Category: Services

CAMH-Crisis2

Crisis care for children and young people with mental health problems: national mapping, models of delivery, sustainability and experience is a new project funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) Programme, which my colleague Clare Bennett and I are jointly leading. The wider team includes Martin Elliott, Leanne Sawle, Aled Jones, Steven Pryjmachuk, Claire Fraser, Euan Hails, Iain McMillan, Nicola Evans, Mair Elliott, Rachael Vaughan and Aneta Taylor.

Our study builds on the now-completed Crisis responses for children and young people: an evidence synthesis of service organisation, effectiveness and experiences, led by Nicola Evans, about which I most recently wrote a post here. It also has a clear connection to the Developing a model for high quality service design for children and young people with common mental health problems project led by Steven Pryjmachuk, with which it shares aspects of study design.

Our new CAMH-Crisis2 study began in November 2022, and a summary of what we’re doing is here:

There has been a sharp and worrying increase in mental health problems experienced by children and young people. Prior to the pandemic, one in eight 5-19 year olds in England had a probable mental disorder. In 2020, amongst 5-16 year olds this figure had risen to one in six. Amongst those with a mental health difficulty, almost half of older teenagers and a quarter of 11-16 year olds report having self-harmed or attempted suicide. Extreme psychosocial distress, with or without self-harm, is often referred to as a ‘crisis’. Services for young people in crisis are a UK priority, and provision is expanding in the NHS, social care and educational settings. However, despite this and the appearance of national standards very little research into crisis services for young people has been undertaken. We therefore do not know what crisis responses currently exist, who uses services, or what works best for children and young people and their families.

Against this background this project will answer the question, ‘How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services’? We will work with a group of young people who advise on research, some of whom have used crisis services, to address the following three objectives:

  1. To describe and map NHS, local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales.
  2. To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services.
  3. To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families.

To help us answer our research question and to meet our objectives we will make use of normalisation process theory. This supports studies into what helps, and what hinders, the implementation and sustainability of new approaches to care.

We will meet our first objective using a survey, creating a detailed record of crisis responses across England and Wales and how they are organised, implemented and used. To meet our second objective, from this detailed record we will identify eight contrasting services selected for variety in terms of: geographic and socioeconomic setting (England/Wales, urban/rural, and relative affluence/poverty); populations served (including ethnic diversity); and service configuration (including third sector and/or social care involvement). Treating each as a case study, we will conduct interviews with children and young people and family members who have used the service. We will also interview commissioners, managers and practitioners, including those providing a crisis response and those working in other parts of the local system. We will gather operational policies and related documents, and data on how each service is used and by whom. In our analysis we will focus on understanding how each crisis service is provided, experienced, implemented and sustained. To meet our final objective we will compare and contrast each case study, and use our synthesised findings to advance the available international evidence for best practice in service provision. We will close by drawing clear, actionable, lessons for the future commissioning and provision of high-quality crisis responses which are sensitive to the support and access needs of a diverse range of children and young people receiving care from a range of services.

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CAMH crisis animations

Over the last few years I’ve been a part of a team led by my Cardiff colleague, Dr Nicola Evans, synthesising the evidence in the area of mental health crisis responses for children and young people. Here is a link to the project, which has been funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery (HSDR) Research Programme.

Now, with the project having concluded, an animation with English and Welsh language versions has been produced. Here they are:

Conferences

This month brought, for me, the welcome return of face-to-face conferences. First, I was pleased to have received an invitation earlier in the year to deliver a keynote lecture at the RCN International Nursing Research Conference 2022, which took place at the Royal Welsh College of Music and Drama on September 5th and 6th. Rather than speak about any one, particular, study I used this as an opportunity to travel over a larger programme of research in the mental health field, pulling out underpinning ideas and key messages along the way.

Boiled down, my talk revolved around four ideas: health care can be thought of as a complex system; complex health systems can be understood through the study of cases, existing at different ‘levels’ of organisation (macro, meso and micro); to appreciate cases of health care system complexity it makes sense to use a plurality of analytic and methodological approaches; and research of this type demands a collaborative, stakeholder-informed, approach. These will be familiar themes to readers of this blog site. My talk at the RCN event, however, represented the most sustained effort I’ve made to date to articulate the principles and practices underpinning the research programme I have been involved in, to synthesise the main lessons learned, and to pull out some overarching observations. At some point it would make sense to write all of this up in an article.

Hot on the heels of the RCN International Nursing Research Conference came the 28th International Mental Health Nursing Research Conference, which took place at St Catherine’s College, Oxford, on September 8th and 9th. St Catherine’s was the home for the Network for Psychiatric Nursing Research Conference, as this event was originally known, for many years: returning there earlier this month seemed fitting after the two online editions of the event which happened in 2020 and 2021. I was pleased to be part of a symposium presenting findings from three NIHR-funded studies into mental health crisis services. Led By Dr Nichola Clibbens, this included a talk by Nicola and Michael Ashman drawing from their (and their colleagues’) realist synthesis of how, for whom and in what circumstances different community mental health crisis services work. Also featuring was a presentation from Professor Steve Gillard and Dr Katie Anderson on mental health decision units in acute care pathways. Third in the linked series of presentations was my talk summarising findings from an evidence synthesis, led by Dr Nicola Evans, into crisis responses for children and young people aged 5 to 25.

More generally, I very much appreciated the opportunity at both these events to renew my connections with friends and colleagues, and to meet and hear new people with interesting things to say. In the case of MHNR2022, particular thanks are due to the organising committee, which brought this conference together under the umbrella of Mental Health Nurse Academics UK without a dedicated events team in support.

New theses

Here is news of two completed doctoral theses which I have helped support as a supervisor, both being within the mental health field. First is Fortune Mhlanga’s Implementing recovery-oriented practice in mental health services: a qualitative case study, which is all about how recovery ideas are used in everyday practice. The summary for Fortune’s study is this:

Although the recovery philosophy has been adopted in mental health services in various Western countries including England, its implementation in practice has been described as “slow and patchy”. Furthermore, there are suggestions in the literature that there is a lack of clarity around the implementation of recovery-oriented practice (ROP) and a dearth of research exploring the phenomenon. This study aimed to discover how recovery-oriented practice is implemented in an NHS Trust providing care for people experiencing mental health problems, in order to add to what is already known about the implementation of ROP to inform future practice.

A qualitative case study approach was employed to investigate the implementation of ROP from strategic to grassroots level in two practice settings (Community Mental Health Team and Rehabilitation ward) within one NHS Trust providing mental health services in the South of England. Semi-structured interviews were conducted with 16 participants (senior managers, practitioners, service users) investigating their perceptions and experiences of ROP. Data were analysed using thematic analysis and further interpreted by situating it in the literature.

Main findings

• Whilst there was a shared common understanding of the meaning of recovery and ROP in the organisation, there was a fundamental difference between practitioners and service users’ conceptualisations with service users leaning more towards clinical recovery.

• At strategic level, strategies to facilitate implementation of ROP focused on changing the culture within the organisation through Implementing Recovery through Organisational Change (ImROC) recommended interventions such as: Recovery College, peer workers and use of the Recovery Star. At grassroots level, implementation was via the development of therapeutic relationships between service users and practitioners.

• Salient barriers to the implementation of ROP included: time taken completing paperwork resulting from performance measures used by commissioners in the community team, the shortage of resources and the tension between risk management and ROP in both settings.

Study contribution

This study addresses the gap in research on the implementation of ROP through an exploration of how ROP was being implemented in two practice settings in an NHS organisation providing mental health care. Methodologically, the qualitative case study approach adopted in the study allowed triangulation of data from participants ranging from grassroots level to strategic level. Furthermore, the approach taken with the sample consisting of service users, senior managers and practitioners from inpatient and community practice settings within the same organisation is not comparable with any other studies on ROP that have been conducted in England. This study therefore informs implementation efforts of similar organisations and makes recommendations for practice, commissioners and research.

Second up is Bethan Mair Edwards’ A window of opportunity: Describing and developing an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia, which addresses the development of OT practice in the support of people with memory difficulties. The summary from Bethan’s thesis is this:

Aim

There is a scarcity of evidence generated in a UK context to inform the practice of occupational therapists working with people living with early-stage dementia. This Thesis’ overarching aim was to describe and develop an evidence, theory, and practice-informed occupational therapy intervention for people living with early-stage dementia.

Methods

In accordance with the MRC Framework for the Development and Evaluation of Complex Interventions, an Intervention Mapping approach was utilised to guide the development process. Thesis Objectives were developed based on Intervention Mapping Steps 1 – 3, and to meet these objectives, this Thesis consists of three studies. Study 1 (a two-stage mixed methods evidence synthesis) and Study 2 (semi-structured interviews with people affected by dementia and occupational therapy practitioners) sought to understand the intervention population and context, as well as identify existing research and practice-based interventions. Study 3 involved describing and developing an intervention programme theory and programme design.

Findings

Studies 1 and 2:

Multiple personal and environmental (social, physical, and occupational) determinants associated with the occupational performance problems that people living with earlystage dementia may experience were identified. Existing research and practice-based interventions were heterogenous in nature and no programme theories were reported; however, strategies that problem-solve occupational performance problems were identified as a primary intervention component. In practice contextual barriers were associated with resources, other professionals’ awareness and understanding of occupational therapy, and a lack of control and influence over service development and policy.

Study 3:

A logic model of the problem and population, matrices of change, and a simple intervention logic model were developed to articulate a proposed programme theory. A broad overview of the proposed interventions’ design, including components and context, were specified and key uncertainties outlined.

Conclusion

This research has developed a robust foundation for further development work at Intervention Mapping Steps 4 – 6, including developing theoretically informed implementation strategies and producing materials in preparation for a feasibility evaluation.

Two super pieces of work, with real relevance for interprofessional mental health services and practice: congratulations to both.

Accessible summary

In what will, I imagine, be a final post about the MENLOC evidence synthesis here is our accessible summary. This has been produced with a wide readership in mind, and for completeness includes links to the full Health and Social Care Delivery Research monograph reporting the project in full, and to our two derived papers. The first, in Palliative Medicine, reports on our research, policy and guidance synthesis and the second, in BMJ Open, reports on findings from our synthesis of case studies.

For a copy, click below:

MENLOC monograph

With funding from the National Institute for Health Research comes the opportunity (and indeed, the requirement) to produce a detailed monograph reporting on all aspects of the project which has been supported. The Health and Social Care Delivery Research monograph arising from the MENLOC evidence synthesis, about which I have added various posts on this site, has now appeared. As with all NIHR project reports, this is free to download.

Here is the plain English summary:

In this study we brought together evidence from research, policies, guidance and case studies in the area of end-of-life care for people with severe mental illness. End-of-life care refers to the help given to people with life-threatening conditions in their expected last 12 months of life. Severe mental illness refers to a range of issues for which care is usually provided by specialist mental health services.

An advisory group, which included people who had experience of mental health and end-of-life care, helped us throughout our project. We searched research databases, journals and online sources. We assessed research articles for their quality and summarised their content. In one review we combined content from research with content from policy and guidance. In another review we combined the content of the case studies. We wrote synthesis statements summarising the research evidence, and assessed how much confidence decision-makers should have in these statements.

We included 104 documents overall. We synthesised research, policy and guidance under themes reflecting their content: the structure of mental health and end-of-life care services; professional practice; providing and receiving care; and living with severe mental illness. We synthesised case studies under themes relating to delays in diagnosis, making decisions, treatment futility, supporting people and the experience of care.

Our project has implications for care. The evidence suggests that partnerships should be built between mental health and end-of-life care staff, and that people should be supported to die where they choose. Care staff need education, support and supervision. A team approach is needed, including support for advocacy. Physical health care for people with severe mental illness needs to be improved so that life-threatening conditions can be recognised sooner.

Future research should involve people with severe mental illness at the end of life and their carers. Research is also needed to evaluate new ways of providing and organising care.

Second MENLOC paper

Here is our second published paper from the MENLOC project, which has synthesised what is known about end of life care for people with severe mental health problems. This article, led by Michael Coffey, reports on our theming of the evidence derived from previously-published case studies. The paper is in BMJ Open, is open access, and has this as its abstract:

Objectives: People with severe mental illness (SMI) have significant comorbidities and reduced life expectancy. The objective of the review reported in this paper was to synthesise material from case studies relating to the organisation, provision and receipt of care for people with SMI who have an end-of-life (EoL) diagnosis.
Design: Systematic review and thematic synthesis.
Data sources: MEDLINE, PsycINFO, EMBASE, HMIC, AMED, CINAHL, CENTRAL, ASSIA, DARE and Web of Science from inception to December 2019. Supplementary searching for additional material including grey literature along with 62 organisational websites.
Results: Of the 11 904 citations retrieved, 42 papers reporting 51 case studies were identified and are reported here. Twenty-five of the forty-two case study papers met seven, or more quality criteria, with eight meeting half or less. Attributes of case study subjects included that just over half were men, had a mean age of 55 years, psychotic illnesses dominated and the EoL condition was in most cases a cancer. Analysis generated themes as follows: diagnostic delay and overshadowing, decision capacity and dilemmas, medical futility, individuals and their networks, care provision.
Conclusions: In the absence of high-quality intervention studies, this evidence synthesis indicates that cross-disciplinary care is supported within the context of established therapeutic relationships. Attention to potential delay and diagnostic overshadowing is required in care provision. The values and preferences of individuals with severe mental illness experiencing an end-of-life condition should be recognised.

Crisis responses

In recent months I’ve been part of a team, led by Nicola Evans, bringing together the evidence in the area of responses for children and young people in mental health crisis. Our working definition of a ‘crisis response’ has been the provision of a service in response to extreme psychosocial distress, which for children and young people may be provided in any location such as an emergency department, primary care, a specialist or non-specialist community service, a school, a college, a university, a youth group, or via a crisis support line. Our objectives have been:

  • To critically appraise, synthesise and present the best available evidence on the organisation of crisis services for children and young people aged 5 to 25 years, across education, health, social care and the third sector.
  • To determine the effectiveness of current models of mental health crisis support for children and young people.
  • To explore the experiences and perceptions of young people, families and staff with regards to mental health crisis support for children and young people aged 5 to 25 years.
  • To determine the goals of crisis intervention

As a project team we’ve been informed by a stakeholder advisory group, and have cast a wide net by searching not only for research but also other relevant evidence including guidance, case studies and more. Methodologically, therefore, this review bears comparison with others I’ve previously written about on this site including the RiSC study and MENLOC. More on this crisis care evidence synthesis to follow in due course.

Perinatal mental health care

Continuing from this recent post celebrating the publishing of papers from doctorates I’ve had a hand in supervising, here now are links to Nicola Savory’s PhD and to a first article from this in the journal Midwifery. Nicola is a midwife, and in her thesis (funded by RCBC Wales) used quantitative and qualitative methods to investigate women’s mental health needs in the antenatal period.

Nicola’s whole-thesis summary is this:

Background: Existing research on poor perinatal mental health largely focuses on recognition and treatment of postnatal depression. Consequently, there is a need to explore antenatal mental health.
Aim: To assess poor mental health prevalence in pregnancy, its relationship to sociodemographic characteristics, self-efficacy and perceived support networks. To understand experiences and barriers preventing women with mental health problems from receiving help and explore midwives’ understanding of their role.
Method: Questionnaires were completed by women in early pregnancy. A subset identified to have mental health problems, were interviewed in late pregnancy to explore their experiences and barriers to receiving care. Midwives completed questionnaires exploring their experiences of supporting women with mental health problems and focus groups further discussed the issues raised.
Results: Amongst participants (n=302), the Edinburgh Postnatal Depression Scale (EPDS) identified 8.6%, and the Generalised Anxiety Disorder Assessment (GAD-7) 8.3%, with symptoms of depression or anxiety respectively. Low self-efficacy (p=0.01) and history of previous mental health problems (p<0.01) were most strongly associated with anxiety or depression. Thematic analysis of interviews with women (n=20) identified three themes: ‘past present and future’; ‘expectations and control’; and ‘knowledge and conversations’.
Questionnaires were completed by 145 midwives. The three themes identified from the focus groups with midwives were: ‘conversations’; ‘it’s immensely complex’; and ‘there’s another gap in their care’.
Conclusion: Prevalence rates of anxiety and depression amongst women in early pregnancy were found to be similar to those reported in the literature. Low self-efficacy and previous poor mental health were significant predictors of anxiety and depression. Continuity and more time at appointments were suggested by midwives and women to improve discussions regarding mental health. Midwives were keen to support women but lacked knowledge and confidence. Consistent reference was made to the need for training regarding the practical aspects of supporting women’s mental health.

Nicola has a series of journal papers lined up from her doctorate, with the one I’ve linked to above (‘Prevalence and predictors of poor mental health among pregnant women in Wales using a cross-sectional survey’) being just the first.

More observations from a small country

This new paper has been a long time in the making. Work on it began with preparations for an address given at the Australian College of Mental Health Nurses conference in 2018. Refinements and updates happened towards the end of 2019, in the context of preparing for a talk delivered at a Royal College of Nursing-sponsored event in Cardiff in 2019, with a further version presented at an online conference organised by Julia Terry, from Swansea University, during the 2020 coronavirus lockdown. Along the way the written article has benefited from a critical reading from both Michael Coffey and  Nicola Evans, and from no fewer than four anonymous peer reviewers. My thanks to all of them.

Observations from a small country: mental health policy, services and nursing in Wales can be downloaded in green open access form from the Cardiff University institutional repository, and has this as its abstract:

Wales is a small country, with an aging population, high levels of population health need and an economy with a significant reliance on public services. Its health system attracts little attention, with analyses tending to underplay the differences between the four countries of the United Kingdom (UK). This paper helps redress this via a case study of Welsh mental health policy, services and nursing practice. Distinctively, successive devolved governments in Wales have emphasised public planning and provision. Wales also has primary legislation addressing sustainability and future generations, safe nurse staffing, and rights of access to mental health services. However, in a context in which gaps always exist between national policy, local services and face-to-face care, evidence points to the existence of tension between Welsh policy aspirations and realities. Mental health nurses in Wales have produced a framework for action, which describes practice exemplars and looks forward to a secure future for the profession. With policy, however enlightened, lacking the singular potency to bring about intended change, nurses as the largest of the professional groups involved in mental health care have opportunities to make a difference in Wales through leadership, influence and collective action.

The argument I’ve developed here is that policy for health care in Wales, and for mental health care specifically, has distinctive features. As a peer reviewer I continue to have to correct manuscripts which conflate ‘England’ with the ‘UK’, and I’ve tried in this article to point out some of the things which make Wales different. I have also highlighted what seem, to me, to be gaps between well-intentioned policy aspirations and actual experiences as revealed through research. Overall, though, I intend the paper to convey a message of optimism, noting (amongst other things) the high value placed on the relational work of mental health nurses and the positive differences nurses make. Enjoy the read!