Management by geographical area or management specialised by disorder? A mixed-methods evaluation of the effects of an organisational intervention on secondary mental health care for common mental disorder

In 2010, South London and Maudsley NHS Foundation Trust (SLaM) established a programme replacing the borough directorates responsible for adult mental health services with three Clinical Academic Groups (CAGs), each of which took on a subset of adult services straddling all four boroughs. Care pathways were also introduced. We studied the Mood Anxiety and Personality CAG, which took on assessment and treatment teams and psychotherapy services. Objectives We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality. Methods Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time. Results The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment. Conclusions SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services

Identifying mortality risks in patients with opioid use disorder using brief screening assessment:Secondary mental health clinical records analysis

BACKGROUND: Risk assessments are widely used, but their ability to predict outcomes in opioid use disorder (OUD) treatment remains unclear. Therefore, the aim was to investigate if addiction-specific brief risk screening is effective in identifying high mortality risk groups and if subsequent clinical actions following risk assessment impacts on mortality levels.  METHODS: Opioid use disorder (OUD) patients were identified in the South London and Maudsley Case Register. Deaths were identified through database linkage to the national mortality dataset. Cox and competing-risk regression were used to model associations between brief risk assessment domains and all-cause and overdose mortality in 4488 OUD patients, with up-to 6-year follow-up time where 227 deaths were registered. Data were stratified by admission to general mental health services.  RESULTS: All-cause mortality was significantly associated with unsafe injecting (HR 1.53, 95% CI 1.10-2.11) and clinically appraised likelihood of accidental overdose (HR 1.48, 95% CI 1.00-2.19). Overdose-mortality was significantly associated with unsafe injecting (SHR 2.52, 95% CI 1.11-5.70) and clinically appraised suicidality (SHR 2.89, 95% CI 1.38-6.03). Suicidality was associated with a twofold increase in mortality risk among OUD patients who were not admitted to mental health services within 2 months of their risk assessment (HR 2.03, 95% CI 1.67-3.24).  CONCLUSIONS: Diagnosis-specific brief risk screening can identify OUD patient subgroups at increased risk of all-cause and overdose mortality. OUD patients, where suicidality is evident, who are not admitted into services are particularly vulnerable

The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Background: The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap. Methods: The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses. Results: Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study. Conclusions: People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery. Main limitation: Our programme included only NHS, non-secure, inpatient mental health rehabilitation services. Trial registration: Current Controlled Trials ISRCTN25898179. Funding: The NIHR Programme Grants for Applied Research programme

Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder:a mixed-methods approach

BackgroundRecovery in mental health is a relatively new concept, but it is becoming more accepted that people can recover from psychosis. Recovery-orientated services are recommended for adult mental health, but with little evidence base to support this. ObjectivesTo facilitate understanding and promotion of recovery in psychosis and bipolar disorder (BD), in a manner that is empowering and acceptable to service users. MethodThere were six linked projects using qualitative and quantitative methodologies: (1) developing and piloting a service user-defined measure of recovery; (2) a Delphi study to determine levels of consensus around the concept of recovery; (3) examination of the psychological factors associated with recovery and how these fluctuate over time; (4) development and evaluation of cognitive–behavioural approaches to guided self-help including a patient preference trial (PPT); (5) development and evaluation of cognitive–behavioural therapy (CBT) for understanding and preventing suicide in psychosis including a randomised controlled trial (RCT); and (6) development and evaluation of a cognitive–behavioural approach to recovery in recent onset BD, including a RCT of recovery-focused cognitive–behavioural therapy (RfCBT). Service user involvement was central to the programme. ResultsMeasurement of service user-defined recovery from psychosis (using the Subjective Experience of Psychosis Scale) and BD (using the Bipolar Recovery Questionnaire) was shown to be feasible and valid. The consensus study revealed a high level of agreement among service users for defining recovery, factors that help or hinder recovery and items which demonstrate recovery. Negative emotions, self-esteem and hope predicted recovery judgements, both cross-sectionally and longitudinally, whereas positive symptoms had an indirect effect. In the PPT, 89 participants entered the study, three were randomised, 57 were retained in the trial until 15-month follow-up (64%). At follow-up there was no overall treatment effect on the primary outcome (Questionnaire about the Process of Recovery total; p = 0.82). In the suicide prevention RCT, 49 were randomised and 35 were retained at 6-month follow-up (71%). There were significant improvements in suicidal ideation [Adult Suicidal Ideation Questionnaire; treatment effect = –12.3, 95% confidence interval (CI) –24.3 to –0.14], Suicide Probability Scale (SPS; treatment effect = –7.0, 95% CI –15.5 to 0) and hopelessness (subscale of the SPS; treatment effect = –3.8, 95% CI –7.3 to –0.5) at follow-up. In the RCT for BD, 67 participants were randomised and 45 were retained at the 12-month follow-up (67%). Recovery score significantly improved in comparison with treatment as usual (TAU) at follow-up (310.87, 95% CI 75.00 to 546.74). At 15-month follow-up, 32 participants had experienced a relapse of either depression or mania (20 TAU vs. 12 RfCBT). The difference in time to recurrence was significant (estimated hazard ratio 0.38, 95% CI 0.18 to 0.78; p < 0.006). ConclusionsThis research programme has improved our understanding of recovery in psychosis and BD. Key findings indicate that measurement of recovery is feasible and valid. It would be feasible to scale up the RCTs to assess effectiveness of our therapeutic approaches in larger full trials, and two of the studies (CBT for suicide prevention in psychosis and recovery in BD) found significant benefits on their primary outcomes despite limited statistical power, suggesting definitive trials are warranted. FundingThe National Institute for Health Research Programme Grants for Applied Research programme

Liaison & Diversion Minimum Dataset

The Liaison & Diversion Minimum Dataset (MDS) was developed in collaboration between staff at Northumbria University, Manchester University, South London and Maudsley NHS Foundation Trust. The MDS was used by 39 liaison & diversion services to identify the needs of clients, interventions undertaken and outcomes achieved