Recent Submissions

  • The social worker in community mental health teams: Findings from a national survey

    Hughes, Jane; Challis, David (2021)
    Summary: Social workers have been members of community mental health teams (CMHTs) for many years. However, a combination of factors has resulted in their removal from CMHTs in some areas in recent years. This study presents findings from a 2018 national survey of CMHT team managers (44% response rate), to ascertain the current position of the social worker within CMHTs in England. Analyses focussed on membership, roles and tasks, and change within the previous 12 months. Descriptive statistics were used to analyse the quantitative data and content analysis to interpret free text comments. Findings: Social workers were found to undertake a variety of generic roles and tasks but were reported to do so proportionally less often than nurses. A large minority were involved in non-traditional social work tasks such as monitoring medication. In one-fifth of teams, managers thought they had too few social workers. Free text comments suggested that managers valued social workers for their social perspective and expressed concern regarding their removal or the curtailment of their role, perceiving this as having a negative effect on overall CMHT service delivery. Applications: The findings provide evidence of some instability in the position of social workers within CMHTs in relation to both their membership and their involvement in traditional and non-traditional roles and tasks. Free text comments suggest that if a biopsychosocial model of mental health support, now recognised as essential to long-term wellbeing, is to be achieved, a social work presence in CMHTs is required. © The Author(s) 2021.
  • Community Occupational Therapy for people with dementia and family carers (COTiD-UK) versus treatment as usual (Valuing Active Life in Dementia [VALID]) study: A single-blind, randomised controlled trial

    Challis, David; Orrell, Martin (2021)
    Background: We aimed to estimate the clinical effectiveness of Community Occupational Therapy for people with dementia and family carers-UK version (Community Occupational Therapy in Dementia-UK version [COTiD-UK]) relative to treatment as usual (TAU). We hypothesised that COTiD-UK would improve the ability of people with dementia to perform activities of daily living (ADL), and family carers' sense of competence, compared with TAU.Methods and Findings: The study design was a multicentre, 2-arm, parallel-group, assessor-masked, individually randomised controlled trial (RCT) with internal pilot. It was conducted in 15 sites across England from September 2014 to January 2018. People with a diagnosis of mild to moderate dementia living in their own home were recruited in pairs with a family carer who provided domestic or personal support for at least 4 hours per week. Pairs were randomised to either receive COTiD-UK, which comprised 10 hours of occupational therapy delivered over 10 weeks in the person with dementia's home or TAU, which comprised the usual local service provision that may or may not include standard occupational therapy. The primary outcome was the Bristol Activities of Daily Living Scale (BADLS) score at 26 weeks. Secondary outcomes for the person with dementia included the following: the BADLS scores at 52 and 78 weeks, cognition, quality of life, and mood; and for the family carer: sense of competence and mood; plus the number of social contacts and leisure activities for both partners. Participants were analysed by treatment allocated. A total of 468 pairs were recruited: people with dementia ranged from 55 to 97 years with a mean age of 78.6 and family carers ranged from 29 to 94 with a mean of 69.1 years. Of the people with dementia, 74.8% were married and 19.2% lived alone. Of the family carers, 72.6% were spouses, and 22.2% were adult children. On randomisation, 249 pairs were assigned to COTiD-UK (62% people with dementia and 23% carers were male) and 219 to TAU (52% people with dementia and 32% carers were male). At the 26 weeks follow-up, data were available for 364 pairs (77.8%). The BADLS score at 26 weeks did not differ significantly between groups (adjusted mean difference estimate 0.35, 95% CI -0.81 to 1.51; p = 0.55). Secondary outcomes did not differ between the groups. In total, 91% of the activity-based goals set by the pairs taking part in the COTiD-UK intervention were fully or partially achieved by the final COTiD-UK session. Study limitations include the following: Intervention fidelity was moderate but varied across and within sites, and the reliance on primarily proxy data focused on measuring the level of functional or cognitive impairment which may not truly reflect the actual performance and views of the person living with dementia.Conclusions: Providing community occupational therapy as delivered in this study did not improve ADL performance, cognition, quality of life, or mood in people with dementia nor sense of competence or mood in family carers. Future research should consider measuring person-centred outcomes that are more meaningful and closely aligned to participants' priorities, such as goal achievement or the quantity and quality of activity engagement and participation.Trial Registration: Current Controlled Trials ISRCTN10748953.
  • Taking part in the community occupational therapy in dementia UK intervention from the perspective of people with dementia, family carers and occupational therapists: A qualitative study

    Orrell, Martin (2020)
    AIMCommunity Occupational Therapy in Dementia (COTiD-UK) is a manualised intervention delivered to the person with dementia and their identified family carer primarily in their own home. The focus is on enabling both the person with dementia and their family carer to engage in personally meaningful activities. This qualitative study examines the experiences of people with mild to moderate dementia, their family carers and occupational therapists, of taking part in the COTiD-UK intervention.METHODA purposive sample of 22 pairs of people with dementia and a family carer and seven occupational therapists took part in semi-structured interviews that were audio recorded, transcribed and inductively analysed using thematic analysis.FINDINGSThemes from the occupational therapist interviews relate to the COTiD-UK intervention philosophy and content, aspects of delivering it in practice and thinking ahead to it becoming usual practice. Themes from the pair interviews relate to the focus of COTiD-UK sessions on meaningful occupation and working together and a sense of being able to plan to live well with dementia in the short- and longer-term as a result of the intervention.CONCLUSIONThis person-centred occupation-focussed intervention was highly valued by people with dementia and their family carers and the occupational therapists delivering it.
  • Chronic enterocutaneous fistula: management in the community setting

    Anders, Tessa (2020)
    Despite being aggravating and potentially embarrassing, enterocutaneous fistulas can be successfully managed, with patients being able to resume many of their normal daily activities while the fistula continues to drain. Nevertheless, the management of enterocutaneous fistulas in the community can pose many challenges to nurses, the most common being peri-fistula moisture-associated skin damage. This article presents fistula management plans, which can facilitate the long-term support of these patients, promoting patient comfort and adherence to treatment.
  • Perceptions of the social worker role in adult community mental health teams in England

    Hughes, Jane; Challis, David (2020)
    There is a growing recognition of the importance of the social work contribution within community mental health services. However, although many texts describe what the mental health social work contribution should be, little empirical evidence exists about their role in practice and the difference it might make to service users. This qualitative study sought to articulate this contribution through the voices of social workers and their multidisciplinary colleagues via focus group discussions across four English Mental Health Trusts. These considered the impact of the social worker on the service user. Thematic analysis resulted in the identification of three over-arching themes: social workers own perceptions of their contribution situated within the social model; the high value their colleagues placed on social work support and leadership in a range of situations and the concerns for service users if social workers were withdrawn from teams. Key findings were that social workers are the only professional group to lead on the social model; that this model enhances the whole teams’ practice and is required if service users are to be offered support that promotes long-term recovery and that without social workers, the community mental health team offer would be more transactional, less timely, with the potential for the loss of the service users’ voice. If social work is to make a full contribution to community mental health team practice, it must be clearly understood and provided with the support to enable social workers to operate to their full potential. © The Author(s) 2020.
  • Peer support for discharge from inpatient to community mental health services: Study protocol clinical trial (SPIRIT Compliant)

    Repper, Julie (2020)
    INTRODUCTION: In the period shortly after discharge from inpatient to community mental health care, people are at increased risk of self-harm, suicide, and readmission to hospital. Discharge interventions including peer support have shown potential, and there is some evidence that community-based peer support reduces readmissions. However, systematic reviews of peer support in mental health services indicate poor trial quality and a lack of reporting of how peer support is distinctive from other mental health support. This study is designed to establish the clinical and cost effectiveness of a peer worker intervention to support discharge from inpatient to community mental health care, and to address issues of trial quality and clarity of reporting of peer support interventions. METHODS: This protocol describes an individually randomized controlled superiority trial, hypothesizing that people offered a peer worker discharge intervention in addition to usual follow-up care in the community are less likely to be readmitted in the 12 months post discharge than people receiving usual care alone. A total of 590 people will be recruited shortly before discharge from hospital and randomly allocated to care as usual plus the peer worker intervention or care as usual alone. Manualized peer support provided by trained peer workers begins in hospital and continues for 4 months in the community post discharge. Secondary psychosocial outcomes are assessed at 4 months post discharge, and service use and cost outcomes at 12 months post discharge, alongside a mixed methods process evaluation. DISCUSSION: Clearly specified procedures for sequencing participant allocation and for blinding assessors to allocation, plus full reporting of outcomes, should reduce risk of bias in trial findings and contribute to improved quality in the peer support evidence base. The involvement of members of the study team with direct experience of peer support, mental distress, and using mental health services, in coproducing the intervention and designing the trial, ensures that we theorize and clearly describe the peer worker intervention, and evaluate how peer support is related to any change in outcome. This is an important methodological contribution to the evidence base. TRIAL REGISTRATION: This study was prospectively registered as ISRCTN 10043328 on November 28, 2016.
  • Changes in commissioning home care: an English survey

    Hughes, Jane; Chester, Helen; Challis, David (2020)
    Purpose: The purpose of this study is to examine changes in the nature, form and range of commissioning arrangements for home care. Design/methodology/approach: Data from two discrete national surveys of English local authorities with social service responsibilities were used. In the first, undertaken in 2007, responses from 111 of the 151 local authorities (74%) were received; in the second, undertaken in 2017, responses from 109 local authorities (72%) were received. A combined data set of 79 complete cases, 52% of local authorities, was created. Percentage point differences across the two time periods were calculated and tested to identify significant changes and a systematic analysis of the free-text responses regarding intended changes to the commissioning process in each data set was undertaken. Findings: Findings identified substantial changes in some aspects of the commissioning of home care in the 2007-2017 decade. Collaboration between stakeholders had increased, particularly regarding the identification of future needs. Improved conditions of service and remuneration for home care workers were evident within the commissioning process. Standardised charges for home care (regardless of time and day) had also become more widespread. Initiatives to prompt providers to deliver more personalised care were more evident. Originality/value: This paper describes the evolution of commissioning arrangements for home care in localities in response to national policy initiatives. It provides guidance to commissioners in meeting the needs of current service users and emphasises the importance of collaboration with stakeholders, particularly providers, in securing future capacity.
  • The challenges of commissioning home care for older people in England: Commissioners' perspectives

    Hughes, Jane; Chester, Helen; Challis, David (2020)
    Home care for older people in England is commissioned through local authorities working predominantly with independent providers of care. Commissioners operate in a market model, planning and procuring home care services for local populations. Their role involves 'managing' and 'shaping' the market to ensure an adequate supply of care providers. Another imperative, emerging from the principles of personalisation, is the drive to achieve user outcomes rather than 'time and task' objectives. Little formal research has investigated the way commissioners reconcile these different requirements and organise commissioning. This study investigated commissioning approaches using qualitative telephone interviews with ten commissioners from different local authorities in England. The characteristics of commissioning were analysed thematically. Findings indicated (a) commissioning involved complex systems and processes, uniquely shaped for the local context, but frequently changed, suggesting a constant need for reframing commissioning arrangements; (b) partnerships with providers were mainly transactional, with occasional examples of collaborative models, that were considered to facilitate flexible services more appropriate for commissioning for personalised outcomes; and (c) only a small number of commissioners had attempted to reconcile the competing and incompatible goals of tightly prescribed contracting and working collaboratively with providers. A better understanding of flexible contracting arrangements and the hallmarks of a trusting collaboration is required to move beyond the procedural elements of contracting and commissioning. © The Author(s), 2020. Published by Cambridge University Press.
  • Self-management and social participation in community-dwelling people with mild dementia: A review of measuring instruments

    Orrell, Martin (2019)
    Background:In order to evaluate interventions promoting social health in people with dementia it is essential to have reliable and valid measures. The present review aims to provide an overview of available instruments for the assessment of two domains of social health in community-dwelling people with mild dementia, i.e., the ability to manage life with some degree of independence (self-management) and participation in social activities. <br/>Method(s):An electronic search was conducted in the following databases: PubMed, CINAHL, and PsycINFO. Characteristics of the instruments, feasibility and psychometric properties of the instruments included are reported on. <br/>Result(s):We identified eight instruments measuring aspects of self-management and three instruments measuring social participation. Validity and reliability of self-management instruments varied between moderate and good. Little information was found on the psychometric properties of the instruments for social participation. In general, feasibility and responsiveness data regarding application in community-dwelling people with dementia were scarce for both types of instruments. <br/>Conclusion(s):Future research into assessment tools for social health should focus on the development of instruments for self-management that also cover the areas of coping with and adapting to the emotional consequences of the disease; instruments for social participation covering the involvement in social interactions that are experienced as meaningful by the person; and on the psychometric properties and responsiveness of instruments. More attention should also be given to the feasibility (ease of use) of these instruments for people with mild dementia, professionals, and researchers.<br/>Copyright &#xa9; 2019 International Psychogeriatric Association.
  • Cost-utility analysis of community occupational therapy in dementia (Cotid-Uk) versus usual care: Results from valid, a multi-site randomized controlled trial in the UK

    Orrell, Martin (2018)
    Objectives: Aim of this work is to assess the costs, outcomes and the cost-utility of the Community Occupational Therapy in Dementia (COTiD-UK) intervention compared to Treatment as usual (TAU), using the within-trial data from the VALID RCT. <br/>Method(s): A cost-utility analysis of the COTiD-UK intervention compared to TAU was performed using within-trial costs and outcomes data adopting the NHS perspective. Costs were calculated in 2017UK and include the cost of the COTiD-UK training for occupational therapists, the COTiD-UK intervention to person with dementia and supporters, the cost of NHS resource use (e.g. A&E and hospital admissions, GP consultations, etc.), medications, adaptations and equipment costs and changes in accommodation. The effectiveness of the intervention, captured using EQ5D-5L and DEMQOL questionnaires in both arms, were converted into QALYs, both for the person with dementia and the supporters. Extensive sensitivity analysis has been performed to control for uncertainty in the parameter values used. <br/>Result(s): The preliminary results of the analysis show that at 26 weeks there is some evidence that NHS costs are significantly higher in the COTiD-UK arm for person with dementia alone and for the person with dementia and supporters combined: this is mainly due to the cost of the COTiD-UK intervention. There is some evidence that in the intervention arm QALYs are higher in the person with dementia, but the findings are not statistically significant. Further work is currently exploring the broader societal costs and also modelling the long-term results beyond the trial. <br/>Conclusion(s): The preliminary results of this analysis seem to suggest that COTiD-UK is effective for the person with dementia, but the ICER is exceeding the recommended threshold of 20,000 per QALY. However these results do not take into account the societal costs (private costs, transport costs, productivity losses) for person with dementia and supporters, that may provide better results.<br/>Copyright &#xa9; 2018
  • Intensive case management for severe mental illness

    Irving, Claire B. (2017)
    Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. ICM evolved from 2 original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasizes the importance of small caseload (fewer than 20) and high-intensity input.
  • Community based mental health services in action

    Payne, Gary; Somerton, Kevin; Leeks, Alyson (2018)
  • Impact of untimely access to formal care on costs and quality of life in community dwelling people with dementia

    Orrell, Martin (2018)
    BACKGROUNDAccess to formal care is not always timely and a better understanding on the impact of untimely access is needed.OBJECTIVETo examine, from a societal perspective, the impact of untimely access to formal care in terms of total costs and quality of life over one year in community dwelling people with dementia.METHODSWithin the Actifcare study, needs, resource use, and quality of life were observed for one year in a cohort of 451 community dwelling people with dementia in 8 European countries. Untimely access to care was operationalized as having at least one unmet need for care identified by the Camberwell Assessment of Need for the Elderly (CANE) instrument. Two regression models were built for both total costs and quality of life measured by the EQ-5D-5L, one using sum of unmet needs and one using a predefined selection of need items.RESULTSUnmet needs were not associated with higher total costs but they were associated with a lower quality of life of people with dementia. Of all CANE items, only an unmet need for "company" was significantly related to lower total costs.CONCLUSIONTotal costs did not seem to differ between participants with unmet and met needs. Only few associations between specific unmet needs and costs and quality of life were found. Furthermore, quality of life of people with dementia decreases when multiple unmet needs are experienced, indicating that assessing and meeting needs is important to improve quality of life.
  • Predictive validity of a severity weighted functional comorbidity index in geriatric rehabilitation

    Godfrey, Deborah (2018)
    Background: In geriatric rehabilitation, functional prognosis informs expectations regarding recovery and discharge planning. Assessing pre-existent comorbidity may aid functional prognosis but existing indices have limitations in older populations. We investigated the predictive validity of the weighted Functional Comorbidity Index (wFCI) for recovery of mobility in an older cohort undergoing rehabilitation.
  • Supporting student nurses who have their first clinical placement in the community nursing team

    Taylor, Rachel; Pitt, Margaret (2018)
    First year student nurses are increasingly undertaking their first placement with community nurses. The importance of how this initial learning experience is introduced by the higher education institution, as well as how the student is welcomed and integrated into the community nursing team, cannot be underestimated. Following positive anonymous feedback from students, which indicated that they had benefitted from the introduction, welcome and integration they experienced, the university and mentors reviewed how this had been done to identify good practice to share with colleagues. Students indicated that their welcome and integration had helped them to feel part of the team and enhanced learning, because they were so well supported, and mentors had facilitated learning experiences by acknowledging that this was their first placement experience. It is notable that mentors were committed to the students' learning and used workplace social capital to optimise the student experience. At a time when retention of students is essential to increase the future workforce, mentors dedicated to student learning are acting as ambassadors for the community workforce, and may well encourage students to have a career in community nursing.
  • Community forensic psychiatry

    Puri, Ramneesh (2017)
    Provision of forensic psychiatry aftercare in the community is well established in the United Kingdom. The vast majority of outreach services affiliated with secure units have evolved into designated community forensic mental health teams (CFMHTs) to provide such care. There is, nonetheless, marked variance in the structure and remit of services concerned with the provision of this care as a result of differences in commissioning and presumed local requirements.
  • Chair based exercise in community settings: A cluster randomised feasibility study

    Robinson, Katie R. (2018)
    BACKGROUND: Some older people who find standard exercise programmes too strenuous may be encouraged to exercise while remaining seated - chair based exercises (CBE). We previously developed a consensus CBE programme (CCBE) following a modified Delphi process. We firstly needed to test the feasibility and acceptability of this treatment approach and explore how best to evaluate it before undertaking a definitive trial. METHODS: A feasibility study with a cluster randomised controlled trial component was undertaken to 1. Examine the acceptability, feasibility and tolerability of the intervention and 2. Assess the feasibility of running a trial across 12 community settings (4 day centres, 4 care homes, 4 community groups). Centres were randomised to either CCBE, group reminiscence or usual care. Outcomes were collected to assess the feasibility of the trial parameters: level of recruitment interest and eligibility, randomisation, adverse events, retention, completion of health outcomes, missing data and delivery of the CCBE. Semi- structured interviews were conducted with participants and care staff following the intervention to explore acceptability. RESULTS: 48% (89 out of 184 contacted) of eligible centres were interested in participating with 12 recruited purposively. 73% (94) of the 128 older people screened consented to take part with 83 older people then randomised following mobility testing. Recruitment required greater staffing levels and resources due to 49% of participants requiring a consultee declaration. There was a high dropout rate (40%) primarily due to participants no longer attending the centres. The CCBE intervention was delivered once a week in day centres and community groups and twice a week in care homes. Older people and care staff found the CCBE intervention largely acceptable. CONCLUSION: There was a good level of interest from centres and older people and the CCBE intervention was largely welcomed. The trial design and governance procedures would need to be revised to maximise recruitment and retention. If the motivation for a future trial is physical health then this study has identified that further work to develop the CCBE delivery model is warranted to ensure it can be delivered at a frequency to elicit physiological change. If the motivation for a future trial is psychological outcomes then this study has identified that the current delivery model is feasible. TRIAL REGISTRATION: ISRCTN27271501 . Date registered: 30/01/2018.
  • Implementation of individual placement and support (IPS) into community forensic mental health settings: Lessons learned

    Bird, Yvonne; Russell, Jo; Sahota, Karan; Khalifa, Najat (2018)
    IntroductionAssessment of the effectiveness of individual placement and support in forensic mental health settings is a relatively new field of research despite evidence demonstrating its effectiveness in generic mental health settings.MethodIPS was implemented into a community forensic mental health setting within a large National Health Service trust in the United Kingdom over 6 months. Using the Consolidated Framework for Implementation Research this paper describes the lessons learned from implementing individual placement and support into such settings.ResultsOur findings suggest that implementation of individual placement and support in forensic mental health settings is complex and requires robust planning and collaboration with internal and external agencies. Barriers to implementation included staff attitudes, difficulty engaging employers and lack of employment related performance indicators, and facilitators included the support of service managers and outside groups. Adaptations to the IPS model were made to address challenges encountered, including difficulty starting rapid job searches, concerns about stigma, lack of confidence, uncertainty around employment opportunities, offence restrictions and lack of interest from potential employers.ConclusionThis paper adds to the limited literature in the field. Findings are relevant to practitioners and service providers who wish to implement individual placement and support services for people with mental disorder and offending histories.
  • 'I don't want to take any risks even if it's gonna mean this service-user is gonna be happier': A thematic analysis of community support-staff perspectives on delivering Transforming Care

    Clifford, Adam; Jones, Jo (2018)
    Background: Transforming Care is making mixed progress in supporting people with intellectual and developmental disabilities, and complex needs, move to more appropriate specialist accommodations closer to home. Community support staff often spend greatest amounts of time with service‐users, yet are some of the least heard voices about why placements succeed and fail to varying extents. Method: Managers and support staff (n = 13), working in ostensibly “specialist” community placements, were interviewed about perceived barriers and facilitators to implementing Transforming Care. Transcripts were subjected to thematic analysis. Results: Participants identified difficulties balancing people's rights, safety and quality of life needs, and felt the system's expectations of them are hard to deliver within the resources, legislation, values and support models provided them. Multidisciplinary expertise was highly valued for both emotional and practical support, but was least valued when perceived as overly blaming or inspectorial. Specialist health input was seen to withdraw prematurely for this particular client group. Conclusion: Recommendations are provided for how staff perspectives should inform Transforming Care in interests of service‐users.

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