Title: Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental IIlness (ODDESSI)
Funder: Department of Health and Social Care

Abstract: Aims and Objectives This programme has four aims: to develop a protocol acceptable to clinicians and service users for the delivery of Open Dialogue (OD) for the management of mental health crisis, to assess the clinical and cost-effectiveness of OD, to understand the experience of service users, carers and staff of OD and finally, to develop a model of OD that can be implemented in routine NHS care. Background and Rationale In England there is excessive pressure on psychiatric beds which has been attributed to increased demand for beds, often in the context of reduced community resources, limitations in crisis response (including Emergency Departments and Crisis Response and Home Treatment Teams (CRHTTs)) and the decreasing availability of long-term community support. Research suggests CRHTTs may not be associated with a reduction in hospital admissions which could be due to atrophy of their key functions. Epidemiological research implicates poor social networks in the development and maintenance of mental Disorder. Interventions which target the social network may have a role in ameliorating mental health crises and reducing the likelihood of relapses. Given the brief nature of CRHTT contacts and lack of continuity of care such interventions are not currently provided. A systematic review identified few studies of social network interventions , of which few were crisis care or explicitly focused on bringing about change through the network. Open Dialogue (OD) is a new therapeutic practice and service delivery model developed in Finland that explicitly targets social networks as a focus for the intervention (Seikkula 2006; 2011). In contrast to current care models, in which families are rarely directly involved, OD uses network meetings attended by family members, friends and other professionals involved as the central means of intervention delivery. Service users and their network engage in shared decision making with professionals to deploy appropriate pharmaceutical, psychological or social interventions with the aim of developing longer term mutual support. PSWs work with the service user to develop a more coherent and sustainable network. Continuity of care is a key principle. Research Plan The research plan has five related Workpackages. The first is a programme of work to develop the Open Dialogue intervention so that it is adapted for use in the NHS. In WP1 we will also undertake development work of the role of service users as key members of the OD team; Peer Support Workers (PSW). After completion, we will move to the feasibility trial in WP2 to assess whether it is possible to assess OD in a large multicentre cluster RCT; if the feasibility study is positive we will progress to WP3. This is a large (506 participant) multicentre trial of OD compared to Treatment as Usual for people presenting to NHS services in crisis. WP4 is a process evaluation of the RCT which also contains further development work on implementation of OD and development of an in-service training programme to support the sustainability of OD in routine care. Projected outputs and dissemination plans In addition to the preparation of peer reviewed publications and presentation at national and international conferences, we will develop a dissemination plan in collaboration with organisational and service user stakeholders which will include the following on a specifically designed ODESSI website; a protocol for the delivery of OD accessible summaries of programme progress an implementation toolkit a suite of outcome and process measure including fidelity and adherence a sustainable in-service training programme We will establish with key participants a national training programme and develop links with Health Education England, NHS England, AHSNs, local commissioners, relevant Royal Colleges and other professional bodies to promote the implementation of OD. We will collaborate with key service user groups to support the role of peer support workers. We will work with both organisational and service user stakeholder groups to agree a programme of sharing of research findings will all research participants. Benefits to patients and the NHS We expect that the primary benefit of OD will be a reduction in relapse and an associated increase in quality of life. If the estimated difference in relapse rates that underpin our assumptions about power are to be realised, we estimate that across the country this would result in a reduction in the number of relapses and consequent admissions to hospital with savings in the region of &pound;60 million per annum (based on a recent economic model developed by the NICE). A major component of this study is the development of the PSW role. This programme is among the first studies in UK to evaluate PSWs and could have major implications for the nature of the NHS workforce. More generally, we anticipate that the in-service training model could train over 3000 OD practitioners in the five years following the completion of the programme.

Lay abstract: In the NHS there are significant problems in providing care and support for people in a mental health crisis. People needing intensive support during a crisis often find themselves in hospital Emergency Departments and have problems getting good community support from mental health services. This lack of support means more people are admitted to hospital than should be, leading to a shortage in psychiatric beds. In principle, community-based crisis teams are effective in managing crises in people s homes. However, they are not as effective as they could be in preventing hospital admissions due to limited resources and the provision of short-term crisis management. Developed in Finland, Open Dialogue (OD) is a new method for working with people in crisis. An OD team works with the service user from initial crisis and beyond, organising treatment and longer term care to prevent crises recurring. In contrast to crisis teams, OD places a greater emphasis on working with the service user, their families and friends, and others (for example healthcare professionals or local community members) to form a network of support. This network is the basis for making treatment decisions which can lead to better long-term outcomes for service users. There is some evidence from Finland to suggest that OD is an effective way to help people in crisis, but no high quality scientific studies have been undertaken to confirm this. This research aims to investigate: whether services can be re-organised to evaluate OD how effective the training of NHS staff is to provide OD whether OD can be used to treat people in crisis whether service users, their families and staff have a positive experience of OD whether it is possible for OD to become part of routine care in the NHS We will assess: whether OD is better than usual crisis care, concentrating on if people become unwell again after initial treatment. how much OD costs and whether it is good value for money compared with usual care what changes need to be made to mental health services to ensure that OD can become part of standard NHS care what new ways of working will support the implementation of OD An important part of this study will be training service users to become peer support workers in the OD team who will help build longer term support networks for service users. When our research is finished we will analyse the results and publish them in papers read by academics, healthcare professionals, service users and managers and develop methods to help the NHS implement OD. We will also present our findings at international and national conferences. Service users will be heavily involved in communicating our findings to the wider public.

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