MH-CREST: How do community crisis care services work, who do they work for, and in what circumstances?

I am excited to announce the start of MH-CREST following an intense year of development. The MH-CREST research team is a partnership between The School of Healthcare at the University of Leeds, the University of Sheffield and our sponsor Sheffield Health and Social Care NHS Foundation Trust. Together, the MH-CREST team hold expertise in mental health nursing, lived experience, social and psychological sciences, psychiatry, information science, evidence synthesis, and realist methodology. As a new NIHR Principal Investigator, I have been on the steepest learning curve but so far have survived with the support of my colleagues!

Nicola has been on a steep learning curve

We held our first research team meeting in September and started to tackle some important but tricky questions:

What is a mental health crisis?

Mental health crises can be defined in different ways, but after much discussion, the MH-CREST team decided we would define crisis as:

1. A relapse in a psychiatric condition, characterised by increased symptom severity (such as voice hearing, suicidal thoughts, and other behaviours that could cause harm) and decreases in social functioning (including reduced self-care) (Crompton & Daniel, 2006)

2. A reaction to adverse life events that disrupts the lives of the person and their family because their usual ways of coping have not worked (Tobitt & Kamboj, 2011)

3. An opportunity for change that may enable people to develop new ways of coping (Caplan, 1989)

These definitions have helped us to decide what types of evidence we will include in our project and which stakeholders we should speak to.

map of crisis services developed with stakeholders

What evidence will be included in MH-CREST?

Most UK mental health crisis care is in community settings because hospital care is hard to access, unpopular, and costly for the NHS. There is some evidence that community crisis services in the UK provide value for money and are effective for many people, others report not being able to access services and their needs not being met (Mind, 2011, 2012; CQC, 2015). Before the project started, we consulted people who have accessed mental health crisis services and these sessions suggested that crisis services resemble a tangled web of overlapping services with complex referral routes and blurred functions.

a tangled web of overlapping services with complex referral routes and blurred functions

UK crisis services are diverse, vary in different parts of the country and have many different names. They are provided by the voluntary sector, NHS, local authority or social enterprise (a type of business that uses profits to improve people’s lives) and are increasingly delivered as a collaboration between providers.

some of the different names for crisis services in the UK

Following discussion, the MH-CREST research team agreed to focus on crisis care for people who are in a community setting. The people we consulted before the project started also thought that the focus should be on crisis services for people in community settings rather than hospital because community services are generally preferred, provide the respite, information and support that people ask for, and avoid the need to be away from home and family. Crisis care is complex so we will revisit and refine our definitions as the project progresses.

How do crisis care services work, who do they work for, and in what circumstances?

We will review previous research and speak to stakeholders to understand how crisis care services work, for whom and in what circumstances – this type of literature review is called ‘a realist evidence synthesis’ (Pawson et al., 2005). We will start by developing informed hunches (‘programme theories’) about how crisis services are supposed to work by reading journals, books, policy documents and talking to stakeholders with expertise as health professionals, service users, family members, commissioners, policy makers and academics.

Once we have identified programme theories about how crisis services are supposed to work, we will test them by re-examining previous research and consulting stakeholders. We may also be able to link what we find to broader (middle range) theories that help us to explain how crisis services work (or don’t work). In a final step, we will work in partnership with the stakeholders to write ‘pen portrait’ examples that connect our theories to peoples’ lived experiences.

Why is the project important and what will it do?

UK mental health crisis services have had investment for some time and important research has been published, but there are still gaps in our understanding. We already know from research findings and from listening to the experiences of people using services, that crisis care outcomes vary in different contexts and people find it hard to access the right help when they need it. For example:

  • in some parts of the UK, crisis services are not available 24 hours
  • people who are black or belong to a minority ethnic group (BAME) find it hard to access crisis care that meets their needs

This project will explain why outcomes vary across different services designs and providers and identify what is needed to simplify the pathways through crisis care, improve access and reduce variability. Using this information, health services commissioners will be able to design crisis care based on what leads to the best outcomes for people experiencing a mental health crisis wherever they live enabling them to access the right crisis care at the right time.

Nicola Clibbens is a Lecturer in Mental Health at the University of Leeds. To find out more about the MH-CREST project click here and here or contact Nicola. Follow Nicola and the MH-CREST project on Twitter @UniLeedsMH using the hashtag #MHCrest.

This study is funded by the National Institute for Health Research (NIHR) HS&DR programme (NIHR127709). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

References

Caplan, G. (1989) Recent developments in crisis interventions and the promotion of support services, Journal of Primary Prevention, 10, 1, 3-25.

Crompton, N., & Daniel, D. (2006) Guidance statement on fidelity and best practice for crisis services. London, Department of Health, NHS National Institute for Mental Health in England, Care Services Improvement Partnership, London.

Mind (2011) Listening to experience: An independent inquiry into acute and crisis care, Mind, London.

Mind (2012) Mental Health Crisis Care: A briefing for clinical commissioning groups, Mind, London.

Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2005) Realist review: a new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy, 10, 21-34.

The Care Quality Commission (2015) Right here, right now: People’s experiences of help, care and support during a mental health crisis, CQC, London.

Tobitt, S. & Kamboj, S. (2011) Crisis resolution/home treatment team workers’ understanding of the concept of crisis, Social Psychiatry and Psychiatric Epidemiology, 46, 671-683.

April/May Update

Since our last update, we’ve published three blogs, won 2 prizes and published another paper. In April, Emily Pattinson wrote about the new study led by Liz Hughes that will explore NHS staff views about collecting sexual identity data from patients. Then, Susan Guthrie blogged about embarking on her PhD as one of the new CArDiNAL Fellows. Finally, Krysia Canvin marked Menstrual Hygiene Day 2019 by revisiting the issue of period poverty and its impact on service users’ dignity in mental health settings. She concluded by reflecting on how, ultimately service users’ dignity is at the centre of all our research endeavours.

Out and About

Leila Sharda, final year PhD student, attended the Faculty of Liaison Psychiatry Annual Conference, 15th May – 17th May. The conference was held at the Royal College of Psychiatrists in London and focused on long term conditions. Leila’s research examines how general hospitals respond to patients diagnosed with a personality disorder who are distressed. She presented a poster and gave a talk about the adverse responses these patients receive. Leila’s work was very well received: she was awarded joint first prize for her oral presentation by the panel of expert judges.

Leila’s poster of her PhD findings

Dakota Scollen (@DakotaScollen), third year mental health nursing student, attended the Future of Mental Health Nursing Conference in Edinburgh after winning a competition. Entrants were invited to submit a quote that captures the essence of Mental Health Nursing. Dakota won with her entry, a favourite quote from Alice in Wonderland:

“When you can’t look on the bright side, we’ll sit with you in the dark”

The Mad Hatter, Alice in Wonderland by Lewis Carroll

Look out for Dakota’s blog about the conference, coming soon.

Latest Publications

The contribution of mental health services to a new strategic direction for sexual assault and abuse services

Liz Hughes contributed to a paper published recently in the Journal of Forensic and Legal Medicine led by Professor Charlie Brooker. The paper reports a freedom of information request to NHS mental health care providers to ask whether they had a clear pathway to sexual assault referral centres following disclosure of sexual assaults by people using their services. Very few trusts reported that they had such a pathway. Given that sexual violence is not uncommon in people who use mental health services, and that sexual assault has a significant impact on mental health, there is a need for better joined up services.

Look out for a blog about Liz’ related study about the effectiveness of sexual assault referral centres with regard to mental health and substance use, coming soon.

CArDiNAL: A New Clinical Academic Research Fellowship

The beginning…

I am delighted to be starting my PhD journey with the University of Leeds in tandem with Leeds and York Partnership Foundation Trust. The new CArDiNAL (ClinicAl Doctoral Nurses and ALlied Health Professionals) Clinical Academic Research Fellowship embeds and promotes my research role within my clinical (Speech and Language Therapist) Specialist post. A strength of this new post is the support of a cohort of clinical academic fellows – including different Allied Health Professionals and Nursing Specialists – together, we form a community of research active clinicians across the Yorkshire and Humber footprint.

“The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic.”

Without this important initiative by Yorkshire and Humber NIHR CLAHRC I would not have been able to embark on this research journey whilst continuing to practice as a Speech and Language Therapist. As well as adding to the wider evidence-base for dysphagia in mental health, my research and ongoing clinical practice will inform each other. The service users on my clinical caseload, their caregivers and the multidisciplinary team have directly influenced my research topic and I will use my specialist skills to support involvement from other service users with communication difficulties in co-production.

“How can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems?”

My PhD research will consider everyday quality of life around mealtimes and I will continue to identify and unpack good practice. My pilot work progressed from an initial case study (highlighting the different perspectives of an inpatient and members of his staff team; see Guthrie et al. 2012) to projects considering the risks associated with swallowing difficulties, communication and choking incidents in adults with mental health conditions (Guthrie and Stansfield 2017; Guthrie and Roddam 2011), leading me to ask: how can service users, caregivers and clinicians be supported to recognise the early warning signs of eating, drinking and swallowing problems? I developed a free booklet to support service user, carer and staff discussions about mealtimes (Guthrie 2013). The pictures, text and checklist suggest conversation topics, including aspects of swallowing difficulty that may have gone unrecognised or been overlooked. Any concerns about swallowing should always be referred to Speech and Language Therapy for assessment and advice.

I am keen to hear any patient or caregiver “stories” of the experience of living with mental health conditions and dysphagia.

Susan Guthrie is a Highly Specialist Speech and Language Therapist and CArDINAL Clinical Academic Research Fellow. For more information about her PhD research you can contact her here or directly via hcsg@leeds.ac.uk. You can also follow Susan on Twitter @SusanGuthrieSLT and on Researchgate.

References

Guthrie, S. and Roddam, H. (2011) Reporting and learning from choking incidents in adults with learning disabilities. Speech and Language Therapy in Practice.

Guthrie, S., Roddam, H., Panna, S. and Fairburn, G. (2012) Capacity to choose and refuse? A case study. Advances in Mental Health and Intellectual Disabilities, 6(6), pp.293-300.

Guthrie, S. (2013) Me at Mealtimes [Free online booklet]

Guthrie, S. and Stansfield, J. (2017) Teatime Threats. Choking Incidents at the Evening Meal. Journal of Applied Research in Intellectual Disabilities, 30(1), pp.47-60.

How comfortable are NHS staff with asking about sexual identity?

As of April 2019, sexual identity monitoring became mandatory across the NHS. Health disparities – inequalities in the provision of or access to healthcare – are faced by many different minority groups. Collecting monitoring information such as age, race and socioeconomic group makes healthcare providers aware of these disparities and therefore better able to take action to address them. The existence of disparities in accessing health care has been the subject of increased empirical study in recent years, yet without accurate and suitable monitoring data on patients’ sexual orientation it is difficult to know the true extent of these disparities. In 2013 the Lesbian, Gay, Bisexual and Trans (LGBT) Public Health Outcomes Framework Companion Document (Williams et al., 2013) recommended that sexual orientation and gender identity should be routinely monitored in health and social care to allow for a better understanding of disparities facing the LGBT community when accessing health care.

Research in the US suggests staff and patient perceptions of collecting sexual orientation monitoring information differ drastically, with staff greatly over-estimating how much discomfort collecting this information would cause patients. While 80% of healthcare staff thought that asking patients about their sexuality or gender identity would cause offence, only 11% of patients reported they would be offended when asked (Maragh-Bass et al. 2017).

“80% of healthcare staff thought that asking patients about their sexuality or gender identity would cause offence.” (Maragh-Bass et al. 2017)

Kate Ward – in association with The Rainbow Alliance – conducted a service audit at Leeds and York Partnership Foundation Trust. Her findings mirrored those of previous research: a disconnect between UK staff and patients perceptions of recording information about sexual orientation. In the absence of any UK studies on this topic we have devised a survey to try to gain some insight into NHS staff’ views about collecting mandatory sexual orientation monitoring data.

“How comfortable do NHS staff feel about collecting information about patient sexuality?”

We will invite NHS staff who collect sexual orientation data during their day-to-day interactions with patients to share their opinions and behaviours . A 5 minute online survey will be used to collect information about how staff currently collect information about sexual orientation within their trust. As a result of this survey, we hope to gain a better understanding of how staff feel about collecting sexual orientation data from patients and what support staff would like to be put into place. In addition, each trust involved in the study will receive a document showing the how their trust is collecting sexual orientation information and the opinions of their staff, this document will help trusts understand how they are conforming to the sexual orientation monitoring information standard.

“What support would staff like?”

We will send out an online questionnaire to a sample of acute care and mental health NHS Trusts for completion by any employee that collects patient information as part of their role. The questionnaire will ask a series of questions about that individual staff member’s opinions and behaviours surrounding sexual orientation monitoring. We will also ask staff to volunteer information about their own sexual orientation, LGBTQ+ training and job role. All questionnaires will be anonymous. We will use this information to investigate any potential connections between comfort and willingness to collect information about sexual orientation and staff members own sexual orientation, job role and LGBTQ+ awareness.

Do you have to record sexual orientation as part of your role? How do you feel about that? We’d love to hear your thoughts.

For further information please contact us or Emily Pattinson directly e.m.pattinson@leeds.ac.uk. Follow Emily (@EmilyPatPsyc) and Liz (@LizHughesDD) on Twitter.

References

Maragh-Bass, A.C. and colleagues (2017) Risks, benefits, and importance of collecting sexual orientation and gender identity data in healthcare settings: a multi-method analysis of patient and provider perspectives. LGBT Health, 4(2), 141-152.

Williams, H. and colleagues (2013) The lesbian, gay, bisexual and trans public health outcomes framework companion document. The Lesbian and Gay Foundation.

March Update

This month we published two blogs written by PhD students affiliated to the Mental Health Research Group. Both Susan and Angela are engaged in important work that focuses on areas of which the public – including many of us working in mental health – are unaware. On Delusion Awareness Day, Angela gave us an insight into the occurrence of delusions in intensive care. Susan then brought our attention to the difficulties eating, drinking and swallowing that may be experienced by people with mental health conditions on Swallowing Awareness Day.

Out and About

Liz was invited to speak at a joint mental health and HIV cross party group at the Scottish Government on 20th March. Liz described her systematic review (available free from The Lancet) of blood borne viruses in people with serious mental illness and how there is limited data in BBV prevalence in this group in the UK. She then introduced her new feasibility study of sexual health promotion for people with severe mental illness: the Respect study (details coming soon).

Nicola held a very successful World Café event on 14th March in collaboration with staff from Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH). Thirty-five carers and carer champions attended the event and their contributions (pictured) – and some very large slices of cake – made the day a great success. We learned a lot about what carers want from health research and how they would like to be involved. The project is funded by the School of Healthcare Pump Priming Fund and supported by the RDaSH Patient and Public Engagement Team.

John attended the two-day Educational Meeting on the Multidisciplinary Management of Acute Disturbance hosted by the British Association for Psychopharmacology (BAP) and the National Association of Psychiatric Intensive Care & Low Secure Units (NAPICU). The event made it clear just how little research has been conducted into the use of rapid tranquilisation (particularly how to reduce its use), and services users’ views of this practice. Evidence-based guidance on the clinical management of acute disturbance (de-escalation and rapid tranquilisation) produced jointly by BAP and NAPICU in 2018 is available online from BAP.

Latest Publications

Sexual Violence and Mental Health Services: A Call to Action

Liz published an editorial in which she issues a call for action on sexual violence in mental health services. In the absence of routine enquiry about experiences of sexual violence, the editorial explores the evidence and makes some recommendations about how staff can discuss sexual issues.

Provision of Care for Women in the Postpartum Period (STUDY Protocol)

Rebekah Shallcross, who recently joined us here in Leeds, has published the protocol for the ESMI study, a collaboration with University of Manchester and Kings College London. The study will compare the effectiveness and cost-effectiveness of mother and baby units with general psychiatric inpatient wards and crisis resolution team services.

Staff Experiences and Understandings of the REsTRAIN Yourself Initiative

Finally, John has published the first in a series of papers coming out this year that present findings from REsTRAIN Yourself. REsTRAIN Yourself is the UK adaptation of “6 Core Strategies”, an intervention designed to reduce the use of restrictive practices. The study was led by Professor Joy Duxbury, now at Manchester Metropolitan University, and the toolkit is free to download.

February Update

February may be a short month, but we have been no less busy…

John has been out and about. He attended a meeting of NHS England’s Expert Reference Group: Restrictive Practices where he presented evidence for the current use of rapid tranquilisation in inpatient settings. The talk was based on work conducted jointly with Peter Pratt, NHS England & NHS Improvement Head of MH & LD Medicines Strategy (follow Peter @jppharm). John also attended a conference promoting nursing research in Greater Manchester Mental Health NHS Foundation Trust where he had been invited to talk about the need to develop research into safe, effective and therapeutic staffing in inpatient units.

Nicola and John joined fellow academic mental health nurses to discuss various matters at their meeting at the University of Birmingham. An overview of the meeting can be found on the MHNAUK website.

Forthcoming Events

7 March

We are delighted to announce that Richard Gray, Professor of Clinical Nursing Practice will be delivering a School of Healthcare Education and Debate lecture on 7th March. Professor Gray, who is visiting from La Trobe University, Melbourne, Australia, will speak about ‘How to Enhance the Physical Activity of People with Severe Mental Illness?’ For further details and to register please visit Eventbrite.

14 March

Nicola blogged earlier this month about her Carers World Café event on 14th March where she hopes to find out more about the research priorities of carers of people with mental illness. Spaces are still available and if you would like to attend please contact us or Nicola for further information and to reserve a place.

5 June

We continue to make progress with our NIHR-funded studies and we are preparing a range of reports and resources in different formats. Some of these will be made available via this website, so watch this space. We are also pleased that half of the available places have already been reserved for our @BCTcompare free dissemination event in June. We are very keen to ensure that service users and carers attend and contribute to the discussion and can cover travel expenses. If you would like to attend or to enquire about travel expenses, please contact us or reserve a ticket via Eventbrite.

New Project Starting Soon

Liz and her team are about to embark on a new study in April examining NHS staff views about collecting sexual orientation data. More information to follow!

Tickets Available – Reducing Restrictive Practices: Understanding Key Intervention Components

As we move into the final stages of COMPARE: Establishing components of programmes to reduce restrictive practices: an evidence synthesis, we are pleased to announce that we will share our findings at a dedicated event:

Reducing Restrictive Practices: Understanding Key Intervention Components

12.30-15.30 5 June 2019
Horizon Conference Centre, Leeds

We have identified and mapped over 100 interventions that have been implemented in various adult mental health settings across the world. A free, interactive directory will be made available following this event. Using a specially designed taxonomy, we were able to discern between the active components of a substantial proportion of these interventions. Consequently, for the first time, we will be able to indicate which intervention components have the most (or least) potential to reduce restrictive practices.

We will also introduce a new study that builds on and extends this work: CONTRAST: Establishing components of interventions to reduce restrictive practices with children and young people: an evidence synthesis. Here, we will seek to identify interventions to reduce restrictive practices with children in a range of residential settings.

“We particularly encourage service users and carers to come along and join in the discussion.”

A draft programme for the event can be found below. Please join us for a complimentary lunch from 12.30 onwards. We hope that we will be joined by a wide range of stakeholders with an interest in the reduction of restrictive practices for plenty of networking and discussion. We particularly encourage service users and carers to come along and join in the discussion and we can cover travel expenses for those who wish to do so. Please contact us to make arrangements.

If you have any questions about the event, please do not hesitate to contact us. For travel and parking information visit Horizon, Leeds

Tickets are available via Eventbrite.

January 2019 – Welcome!

In the month that we launch our new website we’ve been busy. The start of the month saw Liz Hughes publish a joint position paper with other members of Mental Health Nurse Academics UK and people with lived experience: “Seeing Red” raises the issue of period dignity in inpatient mental health settings. Liz engaged in a streamed video chat about this issue with UNITE Mental Health.

In addition, Liz is a co-investigator on a new study Identifying and evaluating mental health early intervention services and self-care support for lesbian, gay, bisexual and transgender young people: a mixed methods study led by Lancaster University and funded by the Health Services and Delivery Research stream of the NIHR. The study will examine and evaluate access to mental health support for young people who identify as lesbian, gay bisexual, or transsexual (LGBT). LGBT young people report significantly higher rates of depression, self-harm, suicidality and poor mental health than heterosexual youth. We are pleased to welcome Dr Emily Pattinson, who will be working with Liz on this three year study, to the Mental Health Research Group. 

John Baker and Kathryn Berzins have been busy blogging for the National Elf Service (@mentalelf on Twitter). Kathryn’s blog examined a review which focused on the role of carers under the Mental Health Act, and John’s discussed a recently published systematic review on Community Treatment Orders.

A journal accepted our first paper to explore some of the work led by Joy Duxbury’s team to reduce the use of restrictive interventions in acute mental health settings informed by the 6 Core Strategies approach (more on this in a future blog).

Nicola Clibbens‘ upcoming World Café will focus on carers’ views about their participation in mental health research featured on the radio (Hallam FM). The World Café event will be held in Doncaster at The Dome in Doncaster on 14th March 1-3.30pm as a partnership between Rotherham, Doncaster and South Humber NHS Trust and The University of Leeds.