Inpatient mental health care involves staying in a hospital or specialised facility to receive intensive, round-the-clock support for serious mental health needs (Staniszewska et al., 2019). Whereas acute inpatient services typically respond to immediate crises, longer-term wards support individuals with more complex needs and a higher level of ongoing risk.
Inpatient services are a core component of our mental health system — whether someone stays for a night, weeks, or even several years. However, inpatient care has recently come under growing scrutiny – and for good reason.
Concerns have been raised about the widespread use of coercive practices in acute inpatient services (Nyttingnes et al., 2018; Belayneh et al., 2024). These include physical restraint (physically holding a person), seclusion (holding a person in a locked room) and chemical restraint (the use of sedating medication to manage distress or behaviour, sometimes administered “as needed” rather than as part of any planned treatment). Poor relationships between staff and service users have also been noted, with people in receipt of services consistently highlighting the centrality of staff interpersonal skills to feeling safe and supported within crisis settings.
A recent blog here described how adversity in inpatient mental health care extends far beyond the harm caused by restrictive interventions, highlighting a complex interplay between systemic, environmental, and individual factors contributing to adverse experiences for patients.
The concerns described above chime uncomfortably with modern mental health agendas of prioritising autonomy, compassion, trauma-informed and person-centred care. In light of these tensions, and the growing number of crisis alternatives – ranging from crisis cafes to intensive home treatment services – researchers at the NIHR Policy Research Unit in Mental Health set out to map current alternatives to traditional inpatient care, both nationally and internationally. Griffiths and Baldwin’s findings raise important questions about how mental health services could evolve to better suit people’s needs, providing a valuable starting point for service planners considering developments in care.
Standard acute and long-term inpatient care provides intensive, round-the-clock support for people experiencing serious mental health challenges.
Method
Researchers used two, simultaneous approaches to map available alternatives to standard inpatient care. These were: a literature review, and a call for information from international experts. Researchers also established what they called an ‘expert working group’, comprising academics and researchers with relevant experience, as well as lived experience researchers who had accessed different mental health services in the past. This group helped guide the conduct of the research.
Key international experts with knowledge of inpatient care were invited for an interview. The expert working group were responsible for identifying experts to contact, although additional experts were recruited through snowball sampling – that is, existing experts indicated other experts who might have a useful contribution. During interviews, researchers took note of any alternative care models recommended by the experts and screened them for relevance. Some experts chose to provide information over email or telephone.
Parallel to the interviews, researchers conducted a series of literature searches to scope the landscape of alternatives to standard inpatient care. Additional searches were performed to address gaps or insufficient detail in the service models recommended by experts.
Ultimately, researchers triangulated their findings using a mapping exercise, which helped them broadly classify alternative service models into the three main categories described below.
Results
Researchers identified 65 alternative service models to standard inpatient care. These were organised broadly organised according to the setting (e.g., community-based, hospital-based, or cross-setting) and the target population (e.g., adults versus children). Across these categories, ‘community-based alternatives’ were the most common category of alternative service models, followed by hospital-based and cross-setting approaches. We’ll explore each of these in more detail below.
Community-based alternatives
Thirty-nine of the 65 alternative models were community-based – that is, delivered at-home or in community settings rather than a traditional hospital environment. Examples included:
This indicates that numerous alternatives to standard inpatient care already exist within the community.
Hospital-based alternatives
Twelve of the 65 alternative models identified were hospital-based. This category included any non-standard service models offered within a hospital setting, such as inpatient wards. However, these models were often different to conventional inpatient hospital care in that they were more time-limited or operated under a specific therapeutic model (e.g., trauma-informed approaches).
Examples included:
- Extended psychiatric liaison services
- Brief-stay crisis units
- Inpatient services implementing a specific therapeutic model (Safewards)
Importantly, the identification of various non-standard inpatient models being delivered in hospital-based settings suggests that some enhancements to care may be achievable within existing inpatient settings – in other words, without systemic structural changes.
Cross-setting approaches
Across all alternative service models, 14 were categorised as ‘cross-setting’ approaches. This category describes broader frameworks that can be implemented across different types of settings. Some examples included:
- ‘Therapeutic communities’
- ‘Open Dialogue’
- ‘Multisystemic therapy’
- ‘Enabling environments’
Through a mapping exercise, researchers identified three typologies of alternatives to standard inpatient care
Conclusion
Overall, the results from this study demonstrate that there are a wide variety of approaches that could be used as alternatives to standard inpatient mental health care, both for adults and young people. These alternatives exist across a range of settings and have varying levels of evidence and implementation.
In particular, the number of hospital-based alternatives is significant, primarily because substantial improvements to care may be possible within existing, hospital-based structures. According to the authors:
Whilst inpatient mental health services remain an integral part of the mental health care continuum, these typologies can inform the description, evaluation, and comparison of different service models, offering key insights for the design, development and implementation of alternative mental health service models and crisis systems.
The study showed that there are a variety of available alternatives to standard long-term and acute inpatient care – many of which are already being delivered within hospital-based settings
Strengths and limitations
Crucially, this study was the first systematic attempt to identify available alternatives to standard inpatient care models internationally. This study fills an important gap in the literature and marks the beginning of an evidence-base that could be used to inform service planners’ decision-making.
However, there are important limitations to this study. Although the research adopted an innovative approach involving interviews with experts in mental healthcare, there were no clear criteria that experts needed to meet in order to be contacted. Moreover, the paper does not detail how the expert working group decided who to contact. Although snowball sampling was used to reach additional experts, there is a clear risk of omission when sampling is not purposive.
Although the study incorporated lived experience researchers within its expert working group, it is unclear whether these researchers had direct experience of inpatient care. The extent to which we can say the research was co-produced with individuals with experience of standard inpatient care services is therefore ambiguous.
The paper provides fairly exhaustive supplementary material, including additional data on service use outcomes associated with different models, such as satisfaction with care, number of inpatient bed days, and readmissions. However, the authors state that this outcome evidence was ‘not subjected to quality appraisal’. This is important, as quality appraisal is a crucial way in which we establish the reliability and credibility of any evidence presented as part of a scientific study. Without quality appraisal, we cannot hold the same level of confidence in the findings – even if they’re only supplementary material.
Finally, although the study claims to identify alternatives to standard inpatient care internationally, the findings are biased towards western models. The extent to which researchers were able to understand alternative service models in low- and middle-income countries, where there may be less published literature on alternatives to inpatient care, remains unestablished.
As none of the outcome evidence in this study was subjected to quality appraisal, the findings should be interpreted with caution
Implications for practice
The main finding from this paper is that there are multiple alternatives to standard inpatient care; many of which are being delivered internationally, across a variety of settings. Crucially, some of these alternative service models are already being delivered within hospital-based settings, suggesting that some of these alternative service models could be integrated without altering current structures, systemically.
The authors’ classification of alternative service models could help planners and commissioners understand ‘the whole range of options’ when deciding which improvements to prioritise and invest in.
However, future studies should investigate the implementation challenges surrounding these alternative models – that is, what might make certain models easier or more difficult to introduce? Research investigating their effectiveness in practice is also required – are there particular models that are better suited to certain individuals, at particular times? As the authors put it: “what works best for whom, when and how”!
In investigating currently available alternatives to standard acute and long-term inpatient care, this paper makes an important move towards the World Health Organisation (WHO)’s call for mental health care that is more person-centred and rights-based. However, as the authors state, we cannot be sure that these alternatives eradicate all of our existing concerns with standard inpatient care, such as coercive and restrictive practises. More research is needed to determine how non-standard, hospital-based models compare with standard acute and long-term impatient care services in this respect. Only then will it be clear whether alternative models will take us in the right direction – and outside the box.
All in all, this paper provides a valuable starting point for service planners and developers when considering change. It appears that inpatient care could be delivered in a substantially different way to what is traditional, within existing structures. However, we need to understand more about how alternatives care models compare with standard care on dimensions such as coercive and restrictive practises and service user satisfaction.
Statement of interests
Amber Jarvis is a Research Assistant on the Community Navigator Trial. One of the authors of this study, Brynmor Lloyd-Evans, is the Chief Investigator for the Community Navigator Trial. However, there was no communication between them concerning the content of this article.
Links
Primary paper
Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/
Other references
Belayneh, Z., Chavulak, J., Lee, D. C. A., Petrakis, M., & Haines, T. P. (2024). Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta‐analysis. Journal of clinical nursing, 33(4), 1256-1281: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jocn.17041
Nyttingnes, O., Ruud, T., Norvoll, R., Rugkåsa, J., & Hanssen-Bauer, K. (2018). A cross-sectional study of experienced coercion in adolescent mental health inpatients. BMC Health Services Research, 18, 1-10: https://pubmed.ncbi.nlm.nih.gov/29848338/
Staniszewska, S., Mockford, C., Chadburn, G., Fenton, S. J., Bhui, K., Larkin, M., … & Weich, S. (2019). Experiences of in-patient mental health services: systematic review. The British Journal of Psychiatry, 214(6), 329-338: https://pubmed.ncbi.nlm.nih.gov/30894243/
