Title: IMPlementation of A Relatives’ Toolkit (IMPART study): Examining the critical success factors, barriers and facilitators to implementation of an online supported self-management intervention in the NHS
Funder: Department of Health and Social Care

Abstract: A theory driven case study design will identify the critical success factors, barriers and facilitators to implementation of an online supported self-management intervention in the NHS. The Relatives’ Education And Coping Toolkit (REACT) is an evidence-based online supported self-management intervention for relatives of people with recent onset psychosis, which has been shown to significantly reduce distress and increase perceived ability to cope. The intervention was co- produced with relatives, is recovery focussed, and offers an effective way for mental health services across the UK to meet the new 2014 NICE Guideline for psychosis recommendation to provide an education and support programme to relatives. Previous NICE guidelines (2009) have recommended relatives are supported through structured Family Intervention. However, NHS Trust surveys estimate that only 1 – 17% of families have received this (4-6). It is therefore vital that the new guidelines are more successfully implemented. Supported self-management interventions, delivered using interactive technology, are becoming an increasingly popular way to deliver cost effective healthcare to people with chronic needs but implementation of these approaches in routine clinical practice is poorly understood. This study will produce a national Implementation Plan for the REACT toolkit, but the relevance of the findings more broadly will also be articulated. Our methodology is informed by the Normalisation Process Theory (NPT). This theory has been successfully used to inform a wide range of NHS implementation studies. NPT will be used to guide exploration of factors that would be hypothesised to impact on the implementation process. In Phase 1 (0-6mths) we will develop our theory of implementation of REACT and generate specific hypotheses, through systematic literature review, analysis of REACT feasibility trial data, and stakeholder workshops. Phase 2 (7-24mths) uses an iterative case study design to collect and analyse data to test our implementation hypotheses in 6 NHS Trusts (purposively sampled to maximise generalizability of findings). REACT will be introduced to sites in 3 waves, at 6 monthly intervals (2 sites in each wave), with findings from data collection in each wave being used to inform development of the Implementation Plan. In Phase 3 (25-30mths) we will develop the final Implementation Plan, assess wider applicability for other supported self-management interventions in the NHS, and draw out implications for further development of implementation theory.

Lay abstract: Relatives of people with psychosis provide a large amount of vital unpaid care, but at huge personal cost in terms of high levels of distress, and significant practical, financial and emotional burden. Currently relatives do not receive adequate support or information, despite this being recommended by UK government guidelines. The Relatives’ Education And Coping Toolkit (REACT) has been developed in response to this need, and is an online supported self-management toolkit for relatives of people with recent onset psychosis. REACT is recovery focussed, co-produced with relatives, and designed to provide relatives with the information and skills they need to support someone with psychosis. REACT has a modular format with the content divided into 13 sections which can be used flexibly depending on individual needs. Each relative is supported to use the toolkit via email / telephone contact with a member of the clinical team. REACT has already been shown to be effective in reducing relatives’ distress and increasing their sense of being supported (22). The challenge now is how to ensure this intervention is made widely available to relatives. Unfortunately many evidence based interventions do not reach frontline clinical services. There is an urgent need to understand how to close the gap between evidence and practice. In this study we aim to investigate the factors which impact on how the REACT toolkit is implemented in the NHS, in order to produce a national Implementation Plan for all NHS Trusts. First we generate hypotheses about the factors which are likely to impact on implementation of REACT, based on existing theory, our feasibility data, and clinical expertise within the Trusts. We will then introduce REACT to 6 NHS Trusts on a phased basis over 18 months (2 sites at a time), closely examining how REACT is implemented and using information gathered to draft and modify an Implementation Plan. Data collection in each trust is guided by a Stakeholder Group including service users, relatives, clinicians, and senior managers. Lastly, we will finalise the Implementation Plan based on the information collected. We will examine how the findings of our research can be generalised to other self-management interventions in the NHS. The study is good value for money. First it promotes an inexpensive way to ensure relatives are well supported and able to continue their caring role, which saves the NHS a lot of money. Secondly, the outputs will have a broad relevance in the NHS. Supported self-management interventions are becoming an increasingly popular way to deliver cost effective healthcare and potentially improve access, but how these approaches get delivered in routine clinical practice is poorly understood. The knowledge gained from this study can help ensure potential benefits from these innovations are realised. The Research Team includes: senior clinicians and service leads within EIS; a relative of someone with psychosis; a user-focussed research charity; clinical academics with a track record of evaluating new mental health interventions in the NHS; and an expert in implementation science. Many of the team have worked together previously on developing and evaluating the REACT intervention, with additional members added for relevant methodological expertise around implementation and delivery.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH