Deborah Rutter

Patients or partners? Case studies of user involvement in the planning and delivery of adult mental health services in London

User or patient involvement (UI) in the planning and delivery of health services is an aspiration of many industrialized economies, and has been promoted by United Kingdom (UK) governments for over two decades. This paper reports the findings of qualitative case studies of UI in two mental health provider Trusts in London. Semi-structured interviews were conducted with a variety of stakeholders, including Trust staff at all levels and user group members, to compare the expectations of diverse stakeholders and the extent to which these were achieved. We found that UI remained in the gift of provider managers: providers retained control over decision making, and expected users to address Trust agendas and conform to Trust management practices. Users wanted to achieve concrete changes to policies and services, but had broader aspirations to improve the status and condition of people with mental health problems. Suggestions are made about the direction of future strategies to improve UI.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

Objective:  To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: prevalence and service needs in an inner London borough.

Background: There is great concern in the UK, and other countries, about the clinical management of psychosis and substance misuse co-morbidity. However, relatively little is known about the UK prevalence and management of co-morbidity. Method: We implemented a screening survey of patients who were in treatment with an inner London adult mental health service and measured the prevalence of substance misuse amongst 851 psychotic patients. Caseworkers reported substance misuse and assessed clinical management arrangements. Results: Current prevalence of substance misuse was 24.4 % (95% CI: 21.3–27.1). Rates of co-morbidity were higher in males (31 % vs 16 %, χ2 1df=26.0, P < 0.001) and patients over 51 (χ2 3df=50.1, P < 0.001). Adjusted odds of co-morbidity in patients under 51 were 0.19 (95 % CI: 0.10–0.34) and 0.47 for females (95 % CI: 0.32–0.69). Substance misuse interventions were provided to 20 % of co-morbid patients – Only 5 % were compliant. Conclusions: The findings suggest substance misuse may be highly prevalent amongst psychotic patients. Most co-morbid patients do not receive appropriate treatment. The development of evidence-based interventions should be a priority.

JOB SATISFACTION AND BURNOUT AMONG STAFF WORKING IN COMMUNITY-BASED PERSONALITY DISORDER SERVICES

Aims: To examine levels of burnout among staff working in community-based services for people with personality disorder (PD) and to explore factors which add to or lower the risk of burnout among people working in such services. Methods: In-depth interviews with staff working at 11 dedicated community-based personality disorder services in England together with a cross-sectional staff survey using the Maslach Burnout Inventory. Results: Levels of burnout were generally lower than those reported in previous studies among mental health workers and levels of personal accomplishment were higher. Staff reported positive as well as negative experiences of working with people with PD. Strong team-work, clear leadership and opportunities for reflective practice were thought to protect staff from burnout. Conclusions: The low levels of burnout we found may reflect the early stage of the development of these services. However, it is also possible that working with people with PD does not in itself lead to burnout, especially when services are organized to share and contain work-related anxiety.

The assessment of dangerous and severe personality disorder: lessons from a randomised controlled trial linked to qualitative analysis

Randomised controlled trials are difficult to carry out in high security prisons and very few have succeeded. We describe here a randomised controlled trial of early versus late assessment for the pilot phase of the new DSPD programme for dangerous and severe personality disorder, which assessed prisoners (n = 75) at baseline, then six months, and then one year after randomisation. The trial enjoyed 100% success in getting records and obtained useful qualitative data that helped to explain the findings, but the trial was compromised by repeated protocol violations on grounds that were seldom acknowledged openly but which we conclude were primarily due to ignorance of the purpose of such trials. This led to such contamination of the two arms of the trial that no clear conclusions could be drawn from the trial itself, except that relative costs showed expected differences. However, the trial also showed that the assessment programme was associated with better quality of life in terms of social relationships (p = .03), with an increase in aggression (p = .01), and with worse social functioning in those with less severe personality disorder (p < .01), with the qualitative data suggesting that frustration and unfulfilled expectations lay behind these findings. Suggestions are made about revisions to the assessment process and the changes necessary for successful trials to be mounted in the future.

Evaluating new treatments in psychiatry: the potential value of combining qualitative and quantitative research methods

Clinical trials have been extensively used in order to explore the effectiveness of drug treatments for psychiatric disorders. Double-blind, randomized controlled trials provide the potential to explore the effectiveness of treatments free from the effects of bias and confounding factors. More recently clinical trials have been used in order to evaluate the effects of more complex interventions such as psychological treatments and alternatives to inpatient treatment. Clinical trials of complex interventions present several methodological challenges including the need to identify their mechanisms of action, problems ensuring the fidelity of the experimental intervention and variations in the effects that interventions have in sub-groups of people. We argue that some of these challenges can be met by incorporating qualitative research methods into the experimental evaluation of complex interventions. The benefits and some of the problems of combining methods are illustrated by examples of recent and ongoing research.

The prevalence and management of co-morbid substance misuse and mental illness: results of a screening survey in substance misuse and mental health treatment populations

A cross-sectional survey of clinical staff was carried out among statutory (public sector) substance misuse services and community mental health teams (CMHTs) in an inner London borough. We identified 368 current patients of drug and alcohol misuse services and 930 current patients of CMHTs. We measured the prevalence of co-morbid substance misuse and mental illness among these patients. We found strong evidence of co-morbid mental health problems in 128 substance misuse patients (34.8%) and evidence of possible co-morbidity in a further 18.5% of cases. Among mental health service patients, 227 (24%) were reported to have current substance misuse problems. Shared care of patients was uncommon and only a minority of co-morbid patients received treatment for both problems or the specialist assessment which key workers felt they needed. The findings suggest that co-morbidity is highly prevalent among mental health and substance misuse patients. Further research is needed to corroborate these findings, but th...

User involvement in efforts to improve the quality of drug misuse services in England: A national survey

Aim: To examine the extent of user involvement (UI) in efforts to improve the quality of drug misuse services in England, to identify outcomes of involvement, and explore factors that promote and hinder this process. Methods: Cross-sectional survey of service commissioners, providers and members of user groups in a representative sample of 50 of the 149 English Drug Action Teams (DATs) in England. Findings: We found wide variation in the degree to which systems for involving users had been implemented. Thirty-nine (84.7%) of the 46 DATs that responded reported working with service users, but only 22 (47.8%) involved them directly in commissioning services. User groups had generally been set up with the support of service providers, and had been running for an average of three years. Most stakeholders were able to identify changes to the organization and delivery of services resulting from user involvement, but the impact of these changes on engagement and retention in services has not been examined. Stakeholders reported that cultural, organizational, and individual variables hindered UI, including staff resistance and limited numbers of users willing to be involved. Conclusions: Our findings suggest that most commissioners and providers of drug services in England involve users in efforts to improve service quality. Direct payments to users, effective systems for delivering feedback, and a better understanding of the impact of the outcomes of involvement may help to sustain this process.

Dedicated personality disorder services: a qualitative analysis of service structure and treatment process

Background: In response to concerns about the quality of services for people with personality disorder, 11 new community-based services were set up in England. Aims: To identify factors that contribute to high quality care for people with personality disorder from the perspective of different stakeholders. Methods: Qualitative interviews with service users, carers, providers and commissioners of services at each of the 11 sites. Results: Despite marked differences in the structure of the services, key themes emerged concerning their general approach to service delivery. These include the need to combine psychological treatments with social interventions and opportunities for peer support, and the importance of clear boundaries which are shared by service users. Services need to actively involve users both in managing their crises, and in planning future service developments. Differences in the accounts of stakeholders emerged around the assessment process, provision of out-of-hours care, and the range and type of clients dedicated services should try to work with. Conclusions: These data highlight factors which stakeholders believe constitute high quality care for people with PD. Services should pay particular attention to supporting clients during assessment process and developing more effective ways to engage people with high levels of personality disturbance and low levels of motivation to change.

The Quantification of Violence Scale: a Simple Method of Recording Significant Violence

Background: Although there are many rating scales recording the incidence and intensity of violence there are none that are specifically concerned with the measurement and assessment of severe violence. Aims: To develop a scale sensitive to variation centred on severe violence, establish its normative values, test its feasibility, and assess its reliability and validity in different populations. Method: The Quantification of Violence Scale (QOVS) was developed in two stages. First, a list of 30 commonly eXperienced violent episodes in clinical psychiatric practice were evaluated and tested by weighting each episode by severity. Second, a numerical scale used to record the severity of the episode according to its degree of planning, intent and consequences. Violent episodes in two clinical populations were compared using the Modified Overt Aggression Scale (MOAS) and the preliminary version of the QOVS over periods up to 18 months, following which the numerical scale was developed. Results: Good (0.60—0.74) to EXcellent (> 0.75) test—retest and inter-rater reliability agreement was obtained with both forms of the scale (intra-class correlations of 0.75 and 0.69 respectively), and similar agreement with MOAS scores was reached (0.67) in clinical populations. The scale was quick and easy to use in practice, and a score defining severe violence (9 on the numerical scale and 16 on the matched scale) was determined. Conclusions: The QOVS, in its two forms, is a useful measure of recording significant violence in clinical and forensic practice.