East London NHS Foundation Trust Research Articles

Association between continuity of care and attendance of post-discharge follow-up after psychiatric emergency presentation

The number of accident and emergency (A&E) hospital attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition more than tripled between 2010 and 2022. After discharge from the hospital, attendance at follow-up appointments in the community is critical to ensure the safety of young people and optimise the use of clinical resources. A retrospective cohort study was conducted to evaluate the association between follow-up attendance and the continuity of clinicians and clinical teams, using electronic clinical record data from East London NHS Foundation Trust (ELFT), between April 2019 and March 2022. Multi-level mixed effects logistic regression was performed to model the follow-up attendance odds based on whether the same or different clinician and clinical team offered the initial A&E and the community follow-up appointment or whether a crisis team was involved. 3134 A&E presentations by 2368 young people were identified within the study period. Following these presentations, 2091 follow-up appointments in the community were offered. The attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in A&E (odds ratio (OR) = 3.66; 95% CI 1.65–8.13). Whether the same clinical team provided the community follow-up appointment, or whether a crisis team was involved before discharge made no difference to the likelihood of follow-up attendance. The findings support the importance of the continuity of clinicians in the care of young people in crisis.

Do Quality and Safe Care Champions in community nursing teams positively impact on patients?

Quality Always' Clinical Assessment and Accreditation Scheme (CAAS), which consists of a process of assessments, reviews and accreditation in community healthcare services, was established in 2014 to drive improvements in the quality of patient care. The authors set out to understand whether the methodologies put in place to establish quality patient care were effective within the community nursing setting. To understand whether a quality and safe care champions network would support frontline community staff to embed evidence-based practice and affect the quality of care received by patients in the community setting. A study was undertaken on data from the CAAS, as well as patient safety and experience data, to identify whether there was any correlation between quality and safe care champions and the quality of patient care. The authors identified data and practical examples to demonstrate a correlation between the engagement of champions in a community nursing team and improvement in quality standards for patients, including the most effective methods of engaging the community nursing quality and safe care champions. The authors conducted a benefits realisation exercise using elements of the East London NHS Foundation Trust's framework. This provided useful information for the community trust as a proof of concept regarding supporting a network of Quality and safe care champions in the community setting and understanding their impact on safe patient care.

Building capacity and capability for quality improvement: developing an organisational approach

There has been an increase in the adoption of quality improvement methods to tackle complex problems in healthcare. One of the key requisites for sustainable quality improvement is ensuring that organisations have the capacity and capability to make these changes effectively. This article uses a case study methodology to describe the learning from 9 years of developing, delivering and evaluating quality improvement learning programmes at East London NHS Foundation Trust. The key quality improvement learning progammes are evaluated using a Kirkpatrick framework across four levels: reaction, learning, behaviour and outcomes. Five key principles were identified: using a dosing approach; standardising development, delivery and evaluation; developing a community to support learners; making training relevant; and the importance of leadership. However, the authors believe that more research is needed to develop standardised approaches to evaluating quality improvement capability building and to understand why some quality improvement projects are less successful than others.

Evaluating the Impact of a Simulation Based Training Course in Intellectual Disability Psychiatry and Autism Co-Delivered by Actors With Intellectual Disability

AimsInequalities in health outcomes, and avoidable deaths, in people with intellectual disability has highlighted the need for improved training and education in Intellectual Disability and Autism. Simulation training facilitated by actors with intellectual disability has been shown to improve connection with people with intellectual disability (Attoe et al 2017). The aim of this project was to develop a simulation-based training course, focused on topics in mental health, intellectual disability and autism, to improve participant confidence in clinical knowledge and skills, as well as support leadership and professionalism training. Here we evaluate the impact of the training on participants’ confidence, and the longer-term effect on attitudes and working practice after attendance.MethodsA novel simulation-based training course, directed at Specialty Trainees, was developed based on the Specialty Training in Learning Disability curriculum. The course was co-delivered by a person with intellectual disability. Participants who attended the simulation training completed general feedback, pre-course and post-course confidence questionnaires and attended a semi-structured group interview at 2 months. Questionnaire data weres analysed using descriptive and inferential statistics. Group interview data were analysed using open & axial coding, and thematic analysis of content. The project was approved by East London NHS Foundation Trust Governance and Ethics Committee for Studies and Evaluations.ResultsEight psychiatrists participated in the training and completed the pre-course and post-course questionnaires. Independent t-test found significant increase in confidence for all scores from pre-course (M = 6.54, SE0.24) to post-course (M = 7.81, SE = 0.36), t= –2.93 p = 0.01. This included ratings of confidence in knowledge in areas such as mental health legislation, and improved confidence in skills such as communication with families of people with intellectual disability and difficult conversations with senior supervisors. In follow-up interviews we elucidated themes of the importance of supported, structured training opportunities with people with intellectual disability, and the value of connection with peers and supervisors.ConclusionSimulation based training in psychiatry, co-delivered with actors with intellectual disability, was reported to be an engaging and enjoyable form of learning. The evaluation suggests such training is effective in increasing trainee confidence in knowledge and skills at the time of training as well as resulting in a lasting change in attitudes after the training. We recommend such training be further developed and delivered at both postgraduate and undergraduate level.

Evaluation of a Drama-Based Experiential Learning Group Programme for Multidisciplinary Staff and People With Lived Experience in Psychiatry

AimsExperiential learning, such as simulation-based training, is widely used in health education. Dramatic self-expression adds another layer through enacted perspective taking, and embodied self-exploration of interaction with others, to foster situated learning. We describe the evaluation of an innovative drama-based experiential learning project involving collaboration between multidisciplinary mental healthcare staff and people with lived experience of mental illness. The programme was facilitated at East London NHS Foundation Trust by a theatre company experienced in delivering workshops with service users. A weekly group programme took place online over 8 weeks during the COVID-19 pandemic and included activities of improvisation, embodied enactments and debriefing. The programme led to co-production of a drama piece that was filmed and distributed online. It was hypothesised that the experiential learning might result in individual benefits for all participants, such as improved well-being and increased mutual understanding of each other's experience of mental health care. The project aimed to improve relationships between healthcare disciplines, and between staff and service users. Additionally, aims were to empower service users, and support staff to practice core interpersonal skills. Objectives of the evaluation were to study the impact of the experiential learning, understand participants’ experience, and explore challenges and benefits.MethodsA mixed methods approach was taken to evaluate the programme. Following completion of the project, participants were invited to complete a questionnaire utilising a Likert scale rating of overall satisfaction with the project, perceived benefit and impact on specific domains such as working with others. One-to-one semi-structured interviews were conducted according to a topic-guide, and qualitative data were analysed using open & axial coding for thematic analysis.Results11 participants, including Psychiatrists, Occupational Therapists and current service users, completed the experiential learning and filming. Questionnaire data suggested participants were highly satisfied with the learning and felt it would be valuable to others. Themes include the positive experience of creativity, dismantling of hierarchy, improved empathy, confidence and connection. Potential challenges were digital inequality and lack of dedicated time for professional development.ConclusionA drama-based experiential learning group programme for healthcare staff and service users is a highly beneficial learning experience. Participants describe changes on a personal level as well as improved understanding of others’ perspectives. This form of experiential learning features collaborative working that aligns with principles of co-production and supports the development of interpersonal skills; the findings suggest that drama-based experiential learning is a useful method in health education to complement knowledge acquisition.

Electronic prescribing system cuts dispensing errors by almost half in one trust

Electronic prescribing systems have reduced the number of medicine dispensing errors by 45% in one London hospital trust, an audit report has revealed. An audit of the electronic prescribing and medicines administration (ePMA) system at East London NHS Foundation Trust, obtained by the Pharmaceutical Journal through a freedom of information (FOI) request and dated September […]

Quality improvement in practice—part three: achieving the triple aim through the systematic application of quality improvement

The triple aim is defined as the simultaneous pursuit of improvement across three areas: population health outcomes, quality of care and value for the system. Since the triple aim framework was first introduced in 2008, it has been applied in various contexts across several countries. The triple aim has been proposed as a core purpose of the integrated health and care systems in England. However, little has been written about how the systematic application of quality improvement can support the process of achieving the triple aim, despite the increasingly widespread use of quality improvement methods and tools in the quality of care element of the triple aim. This article, the third in a three-part series about applying quality improvement to practice, puts forward a step-by-step guide for healthcare systems to use their existing quality improvement capabilities to help them achieve the triple aim, with examples and learning from the authors' experience at East London NHS Foundation Trust.

A review of serious untoward incidents (SUIS) of patients with personality disorder (PD)

AimsThe aim of this paper is to describe key findings and recommendations of SUI reports regarding patients with a diagnosis of PD in East London NHS Foundation Trust (ELFT). Patients with a diagnosis of PD are often involved in SUIs with regards to risk to themselves or others. Contributing factors might be the nature of their disorder in terms of mood instability and impulsivity, self-harming or antisocial behaviour, and the difficulties posed to assessing clinicians in predicting risk.BackgroundPatients with PD present severe challenges to services. SUI findings thus serve as a lightning rod for issues in their management. With the emergence of NICE guidelines for borderline PD [2009] and antisocial PD [2009] regarding risk assessments, there has been greater optimism for management of PDs.MethodA case series of 50 SUI reports of patients with a diagnosis of PD were identified from the governance and risk management team of ELFT. Themes were categorized as positive practice, contributory factors, and recommendations. Findings are related to guidelines in NICE and RCPsychiatry. Any patient with a diagnosis of PD (of any sub-type) that was involved in a SUI in ELFT met the inclusion criteria. There were no exclusion criteria.ResultThe most frequent themes in positive practice were ‘continuity of care’ and ‘clinical practice’. The most frequent subthemes in clinical practice were ‘assessments’ and ‘follow-up’. ‘Continuity of care’ included examples of collaborative working between various teams, as in joint assessments, good communication, and timely referrals. In contributory factors ‘poor documentation’ was the most frequent theme. 14 reports found no contributory factors. In recommendations the most frequent theme was the need for development and implementation of PD policies and for improved risk management.ConclusionNICE guidelines stress the importance of continuity of care and good clinical care and it is commendable that these were findings in positive practice. The importance of documentation being accurate and timely needs underlining in hard pressed time poor clinicians. Services would do well to review PD policies specifically regarding risk management at a wider Trust and local service level. Our findings point to the ongoing need for workforce development as recommended in the RCPSych position statement on PD published in January 2020.

Transition from child and adolescent MHS to adult MHS: what happens to young people with personality disorder?

AimsHypothesis: Personality Disorder (PD) adolescents, compared to non-PD case, have a worse experience at transition.Aims: To describe the outcomes of referrals of adolescents for transition to adult services and compare PD and non-PD populations to identify potential improvements to allow for better transition experience of the PD patients.BackgroundBorderline PD is prevalent in adolescents - although there is a reluctance to make the diagnosis. When patients reach graduation from CAMHS, many fall through the ‘gap’ in services during the transition. Consequently, adding the paucity in research about the transition experience of PD patients, it is important to evaluate what happens to these patients during the transition process to help better understand their experience, and how it can be improved.MethodPatient's clinical records from Tower Hamlet CAMHS, East London NHS Foundation Trust, were reviewed retrospectively from July 2018 to November 2019, assessing whether optimal transition standards were met. A total of 41 cases that transitioned from CAMHS to AMHS were identified. Transition standards compared were: information sharing – case and risk, parallel care, transition planning and continuity. PD diagnosis was identified based on the recording of this diagnosis or meeting DSM5 criteria from the notes. PD and non-PD transition experience was compared.Result36 were given a diagnosis by the CAMHS clinician at transition and 5 had no diagnosis assigned. No cases had a PD diagnosis made by the CAMHS clinician, however 1 case mentioned ‘PD traits’, 1 mentioned ‘EUPD’ as a possible differential and 2 cases were labelled as ‘emotional dysregulation’. The research team found 17 cases that met DSM5 criteria for PD diagnosis.Comparing transition experience of PD vs non-PD patients, the PD patients had a less optimal transition process. Statistical analysis using Chi Square Tests, showed significantly less optimal transition planning (X2 = 5.103, p < 0.05) and continuity (Fisher's exact test p = 0.049). Cohens W indicated a medium effect for transition planning and continuity.ConclusionAdolescents with a diagnosis of PD transition less well to Adult MHS than those without the PD diagnosis. Implications of our findings point to 1) the importance of considering a diagnosis of PD 2) if the diagnosis of PD is made, to anticipate greater difficulties in transition 3) the need to identify specific reasons for transition difficulties related to patient, clinician and system factors and their interrelation.

Donna Kinnair: campaigning for the real value of nursing

Nursing had always been a career that Professor Dame Donna Kinnair, Chief Executive and General Secretary of the UK Royal College of Nursing (RCN) and Non-Executive Director, East London NHS Foundation Trust, wanted to be a part of. Her family came to the UK in the 1950s, part of the Windrush generation. “I have a brother who is a doctor, and a sister who is a midwife…nursing was actually a part of my family, it was also part of my family history in the Caribbean”, she says. Yet nursing wasn't the path she initially followed. Before nurses' training was moved into higher education, she explains, “if you could go to university, you were encouraged to. I think very much from the careers perspective, nursing wasn't seen as something that would enable you to progress to the best of your ability”. And so she started a university degree, and only later entered the profession as a student nurse in 1983. After working as a nurse in community and hospital settings she eventually took up leadership roles, including as Director of Commissioning for the London Borough of Southwark and Southwark Primary Care Trust. She realised that her nursing studies were just as taxing as her time in academia and that the move to make nursing a degree-bearing subject was fitting for this highly skilled profession. “We are people who study hard and provide a critical life-saving service”, she says.

Transference-focused psychotherapy as an aid to learning psychodynamic psychotherapy: qualitative analysis of UK psychiatry trainees' views.

Learning psychotherapy can be difficult and stressful. We explore core trainees' (n = 5) views on undertaking a psychodynamic psychotherapy training case using transference-focused psychotherapy (TFP), in an East London NHS Foundation Trust supervision group. We used framework analysis of focus group interviews to examine trainees' concerns, their views about this experience and its impact on general psychiatric practice. Trainees described various concerns on starting: providing an effective intervention, insufficient experience and training-related pressures. However, they found that TFP addressed some of them and was helpful for learning psychodynamic psychotherapy. Difficulties around the countertransference remained at end-point. Trainees suggested that introductory teaching and learning through observation might be worthwhile. Trainees' experience suggests that an evidence-based operationalised approach such as TFP can be integrated into the core psychiatry curriculum as a psychodynamic psychotherapy learning method. Trainees report benefits extending to other areas of their practice.

Quality improvement at East London NHS Foundation Trust: the pathway to embedding lasting change

PurposeEast London NHS Foundation Trust (ELFT) is a major provider of mental healthcare and community health services. Quality improvement (QI) has become central to its organisational policy and goals for which it has received national and international attention.Design/methodology/approachThis piece reflects on the Trust's transformation and its approach. It provides many examples and discusses several of the associated challenges in building and sustaining QI momentum. It is the result of a range of perspectives from staff involved in planning and building large-scale QI capability. It contextualises QI's current status in UK mental healthcare.FindingsSeveral key factors were identified: board-led commitment to organisational transformation; investment in training and resources to support staff motivation; clear and realistic project goals in line with the service's over-arching strategic direction; support for service users and staff at all levels to get involved to address issues that matter to them; and, finally, placement of a high value on service user and staff qualitative feedback.Practical implicationsBuilding QI capability represents a significant challenge faced by all large healthcare providers. Sharing experiences of change can assist other organisations achieve the necessary buy-in and support the planning process.Originality/valueAchieving and sustaining lasting organisational change in healthcare is challenging. This article provides a background on QI at ELFT and reflects on the pathway to its present position at the forefront of the application of QI within healthcare.

Improving smoking cessation in first episode psychosis: a quality improvement project by the City & Hackney Early and Quick Intervention Psychosis (EQUIP)

Smoking tobacco is a major public health issue and a significant cause of increased mortality. People with a first episode of psychosis are more likely to smoke and the subgroup...

To improve the communication between a community mental health team and its service users, their families and carers.

This article describes the application of quality improvement (QI) to solve a long-standing, ongoing problem where service users or their carers felt they were not given enough information regarding diagnosis and medication during clinic assessments in a community mental health setting. Service users and carers had shared feedback that some of the information documented on clinic letters was not accurate and the service users were not given the opportunity to discuss these letters with the clinician. The aim of this QI project was to improve the communication between the community mental health team (CMHT) and service users and their carers. Wardown CMHT volunteered to take on this project. The stakeholders involved were the team manager and deputy manager, the team consultant, the team specialist registrar, team administrative manager, two carers and one service user. The project had access to QI learning and support through East London NHS Foundation Trust’s QI programme. The team organised weekly meetings to brainstorm ideas, plan tests of change to review progress and to agree on the next course of action. The outcome was an increase in service user satisfaction from 59.9% to 78% over a period of 6 months, and a reduction in complaints to zero.

Quality improvement in forensic mental health: the East London forensic violence reduction collaborative.

Ward-based violence is the most significant cause of reported safety incidents at East London NHS Foundation Trust (ELFT). It impacts on patient and staff safety, well-being, clinical care and the broader hospital community in various direct and indirect ways. The contributing factors are varied and complex. Several factors differentiate the forensic setting, which has been identified as a particularly stressful work environment. Staff must constantly balance addressing therapeutic needs with robust risk management in a complex patient cohort. ELFT identified reducing inpatient physical violence on mental health wards as a major quality improvement (QI) priority. The aim was to use a QI methodology to reduce incidents of inpatient violence and aggression across two secure hospital sites by at least 30% between July 2016 and March 2018. Collaborative learning was central to this project. It sought to foster a culture of openness within the organisation around violence and to support service users and staff to work together to understand and address it. A QI methodology was applied in medium and low secure inpatient settings. A change bundle was tested for effectiveness, which included: safety huddles, safety crosses and weekly community safety discussions. Operational definitions for non-physical violence, physical violence and sexual harassment were developed and used. Reductions of 8% and 16.6% in rates of physical and non-physical violent incidents, respectively, were achieved and sustained. Compared with baseline, this equated to one less incident of physical and 17 less of non-physical violence per week averaged across seven wards. Three wards achieved at least a 30% reduction in incidents of physical violence per week. Five wards achieved at least a 30% reduction in incidents of non-physical violence per week. This collaborative brought significant improvements and a cultural shift towards openness around inpatient violence.

Exploring the cultural flexibility of the ACT model as an effective therapeutic group intervention for Turkish speaking communities in East London

AbstractThis study describes a successful community-based partnership project between statutory and third-sector services in East London; The City and Hackney Black and Minority Ethnic (BME) Access Service [East London NHS Foundation Trust (ELFT)] collaborated with Derman, a local community organization supporting the well-being of Turkish-speaking communities, to explore the cultural adaptability of an empirically supported, third-wave cognitive behavioural intervention, Acceptance and Commitment Therapy (ACT). The aim was to develop a culturally acceptable group that was responsive to the therapeutic needs of participants from Turkish-speaking communities. The study implemented a mixed-method analysis with a one group pre/post-test design to examine the effectiveness of a 7-session culturally adapted ACT group intervention and a descriptive approach was implemented to assess usefulness, relevance and acceptability. Results demonstrated an overall positive effect of the culturally adapted ACT intervention in terms of both symptoms and patient-reported outcomes. Participants showed significant improvements on measures of depression (p= 0.014), anxiety (p= 0.041) and psychological distress (p= 0.003). The magnitude of these changes was categorized as large, with effect sizes from 0.90 to 2.03. Qualitative responses indicated that the group was experienced as enjoyable and useful and was considered to be an accessible and acceptable therapeutic format. Although a pilot within clinical practice, the findings provide preliminary support for the clinical utility of ACT as an effective, culturally acceptable therapeutic approach for Turkish-speaking communities living in an urban UK setting. The study highlights the importance of culturally appropriate service development and a need for further research within this area.

Building the business case for quality improvement: a framework for evaluating return on investment

There is increasing interest and belief in applying quality improvement (QI) to help solve our most complex challenges in healthcare, yet little published literature to help leaders develop a business case and evaluate return on investment from QI. This is even more pronounced in fields such as mental health and community health services. This paper presents a framework to help identify, understand and evaluate return on investment from large-scale application of QI in healthcare providers. The framework has been developed at East London NHS Foundation Trust (ELFT), a provider of predominantly mental health and community health services to a population of 1.5 million people, which has been undertaking QI at scale since 2014. This paper presents case studies and examples from ELFT to illustrate return on investment from QI at multiple levels: improving outcomes for patients and service users, improving the experience of staff, improving productivity and efficiency, avoiding costs, reducing costs and increasing revenue.

Improving mental health knowledge of the Charedi Orthodox Jewish Community in North London: A partnership project.

This article describes a successful community-based partnership project between statutory and third-sector services targeting the strictly Orthodox Jewish community (OJC). The City and Hackney Black and Minority Ethnic (BME) Access Service (East London NHS Foundation Trust (ELFT)) collaborated with Bikur Cholim, a local third-sector organisation based in the heart of a north London Charedi OJC, to develop a brief culturally tailored psychoeducational group intervention focusing on mental health promotion and prevention. In total, 34 carers in the Charedi OJC were provided with general information on mental health, the availability of support services and self-care. Overall improvements in well-being, increased intentions to access services, particularly talking therapies, and qualitative feedback indicated that the group was very well received. The project endorses the value of culturally relevant psychoeducation, enabling suggestions for culturally appropriate service development.

Reducing bed occupancy and length of stay on a functional older adults' psychiatric ward.

A quality improvement project was initiated on Ivory ward, a functional older adult psychiatric inpatient ward at Newham Centre for Mental Health, part of the East London NHS Foundation Trust. The project was started by staff on the ward after it had come to their attention that their ward had the highest bed occupancy and length of stay across similar wards in the trust. The mean bed occupancy in the 9 months before the project started was 87.7%. The mean length of stay on the ward in the 9 months before the project started was 70 days. The team used the model for improvement, which is the trust’s methodology of choice for quality improvement projects, to reduce bed occupancy and length of stay. The focus was on running small-scale tests of change to see whether these could lead to improvement. These change ideas were refined, scaled up or discontinued as appropriate to help achieve the aim. The project’s aim was to promote quality of care by reducing patient length of stay on Ivory ward to 45 days and bed occupancy to ≤70% or by 1 January 2016. The project team managed to reduce bed occupancy to 58% and length of stay to an average of 35 days.

The Handy Approach – Quick Integrated Person Centred Support Preparation

Cost effective care requires comprehensive person-centred formulation of solutions. The East London NHS Foundation Trust Community Health Services in Newham have piloted models of Integrated Care called ‘Virtual Wards’ which...