Title: Improving access to psychological therapy on acute mental health wards
Funder: Department of Health and Social Care

Abstract: Aims To increase access to psychological therapy on mental health inpatient wards and therefore improve patient, staff, ward and economic outcomes. Background Last year, 103,840 people spent time on mental health wards. Each admission costs over &pound;12,000, but inpatient care does not meet patients needs for evidenced-based psychological therapies. We propose an intervention to overcome this problem. Psychologists will deliver brief or longer therapy according to patients needs and wishes, as well as work with ward staff to create more psychologically-informed care environments. Research plan WP1. We will refine our proposed intervention to ensure that it is based on the best available evidence and acceptable to key stakeholders. This work will be informed by: a) a recently undertaken systematic review of therapy trials for inpatients; b) semi-structured interviews with 15-20 patients with recent inpatient experience, 10-15 carers and 15-20 staff exploring any adaptations we need to make to our intervention so it is acceptable to stakeholders and contextual factors that may impact on implementation; c) pilot study where we will implement the first iteration of the intervention to assess implementation and acceptability. Findings from a), b) and c) will be synthesised using consensus methods. The output will be a logic model for the intervention and a therapy manual to support delivery. WP2. We will evaluate the effect of the intervention on patient, staff, ward and health economic outcomes using a cluster randomised controlled trial with a 9-month internal pilot. Thirty four wards will be recruited in pairs (to stagger recruitment/intervention delivery). We will collect outcome measures at: baseline, 6-months and 9-months. Following baseline assessments, wards will be randomised to the intervention arm of the trial plus usual care, or usual care only. Co-primary outcome measures are serious incidents (risky behaviours) on the ward collected at the cluster level and patient well-being (Warwick-Edinburgh Mental Well-being Scale; WEMWBS) collected that the individual patient level for all patients within the clusters at baseline who consent complete self-report outcome measures. Assuming a mean number of 5.22 serious incidents in the control arm, 16 wards per arm has more than 80% power to detect a reduction in mean number of serious incidents to 3.13 (40% reduction). A sample of 384 (9 patients per cluster) at baseline will give us 85% power to detect an effect size of 0.04 for WEMWBS (3.5 point change on the scale) Secondary outcomes will be average length of stay, staff sickness, patient symptoms and functioning, perceptions of ward atmosphere and staff burnout. Analysis will follow intention-to-treat principles and we will follow the CONSORT statement for cluster RCTs. Treatment effects for the cluster level outcomes will be estimated using appropriate mixed models with a fixed effect for ward gender, and a random intercept for Trust. Individual (patient/staff) level outcomes measures will be analysed using an appropriate mixed models with random intercepts forward. Baseline measures assessed prior to randomisation will be used as covariates where possible. The EQ-5D-5L will be used to assess health status and to estimate Quality-Adjusted Life Years which will be the primary measure of health benefit for the economic analysis. A resource use inventory will be used at baseline and follow-ups to identify services used by trial participants and estimate the costs of health and social care. WP3. A mixed-methods process evaluation will be embedded within WP2 and build on qualitative work in WP1 to identify contextual factors that promote/inhibit implementation and routine incorporation into everyday practice. We will record the number of patients who were offered and received therapy and the number of and quality of therapy sessions delivered. Qualitative interviews will be carried out with 30-40 inpatient staff and 30-40 patients about their experiences of the intervention and analysed using thematic analysis. Researchers will be trained to directly observe and record staff and patient behaviour on wards to understand how the intervention is actually implemented. Both topic guides and observational checklists will be informed by the intervention logic model, implementation issues arising in WP1 and ongoing experiences in delivering WPs 2 and 3. We will use sampling frames to purposively sample interview participants and observation sites. Outputs and dissemination The output will be a potentially effective and cost-effective ward-based intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver and is acceptable to patients, carers and staff. We will include a comprehensive dissemination strategy developed in collaboration with key stakeholders. Benefits to patients and NHS Improving access to psychological therapies in inpatient settings is likely to reduce serious incidents that put patients at risk of harming themselves or others. Serious incidents are distressing for all involved and can prolong the length of inpatient stay, as well as requiring substantial staff resource. Psychological therapies are also likely to improve patient well-being, mental health symptoms, experiences of inpatient care and reduce staff burnout.

Lay abstract: Between 2014 and 2015, 103,840 people with severe mental illness spent time as inpatients because they were at risk of harming themselves or others. NICE recommend psychological therapies, like cognitive behaviour therapy, for severe mental illness. People want psychological therapies on inpatient wards, but they are not offered them. Mental Health Trusts prioritise spending money for therapy on outpatient services and ward staff often think that inpatients are too unwell to benefit from talking-based treatments like psychological therapy, so don t refer them. Therapy needs to be delivered differently in inpatient settings compared to the community. The overall length of therapy needs to be shorter and more focused, as patients may not be on wards for very long. Therapy sessions needs to be shorter and more frequent if patients have difficulties with concentration. Therapy is also more likely to involve other people, such as ward staff or relatives. We need to see how effective it is to deliver therapy in this way to inpatients. With this new knowledge, Trusts can make informed decisions about how to allocate money for therapy. It costs a lot of money to treat someone as an inpatient. Therefore, spending money on therapy to get people better quicker may be a good use of money. If inpatient therapy is shown to be effective, this evidence will also help overcome negative staff attitudes towards therapy for inpatients. The overall aim of this programme of work is to increase access to psychological therapy on mental health inpatient wards. We will achieve this aim by completing three work packages. Building on previous work, we will work alongside service users and other stakeholders, such as inpatient staff to adapt existing psychological therapy for inpatient settings. We will evaluate if a ward-based intervention that aims to increase access to psychological therapy improves outcomes. Based on knowledge so far, the intervention will give patients the opportunity to experience therapy sessions of a duration that matches their needs and wishes. If patients don t want therapy, psychologists will work with the ward staff to help staff get a better understanding of patients psychological needs. We will recruit 34 wards. Half will receive the intervention over six months and the other half will continue with usual care. We will measure the effectiveness of the intervention, in terms of reductions in events which pose risk to patients themselves or others, patient wellbeing/quality of life, staff burnout and ward atmosphere. We will also assess if the intervention saves money. We will interview key stakeholders and record and observe how the intervention is actually delivered on the wards to find out how the intervention works and ways of overcoming barriers to embedding it within the NHS.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH