Mental health services in England are about to be measured against a new set of standards that define what "recovery" actually means in practice. The problem is that while the NHS and mental health professionals agree that services should help people rebuild satisfying, hopeful lives despite ongoing illness, there is no agreed way to measure whether services are actually doing that. This project will develop quality standards, a manual for staff to follow, and the tools needed to assess both patient outcomes and how faithfully teams implement the recovery approach. The team will test these tools with 80 patients and 80 staff, then run a cluster randomised trial involving 30 teams across London and Gloucestershire to see whether the manualised intervention improves outcomes compared to usual care. If successful, the research could give the NHS a standardised, evidence-based way to shift mental health services from simply managing symptoms toward supporting people to regain control over their lives. The team also plans to create a user-led social enterprise to train NHS staff, embedding the approach beyond the life of the grant.
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AIMS AND OBJECTIVESThis proposal will develop recovery-focussed (a) quality standards, fidelity measure and outcome measures; (b) manualised interventions; and (c) randomised controlled trial evidence.BACKGROUNDThere is a policy and professional consensus about the importance of ‘recovery’ in mental health services, defined as “a way of living a satisfying, hopeful, and contributing life” even with any limitations caused by illness [1-3]. This has recently been elaborated: “Recovery is the process of regaining active control over one’s life. This may involve discovering (or rediscovering) a positive sense of self, accepting and coping with the reality of any ongoing distress or disability, finding meaning in one’s experience, resolving personal, social or relationship issues that may contribute to one’s mental health difficulties, taking on satisfying and meaningful social roles and calling on formal and / or informal systems of support as needed” [4]. Mental health is an NHS priority area.The emerging evidence base for values, interventions and evaluation methodologies all inform the proposal. The research team have a track record of significant contributions and pilot studies.RESEARCH PLANSThe proposal utilises the latest MRC framework for evaluating complex interventions [5,6], and relates to adult mental health services in England.Module 1. Define the problemMental health services are insufficiently recovery orientated, but the extent of the problem is unknown. Quality standards will be developed. In relation to these standards, national prevalence will be investigated by (i) using a national dataset of mental health services; (ii) a national survey of 60 representative team managers, which will also involve asking 10 patients from each team to complete a recovery measure. Focus groups (n=15) will identify contextual blocks and enablers of recovery implementation.Module 2. Optimise the interventionA systematic review will identify the evidence for pro-recovery interventions. These will be evaluated against four criteria: clinical effectiveness; cost-effectiveness; meaningfulness; and feasibility for implementation in the NHS. A manualised intervention will be developed.Module 3. Optimise the evaluationCandidate recovery outcome measures will be identified through review, and then evaluated in 80 patients and 80 staff to establish their concurrent, content, consensual and cross-cultural validity, internal consistency, test-retest reliability and sensitivity to change. Two innovative approaches to identifying individualised primary outcomes will be investigated – selecting from a predefined list and using recovery-focussed goal attainment scaling. Fidelity scales will be developed and piloted.Module 4. Optimise trial parametersA cluster randomised controlled trial will investigate the impact of the intervention manual developed in Module 2. The trial will involve 30 teams from London and Gloucestershire, with 10 patients and up to 10 staff participating from each team. The intervention will be evaluated in relation to standardised clinical outcomes, resource consequences, and the standardised recovery outcomes and individualised outcomes piloted in Module 3. Process evaluation will identify factors influencing implementation.Module 5. Knowledge transferA multi-level approach [7] to influencing NHS practice will be used, including: publication of a scientific book, training manual and information leaflets; scientific and practice-focussed conferences; web-site development; and exploring feasibility of a user-led social enterprise business to provide training and consultancy to the NHS.RESEARCH TEAMTeam expertise includes health services research (outcomes, effectiveness), statistics, economics, behaviour change, public health, qualitative, user-research, systematic reviews and culture.RESEARCH ENVIRONMENTThe South London and Maudsley NHS Foundation Trust (SLaM) and the Institute of Psychiatry (IoP), King’s College London have
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