Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention

BACKGROUND

Health services face the challenges created by complex problems, and so need complex intervention solutions. However they also experience ongoing difficulties in translating findings from research in this area in to quality improvement changes on the ground. BounceBack was a service development innovation project which sought to examine this issue through the implementation and evaluation in a primary care setting of a novel complex intervention.

METHODS

The project was a collaboration between a local mental health charity, an academic unit, and GP practices. The aim was to translate the charity's model of care into practice-based evidence describing delivery and impact. Normalisation Process Theory (NPT) was used to support the implementation of the new model of primary mental health care into six GP practices. An integrated process evaluation evaluated the process and impact of care.

RESULTS

Implementation quickly stalled as we identified problems with the described model of care when applied in a changing and variable primary care context. The team therefore switched to using the NPT framework to support the systematic identification and modification of the components of the complex intervention: including the core components that made it distinct (the consultation approach) and the variable components (organisational issues) that made it work in practice. The extra work significantly reduced the time available for outcome evaluation. However findings demonstrated moderately successful implementation of the model and a suggestion of hypothesised changes in outcomes.

CONCLUSIONS

The BounceBack project demonstrates the development of a complex intervention from practice. It highlights the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention; and describes the use of the research process in the generation of practice-based evidence. Implications for future translational complex intervention research supporting practice change through scholarship are discussed.

Rethinking how we understand individual healthcare needs for people living with long-term conditions: a qualitative study

It has been suggested that we need to 'Think Differently' about how we organise care for people with long-term conditions. Current approaches prioritise reducing population disease burden, meaning health need is defined predominantly in terms of disease status, or even risk of disease. However, the result is care which overburdens some individuals. The World Health Organisation has described the need to view health as a 'resource for living' and not an end in itself. This study considers whether this view of health offers an alternative view of healthcare need in people living with long-term conditions. We know that chronic disease can be disruptive for some people; but not all. Our research question asked: Why do people experience long-term conditions differently, and what are the implications for understanding healthcare need? Our phenomenographic study involved qualitative interviews with 24 people living with at least one of the three conditions (diabetes, depression and chronic pain) and explored resources for and demands on daily living. Interviews all took place during 2012 and 2013. A narrative form analysis identified three patterns of illness experience (Gliding Swan, Stormy Seas and Stuck Adrift). Narrative content analysis revealed four factors explaining the variation: personalising care, existence of meaningful anchors, partnership and excess demands. We thus propose three new categories of healthcare need described by a consideration of health as a resource for living: Resilient, Vulnerable and Disconnected. We discuss how the emerging findings may offer scope to develop new needs assessment and patient-reported outcome measure tools. And so, offer a different way of thinking about the organisation for care for people with long-term conditions.

Current dilemmas in the assessment of suffering in palliative care

Objective:

Although relief from suffering is essential in healthcare and palliative care, few efforts have aimed at defining, operationalizing, and developing standards for its detection, assessment, and relief. In order to accurately explore and identify factors that contribute to suffering, more attention needs to be focused on quality assessment and measurement, not only for assessment purposes but also to test the effectiveness of interventions in relieving suffering. The scope of the present paper is to discuss the strategies that aid in the detection and assessment of the suffering experience in patients with chronic illnesses and/or in palliative care settings, and the dilemmas commonly encountered regarding the quality of available assessment measures.

Method:

A general description of instruments available for suffering assessment is provided. Matters regarding the accuracy of the measures are discussed. Finally, some dilemmas regarding the quality of the measures to screen for and assess suffering are presented.

Results:

There have been some achievements toward adequate suffering assessment. However, a more robust theoretical background is needed, and empirical evidence aimed at supporting it is required. In addition, further examination of the psychometric characteristics of instruments in different populations and cultural contexts is needed.

Significance of results:

An interesting number of assessment measures are now available for use in the palliative care setting, employing innovative approaches. However, further examination and validation in different contexts is required to find high-quality tools for detection of suffering and assessment of the results of intervention.

Understand me; believe in me; accept me as I am: perceptions of psychiatry of later life service

Context The emergence of mental health services for older people is a relatively recent development in Ireland. Therefore, it is important to determine strengths and limitations of this modern-day care service. A starting point is to enquire from those who have been in receipt of their service and/or their respective carers. Aim This study aims to identify and describe the perceptions and experiences of past service users (SUs) and their carers, while in receipt of services from an acute mental health day hospital for Psychiatry of Later Life and to explore their needs/supports.

METHODS

A qualitative, exploratory, descriptive design was employed. Purposive sampling achieved a sample of 13 SUs and six carers. Inclusion criteria set were that the SU had a diagnosis of a psychiatric disorder; had the capacity to make an informed consent and communicate verbally and the SU was discharged from the service between January and July 2011. Finally, carers of SUs in receipt of the service during this time were also included. Data were subjected to thematic, field analysis. Findings 'Person centredness' emerged as an overarching theme. Six inter-related subthemes revealing how SUs and carers viewed their care emerged from the interviews: 'therapeutic engagement'; 'preservation of self-integrity'; 'collaborative care'; 'integrated care'; 'social gains'; and 'the relationship between the expectation, subsequent engagement and the perceived outcome of care'.

CONCLUSIONS

Findings concluded that high levels of care exist within this service. Strengths lie in the development of a therapeutic relationship, preservation of self-integrity, social gains and robust elements of person-centred holistic, integrated and collaborative care Recommendations support the enhancement of a cohesive planned approach to admission, discharge/transition (integrated pathway).

Protecting generalism: moving on from evidence-based medicine?

Quality of decision making in modern health care is defined with reference to evidence-based medicine. There are concerns that this approach is insufficient for, and may thus threaten the future of, generalist primary care. We urgently need to extend our account of quality of knowledge use and decision making in order to protect and develop the discipline. Interpretive medicine describes an alternative framework for use in generalist care. Priorities for clinical practice and research are identified.