Title: Coproducing improved mental health acute inpatient discharge using a Systems Approach: MINDS study
Funder: Department of Health and Social Care

Abstract: What is the problem?_x000D_ _x000D_ Around 50,000 people leave mental healthcare hospitals every year. Leaving hospital (being discharged) is a critical transition point in terms of personal recovery. Many find discharge overwhelming and distressing. There is a risk of becoming unwell again and around 13% of people quickly go back into hospital. This has been made worse by COVID-19. A poorly planned discharge can also increase the risk of suicide. Research shows that identifying people’s needs after they leave hospital and making clear personalised plans can help to support people move safely from hospital to home._x000D_ _x000D_ However, two national surveys with a total of 1,341 people (by the charity Mind and our research team) found that 40% of people leaving mental health hospitals have no plan in place to support them after they leave. National Institute for Health and Care Excellence (NICE) guidelines state that discharge planning should include staff working together with service users (being collaborative), but the surveys revealed that over 50% of service users had no or little involvement in planning._x000D_ _x000D_ Working together to improve discharge_x000D_ _x000D_ There are likely to be many complicated reasons why discharges are not well or collaboratively planned. This could include a lack of understanding of how staff, service users and carers/supporters can work together to plan discharge, the way that staff relate to service users, limited resources, and pressures on staff. We believe that for us to improve discharge planning we need to understand these complicated factors._x000D_ _x000D_ The MINDS project team includes people with lived-experience of discharge from mental health hospital, professionals and researchers. There have been previous attempts to improve discharge, but this project is the first to combine a research approach called ‘realist research’ with a design process called a ‘systems approach’ to understand lived-experience and coproduce a better approach to discharge planning. Realist research and systems approaches involve understanding all the steps in a process from the point of view of the people involved. Including why discharges are often not well planned, what people need to stay well after leaving hospital and how a coproduced discharge planning approach could address this. This should result in discharge processes that are easier to implement, better address the needs of service users and carers, and are more sustainable than what is currently available._x000D_ _x000D_ What will we get from the project?_x000D_ _x000D_ The MINDS project will work closely with a Lived Experience Advisory Group, carers and healthcare professionals to coproduce a Systemic Discharge Care Approach (SDCA) to support staff, service users and carers to meaningfully plan for people to leave hospital. These will centre on people’s individual needs, support collaboration, and help people to think about how to maintain good mental health and wellbeing after they leave hospital; while being balanced to address wider systemic factors. We will ask staff and service users to try using the coproduced SDCA. This is to find out whether it helps people feel more prepared to leave hospital, stay well and have a good quality of life after getting home. If we find that the tools and guidance are helpful, we will develop a future study to make sure that the tools and guidance can be used across all NHS adult mental healthcare hospitals.

Lay abstract: Research questions_x000D_ _x000D_ 1. What are the requirements of service users (SUs) being discharged from adult mental health wards?_x000D_ 2. How is personalised discharge planning understood by SUs, carers and staff and what do they identify as key outcomes to determine this?_x000D_ 3. How do active components of discharge planning and their relationships to each other at individual, interpersonal, community, organisational and policy levels meet SU discharge requirements?_x000D_ 4. How does an understanding of the interaction between system and SU requirements inform a Systematic Discharge Care Approach (SDCA) that supports discharge planning?_x000D_ 5. How can we implement the SDCA to improve SU outcomes?_x000D_ _x000D_ _x000D_ Background_x000D_ _x000D_ Pre-COVID-19, around 50,000 people were discharged from acute mental health settings annually and pressures of the pandemic have increased this. The transition period following discharge is the highest risk area of mental health provision in terms of relapse, readmission, and suicide. Before COVID-19, 13% of SUs in England were quickly readmitted and 32% of suicides were within 2 weeks. COVID-19 has complicated this with significant increases in rapid discharge, exacerbation of mental health difficulty and social distancing rules that impede transition._x000D_ _x000D_ Preparing and planning discharge with SUs, carers and supporters. is critical to aiding successful transition from ward to home and managing this high-risk period. However, evidence suggests that people are often given little (if any) notice of their discharge and are rarely meaningfully involved in discharge planning. Discharge takes place within complex ward systems but previous attempts at intervention development have neglected systemic factors; this has resulted in inconsistent and poor outcomes. This project integrates realist methodology and an engineering-informed healthcare systems approach to build programme theory and coproduce systemic discharge solutions to improve discharge outcomes. These coproduced solutions will be sensitive to SU and staff needs, transferrable across NHS acute mental health settings, easy to implement and so more sustainable than what is currently available._x000D_ _x000D_ _x000D_ Aims_x000D_ _x000D_ Understand discharge planning as a complex intervention within complex systems and coproduce a SDCA. The MINDS study will evaluate the implementation and cost-impact of the SDCA ready for a future clinical trial._x000D_ _x000D_ _x000D_ Objectives_x000D_ _x000D_ 1. Understand discharge planning as a complex intervention within complex ward systems and the discharge planning requirements of people leaving the ward_x000D_ 2. Coproduce a SDCA involving discharge planning processes, personalised discharge planning tools, and system strengthening and implementation guidance_x000D_ 3. Evaluate acceptability, implementation and cost-impact of the SDCA_x000D_ _x000D_ _x000D_ Methods_x000D_ _x000D_ This study combines realist review and evaluation, an established engineering-informed systems approach to healthcare design (Engineering Better Care), with coproduction emphasised at all stages. Implementation and cost evaluation will be undertaken in line with MRC complex intervention development guidance._x000D_ _x000D_ _x000D_ Timelines for delivery_x000D_ Delivered across 36 months_x000D_ _x000D_ Anticipated impact and dissemination_x000D_ _x000D_ Improving the problem of poor discharge would improve the lives, safety and mental health recovery of significant numbers of SUs annually. Dissemination plans include policy impact (including NICE), NHS services and grassroots SU organisations (including partner Mind).

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