Tim Weaver

Systematic review of involving patients in the planning and development of health care

Abstract Objective: To examine the effects of involving patients in the planning and development of health care. Data sources:Published and grey literature. Study selection: Systematic search for worldwide reports written in English between January 1966 and October 2000. Data extraction: Qualitative review of papers describing the effects of involving patients in the planning and development of health care. Results: Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported. Conclusions: Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.

Process, outcome and experience of transition from child to adult mental healthcare : multiperspective study

BACKGROUND Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). AIMS As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS. METHOD We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced. RESULTS Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health. CONCLUSIONS For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

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.

Providing continuity of care for people with severe mental illness- a narrative review.

Abstract.Background:Service users and providers have stated that delivering continuity of care to people with severe mental illness should be a service priority. We reviewed literature on continuity of care for people with severe mental illness (SMI) in order to identify factors that promote and impede this process.Method:A systematic search of electronic databases, sources of grey literature and contact with experts in the field. Two reviewers independently rated all papers for possible inclusion. Data extracted from papers formed the basis of a narrative review.Results:We identified 435 papers on continuity of care, of which 60 addressed the study aims. Most did not define continuity of care. Available evidence suggests that assertive community treatment, case management, community mental health teams and crisis intervention reduce the likelihood of patients dropping out of contact with services.Conclusions:Evidence on which to base services that enhance continuity of care for people with SMI is limited because previous research has often failed to define continuity of care or consider the patient’s perspective.

The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams

BackgroundPersonality status is seldom assessed in community mental health teams except at a rudimentary level. This study challenges the assumption that this policy is either prudent or wise.AimsTo measure the prevalence of personality disorder within community mental health teams and to investigate its relationship to mental state disorders and overall pathology.MethodA cross-sectional survey of 2,528 of 2,567 psychiatric patients (98.5%) managed by community mental health teams in four urban settings in the UK in which diagnoses of personality and mental state pathology were assessed separately. Of these, a sample of 400 was interviewed, with a 70.5% completion rate for more in depth information.ResultsIn total, 40% of all patients in secondary care suffered from at least one personality disorder. Regression modelling showed personality pathology accounted for a greater degree of global psychopathology than psychosis, alcohol or drug dependence, but was associated with anxiety disorders.ConclusionComorbid personality pathology contributes greatly to overall psychopathology in secondary psychiatric care. It should be both recognised and managed.

Attitudes of Staff Towards Patients With Personality Disorder in Community Mental Health Teams

Objective: The purpose of the present paper was to assess the attitudes of clinicians working with personality disordered patients. Methods: Secondary analysis of the Comorbidity of Substance Misuse and Mental Illness Collaborative (COSMIC) data set was undertaken using a priori hypothesis testing. The null hypothesis was that there would be no measurable difference between the attitudes of mental health professionals toward patients with a clinical diagnosis of personality disorder and those with an instrument-rated diagnosis of personality disorder. The potential confounders of global psychopathology, need, social functioning and documented aggression were assessed as possible reasons explaining a rejection of the null hypothesis. Results: Clinicians believed those with the clinical diagnostic label of personality disorder to be more difficult to manage than personality-disordered patients identified by a research tool who did not carry this label. These attitudes were not explained by the potential confounders of psychopathology, social morbidity or acts of aggression. Conclusions: An awareness of a personality disorder diagnosis is associated with a clinician belief that patients will be harder to manage. Objective measures of potential confounders do not explain why this group should be harder to manage. One explanation of this finding is that the label ‘personality disorder’ is stigmatizing. This may also explain the disparity between clinical and research assessments of personality disorder.

Severe mental illness and substance misuse

Evidence from the United States suggests that half of all patients with schizophrenia also have a substance misuse disorder.1 This comorbidity is associated with poor prognosis and heavy use of expensive inpatient care through recurrent “revolving door” admissions.2 The phenomenon has only recently been recognised in the United Kingdom, but one survey of psychotic patients in an inner London district found that 36% misused drugs or alcohol. The same survey observed inpatient admission rates among comorbid patients that were almost double those of patients with psychosis alone.3 This high prevalence, the problems of clinical management,4 and a continued rise in the general rate of drug misuse make comorbidity a major public health issue, and the Department of Health is currently inviting applications for research into the prevalence and pattern of comorbidity. The term “dual diagnosis” is used increasingly in psychiatric practice to describe this combination of …

Transition experiences of mental health service users, parents, and professionals in the United Kingdom: a qualitative study.

OBJECTIVE The aim of this study was to describe the experiences of child and adolescent mental health service (CAMHS) users, parents and professionals in relation to transition between CAMHS and adult mental health services (AMHS) in the United Kingdom. METHODS Young people were sampled from an observational study population of people reaching the transition boundary between CAMHS and AMHS. We thematically analyzed qualitative interviews with service users, parents and clinicians. RESULTS Eleven service users were interviewed and linked interviews were completed with parents (n=6), and responsible clinicians in CAMHS (n=3) and AMHS (n=6). Informal and gradual preparation, transfer planning meetings, periods of parallel care, and consistency in key-workers promoted positive experiences of transition. Transfers between AMHS, changes of key-worker and waiting lists were viewed negatively. Other life transitions, including changes in housing, pregnancy, physical illness, and the involvement of parents or other services were sometimes powerful extraneous influences on transition experiences. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The cumulative effect of multiple transitions is a complex and unsettling experience for many service users. Service user experiences are more likely to be positive if healthcare transition is a gradual process, tailored to the young persons needs and managed in the context of the other simultaneous practical, developmental and psychosocial transitions. Transfer planning meetings and parallel care were valued by all parties and should be standard practice at transition. CAMHS and AMHS need to work jointly to improve the transition process in these ways in order to enhance the outcomes for young people.

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial

BACKGROUND Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. METHODS In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493. FINDINGS Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses. INTERPRETATION Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown. FUNDING National Institute for Health Research (RP-PG-0707-10149).