Title: PARTNERS2: development and pilot trial of primary care based collaborative care for people with serious mental illness
Funder: Department of Health and Social Care

Abstract: Patient and Public Involvement Patient and public involvement is central to our research and its success. Our co-produced research questions arose from mutually perceived needs. We will work with a range of service user organisations to ensure we stay focused on the realities of living with a serious mental illness. Aims and Objectives We aim to develop and trial an innovative primary care based model of collaborative care for people with schizophrenia or bipolar disorder. Collaborative care is a system of delivering care which includes a case manager working in, and in collaboration with primary care, under specialist supervision, providing a platform for appropriate evidence based interventions. Background and rationale Schizophrenia or bipolar disorder are relatively common, costly to the economy and health service and have serious consequences for the individual including poor health and social outcomes. There is strong evidence of patient and carer concern about current services, particularly for those with enduring but stable disorders in secondary care. While there is good evidence to support intensive community services (e.g. assertive outreach), there is less evidence to support the large numbers of individuals who need lower intensity care being managed by community mental health teams (CMHTs). Whilst diet, lack of physical activity, smoking and drug side effects all lead to poor outcomes, problems related to organisation of services and quality of individual care also contribute. Based on our preparatory Cochrane review and extensive audit of current care, PARTNERS2 seeks to improve care through developing collaborative care in primary care for the estimated 73% of people with schizophrenia or bipolar disorder who are currently seen and treated in primary care alone, or in a limited way by CMHTs. PARTNERS2 would be the first research programme focused on collaborative care for people with schizophrenia or bipolar disorder in an English context. This is of major NHS significance given the unplanned way in which people are being discharged from secondary services to reduce short term costs. Research Environment PARTNERS2 represents a collaboration between four leading Universities and is strongly supported by research networks and Clinical Commissioning Groups and Mental Health Trusts in Birmingham, Manchester and South Devon. Research plan In Phase 1, we will develop and refine the model of care and select outcome measures. In Phase 2, we will examine whether the model can be delivered as intended. WS1 will describe current care, help identify who would most benefit from the collaborative care and assess potential risk and safety issues through a retrospective observational cohort study of 300 people and focus groups with service users and carers. WS2 will develop an agreed standardised set of outcomes for use in mental health trials involving people with schizophrenia or bipolar disorder in a community based setting, and the measures to be used in our pilot trial. We will use focus groups with key stakeholders, a Delphi process, systematic review and stated preference technique. WS3 will define and develop the key components of collaborative care through an iterative development process involving up to 150 service users in 12 practices, carers, health professional and managers in our three sites, using a range of qualitative and quantitative data. WS4 will to test the feasibility of patient and practice recruitment and of commissioning the model of care through qualitative work and patient and practice structured surveys.WS5 will draw the findings of the previous four WSs together into a pilot trial protocol and process evaluation. WS6 is a pilot cluster randomised controlled trial and process evaluation involving 60 practices and 300 people in our three localities. Dissemination & projected outputs Dissemination will occur throughout the study to patients and carers, practitioners, planners and policy makers. We will work closely with our PPI partners, and utilise our research, policy and practice networks to ensure our findings translate into changes on the ground. Key outputs include information how to implement and the impact and costs of collaborative care. Relevant expertise & experience of the research team Our multidisciplinary team has worked together for over a decade, and are international leaders in the field of primary care mental health and service innovation for people with serious mental illness. We are supported by national and international collaborators who bring additional perspectives and skills. Management & Governance, including Programme Management and ethical implications We will ensure regular meetings and lines of accountability across and within sites. HL is study guarantor and will work closely with an experienced Programme Manager to ensure PARTNERS2 is expertly managed. Ethical implications will be a standing meeting agenda item and appropriate timely advice will be sought as needed. Justification of costs Most of the budget is allocated to 54 month study posts, ensuring PARTNERS2 is prosecuted to a high standard and will deliver each element on time. We have modelled these costs on our previous successful grants.

Lay abstract: People with schizophrenia and bipolar disorder (manic depression) often live very different lives from the general population. Around 66% live in poverty and isolation, most rate their quality of life as poor, and only 12% are employed. These troubling findings are related to the direct effects of mental illness, the side effects of medicines on both physical and mental functioning and peoples prejudices/attitudes about mental illness. Previous work suggests that many individuals with lower levels of need have minimal and poorly co-ordinated primary and specialist care. Many service users and professionals feel that too much focus is placed on medication and not enough on other aspects of life. Once stabilised on medication, services don t always then focus on supporting these individuals to take the next steps in their recovery and fulfil their potential. PARTNERS2 aims to help primary care and community based mental health services work more closely together. We think this could be achieved by developing a system of collaborative care based in GP surgeries where about 70% of adult service users are seen regularly by an experienced mental health worker who acts both as overall co-ordinator (supporting individuals to access other services and activities) and therapist. This person would see the service user regularly, help them help themselves and facilitate recovery in the broadest sense and, where required, call on the talents of other parts of the health service, particularly secondary mental health care and voluntary/community organisations. This is a simple idea - but we need to work through all the details carefully by testing things out and then set up a pilot trial to see if it makes a difference to the care provided and try out the use of a range of outcome measures. GPs, psychiatrists and service commissioners in Birmingham, Manchester and South Devon have agreed to work with us to reshape services from 2013. This multi-disciplinary research team has worked together for ten years. We know the success of this intervention depends on working closely with people with lived experience. There are ethical considerations for example around mental capacity; however we hope that by working closely with service users and carers, we will be well positioned to address ethical issues as they arise. At the end of the five year Programme, we will know if collaborative care for people with schizophrenia and bipolar disorder in England is likely to work, based on the views of all the people involved in setting it up and using it, how well service users are feeling in themselves, the quality of their lives, how many feel they are more recovered, and what the system costs to run.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH