Service User Groups Research Articles

Clinician views on best practice community care for people with complex emotional needs and how it can be achieved: a qualitative study

BackgroundIndividuals with Complex Emotional Needs (CEN) services, a working description to refer to the needs experienced by people who may have been diagnosed with a “personality disorder”, face premature mortality, high rates of co-morbidity, service user and treatment costs. Service provision for this population is recurrently identified as needing to be transformed: there are serious concerns about quality, accessibility, fragmentation of the service system and the stigma and therapeutic pessimism service users encounter. Understanding clinician perspectives is vital for service transformation, as their views and experiences shed light on potential barriers to achieving good care, and how these might be overcome. In this study, we aimed to explore these views.MethodsWe used a qualitative interview design. A total of fifty participants from a range of professions across specialist and generic community mental health services across England who provide care to people with CEN took part in six focus groups and sixteen one-to-one interviews. We analysed the data using a thematic approach.FindingsMain themes were: 1) Acknowledging the heterogeneity of needs: the need for a person-centred care approach and flexibility when working with CEN, 2) ‘Still a diagnosis of exclusion’: Exploring the healthcare provider-level barriers to providing care, and 3) Understanding the exclusionary culture: exploring the system-based barriers to providing care for CEN. Across these themes, staff highlighted in particular the need for care that was person-centred, relational, empathic, and trauma informed. Major barriers to achieving this are stigmatising attitudes and behaviour towards people with CEN, especially in generic mental health services, lack of development of coherent service systems offering clear long-term pathways and ready access to high quality treatment, and lack of well-developed structures for staff training and support.DiscussionOverall, the findings point towards clinician views as generally congruent with those of service users, reinforcing the need for priorities towards systemwide change to ensure that best practice care is provided for people with CEN. Particularly prominent is the need to put in place systemwide training and support for clinicians working with CEN, encompassing generic and specialist services, and to challenge the stigma still experienced throughout the system.ConclusionsStaff working with this service user group report that delivering best practice care requires services to be flexible, integrated, and sustainably funded, and for staff to be supported through ongoing training and supervision.

PP447 Informing The Development And Evaluation Of An Evidence-Based Service Delivery Model For Mental Health Patients With Complex Needs

IntroductionMental health services for adults have been developed to provide community-based interventions. There is a recognized unmet need in some of the most complex patients that may not be adequately met by existing mental health services provision. Research is warranted to consider the best model of service delivery for this group of service users. The aims of this research were to examine the profile and history of service users defined as having complex needs as well as their service use and associated costs in the Cheshire and Wirral Partnership NHS Foundation Trust (CWP).MethodsA diverse group of stakeholders were invited to provide feedback on the content and design of the proforma for data collection from the medical records of service users. The rationale of the data collection was described to ensure relevant patient-level cost information was collected to identify and quantify the relevant resources consumed, to inform the evaluation of direct medical costs, direct non-medical costs, and indirect costs for each patient. The proforma was designed to also permit comparisons of clinical and service use outcomes for evaluation of patient health and non-health outcomes associated with alternative care pathways.ResultsStakeholder feedback comprised representatives from the CWP, patients, commissioners, the Local Authority, and housing. Relevant data for extraction from patient medical records were identified and a proforma was developed. The following items were identified for inclusion: baseline demographic data, service user data (family background, contact with the criminal justice system, social history), and clinical data (diagnosis, treatment, hospital visits, and other health service use).ConclusionsA proforma was developed with diverse stakeholder involvement to inform data collection on the resource use and cost impact associated with alternative care pathways in the National Health Service and other sectors of the economy. Based on the proforma developed and data extracted, an exploration of patient health and non-health outcomes associated with alternative care pathways will be conducted to inform service evaluation and to promote patient centric care.

Flexibility and Professionalisation: Reflections on Adaptions by Social Work Services in China during COVID-19

This article presents a conceptual framework of ‘flexibility’ to analyse social work responses to COVID-19 breakout in two Chinese cities. It explores how social workers adjusted in three interrelated ways: to new needs and service user groups, by changing the types of resources they coordinate, and collaborating with other professions and policy structures in new forms. It argues for greater attention to ‘flexibility’ in social work theory and practice, suggesting that this concept can boost the social work profession and build professional identity in contexts where social work is being established.

Functional rehabilitation class for South Asian Females (SAF) in Hindi/Urdu: A service evaluation project

Purpose: The Dynamic Health Musculoskeletal (MSK) services, Peterborough serves an ethnically diverse population. The South Asian population is the second-largest ethnic group in Peterborough and it was identified that this group of service users often have low follow-up rates, increased non-attendance for appointments and achieve poorer outcomes from physiotherapy. Reasons for this are proposed as cultural barriers, preference to be seen by a female therapist, limitation to participate in existing classes due to language and cultural barriers and hesitancy of expression when interacting with health care professionals from different backgrounds through translation services.

Day Centres for Homeless People in South London: Early Learning Points from Operating During the First COVID-19 Lockdown in England

Context: Many day centres for homeless people remained open during the first national lockdown in England following the COVID-19 pandemic. Lacking any official guidance on how to adapt, day centres for homeless people had to navigate risks of infection and changes in the situation of homeless people during this time.Objective: This small study aimed to discover how some day centres for homeless people approached and experienced the implications of lockdown. The objective was to draw early learning points to inform further research on the future trajectory of day centre provision for homeless people during the pandemic and beyond.Methods: This rapid qualitative study included semi-structured phone interviews with day centre managers (n = 5) and a systematic search of public facing websites of day centres (n = 10) across four South London boroughs. Data were analysed inductively, using the framework method.Findings: Findings indicate three learning points 1: the importance of strong networks between day centres with local authorities and other organisations for homeless people to enable services to provide humanitarian assistance, 2: the significance of day centres in their role as humanitarian assistants as a first point of contact for newly homeless people 3: the value of a central information hub.Limitations: The regional focus on South London and the sample size, which reflects ethical imperatives involved in avoiding undue pressure on day centre staff during the COVID-19 pandemic, limit this study. The findings are to be considered as a springboard for in-depth research into day centres’ support for homeless people during and after the COVID-19 pandemic.Implications: Findings are valuable as a snapshot of this largely under-researched group of services and service users during the first lockdown. Further research based on the findings could lead to good practice examples to inform the future trajectory of social care provision for homeless people.

Using the Behaviour Change Wheel to design an intervention for partner abusive men in drug and alcohol treatment

BackgroundWe aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting.MethodsWe describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention (‘ADVANCE’) for delivery in substance use services. We employed a comprehensive eight-stage process to guide this development applying the ‘COM-B’ (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) model for intervention design which specifies the following: (1) define the problem, (2) select the target behaviour, (3) specify the target behaviour, (4) identify what needs to change, (5) identify intervention functions, (6) identify policy categories, (7) select behaviour change techniques, and (8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. The identified targets for intervention and mode and method of delivery were then refined over 4 intervention development meetings, using the nominal group technique with the ADVANCE experts, then further refined following consultation with service user groups and wider expert groups via a learning alliance meetings.ResultsOur final intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pre-group individual interviews, followed by 12 × 2-h group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation, and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behaviour changes and development of new skills.ConclusionWe have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use-related intimate partner abuse that is acceptable to staff and clients in substance use services. This led to a feasibility study (ISRCTN 79435190) involving 104 men and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to refine the content and approach to delivery (BMC Public Health, 21: 980, 2021).

Telephone-delivered health behaviour change support for people with a mental health condition: the coaches\u2019 perspective

BackgroundPeople with a mental health condition experience a greater prevalence of chronic disease and reduced life expectancy compared to the general population. Modifiable health risk behaviours, such as physical inactivity and poor nutrition are major contributing factors. Population-level health coaching delivering behavioural change support via telephone for healthy eating, physical activity, and weight management is an opportunity utilised by this group to support improvement in healthy lifestyle behaviours. Health coaches offer a valuable perspective into the provision of services to this high-risk group. This study aims to qualitatively explore coaches’ experiences in providing support to these participants, consider factors which may contribute to engagement and outcomes; and potentially inform future service improvement.MethodA qualitative study design was employed involving semi-structured telephone interviews with six coaches employed in a telephone-based behaviour change support service in New South Wales, Australia, between April and July 2019. Interview data was analysed using an inductive thematic analysis.ResultsCoaches believed that the service was of benefit to people with a mental health condition, however making changes to health risk behaviours was potentially more difficult for this group of service users. Coaches indicated that in supporting this group there was a greater focus on building confidence and readiness to change. They noted that improvement in mental health as a result of physical health changes was an additional ‘measure of success’ of particular relevance. Coaches expressed a desire to receive more mental health training to better deliver coaching to participants with a mental health condition. Program variables such as limited call length were posed as possible barriers to care.ConclusionFurther training and additional support for coaches, in additon to considering variations to aspects of service delivery may assist in improving engagement and outcomes for participants with mental health conditions. Examining mental health consumers’ experiences when engaging with telephone coaching services would be an important area to address in further research.

Secure and Practical Group Nearest Neighbor Query for Location-Based Services in Cloud Computing

Group nearest neighbor (GNN) query enables a group of location-based service (LBS) users to retrieve a point from point of interests (POIs) with the minimum aggregate distance to them. For resource constraints and privacy concerns, LBS provider outsources the encrypted POIs to a powerful cloud server. The encryption-and-outsourcing mechanism brings a challenge for the data utilization. However, as previous work from k − anonymity technique leaks all contents of POIs and returns an answer set with redundant communication cost, the LBS system cannot work properly with those privacy-preserving schemes. In this paper, we illustrate a secure group nearest neighbor query scheme, which is referred to as SecGNN. It supports the GNN query with n n ≥ 3 LBS users and assures the data privacy and query privacy. Since SecGNN only achieves linear search complexity, an efficiency enhanced scheme (named Sec GNN + ) is introduced by taking advantage of the KD-tree data structure. Specifically, we convert the GNN problem to the nearest neighbor problem for their centroid, which can be computed by anonymous veto network and Burmester–Desmedt conference key agreement protocols. Furthermore, the Sec GNN + scheme is introduced from the KD-tree data structure and a designed tool, which supports the computation of inner products over ciphertexts. Finally, we run experiments on a real-database and a random database to evaluate the performance of our SecGNN and Sec GNN + schemes. The experimental results show the high efficiency of our proposed schemes.

A retrospective records study of patterns in mental health and criminal justice service use by people found not criminally responsible on account of mental disorder.

While the presence or absence of previous healthcare and criminal justice system (CJS) contacts in the histories of mentally ill offenders has been well-studied, the frequency of these contacts and when they occur in the period leading up to an index criminal event has received less research attention. To explore patterns of healthcare and CJS use in the year prior to a criminal act leading to a Not Criminally Responsible on Account of Mental Disorder (NCRMD) finding in Canada. In this 3-year retrospective records study, the case files of all patients newly admitted to the British Columbia forensic psychiatric system after a finding of NCRMD between 1st July 2012 and 31st July 2015 were reviewed. Data were extracted on healthcare and CJS use for the 12months before the act leading to the NCRMD finding. Time-based descriptive statistics and two-step cluster analysis were used to investigate service use patterns. Among 94 eligible patients, only four had no service contacts in the year leading up to the index event, leaving 90 in the cohort for further analysis. On average, these 90 patients had seven contacts with health or criminal justice services in the year prior to the index offence. Cluster analysis revealed a high healthcare pathway group who had had many healthcare and few CJS contacts; a limited service user group who had had few contacts of any kind and a heavy service user group who had had a high volume of contacts with both types of service providers. The different patterns of patient contact prior to the index event imply that each practitioner-type has distinct and temporally relevant opportunities to provide preventative interventions to their patients or user groups.

Development of a positive group intervention for coexisting problems: A mixed methods study

Substance misuse commonly coexists with psychological disorder (dual diagnosis) making the problems more complex and the symptoms augmented with far-reaching negative consequences. Despite the wide range of support that treats both problems, clients often relapse. This study was the first empirical attempt to investigate how positive psychology can facilitate recovery by not focusing merely on the disorders but exploring and enhancing the positive aspects of clients’ lives moving them toward optimal human functioning. A mixed methods approach was applied to test a 12-week positive group intervention in two groups of service users (n=10) with coexisting disorders at an outpatient addiction service to explore the feasibility and acceptability of a positive approach in their recovery. Participants seemed to have benefitted from the programme, all positive concepts were found relevant, and the intervention was found feasible and acceptable by service users. It was concluded that a strengths-based positive approach has the potential to serve as a useful adjunct to the treatment of coexisting problems. Implications for treatment are discussed in terms of how positive psychology may be helpful in long-term recovery by providing alternative strategies to cope with mental illness and a substitute for the love, nurturing, and belonging that substances appear to offer to individuals.

Integrating conformance and performance for the evaluation of urban planning implementation from a goal-oriented perspective

Urban planning implementation evaluation (UPIE) is an important tool for the supervision and inspection of the outcomes, processes and effectiveness of planning implementation. Conformance-based evaluation refers to the exploration of the degree of coincidence between actual situations and planning contents. Decision-centred performance evaluation focuses on exploring the role and purpose of plans in the implementation process. Although consensus has been reached on conformance and decision-centred performance evaluation, goal-oriented performance evaluation needs further development. Therefore, the integrated theoretical framework of UPIE, which emphasizes social effectiveness, has been constructed with goal-oriented performance in mind. It is suggested that performance-based evaluation that focuses on social effectiveness reveals the gap between actual situations and planning goals and can be established by the degree of realization of planning goals. Meanwhile, it has put forward a service-capabilities-based evaluation methodology which relies on the spatial matching between service supply and user group demands. Taking the Urban Master Plan of Xi’an (2008–2020) as an example, the results of UPIE show that this blueprint needs further revisions and adjustments. Through a goal-oriented methodology, the integrated theoretical framework can attract more attention to social effectiveness.

A service evaluation and improvement project: outcomes of older adult functional referrals to the North Derbyshire Liaison Team

AimsThis project aims to examine a group of service users over the age of 65 with functional presentations, who were assessed by the Liaison Psychiatry team between June 2018 and 2019.Hypotheis: We believe that there is a need for a community crisis service for the older adult North Derbyshire population with functional presentations.BackgroundDue to the lack of community crisis services for patients over 70, it was felt that a significant number of these patients were admitted to inpatient psychiatric units from medical wards who would benefit from crisis intervention instead. We wanted to see the clinical outcomes of this population, referred to the liaison team, determining whether this was significant concern. If this need is established, based on the data collected, this will enable the trust to look into starting a service for this age group to provide care in their own home. In turn, it will help to reduce unnecessary admissions to acute mental health wards and reduce stays in the general hospital – preventing consequences associated with long term hospital stays.MethodRetrospective analysis using PARIS notes of 366 patients referred to the liaison team were scrutinised to determine the assessment diagnosis and outcome of patients with functional conditions. The inclusion criteria were patients over the age of 65 referred with functional psychiatric illnesses between June 2018 and 2019. We excluded 84 patients assessed to have delirium or organic presentations from our analysis. Data were collected and analysed using Excel.ResultAmong the referrals to the liaison team, the majority of patients were referred with mood disorders followed by self-harm, psychosis and anxiety. Although the majority of patients were referred back to either the community mental health team or primary care, 11% of the sample were admitted to inpatient psychiatric units. This number may have been lower and admission may have been avoided if a community crisis service was in place for this population.ConclusionIn conclusion, the data support our initial concerns that there is a need for crisis services for this age group with functional presentations. There is ongoing discussions around a need to develop this service and therefore our results will contribute to the development of an older adult functional service in Derbyshire.

The use of coproduction to inform an evidence-based service delivery model for mental health service users with complex needs

AimsCo-production recognises that people who use social care services (and their families) and third sector organisations within community settings have knowledge and experience that can be used to help make services better for services users and those who care for them. This study shares the coproduction that took place in the design of a mixed methods study that aims to understand: the profile and history of service users currently defined as having complex needs; the decision-making processes by clinicians that lead to these individuals entering this complex group; service users and carers experience of service use; and, the associated costs. This study involves a comprehensive evaluation that aims to inform an evidence-based service delivery model for mental health service users with complex needs.MethodA study stakeholder group, including clinicians, academics, service users, housing associations, health economists, and statisticians was formed from the outset to inform the mixed methods design, combining quantitative (in-depth analysis of patient records and economic evaluation) and qualitative (written medical notes and in-depth interviews with service users, carers, and clinicians) methods. The study included five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of direct medical costs, direct non-medical costs, and indirect costs for each patient; (3) semi-structured interviews about patients and carers experiences; (4) data from components 1-3 was used to co-produce vignettes jointly with the stakeholders group; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group by using the vignettes as example case studies.ResultCoproduction took place at each stage of the study, including the design, development of data collection tools, data analysis and formation of the vignettes required for stage five. The results demonstrated how co-production and multiagency working have been evident throughout the process of designing the study, the continuous engagement throughout the analysis, dissemination and implementation of the findings.ConclusionThe findings support the application of the core principles of co-production in the design, set-up and implementation of research within an NHS Trust as demonstrable by the acceptability and collaborative working within the study. The study's key outcomes were to: examine the resource use and cost impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how decisions are made in their treatment to inform how services are delivered in the future and made more person-centred and consistent.

Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians

BackgroundTreating chronic depression represents a significant burden for the NHS, yet there is a lack of evidence-based interventions and research specifically focused on this condition. DIALOG+, a technology-assisted and resource-oriented intervention found effective for people with psychosis, may improve care for this service user group. The aim of this study was to explore the acceptability and relevance of DIALOG+ for the treatment of chronic depression in community-based settings.MethodsA convenience sample of 16 mental health professionals and 29 service users with chronic depression tested the DIALOG+ intervention in routine community care appointments for 3 months across 3 different mental health NHS Trusts in England. Of these, 15 clinicians and 19 service users were individually interviewed about their experiences. Interview transcripts were analysed using thematic analysis by an analytic team which included a service user researcher.ResultsAnalysis of the combined dataset identified five overarching themes: DIALOG+ Structure; Therapeutic Communication; Reflecting and Monitoring; Empowerment and Powerlessness; and The Impact of Technology. Overall, service users and clinicians were interested in the continued use of DIALOG+ as part of routine care.ConclusionsDIALOG+ was viewed as acceptable by both service users with chronic depression and their clinicians who work in community care settings, albeit with some caveats. Clinician training required significant improvements to address the issues that were referenced, most notably around support with using technology.

Sharing Lived Experiences Framework (SLEF): a framework for mental health practitioners when making disclosure decisions

ABSTRACT Self-disclosure for mental health practitioners can have benefits for the therapeutic relationship. Most practitioners, however, are wary of doing so, or do not know how to navigate this. This paper aims to present a comprehensive framework to assist mental health practitioners when choosing to self-disclose lived experiences. This framework was created by a working group of academics, clinicians, service users and recovery workers, based on an international project investigating self-disclosure among professionals. Results from this project informed the content of this framework, considering theoretical models of supervision to guide development. The Sharing Lived Experiences Framework (SLEF) details six areas for practitioners to consider: Preparedness, Confidence, Competence, Relevance, Comfort and Supervision. The connection between preparedness and supervision is emphasised. Preliminary data on the SLEF indicates that staff felt more able to navigate disclosure after training on this framework. To the authors’ knowledge, this is the first comprehensive framework to guide practitioners through the disclosure process; from planning, to in-the-moment considerations, to post-disclosure reflection. Although limited available data exist on clinical utility, the SLEF crucially provides a framework for supervision discussions and guided self-reflection for a full range of practitioners on a range of lived experiences.

The Importance of Personal Recovery and Perceived Recovery Support Among Service Users With Psychosis.

More knowledge is needed about whether personal recovery, as defined by the CHIME framework (connectedness, hope, identity, meaning and purpose, and empowerment), is considered important by service users with psychosis. This study examined the importance of personal recovery for a large, heterogeneous group of service users with psychosis and their perceived support from clinicians for personal recovery. This cross-sectional study used baseline data from 321 service users with psychosis from 39 clinical units across Norway. The INSPIRE Measure of Staff Support for Personal Recovery (based on CHIME) was used to examine personal recovery and perceived support provided for recovery. Twenty support-for-recovery items were each rated on importance (yes or no) and on the extent of support received (5-point scale). Bivariate and multiple linear regression models assessed variables associated with rated importance and support. Results: Most service users rated personal recovery items as important, regardless of their symptomatology and functioning. Previous experience with Illness Management and Recovery, knowledge about coping with stress and illness, and having a plan for early detection and prevention of relapse were significantly associated with higher perceived support. Higher self-reported depressive symptoms, lower score on the Global Assessment of Functioning symptom subscale, and male sex were significantly associated with less perceived support. Most service users with psychosis found personal recovery important, regardless of symptomatology and functioning, which has implications for clinical practice and provides empirical evidence that recovery-oriented treatments are relevant for most service users with psychosis in various mental health services.

Remote care for mental health: qualitative study with service users, carers and staff during the COVID-19 pandemic

ObjectivesTo explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the COVID-19 pandemic.DesignQualitative interview study, codesigned with mental health service users and...

Using journey mapping to understand the patient experience with selecting a Medicare part D plan using a pharmacy consultation service

BackgroundPatient experience with community pharmacy services can be informed by human-centered design principles and approaches. Pharmacy services may benefit from detailed evaluations of consumer experience and patient-centered service design. ObjectivesTo use an online journey mapping platform to understand the patient experience with selecting a Medicare Part D plan for individuals that did, and did not, use a free, pharmacy-led, Medicare Part D consultation service. MethodsThis was a two-group cross-sectional survey study in a single, rural community pharmacy. Surveys consisted of 7 demographic items, 30 Likert-type items, and 7 open-ended response items. The pharmacy used purposeful convenience sampling to distribute a paper survey to individuals 65 years of age and older currently enrolled in Medicare Part D between June and August 2019. Surveys were distributed to 36 patients currently enrolled in a Medicare Part D plan, with 18 surveys distributed to patients who had previously used a pharmacy-led Medicare Part D consultation service and 18 surveys distributed to patients who did not use the service. Surveys were uploaded to an online journey mapping platform, producing data visualizations for each group. Multiple choice survey items were analyzed using descriptive statistics, wth service user and nonuser groups compared using Mann-Whitney U tests. Open-ended survey responses were coded by the research team using an inductive approach. ResultsIn total, 36 surveys were returned to the community pharmacy for a response rate of 100%. The journey map platform generated Persona, Empathy, and Current Journey outputs, which mapped Good Experiences and Bad Experiences within the Medicare Part D plan selection experience. Personas differed in their median household incomes ($25,000–$39,999 for service users compared to $50,000–$74,999 for nonusers). Empathy and Current Journey outputs showed that service users had a wider variety of emotions compared to non-users. Mann-Whitney U tests yielded 5 items with statistically significant differences (p-values <0.05) in the plan-selection experience, with both groups similarly uncertain about their plan decision. Qualitative responses indicate patient trust was universally important to a complex decision-making process. ConclusionsAn online journey mapping platform provided insight into how patients experience a pharmacy service that extends beyond satisfaction. For community pharmacies providing Medicare Part D plan consultation services, pharmacies should consider how they can improve the service experience through communication style and patient-centered service design.

When policy fails try something different integrated practice improve outcomes for dual diagnosis co-occurring service users accessing mental health services

Purpose This paper aims to discuss an initiative developed between, Leicestershire Partnership National Health Service Trust and Turning Point, which is the locally commissioned drug and alcohol service in Leicester, Leicestershire and Rutland. The aim was to improve outcomes for clients with dual diagnosis (co-occurring mental health and substance misuse) issues. The purpose of the change in working practice was to engage with local substance misuse agencies more effectively to improve clinical outcomes within this service user group. This was achieved through four interrelated approaches. This comprising providing an integrated service. It included building relationships with substance misuse services, providing specialist dual diagnosis clinics and the introduction of substance misuse workers onto mental health wards and group work specific to substance misuse. The outcomes included easier access to services for service users and greater uptake of service users who were moving onto substance misuse services. This led to a reduction in risk related to prescribing and fewer incidents related to prescribing changes and greater engagement in services. When service users were moving between services better communication led to prescriptions being transferred with no delay and to reduced dropout rates in service. There was improved access to substance misuse services, more referrals and take up of service taking place. There was a greater understanding by staff of co-occurring substance misuse and how to work with this client group. Closer working relationship with substance misuse services and shared skills led to greater confidence in managing this service user group. This demonstrates a cost effective service that can be replicated within similar settings. Design/methodology/approach In clinical practice, shared treatment has proved challenging in light of different service models (Laker, 2006). Substance misuse works on the premise of change comes from the individual, where recovery models in mental health offer a formalised approach. One of the challenges faced by services has been the inability for mental health services to recruit and services become overstretched (Rimmer, 2018); this gave an opportunity for a new method of working to be considered. This led to the development of a new service model. These changes were: • Improving the interface with substance misuse services to improve access to community substance misuse services for mental health clients. • To provide specialist staff within the dual diagnosis field to provide a clinic jointly with local drug and alcohol services. • Introduction of substance misuse workers as team members on acute mental health and rehab wards. • Group Substance Misuse programmes. Findings Working within an integrated model, yet maintaining separate organisations, by offering joint training and clinics has led to a greater understanding of each organisation’s work and increased engagement within the service user group.The introduction of substance misuse workers to acute and rehab mental health inpatient services encouraged service users to engage at the point of admission and to be referred into locally commissioned substance misuse services prior to the point of discharge. Engagement with staff has demonstrated better engagement with substance service by service users following discharge.For clients able to take leave assessment could take place prior to discharge. This led to an increased uptake in services. Due to no opiate substitution given on discharge decreased risk of prescribed medication overdose at point of discharge and led to increase in returning straight to substance misuse services. This meant that service users received medication quicker and the right dose and on discharge ensured reduced risk. The prescribing of Naloxone at discharge is yet to be assessed, but the risk of an overdose within seven days is well-documented and Naloxone is key in reversing this trend. This change in practice can be replicated in any mental health setting and has increased access to services for those using substances. Originality/value Is original no other services have substance workers or joint clinics across the UK. First inpatient unit to welcome patients back post-discharge to attend groups.

Experiences of receiving cognitive analytic therapy for those with complex secondary care mental health difficulties.

Service users with complex mental health difficulties are more difficult to engage in treatment and drop-out rates are higher, resulting in poorer clinical outcomes. Cognitive analytic therapy (CAT) is widely applied to service users with complex needs and shows promise in terms of engagement and outcomes. The aim of the present study was to examine the 'lived experience' of service users who have been retained in a full course of CAT treatment to provide important insights to why CAT seems to be an engaging psychotherapy, to inform future CAT delivery and practice with clients with complex needs. Semi-structured interviews were undertaken with six service users aged between 25 and 47years who had accessed secondary mental health care services and had received an average of 24 sessions of CAT. Transcripts were analysed using interpretative phenomenological analysis (IPA). The analysis yielded three superordinate themes with subthemes within these. The first superordinate theme referred to changes due to CAT (e.g., insight, tools to cope). The second theme referred to strong emotions evoked by CAT (e.g., feeling frustrated, scared, and upset). The final theme concerned the process of CAT (e.g., endings and therapeutic relationship). Whilst service users appeared to develop increased insight and acquire skills, there was variance in experiences of sustained and meaningful change post-therapy. The findings suggest adaptations may be required with these service users such as delivering the sequential diagrammatic reformulation (SDR) in a hopeful way and addressing systemic barriers to 'exits' being made. Overall, service users with complex mental health difficulties describe benefitting from CAT, identifying improved insight and the acquisition of tools to cope. However, therapists need to be attuned to the potential fragility of service users and risk of negative affect, particularly during the reformulation phase. Consideration of delivering the SDR in a hopeful way may be therapeutic. Systemic factors such as service users being pulled to maintain the status quo in their relationships, and lack of support for or resistance to change by important others limit service users from availing of 'exits' from problem procedures. This implicates the need for more attention to systemic and possibly multi-agency working with this group of service users.