NHS Mental Health Research Articles

Effects of patient deaths by suicide on clinicians working in mental health: A survey.

In the UK, at least a quarter of suicides occurs in patients whilst under the care of mental health services. This study investigated the effects of such deaths on non-medical mental health clinicians. An online survey was conducted within a single NHS mental health Trust to elicit both quantitative and qualitative responses from staff across a range of professions. The survey focused on personal and professional impacts and available support. Participants reported significant negative emotional and professional effects that were long-lasting for some. These included mental health difficulties, loss of confidence regarding clinical responsibilities, and actual or contemplated career change. However, there was also some evidence of positive effects and professional growth. Support from colleagues and line managers is clearly important following deaths of patients by suicide. Clinicians' experiences of the support they had received in the workplace were polarized, suggesting that there is no single nor ideal approach that will meet everyone's needs. Participants made recommendations for the types of support that may be helpful. Most commonly, clinicians desired opportunities for focused reflection and support and help with the formal processes following the death. Sensitivity around how clinicians are notified about the death was highlighted as being particularly important. Conclusions are drawn as to how training institutions and employers can help staff to be better prepared for the potential occurrence of patient suicides and the formal processes that follow, with a view to mitigating risks of more serious harm to staff and hence indirectly to patients, and potential loss of highly trained clinicians to the workforce.

Ugly Feelings

At the height of the pandemic, the concept of care and the moral imperative to take care of one another rapidly entered public discourse. Yet while the UK government sought to assure us that we were ‘all in this together’, a very different picture soon emerged as a lack of protective personal equipment meant that NHS staff found themselves at a greater risk of dying of Covid-19. This risk was also disproportionately distributed as many Black and Global Majority NHS staff, who were in front line services, were more at risk than their white colleagues. This article examines three digital monologue performances that were streamed at the height of the pandemic in 2020 and which engage with the negative feelings of anxiety, fear and risk taking which framed contexts of racialised care at this time. Tales from the front line … and other stories-Part 2: NHS Mental Health Worker, was a verbatim performance produced by Talawa Theatre, while Rivers by Meera Syal and First, Do No Harm by Bernadine Evaristo were both commissioned by the Old Vic Theatre and screened as part of The Greatest Wealth project, commemorating the foundation of the NHS. In different ways, these performances explore care giving, but do so by foregrounding the experiences of Black and Global Majority NHS staff. Focusing on the fear and risks of caring for others, these performances explore what, borrowing from Sianne Nagi (2005), I will describe as the ‘ugly feelings’ of care. Instead of depicting the aesthetics of care-giving, these monologues expose the riskiness of caring and the ugliness of racism endured by Black and Global Majority NHS carers while attending to the needs of others. Through an examination of the moments of discrimination and disempowerment experienced by these NHS carers, these performances transform these ‘ugly feelings’ into sites of critical productivity, generating work that calls upon us to decentre our conceptualisation of care and to consider our own political allegiance in order to demand progressive change.

The psychological therapy preferences of patients who hear voices

ABSTRACT Background Voice-hearing is a common, phenomenologically diverse, experience across different mental health diagnoses. Patient preferences for psychological therapies are helpful in informing treatment commissioning and provision, especially in the context of complex and variable experiences like voice-hearing. There is, however, very limited evidence as to the psychological therapy preferences of transdiagnostic voice-hearers. Methods Three-hundred and thirty-five voice hearers were recruited from secondary care NHS mental health services across England, between 2020 and 2022. Participants completed a questionnaire battery, involving a psychological therapy preference survey. Participants ranked their preferences across categories of practical, technical and relational therapy elements. Therapy preferences were examined using non-parametric ANOVAs and the significance of pairwise comparisons between different therapy elements. Results There were significant differences in all categories of preference elements. Clear hierarchies of preference were observed in therapy location, timing, delivery, and therapy approach. Preferences were evident, albeit with less clear vertical hierarchies, for number of sessions, mode, therapist qualities, and therapy focus, tasks and outcomes. Discussion Overall, participants expressed a preference for individual, face-to-face intervention of at least nine sessions, with a highly experienced therapist and a core focus on enhancing coping strategies for voice-hearing experiences.

Recruiting and exploring vulnerabilities among young people at risk, or in the early stages of serious mental illness (borderline personality disorder and first episode psychosis).

IntroductionMany gaps exist in our understanding of the developmental pathways to severe mental illness (SMI), including borderline personality disorder (BPD) and psychosis. However, those who have experienced adverse childhood experiences (ACEs) are at an increased risk and there is evidence to suggest that one of the earliest markers is emotional dysregulation. An area which has received relatively less research attention is the role neurodevelopmental disorders (NDDs) play. The aim of this feasibility study was therefore to explore the clinical profiles of young people early in the course of SMI, including their profiles of ACEs, emotional regulation difficulties, borderline personality traits and NDDs.MethodsA cross-sectional study of young people (aged 15–25) at risk of SMI, currently being seen within NHS mental health services, was conducted. This included those with early symptoms of psychosis and/or BPD as assessed by diagnostic interview. Eligible participants self-completed a battery of sociodemographic, clinical, and psychological measures in the company of a researcher. This included assessments of: symptoms of NDDs; borderline pathology traits; ACEs; and difficulties in emotional regulation. Statistical analyses included Mann–Whitney U tests and multiple regression.ResultsOf the 118 potentially eligible participants who were referred, 48 were ultimately included in the study. Young people early in the course of SMI reported a high prevalence of ACEs and deficits in emotional regulation. In total, 79% met criteria for attention deficit hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD). Emotional dysregulation was found to significantly mediate the association between both ACEs and the frequency of NDDs and borderline personality traits, however given the small sample size these results are preliminary in nature.ConclusionYoung people early in the course of SMI are at an increased risk of experiencing multiple childhood adversities and our results indicate a high prevalence of NDDs amongst them. Emotional dysregulation emerged as a potentially significant early marker of future clinical severity. We suggest that the clinical implications of our findings include routine screening for NDDs and ACEs and an increased recognition of the significance of emotional dysregulation. However, larger scale longitudinal studies are needed to investigate these preliminary findings further.

Implementation of ‘Freedom to Speak Up Guardians’ in NHS acute and mental health trusts in England: the FTSUG mixed-methods study

Background The introduction of ‘Freedom to Speak Up Guardians’ into every NHS trust in England was intended to support workers and trusts to better raise, respond to and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. Objectives The overall aim of this study was to better understand the implementation of Guardians in acute trusts and mental health trusts. Design The Freedom to Speak Up Guardian role was conceptualised as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual trusts) and the micro level (employees, teams and wards/units). A mixed-methods study was designed, which consisted of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking up’ by health-care employees; (2) semistructured telephone interviews with Guardians working in acute hospital trusts and mental health trusts; and (3) qualitative case studies of Freedom to Speak Up Guardian implementation, consisting of observations and interviews undertaken in four acute trusts and two mental health trusts. Interviews were also undertaken with national stakeholders. Setting Acute trusts and mental health NHS trusts in England. Participants Work package 2: Freedom to Speak Up Guardians (n = 87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre-implementation and early implementation decision-making, workers who had spoken up to the Guardian, and national stakeholders. Results Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS trusts. ‘Freedom to Speak Up Guardian’ is best considered an umbrella term, and multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are likely to be possible or meaningful only when this variability is properly accounted for. Many Freedom to Speak Up Guardians identified how a lack of available resources, especially time scarcity, negatively and significantly affected their ability to effectively respond to concerns; their opportunities to collect, analyse and learn from speaking-up data; and, more generally, the extent to which they developed their role and speak-up culture. Limitations It is possible that those whom we interviewed were more receptive of Freedom to Speak Up Guardians or may have been biased by ‘socially desirability’, and their answers may not always have represented respondents’ true perceptions. Conclusions Optimal implementation of the Guardian role has five components: (1) establishing an early, collaborative and coherent strategy congruent with the values of Freedom to Speak Up fosters the implementation of (2) policies and robust, yet supportive, practices (3) informed by frequent and reflexive monitoring of Freedom to Speak Up implementation that is (4) underpinned by sufficient time and resource allocation that leads to (5) a positive implementation climate that is congruent with Freedom to Speak Up values and is well placed to engender positive and sustainable Freedom to Speak Up culture and the well-being of a Guardian. Future work The following recommendations for future research are considered to be of equal priority. Studies of the speaking-up experiences of minority communities and ‘seldom-heard’ workforce groups are a priority requirement. There is also value in undertaking a similar study in non-hospital settings and where peripatetic working is commonplace, such as in ambulance services and in primary care settings. The role of human resources and ‘middle managers’ in the management of concerns is an area requiring further research, especially regarding concerns relating to unprofessional and transgressive behaviours. Devolved administrations in Scotland and Wales have adopted different approaches to speaking up; research undertaken in these contexts would offer valuable comparative insights. Researching the Guardian role ≥ 5 years post implementation is recommended to understand the medium-term impact and the longer-term sustainability of the role and well-being of Guardians. Study registration This study is registered as ISRCTN38163690 and has the study registration CRD42018106311. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 23. See the NIHR Journals Library website for further project information.

Patient satisfaction with mental and physical health services: Findings from a UK-wide online survey.

Introduction - Despite extensive debate surrounding mental health services in the UK, there is little empirical evidence regarding the views of those who use them. We therefore used data collected as part of a wider survey to examine satisfaction amongst those seeking treatment from mental and physical health services. Methods - An online survey designed with input from people with experience of mental illness was used to measure satisfaction with NHS mental and physical health services at first contact and in the previous 12 months. Results - A total of 2187 people responded. During the 12 months prior to the survey, 526 respondents had sought mental health care and 1379 had sought physical health care. Participants were significantly more satisfied with their most recent contact with mental health services (48.1% very/satisfied) than with their first contact (38.2% very/satisfied). More than 1 in 10 respondents who sought mental health care (11.4%) stated that they received no treatment/support from the NHS, compared to approximately 1 in 20 respondents who sought physical health care (4.6%). Of those who received the mental health treatment they requested (n = 424), most were satisfied or very satisfied with their care (54.7%), although this was lower than the corresponding figure (77.9%) for satisfaction with physical health care received (n = 1190). Conclusion -There was evidence that mental health services are satisfactory for a slim majority of users, but people were generally more satisfied with NHS physical health care. This survey was conducted in the year prior to the coronavirus disease 2019 pandemic. Future research could examine what influences satisfaction with care and whether this picture has changed following the emergence of the pandemic and consequent impact on health service delivery and daily life.

The whistleblower and the bully

Investigations into maternity services at Shrewsbury and Telford NHS Trust and mental health services in Essex are a further two examples of negligence which have caused death or serious harm to patients. Reports into Shrewsbury's maternity services indicate an ‘atmosphere of fear’ which had been growing for almost two decades. The arrogant and bullying manner in which some services are being managed demonstrates a serious issue in how parts of the NHS are being run. John Finch, a freelance journalist specialising in the law and ethics relating to healthcare, explains his stance on the bullying nature which has sadly become engrained among certain healthcare services. He believes that bullies within the management of the NHS should hold some level of responsibility for the increasing statistics of patient harm, as well as for the callous manner in which they try to avoid the responsibility for deficiencies in the system that they are in charge of.

Derivation and Validation of the Management and Supervision Tool (MaST) Risk of Crisis (RoC) Algorithm Using Electronic Health Record (EHR) Data

AimsThe Management and Supervision Tool (MaST) helps NHS mental health care professionals identify patients who are most likely to need psychiatric hospital admission or home treatment, due to severe mental illness, through a Risk of Crisis (RoC) algorithm driven by electronic health record (EHR) data analytics. We describe the derivation and validation of the MaST RoC algorithm, and its implementation to support preventative mental healthcare in the NHS.MethodsThe RoC algorithm was developed and evaluated with EHR data from six UK NHS trusts using Ordered Predictor List propensity scores informed by a priori weightings from pre-existing literature, as well as real-world evidence evaluating the associations of clinical risk factors with mental health crisis using NHS EHR data. Mental health crisis was defined as admission to a psychiatric hospital or acceptance to a community crisis service within a 28-day period. Predictor variables included age, gender, accommodation status, employment status, Mental Health Act (MHA) status (under section or Community Treatment Order), and previous mental health service contacts (including hospital admissions and crisis services). Data were analysed using Ordered Predictor List propensity scores. The algorithm was derived using structured EHR data from 2,620 patients in a single NHS trust and externally validated using data from 107,879 patients in five other NHS trusts. Qualitative and quantitative data on feasibility, acceptability and system efficiency impacts of MaST implementation were obtained through staff surveys and local audits.ResultsThe factors associated with greatest propensity for mental health crisis included recent previous crisis, multiple previous crises, higher number of mental health service contacts in recent weeks, MHA section, accommodation status and employment status. The RoC algorithm identified 64% and 80% crises in its top quintile. Sentiment analysis of staff surveys suggested that the use of MaST improved productivity by reducing time taken to access patient information to support caseload management that was previously difficult to obtain through manual review of EHRs. The systems efficiency audit revealed a reduction in duration of crisis and inpatient admissions following MaST implementation.ConclusionThe MaST RoC algorithm supports the identification of people more likely to use crisis services in NHS mental health trusts, is feasible to implement, and improves systems efficiency. EHR-derived algorithms can support real-world clinical practice to improve outcomes in people receiving NHS mental healthcare.

The Management and Supervision Tool (MaST): an electronic crisis risk prediction tool to support safe and effective mental healthcare

IntroductionThe increasing global burden of mental disorders has led to rising demand for mental healthcare services. Effective resource management is essential to ensure safe and timely access to care. Electronic health records (EHRs) provide a real-time source of data on clinical presentation and prognostic factors that could be harnessed to provide clinicians with actionable insights to prioritise mental healthcare delivery. We describe the development and evaluation of MaST, an EHR data visualisation tool that provides information to clinicians on risk of mental health crisis defined as an admission to a psychiatric hospital or acceptance into a community crisis service.Objectives(i) To develop an EHR-data driven risk prediction tool for risk of crisis. (ii) To evaluate predictive performance in a real-world clinical setting.MethodsThe risk of crisis algorithm was developed and evaluated with EHR data from six UK NHS mental health providers using Ordered Predictor List propensity scores grouped into 5 quintiles. The predictor variables were clinical and sociodemographic factors including previous mental health service contacts.ResultsData from 2,620 patients contributed to algorithm development which was subsequently tested on data from 107,879 patients. The risk of crisis algorithm performed well with an overall accuracy for predicting the greatest risk of crisis (top quintile) ranging from 64% to 80%.ConclusionsThe MaST algorithm accurately predicted risk of mental health crisis in UK community mental health services. EHR data visualisation tools can provide actionable insights to clinicians to prioritise mental healthcare delivery in real-world clinical practice.DisclosureThis study was funded in full by Holmusk.

Curriculum Development: A National Curriculum for Physician Associates in Mental Health

AimsPhysician associates (PAs) are becoming more commonplace in psychiatric services in the UK to help address long term workforce difficulties. The 2019 NHS Long Term Plan detailed a commitment to transforming mental health care in England recognising that services were not meeting current or future increase in demand. Health Education England's (HEE) report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England, described a longer-term strategy to expand the mental health workforce, including recruiting 5,000 people into ‘new roles’ including physician associates. The NHS Mental Health Implementation Plan 2019/20–2023/243 stated an aim of recruiting 140 PAs to the workforce over five years in addition to the requirements specified in the HEE report. A curriculum for PAs working in mental health would set out the competencies required to work in mental health services.MethodsThe curriculum was developed by the National Collaborating Centre for Mental Health (NCCMH). The work was overseen by an expert reference group, comprising experts in training PAs in mental health, PAs, researchers and experts by experience, all selected for their expertise in research, training and service delivery.ResultsThe overarching aims and objectives of the curriculum was to convey a practical understanding of the attitudes, knowledge and skills that underpin the role, thus enabling PAs to offer effective and value-driven support to patients.The completed curriculum has been arranged into seven modules: Knowledge, Professional/Legal Issues, Engagement and Communication, Diagnostic Assessment and Treatment Planning, Interventions, Managing the Interface of Mental and Physical Health and Team Working. This reflects the expected roles and responsibilities of PAs working in mental health.ConclusionHEE and the Royal College of Psychiatrist have recommended all mental health organisations implement an educational programme for new PAs. The curriculum will inform the training requirements for PAs and standardise the training they receive from mental health organisations. It should support the work of PA supervisors and peer coordinators, and those delivering education and training to them. The curriculum will be a dynamic document and work will be needed to adapt it as the role changes, for example with incoming regulation and potential prescribing rights that follow.

An Audit on the Monitoring and Management of Hyperprolactinemia in Inpatient Adults on Regular Antipsychotics in 8 Acute Wards in an NHS Mental Health Trust

AimsThe aim of the audit is to ascertain how well hyperprolactinemia is being monitored and managed across all acute adult inpatient wards in a mental health NHS Trust, for patients on regular antipsychotic mediation. The objectives of the audit are to: 1) Assess whether prolactin is being monitored according to local guidelines for patients on regular antipsychotic medication, 2) Determine whether hyperprolactinemia is being identified and managed according to appropriate guidelines, 3) Assess the standard of documentation around the decisions made.MethodsData were collected retrospectively from the electronic notes and records for 78 patients, who were discharged from 8 acute wards in February 2021. For checking prolactin test results, the relevant reporting systems were accessed. Two data collection forms were used, which separated patients between those already taking antipsychotics prior to their admission and those who were newly initiated on an antipsychotic.Patients who were prescribed at least one regular antipsychotic were included. Patients with pre-existing medical conditions that cause hyperprolactinaemia, ongoing pregnancy or breastfeeding were excluded. The monitoring for and management of hyperprolactinaemia was assessed against NICE and local guidance.ResultsFrom the reviewed data, 41 patients were prescribed at least one regular antipsychotic drug during their admission. 32 patients were already established on an antipsychotic prior to their admission and 9 individuals were started on their first antipsychotic. Hyperprolactinaemia was identified in 9 patients. 19 patients had no prolactin assay performed during their whole admission.44.4% of antipsychotic naïve patients had a baseline prolactin level taken prior to starting an antipsychotic. 9.1% of patients with hyperprolactinaemia had their symptoms assessed by a clinician. 27.3% of patients with hyperprolactinaemia had actions discussed and undertaken to address this.ConclusionThis audit identified that patients are at risk of suffering from hyperprolactinaemia and are being insufficiently monitored. The symptoms of hyperprolactinaemia are not adequately screened or assessed for. This may increase the side effect burden and decrease medication adherence among patients. There is a need to increase the awareness among clinicians about the importance of regular prolactin monitoring to improve patient outcomes.

The Royal College of Psychiatrists Physician Associate Inceptorship Programme: Developing Educational Programmes to Support the Integration of This New Role in Psychiatric Services

AimsPhysician associates (PAs) are becoming more commonplace in psychiatric services in the UK to help address long term workforce difficulties. In 2019, the NHS Long Term Plan detailed a commitment to transforming mental health care in England recognising that services were not meeting current or future increase in demand. Health Education England's (HEE) report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England, described a longer-term strategy to expand the mental health workforce, including recruiting 5,000 people into ‘new roles’ including physician associates. The NHS Mental Health Implementation Plan 2019/20–2023/24 stated an aim of recruiting 140 PAs to the workforce over five years in addition to the requirements specified in the HEE report. HEE and the Royal College of Psychiatrists (RCPsych) have sought to support the integration of PAs into psychiatric teams through the development of the Inceptorship programme. The aim was to develop a bespoke training programme for PAs to bridge the gap between university and working in mental health to be rolled out nationally.MethodsSince 2018, Sheffield Health and Social Care Trust (SHSC) have been providing an Inceptorship Programme for PAs at the trust. Unlike with trainee doctors, there was no curriculum that could be followed. The programme covers the aetiology, diagnosis and management of common psychiatric problems, communication skills and reflective practice. This programme has provided the basis for the RCPsych Inceptorship Programme supported by HEE.ResultsThe SHSC programme has been well received by the 11PAs that have been through the programme, with all PAs recommending other mental health organisations take a similar approach. There have been many additional benefits of the sessions. They allow PAs to gain peer support and it has been a forum to raise issues which often arise when integrating new roles into pre-existing MDTs.ConclusionThe RCPsych Inceptorship Programme is a PA specific educational programme. It is an important tool in addressing the gap between variable mental health experience as a student (which is limited to a 3-week placement and is variable in content) and working in a psychiatric setting. RCPsych and HEE recommend that all mental health organisations employing PAs implement an inceptorship programme based on the work carried out at SHSC. These should comprise of regular, protected sessions that provide PAs with bespoke mental health training to support their integration into psychiatric multidisciplinary teams. HEE have agreed to provide funding to help organisations facilitate it.

Diabetes Care in the Psychiatric Inpatient Setting: A National Survey of Mental Health Professionals Knowledge, Attitudes and Skills

AimsPeople with Severe Mental Illness (SMI) are at increased risk of developing diabetes. There is currently a lack of monitoring and standardisation of diabetes care in the NHS psychiatric inpatient setting. This presents as a missed opportunity, as inpatient admission could be used to improve diabetes care for this population. We surveyed the multi-disciplinary teams in psychiatric inpatient units across England to develop understanding of current diabetes care in this setting.MethodsA 13-item questionnaire was designed to assess the knowledge, attitudes and skills relating to diabetes care. This was piloted via think out loud interviews with 5 staff at a Forensic unit. Amendments were then made to the questionnaire to improve the validity prior to national roll-out.Site coordinators working within General Adult, Old Age, Rehabilitation and Forensic inpatient services were recruited via medical education and academic links. This included 19 inpatient sites within 11 NHS Mental Health Trusts across England. Site coordinators circulated the questionnaire, primarily via electronic survey. A small number of paper responses were also collected.Results156 responses were collected via the national survey (electronic = 136, paper = 20). 6 responses were excluded due to missing professional role information or roles not involving physical healthcare. Respondents included within the analysis comprised 43 Doctors, 55 Nurses and 52 Allied Healthcare Professionals.93% of respondents agreed that addressing physical health needs was an important part of the mental health team's role, although only 28% had received physical healthcare training within the last 12 months.68% agreed that they had adequate skills and knowledge to manage diabetes safely on the ward. 69% agreed that the diabetic care on the ward was of an acceptable standard according to National Institute for Health and Care Excellent (NICE) guidelines. This reflects a need for appropriate training and guidance to help improve this aspect of care.Additionally, only 51% agreed that they felt able to refer a patient with diabetes to the most appropriate diabetes service based on type of diabetes and medication prescribed. This highlights an important issue, as cohesive shared-care and clear referral pathways are key when considering effective diabetes management.ConclusionPsychiatric inpatient admission could be used opportunistically to improve the healthcare disparities for people with comorbid diabetes and SMI. This national survey highlights key areas that would need to be addressed to standardise and optimise diabetes care in this setting. This includes appropriate training, clear guidelines and cohesive shared-care pathways.

The Provision of Mental Health Care for Service Users With Complex Needs Who Are at Risk of Suicide

AimsIndividuals presenting with complex behavioural and mental health needs may not receive the provision of care needed. Those presenting with a more complex clinical presentation may have a history of self-harm and suicide attempts. A common risk factor for preceding suicide is previous self-harm, suicide attempts or discharge from inpatient units. Understanding the descriptive symptom domains for inpatients and those treated in the community and the relationship between them could inform suicide prevention. The aim of this study was to explore the extent of self-harm and suicidal behaviours in individuals with complex mental health needs across inpatient and community settings.MethodsA cohort study design of in-depth written medical notes (n = 80) for people who were known to have complex mental health needs across inpatient and community settings. Data were extracted from medical records onto a coproduced questionnaire. As well as demographic data, information was collated about previous self-harm, suicide planning, suicide attempts, and support seeking regarding suicidal thoughts. The study will include a quantitative in-depth description and inferential analysis of the demographic clinical characteristics of the patient group.ResultsMedical case notes were reviewed for 80 service users with complex mental health needs. Across both groups, approximately three-quarters of participants had previously self-harmed (76%), or planned suicide (n = 73%), and/or attempted suicide (63%). Self-harm (83% vs. 70%) and suicide attempts (72% vs. 65%) were more prevalent in the inpatient group compared to the community group. Social support was received more by community patients than inpatients (70% vs. 50%), even though inpatients were more likely to sough help when experiencing suicidal thoughts compared to people cared for in the community (38% vs. 30%). In both groups, there were often multiple suicide plans and attempts made over their timeline of contact with services.ConclusionSelf-harm, suicide planning, and suicide attempts were prevalent for people treated across both inpatient and community settings. Self-harm and suicide planning was indicative of a later suicide attempt within both settings. In those experiencing suicidal thoughts, few had sought help, suggesting the importance in staff training to enable then to recognise and identify patterns of self-harming and suicidal behaviours in individuals with complex mental health needs. Social support needs for inpatients should be increased, particularly when they sought help for suicidal thoughts. This may help to reduce length of stays in hospital or future readmissions to hospital; thus, reducing the cost implications for the NHS mental health services.

Antipsychotic Optimisation on an Adult Acute Inpatient Ward: A Retrospective Audit

AimsAntipsychotic prescribing in acute inpatient settings is an integral part of patient care. The aim of this audit was to review optimisation of antipsychotics on an acute adult inpatient ward in South West London and St George's NHS Mental Health Trust (SWLSTG). It was ascertained how antipsychotic prescribing on an acute ward meets NICE standards, including duration of antipsychotic use prior to medication change. Furthermore, communication of medication changes was reviewed in the context of the paramount importance of collaborative decision-making in aiding adherence. NICE recommends a 4–6 week trial of antipsychotic medication at optimal dosage. However, it was hypothesised this may vary with side-effects, adherence and risk management in the inpatient environment. To establish the relationship between these factors, data were extracted regarding antipsychotic counselling, baseline physical health investigations, antipsychotic choice, dosage and duration, side-effects and treatment response.MethodsRetrospective data analysis was conducted for patients on an acute adult inpatient ward in SWLSTG. Data extracted from Rio clinical record system and EPMA prescribing software were analysed in Excel. The inclusion criteria were patients admitted or transferred to a 20-bed acute mixed adult ward from 04/08/21 to 04/11/21 with a diagnosis of schizoaffective disorder, schizophrenia, bipolar affective disorder or nonorganic psychosis. This included patients being initiated or continued on antipsychotic medication. From 71 patients, 33 met inclusion criteria. Data were extracted regarding duration of treatment prior to changes in treatment, counselling and pre-treatment investigations. Furthermore, simple statistical analyses were carried out.ResultsThe most commonly initiated antipsychotics on admission were olanzapine (33%), quetiapine (21%), risperidone (15%) and zuclopenthixol decanoate (15%). In those requiring change in antipsychotic regime, mean duration from the start of treatment as inpatient to first change was 11.6 days, time between first and second change 13.8 days, and between second and third change 16.0 days.The data showed in the majority (84.6%) antipsychotics were changed or up-titrated due to inadequate response. Out of the remainder 9.6% were changed due to intolerable side effects and 5.8% due to adherence concerns. In 73% of cases counselling was attempted regarding initial medication changes.ConclusionAntipsychotic therapy was altered more quickly than advised by NICE guidance in the acute inpatient setting evaluated. This can be explained by increased risk, need for intensive management and individual clinical factors including side effects and adherence. Collaborative decision making could be enhanced by ensuring that counselling is attempted for every patient.

Physician Associates in the Frame: Developing a National Competence Framework for Physician Associates Working in Mental Health

AimsPhysician associates (PAs) are becoming more commonplace in psychiatric services in the UK to help address long term workforce difficulties. The 2019 NHS Long Term Plan detailed a commitment to transforming mental health care in England recognising that services were not meeting current or future increase in demand. Health Education England's (HEE) report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England, described a longer-term strategy to expand the mental health workforce, including recruiting 5,000 people into ‘new roles’ including physician associates. The NHS Mental Health Implementation Plan 2019/20–2023/24 stated an aim of recruiting 140 PAs to the workforce over five years in addition to the requirements specified in the HEE report. Competence frameworks make the link between evidence and practice and can be a valuable basis for training, an agenda for supervision and a guide for self-monitoring and personal development for people working in the role.MethodsThe competence framework was developed by the National Collaborating Centre for Mental Health (NCCMH). The work was overseen by an expert reference group, comprising experts in training PAs in mental health, PAs, researchers and experts by experience, all selected for their expertise in research, training and service delivery. The completed framework was then sent to relevant stakeholders including the Faculty of Physician Associates and patient groups for comment and adapted accordingly.ResultsThe completed framework has been arranged into seven domains: Knowledge of Mental Health, Professional/Legal Issues, Engagement and Communication, Diagnostic Assessment and Treatment Planning, Interventions, Team Working and Metacompetences. This reflects the expected roles and responsibilities of PAs working in mental health.ConclusionThe Competence Framework for PAs will help those involved in mental health care services who wish to deepen their understanding of the PA role, and will be useful to team members working with PAs, to their managers and to commissioners. It will support the work of PA supervisors and peer coordinators, and those delivering education and training to them. It also brings a level of standardisation of the role. More work will be needed to adapt the Competence Framework for PAs for specialist contexts, such as in dementia care or children and young people's services.

‘I’m not a failure for asking for help’: A mixed method service evaluation of Strategies for Relatives (START) programme

The STrAtegies for RelaTives (START) programme was developed by Livingstone et al. (2014) to address the gap in NHS interventions available for carers of People Living With Dementia (PLWD) in the United Kingdom. Previous research by Conway and Straughan (2017) suggested that the programme was clinically effective in improving quality of life and carer stress for family members caring for those with dementia, within local NHS mental health services. The current study offers a mixed method evaluation of the START programme in the North East of England, including t-tests of pre- and post-outcome data (N= 24) and qualitative semi-structured interviews with carers of People Living With Dementia (n= 6). Outcome measures demonstrated statistically significant improvements in carer quality of life and wellbeing, as well as a significant reduction in carer strain, post intervention. Therefore, the findings offer further support as to the benefits of the START programme identified by previous research. During semi-structured interviews, carers described profound emotional changes captured in themes of reducing guilt, realising their caring abilities, and feeling more able to reach out for support. These benefits had not been captured during previous research by Conway and Straughan (2017). The results of this study provide further evidence of the benefits of the START programme within local NHS services in improving carer wellbeing.

Mental health service use among mothers involved in public family law proceedings: linked data cohort study in South London 2007–2019

PurposeMental health problems and substance misuse are common among the mothers of children who experience court-mandated placement into care in England, yet there is limited research characterising these health needs to inform evidence-based policy. In this descriptive study, we aimed to generate evidence about the type, severity, and timing of mental health and substance misuse needs among women involved in public family law proceedings concerning child placement into care (‘care proceedings’).MethodsThis is a retrospective, matched cohort study using linked family court and mental health service records for 2137 (66%) of the 3226 women involved in care proceedings between 2007 and 2019 in the South London and Maudsley NHS Mental Health Trust (SLaM) catchment area. We compared mental health service use and risk of dying with 17,096 female-matched controls who accessed SLaM between 2007 and 2019, aged 16–55 years, and were not involved in care proceedings.ResultsMost women (79%) were known to SLaM before care proceedings began. Women had higher rates of schizophrenia spectrum disorders (19% vs 11% matched controls), personality disorders (21% vs 11%), and substance misuse (33% vs 12%). They were more likely to have a SLaM inpatient admission (27% vs 14%) or to be sectioned (19% vs 8%). Women had a 2.15 (95% CI 1.68–2.74) times greater hazard of dying, compared to matched controls, adjusted for age.ConclusionWomen involved in care proceedings experience a particularly high burden of severe and complex mental health and substance misuse need. Women’s increased risk of mortality following proceedings highlights that interventions responding to maternal mental health and substance misuse within family courts should offer continued, long-term support.

The DIAMONDS intervention to support self-management of type 2 diabetes in people with severe mental illness: Study protocol for a single-group feasibility study

Introduction.The DIAMONDS programme aims to evaluate a novel supported diabetes self-management intervention for people with severe mental illness (the “DIAMONDS intervention”). The purpose of this study is to test the feasibility of intervention delivery and data collection procedures to inform a definitive randomised controlled trial (RCT).Methods.Adults aged 18 years or over with a diagnosis of type 2 diabetes and severe mental illness (schizophrenia, schizoaffective disorder, or bipolar disorder) will be eligible for inclusion. Individuals with other types of diabetes or non-psychotic mental illness and those lacking capacity to consent will not be eligible. Participants will be recruited from NHS mental health trusts and general practices across the North of England. All participants will receive the DIAMONDS intervention: weekly one-to-one sessions with a trained facilitator (“DIAMONDS Coach”) to support goal setting, action planning, and diabetes education; ongoing self-management supported by a paper-based workbook and optional digital application (app); and monthly peer-support group sessions with other participants. The primary outcomes are: 1. Recruitment rate, measured as proportion of the recruitment target (N ​= ​30) achieved at 5 months from start of recruitment, 2. Attrition measured as the proportion of missing outcomes data at the end of the recruitment period (5 months from start of recruitment) for physiological and self-reported data items, 3. Intervention delivery rate recorded as the proportion of planned sessions delivered (measured by the number of completed intervention session logs per participant within 15 weeks of the first intervention session). Secondary outcomes include completeness of data collection at baseline and of process evaluation data at follow-up as well as the feasibility and acceptability of the intervention and of wearing a blinded continuous glucose monitoring device. An intervention fidelity framework will also be developed. Recruitment started in July 2021. The study was prospectively registered: ISRCTN15328700 (12th March 2021).Discussion.The results of this feasibility study will inform the refinement of the content and delivery of the DIAMONDS intervention, as well as research procedures, including recruitment and data collection, in preparation for the main DIAMONDS RCT.

Contemporary perceptions and meanings of ‘the medical model’ amongst NHS mental health inpatient clinicians

Debates within health care and public spheres have, at times, created a seeming 'divide' between biological and psychosocial determinants and management of mental health difficulties. The phrase 'medical model' is often held up as an example and is sometimes used pejoratively to infer over-reliance on biology and medication. Our objective was to explore inpatient mental health clinicians' perceptions of the definition and the application of a 'medical model' in contemporary mental health care. In this qualitative study, eighteen clinicians working in adult inpatient teams participated in three mixed focus groups. Data were analysed using framework analysis. Three core themes were identified: (i) power of a 'medical model' and authority of the medic; (ii) responsibility within, and reliance on, a 'medical model'; and (iii) integrated models of contemporary mental health care. Subthemes arose around organisational culture and low resources affecting the power of a 'medical model' and the value of multidisciplinary and person-centred approaches. The findings highlight the importance of recognising inter-professional dynamics and power gradients in mental health teams and organisations, as we begin to move towards more integrated models of collaboration and distributed leadership within the NHS.