Location of Crisis Support medium
house implementation of
Crisis house and
avail of job
opportunities for
Crisis House
Employees of Source of income Caring for service high
Crisis house users and partake

66
 in all training
requirements
Researchers Increase in data To produce medium
available on Crisis research and
houses awareness of
Crisis houses
Policymakers Patient safety, STP Amendments to high
and 5 Year policies were
Forward plan necessary
CQC Quality of service CQC reports for high
service
improvement
NHS Quality of service Budget high
improvement

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Appendix 10: Critical Path Analysis

Task Description Start Date End Date

1 Develop Project Management team 01/09/2018 01/10/2018
Liaise with local Mental health 01/09/2018 21/08/2020
2 services
3 Conduct and report BD surveys 02/10/2018 01/12/2018
4.1 Stakeholder Meeting 1 08/12/2018 15/12/2018
4.2 Stakeholder Meeting 2 13/06/2019 20/06/2019
4.3 Stakeholder Meeting 3 17/12/2019 24/12/2019
4.5 Stakeholder Meeting 4 21/06/2020 28/06/2020
5 Secure budget 17/12/2018 15/02/2019
6 Budget allocation 22/02/2019 24/03/2019
7 Recruitment of employees 26/03/2019 25/05/2019
8 Staff training 30/05/2019 20/06/2019
9 Rent and develop Crisis House 26/03/2019 24/06/2019
10 Signposting of Crisis House 28/06/2019 27/06/2020
11 Service user Questionnaire 05/07/2019 04/07/2020
12 Reporting of data to stakeholders 03/08/2020 01/09/2020

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Appendix 11: Gantt Chart

Appendix 11: Gantt Chart for Crisis House

01/09/2018 10/12/2018 20/03/2019 28/06/2019 06/10/2019 14/01/2020 23/04/2020 01/08/2020 09/11/2020

1
2
3
4.1
4.2
4.3
Project Tasks

4.5
5
6
7
8
9
10
11
12

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Appendix 12: Questionnaire

Coventry’s Women’s Crisis House

Please answer the below in blank pen.

Yes (Y) No (N) Unsure (N/A)

1. I prefer hospitals to
community-based
care
2. Staff at hospitals are
always
communicative
3. Stigmatisation of BD
still exists
4. Would you be open to
a hospital alternative?
5. Would you like a
Crisis House in your
area?

6. Age:
7. How long have you been diagnosed with BD?

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

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8. Please describe your experience during your last hospital stay in an acute
psychiatric ward?

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

9. Have you used Crisis resolution team services before, if so, please describe
your experience?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

10. If you were in a crisis, please provide what you would like from mental health
services?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

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 ______________________________________________________________
______________________________________________________________

11. Recommendations for Crisis House

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Thank you for completing our survey– your feedback is KEY!!!!!

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