Development of the UPSIDES global mental health training programme for peer support workers: Perspectives from stakeholders in low, middle and high-income countries

BACKGROUND

Peer support in mental health is a low-threshold intervention with increasing evidence for enhancing personal recovery and empowerment of persons living with severe mental health conditions. As peer support spreads globally, there is a growing need for peer support training programmes that work well in different contexts and cultures. This study evaluates the applicability and transferability of implementing a manualised multi-national training programme for mental health peer support workers called UPSIDES from the perspective of different local stakeholders in high-, middle-, and low-income countries.

METHOD

Data from seven focus groups across six study sites in Africa (Tanzania, Uganda), Asia (India, Israel), and Europe (Germany 2 sites) with 44 participants (3 service users, 7 peer support workers, 25 mental health staff members, 6 clinical directors and 3 local community stakeholders) were thematically analysed.

RESULTS

397 codes were identified, which were thematically analysed. Five implementation enablers were identified: (i) Enhancing applicability through better guidance and clarity of training programme management, (ii) provision of sufficient time for training, (iii) addressing negative attitudes towards peer support workers by additional training of organisations and staff, (iv) inclusion of core components in the training manual such as communication skills, and (v) addressing cultural differences of society, mental health services and discrimination of mental health conditions.

DISCUSSION

Participants in all focus groups discussed the implementation of the training and peer support intervention to a greater extent than the content of the training. This is in line with growing literature of difficulties in the implementation of peer support including difficulties in hiring peer support workers, lack of funding, and lack of role clarity. The results of this qualitative study with stakeholders from different mental health settings worldwide emphasises the need to further investigate the successful implementation of peer support training. All results have been incorporated into the manualisation of the UPSIDES peer support training.

Effectiveness and cost-effectiveness of online recorded recovery narratives in improving quality of life for people with non-psychotic mental health problems: a pragmatic randomized controlled trial

Narratives describing first-hand experiences of recovery from mental health problems are widely available. Emerging evidence suggests that engaging with mental health recovery narratives can benefit people experiencing mental health problems, but no randomized controlled trial has been conducted as yet. We developed the Narrative Experiences Online (NEON) Intervention, a web application providing self-guided and recommender systems access to a collection of recorded mental health recovery narratives (n=659). We investigated whether NEON Intervention access benefited adults experiencing non-psychotic mental health problems by conducting a pragmatic parallel-group randomized trial, with usual care as control condition. The primary endpoint was quality of life at week 52 assessed by the Manchester Short Assessment (MANSA). Secondary outcomes were psychological distress, hope, self-efficacy, and meaning in life at week 52. Between March 9, 2020 and March 26, 2021, we recruited 1,023 participants from across England (the target based on power analysis was 994), of whom 827 (80.8%) identified as White British, 811 (79.3%) were female, 586 (57.3%) were employed, and 272 (26.6%) were unemployed. Their mean age was 38.4±13.6 years. Mood and/or anxiety disorders (N=626, 61.2%) and stress-related disorders (N=152, 14.9%) were the most common mental health problems. At week 52, our intention-to-treat analysis found a significant baseline-adjusted difference of 0.13 (95% CI: 0.01-0.26, p=0.041) in the MANSA score between the intervention and control groups, corresponding to a mean change of 1.56 scale points per participant, which indicates that the intervention increased quality of life. We also detected a significant baseline-adjusted difference of 0.22 (95% CI: 0.05-0.40, p=0.014) between the groups in the score on the "presence of meaning" subscale of the Meaning in Life Questionnaire, corresponding to a mean change of 1.1 scale points per participant. We found an incremental gain of 0.0142 quality-adjusted life years (QALYs) (95% credible interval: 0.0059 to 0.0226) and a £178 incremental increase in cost (95% credible interval: -£154 to £455) per participant, generating an incremental cost-effectiveness ratio of £12,526 per QALY compared with usual care. This was lower than the £20,000 per QALY threshold used by the National Health Service in England, indicating that the intervention would be a cost-effective use of health service resources. In the subgroup analysis including participants who had used specialist mental health services at baseline, the intervention both reduced cost (-£98, 95% credible interval: -£606 to £309) and improved QALYs (0.0165, 95% credible interval: 0.0057 to 0.0273) per participant as compared to usual care. We conclude that the NEON Intervention is an effective and cost-effective new intervention for people experiencing non-psychotic mental health problems.

Organisational and student characteristics, fidelity, funding models, and unit costs of recovery colleges in 28 countries: a cross-sectional survey

BACKGROUND

Recovery colleges were developed in England to support the recovery of individuals who have mental health symptoms or mental illness. They have been founded in many countries but there has been little international research on recovery colleges and no studies investigating their staffing, fidelity, or costs. We aimed to characterise recovery colleges internationally, to understand organisational and student characteristics, fidelity, and budget.

METHODS

In this cross-sectional study, we identified all countries in which recovery colleges exist. We repeated a cross-sectional survey done in England for recovery colleges in 28 countries. In both surveys, recovery colleges were defined as services that supported personal recovery, that were coproduced with students and staff, and where students learned collaboratively with trainers. Recovery college managers completed the survey. The survey included questions about organisational and student characteristics, fidelity to the RECOLLECT Fidelity Measure, funding models, and unit costs. Recovery colleges were grouped by country and continent and presented descriptively. We used regression models to explore continental differences in fidelity, using England as the reference group.

FINDINGS

We identified 221 recovery colleges operating across 28 countries, in five continents. Overall, 174 (79%) of 221 recovery colleges participated. Most recovery colleges scored highly on fidelity. Overall scores for fidelity (β=-2·88, 95% CI 4·44 to -1·32; p=0·0001), coproduction (odds ratio [OR] 0·10, 95% CI 0·03 to 0·33; p<0·0001), and being tailored to the student (OR 0·10, 0·02 to 0·39; p=0·0010), were lower for recovery colleges in Asia than in England. No other significant differences were identified between recovery colleges in England, and those in other continents where recovery colleges were present. 133 recovery colleges provided data on annual budgets, which ranged from €0 to €2 550 000, varying extensively within and between continents. From included data, all annual budgets reported by the college added up to €30 million, providing 19 864 courses for 55 161 students.

INTERPRETATION

Recovery colleges exist in many countries. There is an international consensus on key operating principles, especially equality and a commitment to recovery, and most recovery colleges achieve moderate to high fidelity to the original model, irrespective of the income band of their country. Cultural differences need to be considered in assessing coproduction and approaches to individualising support.

FUNDING

National Institute for Health and Care Research.

Best practice guidelines for citizen science in mental health research: systematic review and evidence synthesis

Partnering with people most affected by mental health problems can transform mental health outcomes. Citizen science as a research approach enables partnering with the public at a substantial scale, but there is scarce guidance on its use in mental health research. To develop best practise guidelines for conducting and reporting research, we conducted a systematic review of studies reporting mental health citizen science research. Documents were identified from electronic databases (n = 10), grey literature, conference proceedings, hand searching of specific journals and citation tracking. Document content was organised in NVIVO using the ten European Citizen Science Association (ECSA) citizen science principles. Best practise guidelines were developed by (a) identifying approaches specific to mental health research or where citizen science and mental health practises differ, (b) identifying relevant published reporting guidelines and methodologies already used in mental health research, and (c) identifying specific elements to include in reporting studies. A total of 14,063 documents were screened. Nine studies were included, from Australia, Belgium, Canada, Denmark, Netherlands, Spain, the UK, and the United States. Citizen scientists with lived experience of mental health problems were involved in data collection, analysis, project design, leadership, and dissemination of results. Most studies reported against some ECSA principles but reporting against these principles was often unclear and unstated. Best practise guidelines were developed, which identified mental health-specific issues relevant to citizen science, and reporting recommendations. These included citizen science as a mechanism for empowering people affected by mental health problems, attending to safeguarding issues such as health-related advice being shared between contributors, the use of existing health research reporting guidelines, evaluating the benefits for contributors and impact on researchers, explicit reporting of participation at each research stage, naming the citizen science platform and data repository, and clear reporting of consent processes, data ownership, and data sharing arrangements. We conclude that citizen science is feasible in mental health and can be complementary to other participatory approaches. It can contribute to active involvement, engagement, and knowledge production with the public. The proposed guidelines will support the quality of citizen science reporting.

Who uses recovery colleges? Casemix analysis of sociodemographic and clinical characteristics and representativeness of recovery college students

OBJECTIVE

Recovery Colleges support recovery for adults with mental health problems, through coproduction and education principles. This study aimed to determine whether students at three Recovery Colleges in England were representative of mental health service users.

METHODS

Gender, age, ethnicity, diagnosis, involuntary detention, and inpatient admission were extracted from clinical records. Data for all service user students enrolled, and those who had attended 70% of a Recovery College course were compared to mental health services caseloads, using chi-square goodness-of-fit tests.

RESULTS

Clinical records were identified for 1,788 students. Significant differences were identified for gender, age, and diagnosis (p < .001). In some Colleges, more students had recent inpatient admissions or involuntary detentions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Service user students were largely representative of mental health service users, although some groups were underrepresented. Further research is needed to understand why, so that Recovery Colleges can continue to address inequalities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Peer-led recovery groups for people with psychosis in South Africa (PRIZE): protocol for a randomised controlled feasibility trial

BACKGROUND

The available care for people with psychosis in South Africa is inadequate to support personal recovery. Group peer support interventions are a promising approach to foster recovery, but little is known about the preferences of service users, or the practical application of this care model, in low- and middle-income countries (LMIC). This study aims to assess the acceptability and feasibility of integrating peer-led recovery groups for people with psychosis and their caregivers in South Africa into existing systems of care, and to determine key parameters in preparation for a definitive trial.

METHODS

The study is set in Nelson Mandela Bay Metropolitan district of the Eastern Cape Province, South Africa. The design is an individually randomised parallel group feasibility trial comparing recovery groups in addition to treatment as usual (TAU) with TAU alone in a 1:1 allocation ratio. We aim to recruit 100 isiXhosa-speaking people with psychosis and 100 linked caregivers. TAU comprises anti-psychotic medication-focused outpatient care. The intervention arm will comprise seven recovery groups, including service users and caregiver participants. Recovery groups will be delivered in two phases: a 2-month phase facilitated by an auxiliary social worker, then a 3-month peer-led phase. We will use mixed methods to evaluate the process and outcomes of the study. Intervention acceptability and feasibility (primary outcomes) will be assessed at 5 months post-intervention start using qualitative data collected from service users, caregivers, and auxiliary social workers, along with quantitative process indicators. Facilitator competence will be assessed with the GroupACT observational rating tool. Trial procedures will be assessed, including recruitment and retention rates, contamination, and validity of quantitative outcome measures. To explore potential effectiveness, quantitative outcome data (functioning, unmet needs, personal recovery, internalised stigma, health service use, medication adherence, and caregiver burden) will be collected at baseline, 2 months, and 5 months post-intervention start.

DISCUSSION

This study will contribute to the sparse evidence on the acceptability and feasibility of peer-led and recovery-oriented interventions for people with psychosis in LMIC when integrated into existing care systems. Results from this feasibility trial will inform preparations for a definitive trial and subsequent larger-scale implementation.

TRIAL REGISTRATION

Pan-African Clinical Trials Register PACTR202202482587686. Registered on 28 February 2022.  https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=21496 .

Predictors of engagement with peer support: analysis of data from a randomised controlled trial of one-to-one peer support for discharge from inpatient psychiatric care

BACKGROUND

A range of evidence for the effectiveness of one-to-one peer support in mental health services is emerging. Levels of engagement with peer support vary with limited studies showing few individual participant characteristics predicting engagement. Implementation factors that might predict engagement have not been considered.

METHODS

Data were analysed from the intervention arm of the ENRICH trial of one-to-one peer support for discharge from acute psychiatric inpatient care. Two outcomes were considered: (1) a measure of 'engaged with peer worker'; (2) number of face-to-face contacts with peer worker post-discharge. Two sets of independent variables were analysed against each outcome: (1) pre-randomisation participant characteristics; (2) implementation factors measured pre-discharge. Analyses used logistic and zero-inflated negative binomial regression models according to outcome structure.

RESULTS

Data were analysed for 265 participants randomised to peer support who had a known peer worker. Non-heterosexual participants had increased odds of engaging with peer support compared to heterosexual participants, OR = 4.38 (95% CI: 1.13, 16.9, p = .032). Longer duration of first contact with peer worker (OR = 1.03, 95% CI: 1.00, 1.04, p < .001) and more relationship building activities in the first contact (OR = 1.4, 95% CI: 1.13, 1.85, p = .004) were associated with greater odds of engaging with peer support. Analysis of number of contacts post-discharge showed consistent findings.

CONCLUSIONS

Implementation of peer support should include a focus on relationship building in the first session of peer support. The potential for peer support to break down barriers to accessing mental health services experienced by people from marginalised communities warrants further investigation.

Embedding coproduction in organisational culture and practice: a case study

PURPOSE

This paper aims to explore the challenges of coproduction at individual, team, service, organisational and system level and critically describes the work of one organization to describe ways in which coproduction can be facilitated.

DESIGN/METHODOLOGY/APPROACH

This is a case study of the approaches developed (coproduced) within an independent not-for-profit mental health consultancy organization to facilitate coproduction at every level.

FINDINGS

Although much is published about coproduction in research, there is relatively little guidance relating to coproduction in practice. This paper describes the meaning, purpose and impact of coproduction at different levels and gives examples of how it can be achieved. The learning from his work is drawn together to present a series of findings with recommendations including: inclusion, managing power difference, accommodating difference, generating new ways forward rather than debating and selecting existing options.

ORIGINALITY/VALUE

The literature on coproduction in practice is replete with guidance rather than examples of good practice. It is also apparent that the ambition for coproduction has progressed rapidly from coproduction between service providers and people using services to coproduction with all relevant stakeholders. This paper provides contemporary examples of coproduction in different forms and at different levels with attention to ways of overcoming challenges.

The impact of working as a peer worker in mental health services: a longitudinal mixed methods study

BACKGROUND

Peer workers are increasingly employed in mental health services to use their own experiences of mental distress in supporting others with similar experiences. While evidence is emerging of the benefits of peer support for people using services, the impact on peer workers is less clear. There is a lack of research that takes a longitudinal approach to exploring impact on both employment outcomes for peer workers, and their experiences of working in the peer worker role.

METHODS

In a longitudinal mixed methods study, 32 peer workers providing peer support for discharge from inpatient to community mental health care - as part of a randomised controlled trial - undertook in-depth qualitative interviews conducted by service user researchers, and completed measures of wellbeing, burnout, job satisfaction and multi-disciplinary team working after completing training, and four and 12 months into the role. Questionnaire data were summarised and compared to outcomes for relevant population norms, and changes in outcomes were analysed using paired t-tests. Thematic analysis and interpretive workshops involving service user researchers were used to analysis interview transcripts. A critical interpretive synthesis approach was used to synthesise analyses of both datasets.

RESULTS

For the duration of the study, all questionnaire outcomes were comparable with population norms for health professionals or for the general population. There were small-to-medium decreases in wellbeing and aspects of job satisfaction, and increase in burnout after 4 months, but these changes were largely not maintained at 12 months. Peer workers felt valued, empowered and connected in the role, but could find it challenging to adjust to the demands of the job after initial optimism. Supervision and being part of a standalone peer worker team was supportive, although communication with clinical teams could be improved.

CONCLUSIONS

Peer workers seem no more likely to experience negative impacts of working than other healthcare professionals but should be well supported as they settle into post, provided with in-work training and support around job insecurity. Research is needed to optimise working arrangements for peer workers alongside clinical teams.

Peer support for discharge from inpatient mental health care versus care as usual in England (ENRICH): a parallel, two-group, individually randomised controlled trial

BACKGROUND

High numbers of patients discharged from psychiatric hospital care are readmitted within a year. Peer support for discharge has been suggested as an approach to reducing readmission post-discharge. Implementation has been called for in policy, however, evidence of effectiveness from large rigorous trials is missing. We aimed to establish whether peer support for discharge reduces readmissions in the year post-discharge.

METHODS

We report a parallel, two-group, individually randomised, controlled superiority trial, with trial personnel masked to allocation. Patients were adult psychiatric inpatients (age ≥18 years) with at least one previous admission in the preceding 2 years, excluding those who had a diagnosis of any organic mental disorder, or a primary diagnosis of learning disability, an eating disorder, or drug or alcohol dependency, recruited from seven state-funded mental health services in England. Patients were randomly assigned (1:1) to the intervention (peer support plus care as usual) or control (care as usual) groups by an in-house, online randomisation service, stratified by site and diagnostic group (psychotic disorders, personality disorders, and other eligible non-psychotic disorders) with randomly permuted blocks of randomly varying length to conceal the allocation sequence and achieve the allocation ratio. The peer support group received manual-based, one-to-one peer support, focused on building individual strengths and engaging with activities in the community, beginning during the index admission and continuing for 4 months after discharge, plus care as usual. Care as usual consisted of follow-up by community mental health services within 7 days of discharge. The primary outcome was psychiatric readmission 12 months after discharge (number of patients readmitted at least once), analysed on an intention-to-treat basis. All patients were included in a safety analysis, excluding those who withdrew consent for use of their data. The trial is registered with the ISRCTN registry, ISRCTN10043328. The trial was complete at the time of reporting.

FINDINGS

Between Dec 1, 2016, and Feb 8, 2019, 590 patients were recruited and randomly assigned, with 294 allocated to peer support (287 included in the analysis after withdrawals and loss to follow-up), and 296 to care as usual (291 in the analysis). Mean age was 39·7 years (SD 13·7; range 18-75). 306 patients were women, 267 were men, three were transgender, and two preferred not to say. 353 patients were White, 94 were Black, African, Caribbean, or Black British, 68 were Asian or Asian British, 48 were of mixed or multiple ethnic groups, and 13 were of other ethnic groups. In the peer support group, 136 (47%) of 287 patients were readmitted at least once within 12 months of discharge. 146 (50%) of 291 were readmitted in the care as usual group. The adjusted risk ratio of readmission was 0·97 (95% CI 0·82-1·14; p=0·68), and the adjusted odds ratio for readmission was 0·93 (95% CI 0·66-1·30; p=0·68). The unadjusted risk difference was 0·03 (95% CI -0·11 to 0·05; p=0·51) in favour of the peer support group. Serious adverse events were infrequent (67 events) and similar between groups (34 in the peer support group, 33 in the care as usual group). Threat to life (self-harm) was the most common serious adverse event (35 [52%] of 67 serious adverse events). 391 other adverse events were reported, with self-harm (not life threatening) the most common (189 [48%] of 391).

INTERPRETATION

One-to-one peer support for discharge from inpatient psychiatric care, plus care as usual, was not superior to care as usual alone in the 12 months after discharge. This definitive, high-quality trial addresses uncertainty in the evidence base and suggests that peer support should not be implemented to reduce readmission post-discharge for patients at risk of readmission. Further research needs to be done to improve engagement with peer support in high-need groups, and to explore differential effects of peer support for people from different ethnic communities.

FUNDING

UK National Institute for Health Research.

Development of a peer support intervention to improve the experience and outcomes of discharge from inpatient mental health care: the role of experiential knowledge in a coproduced approach

Objectives

Peer support is rapidly being introduced into mental health services internationally, yet peer support interventions are often poorly described, limiting the usefulness of research in informing policy and practice. This paper reports the development of a peer support intervention that aims to improve outcomes of discharge from inpatient to community mental health care. People with experiential knowledge of using mental health services—peer workers and service user researchers—were involved in all stages of developing the intervention: generating intervention components; producing the intervention handbook; piloting the intervention.

Results

Systematic review and expert panels, including our Lived Experience Advisory Panel, identified 66 candidate intervention components in five domains: Recruitment and Role Description of Peer Workers; Training for Peer Workers; Delivery of Peer Support; Supervision and Support for Peer Workers; Organisation and Team. A series of Local Advisory Groups were used to prioritise components and explore implementation issues using consensus methods, refining an intervention blueprint. A peer support handbook and peer worker training programme were produced by the study team and piloted in two study sites. Feedback workshops were held with peer workers and their supervisors to produce a final handbook and training programme.

The ENRICH trial is registered with the ISRCTN clinical trial register, number ISRCTN 10043328, and was overseen by an independent steering committee and a data monitoring committee.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05735-0.

Initial Training for Mental Health Peer Support Workers: Systematized Review and International Delphi Consultation

BACKGROUND

Initial training is essential for the mental health peer support worker (PSW) role. Training needs to incorporate recent advances in digital peer support and the increase of peer support work roles internationally. There is a lack of evidence on training topics that are important for initial peer support work training and on which training topics can be provided on the internet.

OBJECTIVE

The objective of this study is to establish consensus levels about the content of initial training for mental health PSWs and the extent to which each identified topic can be delivered over the internet.

METHODS

A systematized review was conducted to identify a preliminary list of training topics from existing training manuals. Three rounds of Delphi consultation were then conducted to establish the importance and web-based deliverability of each topic. In round 1, participants were asked to rate the training topics for importance, and the topic list was refined. In rounds 2 and 3, participants were asked to rate each topic for importance and the extent to which they could be delivered over the internet.

RESULTS

The systematized review identified 32 training manuals from 14 countries: Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States. These were synthesized to develop a preliminary list of 18 topics. The Delphi consultation involved 110 participants (49 PSWs, 36 managers, and 25 researchers) from 21 countries (14 high-income, 5 middle-income, and 2 low-income countries). After the Delphi consultation (round 1: n=110; round 2: n=89; and round 3: n=82), 20 training topics (18 universal and 2 context-specific) were identified. There was a strong consensus about the importance of five topics: lived experience as an asset, ethics, PSW well-being, and PSW role focus on recovery and communication, with a moderate consensus for all other topics apart from the knowledge of mental health. There was no clear pattern of differences among PSW, manager, and researcher ratings of importance or between responses from participants in countries with different resource levels. All training topics were identified with a strong consensus as being deliverable through blended web-based and face-to-face training (rating 1) or fully deliverable on the internet with moderation (rating 2), with none identified as only deliverable through face-to-face teaching (rating 0) or deliverable fully on the web as a stand-alone course without moderation (rating 3).

CONCLUSIONS

The 20 training topics identified can be recommended for inclusion in the curriculum of initial training programs for PSWs. Further research on web-based delivery of initial training is needed to understand the role of web-based moderation and whether web-based training better prepares recipients to deliver web-based peer support.

Opportunities, Enablers, and Barriers to the Use of Recorded Recovery Narratives in Clinical Settings

Background: Recorded Recovery Narratives (RRNs) describing first-person lived experience accounts of recovery from mental health problems are becoming more available. Little is known about how RRNs can be used in clinical practice and clinical education. Aims: The aim of this paper is to enable implementation planning for RRN interventions by identifying determinants of uptake. The objective was to identify opportunities, barriers, and enablers to the uptake of RRN interventions in clinical practice and education. Method: Three phases of focus groups were conducted with multi-professional mental health clinicians. Phase 1 (4 groups, n = 25) investigated current and possible uses of RRNs, Phase 2 (2 groups, n = 15) investigated a specific intervention delivering recovery narratives. Phase 3 (2 groups, n = 12) investigated clinical education uses. Thematic analysis was conducted. Results: RRNs can reinforce the effectiveness of existing clinical practices, by reducing communication barriers and normalizing mental health problems. They can also extend clinical practice (increase hope and connection, help when stuck). Clinical considerations are the relationship with care pathways, choice of staff and stage of recovery. In educational use there were opportunities to access lived experience perspectives, train non-clinical staff and facilitate attitudinal change. Barriers and enablers related to design (ability to use online resources, accessibility of language, ability to individualize choice of narrative), risk (triggering content, staff skills to respond to negative effects), trust in online resource (evidence base, maintenance), and technology (cost of use, technology requirements). Conclusions: RRNs can both improve and extend existing clinical practice and be an important educational resource. RRNs can improve engagement and hope, and address internalized stigma. Beneficially incorporating RRNs into clinical practice and education may require new staff skills and improved technological resources in healthcare settings. Future work could focus on the use of peer support workers views on RRN use and how to avoid unnecessary and unhelpful distress. Trial Registration Number: Work in this paper has informed three clinical trials: ISRCTN11152837; ISRCTN63197153; ISRCTN76355273.

Workforce diversity, diversity training and ethnic minorities: The case of the UK National Health Service

This research studied an NHS organization as a case to explore how it is responding to cross-cultural issues against a backdrop of policy expectations about equitable and good quality mental health service provision to service users of a minority ethno-cultural group in the UK. Data were collected by conducting semi-structured interviews with 20 participants from three hierarchical levels of the organization. The research found that the concepts of culture and ethnicity are used in a fixed way in the interventions (staff diversity training and ethnic matching) taken by the case organization. It is argued that this fixed understanding of cultural concepts and related interventions may not be helpful in meeting the needs of service users, especially in the context of United Kingdom, which is characterized as a super-diverse society. It appears that the interventions are developed and implemented on the conceptualization of cultural identity as generic and fixed. Organizations working in a multicultural society, or where they have service users from a variety of ethnic and cultural backgrounds, need to develop and implement interventions based on individualized and fluid understanding of such concepts. The findings of this study contribute to cross-cultural management scholarship by taking a critical stance on the concept of culture, as it is operationalized by a large organization. We show how, even when required by national policy, this one-dimensional model of culture causes human resource management interventions, intended to address cultural diversity, to be perceived as ineffective.

Typology of modifications to peer support work for adults with mental health problems: systematic review

BACKGROUND

Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects.

AIMS

To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems.

METHOD

We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications.

RESULTS

A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues.

CONCLUSIONS

Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.

Peer support for discharge from inpatient to community mental health services: Study protocol clinical trial (SPIRIT Compliant)

INTRODUCTION

In the period shortly after discharge from inpatient to community mental health care, people are at increased risk of self-harm, suicide, and readmission to hospital. Discharge interventions including peer support have shown potential, and there is some evidence that community-based peer support reduces readmissions. However, systematic reviews of peer support in mental health services indicate poor trial quality and a lack of reporting of how peer support is distinctive from other mental health support. This study is designed to establish the clinical and cost effectiveness of a peer worker intervention to support discharge from inpatient to community mental health care, and to address issues of trial quality and clarity of reporting of peer support interventions.

METHODS

This protocol describes an individually randomized controlled superiority trial, hypothesizing that people offered a peer worker discharge intervention in addition to usual follow-up care in the community are less likely to be readmitted in the 12 months post discharge than people receiving usual care alone. A total of 590 people will be recruited shortly before discharge from hospital and randomly allocated to care as usual plus the peer worker intervention or care as usual alone. Manualized peer support provided by trained peer workers begins in hospital and continues for 4 months in the community post discharge. Secondary psychosocial outcomes are assessed at 4 months post discharge, and service use and cost outcomes at 12 months post discharge, alongside a mixed methods process evaluation.

DISCUSSION

Clearly specified procedures for sequencing participant allocation and for blinding assessors to allocation, plus full reporting of outcomes, should reduce risk of bias in trial findings and contribute to improved quality in the peer support evidence base. The involvement of members of the study team with direct experience of peer support, mental distress, and using mental health services, in coproducing the intervention and designing the trial, ensures that we theorize and clearly describe the peer worker intervention, and evaluate how peer support is related to any change in outcome. This is an important methodological contribution to the evidence base.

TRIAL REGISTRATION

This study was prospectively registered as ISRCTN 10043328 on November 28, 2016.

A systematic review of influences on implementation of peer support work for adults with mental health problems

PURPOSE

The evidence base for peer support work in mental health is established, yet implementation remains a challenge. The aim of this systematic review was to identify influences which facilitate or are barriers to implementation of mental health peer support work.

METHODS

Data sources comprised online databases (n = 11), journal table of contents (n = 2), conference proceedings (n = 18), peer support websites (n = 2), expert consultation (n = 38) and forward and backward citation tracking. Publications were included if they reported on implementation facilitators or barriers for formal face-to-face peer support work with adults with a mental health problem, and were available in English, French, German, Hebrew, Luganda, Spanish or Swahili. Data were analysed using narrative synthesis. A six-site international survey [Germany (2 sites), India, Israel, Tanzania, Uganda] using a measure based on the strongest influences was conducted. The review protocol was pre-registered (Prospero: CRD42018094838).

RESULTS

The search strategy identified 5813 publications, of which 53 were included. Fourteen implementation influences were identified, notably organisational culture (reported by 53% of papers), training (42%) and role definition (40%). Ratings on a measure using these influences demonstrated preliminary evidence for the convergent and discriminant validity of the identified influences.

CONCLUSION

The identified influences provide a guide to implementation of peer support. For services developing a peer support service, organisational culture including role support (training, role clarity, resourcing and access to a peer network) and staff attitudes need to be considered. The identified influences provide a theory base to prepare research sites for implementing peer support worker interventions.

The impact of mental health recovery narratives on recipients experiencing mental health problems: Qualitative analysis and change model

BACKGROUND

Mental health recovery narratives are stories of recovery from mental health problems. Narratives may impact in helpful and harmful ways on those who receive them. The objective of this paper is to develop a change model identifying the range of possible impacts and how they occur.

METHOD

Semi-structured interviews were conducted with adults with experience of mental health problems and recovery (n = 77). Participants were asked to share a mental health recovery narrative and to describe the impact of other people's recovery narratives on their own recovery. A change model was generated through iterative thematic analysis of transcripts.

RESULTS

Change is initiated when a recipient develops a connection to a narrator or to the events descripted in their narrative. Change is mediated by the recipient recognising experiences shared with the narrator, noticing the achievements or difficulties of the narrator, learning how recovery happens, or experiencing emotional release. Helpful outcomes of receiving recovery narratives are connectedness, validation, hope, empowerment, appreciation, reference shift and stigma reduction. Harmful outcomes are a sense of inadequacy, disconnection, pessimism and burden. Impact is positively moderated by the perceived authenticity of the narrative, and can be reduced if the recipient is experiencing a crisis.

CONCLUSIONS

Interventions that incorporate the use of recovery narratives, such as peer support, anti-stigma campaigns and bibliotherapy, can use the change model to maximise benefit and minimise harms from narratives. Interventions should incorporate a diverse range of narratives available through different mediums to enable a range of recipients to connect with and benefit from this material. Service providers using recovery narratives should preserve authenticity so as to maximise impact, for example by avoiding excessive editing.

Development and Evaluation of a Recovery College Fidelity Measure

OBJECTIVE

Recovery Colleges are widespread, with little empirical research on their key components. This study aimed to characterize key components of Recovery Colleges and to develop and evaluate a developmental checklist and a quantitative fidelity measure.

METHODS

Key components were identified through a systematized literature review, international expert consultation (n = 77), and semistructured interviews with Recovery College managers across England (n = 10). A checklist was developed and refined through semistructured interviews with Recovery College students, trainers, and managers (n = 44) in 3 sites. A fidelity measure was adapted from the checklist and evaluated with Recovery College managers (n = 39, 52%), clinicians providing psychoeducational courses (n = 11), and adult education lecturers (n = 10).

RESULTS

Twelve components were identified, comprising 7 nonmodifiable components (Valuing Equality, Learning, Tailored to the Student, Coproduction of the Recovery College, Social Connectedness, Community Focus, and Commitment to Recovery) and 5 modifiable components (Available to All, Location, Distinctiveness of Course Content, Strengths Based, and Progressive). The checklist has service user student, peer trainer, and manager versions. The fidelity measure meets scaling assumptions and demonstrates adequate internal consistency (0.72), test-retest reliability (0.60), content validity, and discriminant validity.

CONCLUSIONS

Coproduction and an orientation to adult learning should be the highest priority in developing Recovery Colleges. The creation of the first theory-based empirically evaluated developmental checklist and fidelity measure (both downloadable at researchintorecovery.com/recollect ) for Recovery Colleges will help service users understand what Recovery Colleges offer, will inform decision making by clinicians and commissioners about Recovery Colleges, and will enable formal evaluation of their impact on students.

Using Peer Support in Developing Empowering Mental Health Services (UPSIDES): Background, Rationale and Methodology

BACKGROUND

Peers are people with lived experience of mental illness. Peer support is an established intervention in which peers offer support to others with mental illness. A large proportion of people living with severe mental illness receive no care. The care gap is largest in low- and middle-income countries, with detrimental effects on individuals and societies. The global shortage of human resources for mental health is an important driver of the care gap. Peers are an under-used resource in global mental health.

OBJECTIVES

To describe rationale and methodology of an international multicentre study which will scale-up peer support for people with severe mental illness in high-, middle-, and low-income countries through mixed-methods implementation research.

METHODS

UPSIDES is an international community of research and practice for peer support, including peer support workers, mental health researchers, and other relevant stakeholders in eight study sites across six countries in Europe, Africa, and Asia. During the first two years of UPSIDES, a series of qualitative studies and systematic reviews will explore stakeholders' perceptions and the current state of peer support at each site. Findings will be incorporated into a conceptual framework to guide the development of a culturally appropriate peer support intervention to be piloted across all study sites. All intervention and study materials will be translated according to internationally recognised guidelines.Expected Impact: UPSIDES: will leverage the unique expertise of people with lived experience of mental illness to strengthen mental health systems in high-, middle- and low-income countries. UPSIDES will actively involve and empower service users and embed patient-centeredness, recovery orientation, human rights approaches, and community participation into services. The focus on capacity-building of peers may prove particularly valuable in low-resource settings in which shortages of human capital are most severe.

The construction of people with mental health problems as risk objects: Findings of a case study inquiry

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.

Therapeutic relationships, risk, and mental health practice

Despite significant changes to mental health services, nurses remain the professional group most likely to be in close contact with people who experience mental health problems. A core part of the contemporary identity of the mental health nurse is one who is able to provide acceptance and support for an individual's recovery through the therapeutic relationship. Yet there have always been some tensions with the mental health nursing role that can appear to challenge this relational focus. An increasing prominence of risk management in mental health care can position mental health nurses as responsible for enacting restrictions and has reignited interest in the role of mental health professionals in social control. This paper reports on one part of a multiple case study, which aimed to explore mental health professionals' experiences of such tensions in the context of decision-making. Interviews and observations were undertaken in acute ward and assertive outreach settings. Findings suggested that risk dominated decision-making to such an extent it defined the way service users were understood and treated. A distant relationship between professionals and service users helped to create and maintain this situation. There needs to be a greater focus on service users' subjective experiences in the decision-making process to challenge the definition of people with mental health problems as risky.

Developing case management for the long-term mentally ill

Mental health policies and the focus of psychiatric services have shifted over the last three decades from hospital to community care. Greater care in the community and reduced psychiatric bed numbers have contributed to the discharge or non-admission of many patients with severe and persistent disorders who formerly would have been cared for in hospital. Increasing numbers of the chronically ill in the community will necessitate the development of systems to provide continuous and integrated services for such people.

Using single case experimental design to evaluate the clinical effect of a multidisciplinary training in psychosocial interventions for people with serious mental health problems

The provision of skilled support for people with serious mental health problems is informed by research evidence that specific interventions can improve outcome for clients and their carers in a number of areas, and that professionals can be taught these skills. However, evidence of treatment gains is limited and tenuous: there are problems with definitions of populations and interventions, and there is poor comparability between studies. In addition, there are specific difficulties in the evaluation of multidisciplinary training where different professionals have different roles, responsibilities and levels of baseline knowledge and skills. This paper considers the use of single case experimental design in the evaluation of the clinical outcome of a multidisciplinary, postgraduate, skills-based training in psychosocial interventions for people who have serious mental health problems. Single case design has the potential to overcome many of the factors that militate against the use of a randomised controlled trial; furthermore, generalisability is improved by replication across a small group of mixed clients: it allows the impact of the course on each client to be assessed in terms of his/her own goals and permits some explanation of treatment effects as well as giving an insight into the factors which help and hinder students attempting to implement evidence-based practice with this client group.

Coming in from the cold? An analysis of research proposals submitted by the Nursing Section at ScHARRI, 1994-1997

The Nursing Section at SCHARR was established in 1994 as one of six groups that constituted the Sheffield Centre for Health and Related Research (SCHARR). Based at the University of Sheffield, SCHARR was established as a response to the imperatives outlined in NHS Research and Development Strategy documentation for multidisciplinary health services research (HSR). The Nursing Section at SCHARR has always been fully supportive of such principles and over the past three years has worked with many different health-care researchers to maximise the nursing contribution to health services research. This paper analyses the features of 50 proposals made by the Nursing Section to funding bodies since 1994. Approximately half (52%, n=26) of all bids were successful and led to a total of nurse-related research grants worth 2.7 million pounds. Projects were significantly more likely to be funded if the method proposed was qualitative (or a combination of methods) or the lead researcher was a nurse. However, research was no more likely to be funded if a medical colleague was named as a collaborator, a statistician or health economist was involved in the bid, there were more than three named collaborators on the proposal, or the bid came from more than one university. The implications of these results are discussed in the context of recent critical commentaries on the topic of nurses'supposed relative disadvantage in obtaining funds for multidisciplinary health services research.

Focus Group Research

This article considers the philosophical underpinnings that have shadowed the emergence of focus group methods as a counterpoise to positivist research design. Examples of the application of focus group methods are drawn from two studies where the voices of marginalized groups were facilitated: 1) focus groups with patients diagnosed with personality disorder; and 2) focus groups with gypsy travellers. In both groups there were varying degrees of coherence in communication although particular attention here is paid to the role of dissonance and `negative dialectics' in the formation of opinion. Data generation in focus groups is considered in relation to group size, structure and clinical techniques.

Exercise for adolescents with depression: valued aspects and perceived change

INTRODUCTION

Despite systematic reviews demonstrating an association between exercise participation and reduced depressive symptoms in young people, there is no qualitative research exploring the experience of depressed adolescents who have engaged in an exercise intervention.

AIMS

To explore the experience of depressed adolescents who had recently engaged in a preferred intensity exercise intervention.

METHOD

The participants (n = 26) were recruited through health and social care services, were all in treatment for depression, and were purposefully sampled for interview following engagement in a preferred intensity exercise intervention, which was being evaluated via a pragmatic randomized controlled trial. A thematic approach was undertaken to analyse and organize the data.

RESULTS

Numerous beneficial changes were reported by participants alongside specific aspects of the intervention that were valued.

DISCUSSION AND IMPLICATIONS

The findings suggest that preferred intensity exercise can lead to feelings of improved mood, enjoyment and achievement, alongside benefits that transcend depressive symptom reduction. Considering mental health nurses are in key positions to promote exercise in this population, the current findings provide vital information for this purpose.

Co-producing social inclusion: the structure/agency conundrum

There is a raft of policy guidelines indicating that mental health nurses should be increasing the social inclusion of mental health service users. Despite this there is no universally accepted definition of social inclusion and there is a dearth of empirical evidence on the successful outcome of increasing inclusion for mental health service users. Recognizing the lack of clarity surrounding the concept we have a produced a social inclusion framework to assist mental health professionals and service users to co-produce social inclusive outcomes. Although we agree that social inclusion can be a positive aspect of recovery, we question the extent to which mental health nurses and service users in co-production can overcome the social, economic and political structures that have created the social exclusion in the first place. An understanding and appreciation of the structure/agency conundrum is required if mental health nurses are to engage with service users in an attempt to co-produce socially inclusive outcomes.

Evaluation of the Chief Nursing Officer's Review of mental health nursing in England: findings from case studies in mental health trusts

This study is an evaluation of the implementation of the Chief Nursing Officer for England's Review of mental health nursing in mental health trusts (MHTs). The authors employed instrumental case studies in six MHTs. The results showed evidence of acceptance of the Review and some evidence of subsequent actions to implement the Review recommendations, but these were not widespread. A lack of an evidence-based implementation plan hampered the implementation as did an apparent lack of strategic nursing leadership in many MHTs. In conclusion, the vision for mental health nursing reported in the Chief Nursing Officer Review prompted various changes, directly and indirectly, among mental health nurses and the development of areas of good practice in education, practice and leadership. The positive changes evident in some areas may become widespread by a systematic policy implementation plan from the centre, supported by local leadership in practice.

Campaign appears to influence subjective experience of stigma

BACKGROUND AND AIM

An English mental health trust implemented a strategy to dispel the stigma surrounding mental illness and service users. The purpose of this study was to evaluate its impact.

METHOD

A questionnaire was mailed to 600 service users, selected at random, to evaluate the campaign's impact. Factor analysis of 243 responses yielded three factors which could be interpreted in relation to service users' perceptions of: public attitudes towards mental illness, service users' relationships with staff and other inter-personal relationships.

RESULTS

Significant improvement was found in service users' perceptions of public attitudes towards mental illness. This can cautiously be related to the main thrust of the campaign. No change was found in the other two factors, which supports the inference that the campaign specifically influenced users' experience of public portrayals of mental illness.

CONCLUSIONS

This study indicates that certain aspects of stigma may be amenable to change through a targeted campaign. While users' experience of public attitudes may be improved, at least in the short-term, other aspects of stigma did not appear to be amenable to change through community-level interventions. Different dimensions of stigma seem to demand different approaches. The intra-psychic roots of stigma may be the hardest elements to change.

Collective biography and the legacy of Hildegard Peplau, Annie Altschul and Eileen Skellern; the origins of mental health nursing and its relevance to the current crisis in psychiatry‡

Oral history and biographical research gathering previously unpublished material directly from Altschul and Peplau, and new commentaries on Eileen Skellern from colleagues, are triangulated to form a collective biography that accesses historical consciousness of times of great change in psychiatry. We can see core ideas about psychiatric nursing aggregated around the idea active therapeutic engagement. Peplau and Altschul were simultaneously working with innovative methods of community-based therapy during the Second World War in England with shell-shocked soldiers. Both developed founding ideologies in psychoanalysis and therapeutic community practice. A similar trajectory is apparent in the work of Eileen Skellern. User involvement and social inclusion, the corner stones of therapeutic community practice, remain intrinsic to the aspirations of psychiatry today.

Young people supporting parents with mental health problems: experiences of assessment and support

The explosion of interest in young people as carers over the last decade and a half conceals the fact that there are still no reliable estimates of the number of young people with caregiving responsibilities. This is even more problematic in circumstances where the 'looked after' person has a mental health problem. In this study, we reflect on what can be done to identify, assess and support young people in these circumstances. We draw on selected findings from a study that has been examining the constituents of good assessment practice in work with family carers supporting relatives with mental health problems. The study embraces different carer groups but this paper concentrates on the experiences of young carers at one study site where Barnardo's and partner organisations had developed a joint initiative targeting young people who are looking after parents and relatives with mental health problems. Following a review of the literature about young people as carers, the paper describes how Barnardo's worked to support them through its young carers projects. Based on face-to-face interviews with the young people (N = 10) caring for a mother with mental health problems, the main part of the paper provides an account of how they talk about, make sense of and evaluate the support they have received through this combined initiative. The findings underscore the value of one particular young carers project, and provide clues about what lessons may be transferable to other similar projects.

User and carer involvement in the training and education of health professionals: A review of the literature

BACKGROUND

Health policy requires consumer involvement in services, research and education but little is known about how consumers are being involved in healthcare education, the effect on learning and practice, nor how involvement initiatives are being evaluated.

OBJECTIVES

To describe methods of involving consumers in healthcare education, discuss ways in which initiatives have been evaluated, and identify areas for development in education, practice and research.

DESIGN

All papers reporting specific initiatives involving consumers in health care worker training and education were included. Viewpoint articles and studies of consumers training consumers were excluded.

DATA SOURCES

Cinahl, Medline, Assia, PsycINFO, British Nursing Index, Social Science Citation Index, citations from reference lists, relevant websites and personal communication with key people known to be working in this area.

REVIEW METHODS

A narrative approach was taken with categorisation of data to reflect objectives of selected studies; method of involvement; process issues and evaluation.

RESULTS

Thirty-eight papers were included; most provide small-scale qualitative studies of mental health service users and focus on process rather than outcome. Various methods of involvement are described and consumers consistently prioritise the need for training in interpersonal skills over 'technical' skills. There is little research into organisational strategies and no studies investigate the effect of consumer involvement on practice. Two studies indicated that students exposed to consumer involvement demonstrate more empathic understanding and better communication skills.

CONCLUSIONS

There is tentative evidence that consumer involvement in training enhances workers' skills in the manner prioritised by consumers. However, if consumer involvement in training and education is to facilitate services that reflect the priorities of the people using them, it must be developed in partnership with service providers; further research is needed to explore the impact of consumer involvement and to track the development of organisational consumer involvement strategies, also systems for supporting consumers need to be established, including training for both consumers and staff.

Life story work in health and social care: systematic literature review

AIM

The aim of this paper is to review the literature on life story work in health and social care practice.

BACKGROUND

Life story work as an intervention has been used with a number of health and social care clients, such as children people with learning disabilities, older people on medical wards and with older people who have dementia. It may help challenge ageist attitudes and assumptions, be used as a basis for individualized care, improve assessment, assist in transitions between different care environments, and help to develop improved relationships between care staff and family carers. However, to date there has been no attempt to collate the findings from published accounts.

METHODS

A systematic search of the literature on life story work was conducted in February 2004, using nursing, medical and social science databases and a combination of thesaurus and free text search terms. This revealed over 1000 publications; the use of carefully constructed inclusion and exclusion criteria identified 51 relevant items. Fourteen were subsequently selected and reviewed using a set of reflective critical appraisal questions.

FINDINGS

A range of methodological approaches has been adopted to explore the use of life story work with no one specific methodology prevailing. The work has been most frequently used with older people and people with a learning disability and life story books are the most common approach. Staff perceptions of life story work have been explored, but patient and carer views are less frequently reported. The findings of the studies are discussed in broad themes, offering some tentative recommendations for using life story work in practice.

CONCLUSION

Evidence on the use of life story work is immature, leading to the recommendation for more research. Although appraising literature from a range of approaches is complex, there are some potentially far-reaching benefits of life story work in health and social care practice.

Cluster randomized trial of a guideline-based open access urological investigation service

BACKGROUND

Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. "One stop" and "open access" clinics have been advocated as a way of improving out-patient services.

OBJECTIVES

Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service.

METHODS

General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral.

RESULTS

GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0.11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS.

CONCLUSIONS

The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.