A briefing for mental health professionals : why asking about abuse matters to service users (REVA project, briefing 3)

There are high prevalence rates of violent and abusive experience in both the childhoods and adult lives of mental health service users. Histories of childhood sexual and physical abuse amongst women service users are particularly well documented. Although many of the samples in studies are small, figures of over 50% are not unusual (Palmer et al, 1992; Bryer et al, 1987; Walker and James, 1992; Wurr and Partridge, 1996). In secure settings this figure is even higher (Bland et al, 1999). Studies of severe domestic violence among psychiatric in-patients report lifetime prevalence ranging from 30% to 60% (Golding, 1999; Howard et al. 2010). The REVA study, on which this briefing is based, has also found that people who suffer violence and abuse are much more likely to have a mental disorder, self-harm or attempt suicide than those with little or no experience of this kind (Scott et al, 2013). Given the prevalence of experiences of abuse among users of adult mental health services it is vitally important that these experiences are identified to ensure appropriate diagnosis, support and referral. Since 2003 it has been Department of Health policy that all adult service users should be asked about experiences of violence and abuse in mental health assessments. Yet actually disclosing experiences of violence and abuse can be very difficult. Survivors can feel a deep sense of shame and responsibility for the abuse they have experienced – feelings that are often strategically encouraged by their abusers (Clark and Quadara, 2010). These feelings can be compounded by unhelpful responses from professionals when they try to disclose (Imkaanetal, 2014). And survivors consistently say that disclosure has to be ‘at the right time for them’, which may be immediately or many years after the abuse (McNaughton Nicholls, 2012). In this briefing paper we present findings from research funded by the Department of Health Policy Research Programme on responding effectively to the needs of survivors of violence and abuse: the REVA study. The study included specifically asking survivors of violence and abuse about their views on routine enquiry, their experiences of disclosing abuse and their recommendations for how staff should ask clients about abuse

Guidance for Trust managers : implementing and sustaining routine enquiry about violence and abuse in mental health services (REVA project, briefing 2)

Since 2003 it has been Department of Health policy that all adult service users should be asked about experiences of violence and abuse in mental health assessments. However, by 2006 it was apparent that mental health provider trusts were not generally implementing the policy and a two-year initiative was launched to pilot an approach to introducing routine enquiry and embedding it in clinical practice. The pilot involved a total of 15 trusts and its evaluation identified key lessons for effective implementation of routine enquiry in all trusts. In 2012 the Department of Health funded follow-up research on responding effectively to the needs of survivors of violence and abuse to include case-studies of four of the original pilot trusts to implement routine enquiry (the REVA study). This guidance is based on findings from this study

A briefing for commissioners : what survivors of violence and abuse say about mental health services (REVA project, briefing 4)

The Department of Health publication, Commissioning services for women and children who have experienced violence or abuse – a guide for health commissioners, clearly acknowledges that ‘victims of violence or abuse tend to use health services more than average’ and that this is ‘despite often finding it hard to access services’ (Golding and Duggal, 2011: 22). The guidance goes on to state that it is precisely because of this that ‘it is in the NHS interest to identify these women and children, provide opportunities for them to disclose, and provide services [..] to help them improve their physical and mental health’ (ibid). The policy that has been implemented to support this process is known as ‘routine enquiry’ (RE). Since 2003 it has been Department of Health policy that all adult service users should be asked about experiences of violence and abuse in mental health assessments. However, asking about experiences of abuse and violence is not enough. To be effective the policy of routine enquiry has to be underpinned by the provision of appropriate and effective services for survivors of abuse. As the commissioning guidance notes, ‘commissioners should be aware of the importance of clear referral pathways, so that health professionals know where and how to refer women and children to local services’. For appropriate services to be available, commissioners also need to be aware of the type of services and care pathways that people who have experienced abuse feel are appropriate to meet their needs. In this briefing we present information drawn from interviews with mental health service users who have experienced domestic and/or sexual violence. This briefing focusses on the links between experience of abuse and mental health and the implications this has for commissioners to create an effective service landscape. The REVA research included the experience of both male and female service users. Useful guidance focussing on commissioning services specifically for women and girls who have survived violence is also available: see Woman’s Aid and Imkaan, 2014 ‘Successful commissioning: a guide to commissioning services that support women and children survivors of violence’, see www.womensaid.org.uk for details

Involving users in the design of a randomised controlled trial of an intervention to promote early presentation in breast cancer: Qualitative study

Background: The purpose of this study was to explore women's views of the design of a large pragmatic cost-effectiveness randomised controlled trial of the policy of offering a health professional-delivered intervention to promote early presentation with breast symptoms in older women and thereby improve survival, with a view to informing protocol development. The trial will recruit over 100,000 healthy women aged 67+, and outcome data will be collected on those who develop breast cancer. The scale of the trial and the need for long-term follow-up presented a number of design challenges in relation to obtaining consent, ascertaining and contacting participants who developed breast cancer, and collecting outcome data. Methods: Qualitative study involving 69 women participating in 7 focus groups and 17 in-depth interviews. 15 women had a previous diagnosis of breast cancer and 54 did not. Results: The women held strong views and had a good understanding of the rationale of the design of clinical trials. The women recognised that in a very large trial with long-term follow-up it was necessary to incorporate design features to make the trial feasible and efficient. Most strikingly, they supported the idea of opt-out consent and identifying women with breast cancer using routine datasets. Conclusions: This model of user involvement engaged women well with the design challenges of the trial and led to improvements to the protocol. The study strengthens the case for user involvement, in particular through focus groups and in-depth interviews, in the design of trials

Immaterial boys? A large-scale exploration of gender-based differences in child sexual exploitation service users

Child sexual exploitation is increasingly recognised nationally and internationally as a pressing child protection, crime prevention and public health issue. In the UK, for example, a recent series of high-profile cases has fuelled pressure on policy-makers and practitioners to improve responses. Yet, prevailing discourse, research and interventions around child sexual exploitation have focused overwhelmingly on female victims. This study was designed to help redress fundamental knowledge gaps around boys affected by sexual exploitation. This was achieved through rigorous quantitative analysis of individual-level data for 9,042 users of child sexual exploitation services in the UK. One third of the sample was male and gender was associated with statistically significant differences on many variables. The results of this exploratory study highlight the need for further targeted research and more nuanced and inclusive counter-strategies

Community hospitals and their services in the NHS: identifying transferable learning from international developments - scoping review, systematic review, country reports and case studies

Background: The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential. Objectives This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care. Methods A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland. Results The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented. Limitations The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth. Conclusions At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s). Funding: The National Institute for Health Research Health Services and Delivery Research programme

Climate Change, Coral Reef Ecosystems, and Management Options for Marine Protected Areas

Marine protected areas (MPAs) provide place-based management of marine ecosystems through various degrees and types of protective actions. Habitats such as coral reefs are especially susceptible to degradation resulting from climate change, as evidenced by mass bleaching events over the past two decades. Marine ecosystems are being altered by direct effects of climate change including ocean warming, ocean acidification, rising sea level, changing circulation patterns, increasing severity of storms, and changing freshwater influxes. As impacts of climate change strengthen they may exacerbate effects of existing stressors and require new or modified management approaches; MPA networks are generally accepted as an improvement over individual MPAs to address multiple threats to the marine environment. While MPA networks are considered a potentially effective management approach for conserving marine biodiversity, they should be established in conjunction with other management strategies, such as fisheries regulations and reductions of nutrients and other forms of land-based pollution. Information about interactions between climate change and more “traditional” stressors is limited. MPA managers are faced with high levels of uncertainty about likely outcomes of management actions because climate change impacts have strong interactions with existing stressors, such as land-based sources of pollution, overfishing and destructive fishing practices, invasive species, and diseases. Management options include ameliorating existing stressors, protecting potentially resilient areas, developing networks of MPAs, and integrating climate change into MPA planning, management, and evaluation

Agency, Transgression and the Causation of Homelessness: A Contextualised Rational Action Analysis

Academic accounts of the causation of homelessness consistently refer to social structural factors. There is no engagement in these accounts with the possibility that 'agency' (individually taken actions) also has a role. The transgressive nature of factors associated with homelessness-substance misuse, poor mental health, and so on-and a desire to avoid pathologising people experiencing homelessness, may explain this lack of engagement. Transgression refers to acts that challenge boundaries of normative social behaviour. Yet, it is demonstrated in this article that agency has to be 'written back in' if adequate theories of homelessness and causation are to develop. Contextualised rational action theory provides a critical realist conceptual framework from which to do so, without losing sight of the importance of social structures. Drawing on three case studies, it is demonstrated that what may be considered transgressive acts that lead to homelessness-refusal to engage with support services, alcohol misuse, street sex work-can be identified as having a 'thin' rationality, when the context they occur within is incorporated into the analysis. This approach therefore takes agency into proper account, whilst also acknowledging the importance of structural constraints in the generation of transgressive acts and homelessness. The intention here is not to apportion 'blame' or to 'pathologise', but to take people experiencing homelessness and their circumstances, motivations and actions seriously.Edgework, critical realism, case studies,