Summary of the impact

This case study focuses on the research conducted by members of the UoA examining the services offered to service users and carers in secure settings. This includes forensic mental health services and prisons. It has had a significant impact on the development of professional practice in secure settings based on the views, experiences, and needs of service users and carers. It has established service user and carer engagement in research conducted in secure settings. It has also informed service and policy developments in the United Kingdom and internationally.

Underpinning research

The research started with a small scale project looking at the health care provision at Holloway Prison in 2000 followed by a study helping to develop collaborative working with service users in forensic mental health settings. This has led to an on-going large programme of work with a number of studies developed and supported by external research grants from a range of funders. The completed research includes (supporting references):

1. Examining service user satisfaction with services. This led to the first satisfaction scale developed specifically for users in medium secure services and developed with service users as co-researchers. This was followed by a cross sectional survey of two medium secure units in these settings examining service users therapeutic relationship with staff, perceptions of the ward environment and how this relationship influences their level of satisfaction with services. The therapeutic relationship between users and staff was identified as the most significant factor in determining service user satisfaction (1,2,3).
2. The Telehealth Project. Introduced video conferencing facilities to fifteen sites served by Oxleas NHS Foundation Trust, including the forensic service. The research evaluated the introduction of this intervention, and facilitated, closer and better quality service user, carer and clinical consultations (4).
3. Examining carers' views and experiences of forensic mental health services. The most important need identified by this group of carers was to provide regular and appropriate information. Based on the above information, a collaborative project was devised and supported by two medium secure units to introduce, develop and embed a carer support worker role into the two secure units. It also examined the impact the role has on addressing carers support and information needs (5).
4. Examining adherence to antipsychotic medication in mentally ill prisoners. The study found a significant positive correlation between mentally ill prisoners' perceived need for treatment and their adherence to psychiatric medication. Mentally ill offenders' adherence to antipsychotic medication tended to be characterised by passive acceptance rather than by active participation (6).

The continued importance of this work stream is exemplified by ongoing and newly funded work to develop important aspects of forensic inpatient services. These include a pilot trial examining the introduction of a structured communication approach utilising computer tablet technology with non-directive counselling to inpatients in forensic mental health inpatient settings, funded by the Research for Patient Benefit programme (NIHR £246,997) (9). We have just been awarded a large grant for a Knowledge Transfer Partnership (KTP) (£194,640) to introduce and embed peer support workers as co-workers into Oxleas NHS Foundation Trust and evaluating the impact of the introduction. The project commenced in September 2013.

References to the research

Quality of the research

All of the outputs were reviewed in peer reviewed journals and all of the outputs received external funding. The importance of the work is demonstrated by the list of publications in peer reviewed journals and successful continued funding which has increased in value over time as the work has developed and received greater recognition in the field of forensic mental health.

The Comquol study (3) received the important accolade of the 2012 national Mental Health Research Network (MHRN) Service Users Research Enterprise (SURE) award for best service user involvement in a portfolio study. This has been followed up with invitations to address national (i.e. Institute of Psychiatry) and international conferences (International Academy of Law and Mental Health) as well as to service user group conferences and meetings (i.e. SUNLOWS research group, London). Work of the UoA has been used to illustrate good practice at a national level: the collaborative approach to work with service users was highlighted as a case study in a recent NIHR publication of case studies illustrating the impact of service user involvement in mental health research, and other work cited by the Sainsbury Centre report (2008) "Reviewing Service User Involvement in Prison Mental Health Research". Similarly, other work (the procedures used in the service user satisfaction work) has been cited. Funders also have profiled the work, with the telehealth project rated by the funder as outstanding.

Furthermore, Dr MacInnes was invited to join the expert working group of the Royal College of Psychiatrists looking at `Good practice in the prevention and management of violence of patients with mental disorder'. The resultant national guidelines (CR177) were published in July 2013. Prestigious invitations have arisen from this work demonstrating its esteem in the eyes of peers. Examples are an invitation to chair the steering group of a Research for Patient Benefit study being conducted at the University of East Anglia (MacInnes), and invitations to give keynote addresses at conferences in Malaysia (MacInnes) and Hong Kong (D. Bressington, who has also been invited to work collaboratively with researchers at Hong Kong University. Dr MacInnes contributed a chapter on "Carers and Carer's Rights of Mentally Disordered Offenders" for the forthcoming "A Dictionary of Criminal Justice, Mental Health and Risk" to be published by Policy Press while D. Bressington co-authored a chapter on Medication Management in "Mental Health Nursing Skills" published by Oxford University Press in 2009.)

Funding: The following funding sources have supported the research, 2008-13.

1. Telehealth programme - Knowledge Transfer Partnerships Programme - £109,000. (Relates to research output 1).

2. Levels of Satisfaction at the Bracton Centre and Humber Centre for Forensic Psychiatry - Oxleas NHS Foundation Trust and Humber NHS Foundation Trust - £5,000. (Relates to research output 2).

3. Introduction of Carer Support Workers - HEFCE Higher Education Innovation Fund, Oxleas NHS Foundation Trust & Kent and Medway NHS Partnership Trust - £54,770

4. Evaluating the support needs of carers in forensic mental health settings - Oxleas NHS Foundation Trust & Kent and Medway NHS Partnership Trust - £8,500. (Relates to research output 5).

5. A Pilot Trial to Assess the Effect of a Structured Communication Approach on QUality Of Life in secure mental health settings (Comquol). Anticipated Completion Date, March 2014 - Research for Patient Benefit Programme - £246,997. (Relates to research output 3).

6. Phd Studentship - Developing a Model of Gender Based Care for Women in Secure Settings - Oxleas NHS Foundation Trust - £50,000.

7. Prison Impact Study - National Forensic Mental Health Research and Development Programme - £56,000. (Relates to research output 6).

8. Peer Support Workers - Knowledge Transfer Partnerships Programme - £194,640 (commenced September 2013).

Total: £801,407

Details of the impact

Service user satisfaction

Two of the participating sites in the study (in South East London and Yorkshire), have changed their service approach following the results of the findings. In London, a review of the quality (and amount) of interaction between staff and users and development of a new service user information policy followed from research findings showing low satisfaction scores in relation to staff interaction and information giving to ensure that clear, current and accurate information was relayed to service users. In Yorkshire, services instigated group discussions with users to examine perceived dissatisfaction and ways of resolving problems, following low staff interaction and safety satisfaction scores obtained in the research. Further impact has arisen through use of the Forensic Satisfaction Scale developed by the UoA to assess levels of satisfaction in a Confidential Inquiry into the care of mentally disordered offenders by the forensic service in Ireland.

Currently, discussions are underway with a view to introduce the intervention developed in the Comquol study (begun in January 2012) throughout the Trust where the first phase of the intervention took place, following findings from the first cohort of the study showing major positive improvements in virtually all of the assessed service user outcomes (quality of life, satisfaction, therapeutic relationship, ward environment, recovery, as well as reduced stress levels in the nursing staff participating in the intervention). Additional impact has arisen from service user involvement in the development of the project with one service user employed as a member of the research team who is co-facilitating the development of the qualitative phase of the study. This work is still on-going but currently 38 members of staff have been trained in the Structured Communication Approach (another 16 by December 2013) with 40 service users completing the intervention (another 16 by December 2013).

Telehealth project

Impact of the teleheath project has been demonstrated through ongoing use of the facilities and procedures developed as part of the project which has had an impact on discharge rates and reduced staff travel. These principles and policies were embedded into the Trust's working practices as part of the study. The facilities have been used for over 350 meetings/consultations. The resulting improved communication has led to a reduction in the 2-3 month delayed discharge rate of 75% and reduced staff travel. It has been calculated by the Trust the expected savings in the three years following the introduction of telehealth will be £762,554. Important impact has also been obtained from this KTP project in Oxleas NHS Trust. Following positive evaluation at the pilot stage the project has been expanded from an initial five sites to sixteen sites across the Trust, with current plans to introduce telehealth facilities across the whole of the Trust. Over 50 Trust staff were trained in using the technology and 15 staff given in-depth training as local champions and local leads.

Carers views and experiences of forensic mental health services

The development and introduction of carer support worker (CSW) roles in two forensic services in Kent and South East London arose directly as a result of the research work of the UoA. The roles were commissioned as permanent roles in the service and there have since been over 200 consultations between the CSWs and carers in these services. This service development is based on the UoA's systematically developed step by step approach to the development of carer support services in secure settings. This has included developing information and support resources (i.e. in the diagnosis and prognosis of common mental health disorders) the CSWs can access to help maintain informed discussions with carers.

Adherence to antipsychotic medication in mentally ill prisoners

Findings from this study identified the relationship between the personal relevance of medication and increased levels of adherence This was the first major study to systematically examine adherence to antipsychotic medication in mentally ill offenders and clarified the important research design elements to be included when undertaking adherence research with this cohort of participants. Ongoing impact on professional practice arising from this work will continue as the first RCT of an adherence therapy approach utilised with a forensic mental health population (Cavezza et al, 2013), tests an intervention developed based on the work of this UoA. Arising from this body of work,Dr. MacInnes was invited to join the Royal College of Psychiatrist's Invited Review Service and was involved in a serious case review for the Health and Social Services States of Jersey as well as carrying out an Independent Inquiry into breaches of security at a low secure unit at Oxleas NHS Foundation Trust.

Sources to corroborate the impact

1. Oxleas NHS Foundation Trust. Director of Forensic Services, Oxleas NHS Foundation Trust. (Telehealth). (contact I.D. 1)
2. Kent and Medway NHS and Partnership Trust. Consultant Forensic Psychiatrist and Assistant Medical Director. Kent and Medway NHS and Social Care Partnership Trust. (Carers work). (contact I.D. 2)
3. Royal College of Psychiatrists. Consultant Forensic Psychiatrist and former Head of Forensic Faculty, Royal College of Psychiatrists. Head of Confidential Committee of Inquiry Into the Current Care and Treatment Practices in the Central Mental Hospital, Dublin (User satisfaction). (contact I.D. 3)
4. Knowledge Transfer Partnerships. MacInnes. D., Enser. J., DeWeger. E., Francis. S. & Jones. F. (2012) Knowledge Transfer Partnerships: Partners. Final Report (KTP007653). Knowledge Transfer Partnerships, Swindon. (Telehealth).
5. Service User Research Enterprise (SURE) Mental Health Research Network Service User Award for portfolio study with best service user involvement. Changing Lives Inspiring Minds. Annual Research and Knowledge Exchange Report 2013. Canterbury Christ Church University. (User satisfaction).
6. Mental Health Research Network (MHRN). Head of Mental Health Research Network London and South Hub. (User satisfaction). (contact I.D. 4)
7. Humber NHS Foundation Trust. Nurse Consultant. Humber NHS Foundation Trust. (User satisfaction). (contact I.D. 5)
8. Adherence to medication in prisons. Cavezzaa. C., Auroraa. M. and Ogloff. J. (2013) The effects of an adherence therapy approach in a secure forensic hospital: a randomised controlled trial. Journal of Forensic Psychiatry and Psychology, 24 (4), 458-478. (Adherence in prisons)
9. Royal College of Psychiatrists College Report CR177: Prevention and Management of Violence: Guidance for Mental Healthcare Professionals. (User satisfaction) http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr177.aspx.
10. Service user Collaboration. Staley. K. (2013) A series of case studies illustrating the impact of service user and carer involvement on research. NIHR, London. (User satisfaction), http://www.mhrn.info/data/files/NEWS/MHRN_CaseStudiesAugust_2013.pdf.