Title: Development of a Novel Outcome Measure for Forensic Psychiatric Services
Funder: Department of Health and Social Care

Abstract: BackgroundImproving outcome measurement is a national policy priority in mental healthcare. This is important in forensic mental health services, where outcomes remain poorly researched. Outcomes are increasingly used for planning recovery and treatment plans in a collaborative way with patients. A lack of appropriate outcome measures is also a barrier to research in forensic psychiatry. Clinicians working in the field have repeatedly identified a lack of suitable measures.Systematic reviews have identified a lack of research on outcome measures, consensus on the most relevant outcomes and patient input. The only commonly used outcome measure in forensic practice in England is the HoNOS-Secure, which is limited by the fact that it does not involve patients' views and often lacks the confidence of clinicians. AimThe research seeks to establish what outcome domains are important to clinicians and services users in forensic psychiatry. It then aims to develop a novel outcome measure that will accurately capture these domains using both clinicians' and patients' ratings. This tool will be utilised to track and quantify progress and plan care for patients in a collaborative, valid and reliable manner. It will also be a tool that can be used in research in forensic mental health services, enabling investigators to determine the impact of new potential interventions. Goals1) To update the evidence base on outcomes in forensic mental health and assess existing measures 2) To determine which outcome domains are most important to measure in forensic mental health services 3) To develop a new outcome measure for use in forensic mental health services which has the confidence of both clinicians and service users4) To pilot this tool in clinical services to evaluate its feasibility and acceptability and begin to establish its reliability and validityPlan of InvestigationSystematic ReviewThis will build on previous reviews, incorporating new evidence. The instruments identified will be assessed by established quality criteria.Establishing Patients' and Clinicians' Views Clinicians' views will be established through a nationwide survey and three stakeholder events, which will include focus groups. Patients' perspectives would be obtained through detailed interviews with ten patients. The focus groups and interviews will be transcribed and subjected to thematic analysis.Development of the New Tool A modified Delphi process will be used to gain consensus on the domains that should constitute the new tool. Delphi participants will then be asked to come to a consensus on which new items developed by the research team should be included in the draft tool. Cognitive interviews will be used to test the draft measure and content validity of the instrument assessed.Piloting The tool will be piloted in the Oxford Health NHS Foundation Trust forensic service to evaluate its psychometric properties. The feasibility and acceptability of using the new tool will be determined. Completion rates will also be measured to establish ease of use. The tool will also be assessed for internal consistency and inter-rater and test-retest reliability. Concurrent validity will be determined by comparing it to HoNOS Secure and other routinely collected measures. Potential Benefits to Patients and the NHSThis project aims to ensure that the most relevant outcomes for patients and clinicians can be reliably captured using a practical and credible new tool. It is anticipated that there will be direct benefits to patients, who will have a better experience of care as a result of being involved in rating their own outcomes. Such measurement of outcomes will facilitate the development of effective services and help determine the effectiveness of new interventions, within the NHS and beyond.

Lay abstract: Introduction and AimThis research project focuses on forensic psychiatric services. Forensic psychiatric services treat mentally disordered offenders in a range of settings, including in secure hospitals and in the community.The level of security in these hospitals can vary from high, through medium, to low and patients in the community may live in community hospitals, special hostels or independent accommodation.This research project aims to find out what it means for patients in forensic psychiatric services to be making progress in their care. It will consider the perspective of patients themselves and the professionals caring for them. The next step will be to develop a tool, most likely to be a type of questionnaire, to measure how people are doing. This would be filled in by both the patients and the professionals. It would cover a range of areas, such as how the patients' mental health is, the level of risk they pose to themselves or other people, how good their quality of life is and how well they are progressing towards rehabilitation back in to society.It is hoped that if we can measure what is most important for the people using forensic psychiatric services and the professionals looking after them, then we can ensure that the care such patients receive is the best possible.BackgroundPatient groups, professionals and the Government have recognised the importance of measuring the impact of the care provided by the NHS. Increasing emphasis is being placed on making sure that we have the tools to measure these outcomes and ensuring that these include the priorities of patients, as well as professionals. Previous research has shown that while some measures do already exist for use in forensic psychiatric services, these are often limited by several factors. One limitation is that the measures can focus more on the risk that people pose to the public or the state of their mental health and not enough on a person's quality of life or the progress they are making towards rehabilitation back in to society. Another key limitation is that most measures that already exist are rated solely by professionals and do not take in to account the views of the people using such services.Design and MethodsThe first part of the process will be to look at what research has already been published in this area. The outcome tools that already exist will be evaluated to see how good they are at measuring people's progress in forensic psychiatric services. Professionals working in forensic psychiatric services in the UK will be asked to fill in a survey about what they think are the most important things to measure. There will also be several faceto-face events, including focus groups of professionals, to further explore the themes that come up. Ten patients will also be interviewed in depth to gain their views about what is important.In the next stage a panel of both patients and professionals will be presented with information from the first stage and asked to rate the areas that they think are most important to measure. This will happen repeatedly, until there is agreement about the most important areas. The research team will then design questions that address these areas and will ask the panel to decide which questions are the best.This will produce a new tool consisting of one set of questions for patients and another for professionals. Five patients and five professionals will be asked to complete these questionnaires and feedback whether they make sense and if any improvements can be made to the language, order or presentation. The final tool will then be used in the clinical setting to see how it works in practice and how it compares to the other measures that are currently in use.Patient and Public InvolvementPatients and the public will be closely involved not just as participants in the research, but also in determining the way it is carried out. A small advisory group of patients from forensic psychiatric services and patient representatives from national organisations will oversee the research and provide input to make sure that it aligns with both patient and public priorities.DisseminationThe results of the research will be made available through a range of means. As well as publishing the results in scientific journals and presentations at scientific conferences, it is also planned that information will be presented to the public through podcasts, social media and through the national patient networks of mental health charities.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH