Title: Development, Feasibility Testing and Pilot Trial of a Crisis Planning and Monitoring Intervention to Reduce Compulsory Hospital Readmissions (the FINCH Study)
Funder: Department of Health and Social Care

Abstract: Research question: The main research questions addressed are: whether an intervention to prevent compulsory readmission can be developed that is acceptable to people who have recently been compulsorily admitted (including Black and Black British people); whether it appears feasible to evaluate the effectiveness of this intervention in a future fully powered randomised controlled trial; and whether preliminary evidence from this study is congruent with the intervention being effective. Background: The rate of compulsory admission has been rising in the UK. This is highly problematic because of the associated distress and disempowerment, and because mental health care should as far as possible be based on principles of consent and collaboration. People with previous compulsory admissions are at high risk of a repeat compulsory admission, making them an important potential focus for interventions to reduce detentions. Aims and objectives We aim to develop and test an intervention to prevent compulsory readmission and develop self-management skills among people being discharged following a compulsory admission. In the first phase of the study, a co-produced approach will be taken to adapting an intervention that has shown considerable promise in a trial in a large metropolitan area in Switzerland. This stage includes initial investigation of feasibility and acceptability, especially to Black/Black British service users. The second phase involves a pilot trial, intended to assess whether this intervention can be tested through a definitive trial and to make an initial assessment of its potential effectiveness. Methods and Timelines Phase 1 (Months 1-8): A Co-Production Group including researchers, clinicians and service users will meet frequently to make key decisions about adaptation of the study intervention from its Swiss model. Inputs will include: emerging policy guidance on advance statements; relevant research literature; consultation with key experts (including the original intervention's developer), qualitative data collection from staff and service users (especially from Black/Black British backgrounds), and learning from initial delivery of the intervention to 6 service users. Phase 2 (Months 9 to 31): A pilot trial, designed to establish proof of concept, will be conducted in three sites, two in London and one in a non-metropolitan area. Forty people will be randomised to receive the intervention and 40 controls will receive treatment as usual. We aim for at least half of participants to be Black/Black British. The intervention will be finalised in Phase 1: current plans are for four initial sessions focused on psychoeducation, crisis planning, early warning signs of crises and recovery goals, followed by a one year period of monitoring monthly by video call or phone. Recruitment and retention will be examined, as well as outcomes including compulsory readmission over a year (the primary clinical outcome) Anticipated impact and dissemination Clear research evidence on how to prevent compulsory admission is lacking: if our intervention is eventually found to be effective, national and international impact will be high. We will engage stakeholders throughout by a blog, dissemination events, policy briefs and social media, and will publish scientific papers from both phases describing justified conclusions thus far and their implications.

Lay abstract: More and more people are being admitted to psychiatric hospitals without consent (compulsorily admitted or &ldquo;sectioned&rdquo;). Patients and families often find such admissions distressing, disempowering and traumatising. Ethically, treatment should involve collaboration and consent except when truly unavoidable. Strategies for reducing compulsory admissions are therefore urgently needed. People who have had at least one compulsory admission are at particularly high risk of future compulsory admissions. We therefore focus on them in our plans for reducing compulsion. This proposal comes from resarchers who led on inputting evidence to the Independent Review of the Mental Health Act. Evidence on how to prevent compulsory admissions was thin, but we concluded that strategies involving collaborative planning for crises (also called advance statements) are most promising. However, such crisis planning can be hard to put into practice in real-world settings, resulting in some studies in which it has not worked as intended. We have therefore identified as the most promising starting point a study from a metropolitan area of Switzerland, in which crisis planning was part of a well-developed programme designed to prevent compulsory re-admissions. This included individualised strategies for monitoring for early signs of crisis, and for empowering patients to develop and put into practice crisis prevention plans. A trial evaluating this programme had promising findings: we plan to build on this work. Phase One of our study involves adapting this programme to the UK . A co-production group, in which people with relevant lived experience, clinicians and researchers work together on an equal basis, will steer adaptation of the Swiss programme to a UK context, and will finalise methods to test it in an initial trial. Inputs to this will include interviews with service users and staff with relevant experience, and learning from trying out the programme with six people. Any new policy guidance will be incorporated in the programme. Phase Two will be an initial trial of the programme. This is the vital first step towards a large multi-site study giving a more definite answer as to whether it prevents compulsory admissions and is good value for money. We will find out whether we can recruit people to take part in a trial, whether they stick with the programme and find it helpful. We will get some idea of whether the programme seems likely to be effective and whether it should be tested further. We are especially interested in people from Black and Black British backgrounds, as a high-risk group for compulsory admission. A big focus will be making sure the programme is relevant and engaging for them. We will recruit in diverse areas in and around London, aiming for half our participants to be people identifying as Black or Black British.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH