A study of outcomes measures in forensic mental health

Outcomes measures, which is the measurement of effectiveness of interventions and services has been propelled onto the health service agenda since the introduction of the internal market in the 1990s. It arose as a result of the escalating cost of inpatient care, the need to identify what interventions work and in what situations, and the desire for effective information by service users enabled by the consumerist agenda introduced by Working for Patients white paper. The research reported in this thesis is an assessment of the readiness of the forensic mental health service to measure outcomes of interventions. The research examines the type, prevalence and scope of use of outcomes measures, and further seeks a consensus of views of key stakeholders on the priority areas for future development. It discusses the theoretical basis for defining health and advocates the argument that the present focus on measuring effectiveness of care is misdirected without the input of users, particularly patients in their care, drawing together the views of the many stakeholders who have an interest in the provision of care in the service. The research further draws on the theory of structuration to demonstrate the degree to which a duality of action, which is necessary for the development, and use of outcomes measures is in place within the service. Consequently, it highlights some of the hurdles that need to be surmounted before effective measurement of health gain can be developed in the field of study. It concludes by advancing the view that outcomes research can enable practitioners to better understand the relationship between the illness of the patient and the efficacy of treatment. This understanding it is argued would contribute to improving dialogue between the health care practitioner and the patient, and further providing the information necessary for moving away from untested assumptions, which are numerous in the field about the superiority of one treatment approach over another.

Integrated team working: a literature review

Introduction: This literature review was conducted to provide a background understanding of the literature around integrated health and social care prior to a research project evaluating two integrated health and social care teams in England, UK. Methods: A systematic literature search of relevant databases was employed to identify all articles relating to integrated health and social care teams produced in the last 10 years in the UK. Results: Sixteen articles were found and reviewed; all were reviewed by the first reviewer and half by the second reviewer. Discussion: Key themes identified were: drivers, barriers and benefits of integrated working; staff development; and meeting the needs of service users. Conclusion: Recommendations for integrated working include; a focus on the management of integrated teams; a need to invest in resources for the successful integration of teams; a need for the development of clear standards for monitoring the success and failure of integrated teams; and the need for further empirical evidence of the processes used by integrated teams. These findings will be valuable for practitioners who are establishing services or want to improve integrated care in their own practice.

Building cliques and alliances as practices to 'make things happen' in complex networks

The Roma population has become a policy issue highly debated in the European Union (EU). The EU acknowledges that this ethnic minority faces extreme poverty and complex social and economic problems. 52% of the Roma population live in extreme poverty, 75% in poverty (Soros Foundation, 2007, p. 8), with a life expectancy at birth of about ten years less than the majority population. As a result, Romania has received a great deal of policy attention and EU funding, being eligible for 19.7 billion Euros from the EU for 2007-2013. Yet progress is slow; it is debated whether Romania's government and companies were capable to use these funds (EurActiv.ro, 2012). Analysing three case studies, this research looks at policy implementation in relation to the role of Roma networks in different geographical regions of Romania. It gives insights about how to get things done in complex settings and it explains responses to the Roma problem as a „wicked‟ policy issue. This longitudinal research was conducted between 2008 and 2011, comprising 86 semi-structured interviews, 15 observations, and documentary sources and using a purposive sample focused on institutions responsible for implementing social policies for Roma: Public Health Departments, School Inspectorates, City Halls, Prefectures, and NGOs. Respondents included: governmental workers, academics, Roma school mediators, Roma health mediators, Roma experts, Roma Councillors, NGOs workers, and Roma service users. By triangulating the data collected with various methods and applied to various categories of respondents, a comprehensive and precise representation of Roma network practices was created. The provisions of the 2001 „Governmental Strategy to Improve the Situation of the Roma Population‟ facilitated forming a Roma network by introducing special jobs in local and central administration. In different counties, resources, people, their skills, and practices varied. As opposed to the communist period, a new Roma elite emerged: social entrepreneurs set the pace of change by creating either closed cliques or open alliances and by using more or less transparent practices. This research deploys the concept of social/institutional entrepreneurs to analyse how key actors influence clique and alliance formation and functioning. Significantly, by contrasting three case studies, it shows that both closed cliques and open alliances help to achieve public policy network objectives, but that closed cliques can also lead to failure to improve the health and education of Roma people in a certain region.

An exploratory study of the role of trust in medication management within mental health services

Objective - To develop understandings of the nature and influence of trust in the safe management of medication within mental health services. Setting - Mental health services in the UK. Method - Qualitative methods were applied through focus groups across three different categories of service user—older adult, adults living in the community and forensic services. An inductive thematic analysis was carried out, using the method of constant comparison derived from grounded theory. Main Outcome - Measure Participants’ views on the key factors influencing trust and the role of trust in safe medication management. Results - The salient factors impacting trust were: the therapeutic relationship; uncertainty and vulnerability; and social control. Users of mental health services may be particularly vulnerable to adverse events and these can damage trust. Conclusion - Safe management of medication is facilitated by trust. However, this trust may be difficult to develop and maintain, exposing service users to adverse events and worsening adherence. Practice and policy should be oriented towards developing trust.

Medication error in mental health:implications for primary care

Medication errors are associated with significant morbidity and people with mental health problems may be particularly susceptible to medication errors due to various factors. Primary care has a key role in improving medication safety in this vulnerable population. The complexity of services, involving primary and secondary care and social services, and potential training issues may increase error rates, with physical medicines representing a particular risk. Service users may be cognitively impaired and fail to identify an error placing additional responsibilities on clinicians. The potential role of carers in error prevention and medication safety requires further elaboration. A potential lack of trust between service users and clinicians may impair honest communication about medication issues leading to errors. There is a need for detailed research within this field.

User involvement in UK cancer services:bridging the policy gap

Recent UK government initiatives aim to increase user involvement in the National Health Service (NHS) in two ways: by encouraging service users to take an active role in making decisions about their own care; and by establishing opportunities for wider public participation in service development. The purpose of this study was to examine how UK cancer service users understand and relate to the concept of user involvement. The data were collected through in-depth interviews, which were analysed for content according to the principles of grounded theory. The results highlight the role of information and communication in effective user involvement. Perhaps more importantly, this study suggests that the concept of user involvement is unclear to many cancer service users. This paper argues the need for increased awareness and understanding of what user involvement is and how it can work.

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

Development and psychometric evaluation of a new team effectiveness scale for all types of community adult mental health teams:a mixed-methods approach

Defining 'effectiveness' in the context of community mental health teams (CMHTs) has become increasingly difficult under the current pattern of provision required in National Health Service mental health services in England. The aim of this study was to establish the characteristics of multi-professional team working effectiveness in adult CMHTs to develop a new measure of CMHT effectiveness. The study was conducted between May and November 2010 and comprised two stages. Stage 1 used a formative evaluative approach based on the Productivity Measurement and Enhancement System to develop the scale with multiple stakeholder groups over a series of qualitative workshops held in various locations across England. Stage 2 analysed responses from a cross-sectional survey of 1500 members in 135 CMHTs from 11 Mental Health Trusts in England to determine the scale's psychometric properties. Based on an analysis of its structural validity and reliability, the resultant 20-item scale demonstrated good psychometric properties and captured one overall latent factor of CMHT effectiveness comprising seven dimensions: improved service user well-being, creative problem-solving, continuous care, inter-team working, respect between professionals, engagement with carers and therapeutic relationships with service users. The scale will be of significant value to CMHTs and healthcare commissioners both nationally and internationally for monitoring, evaluating and improving team functioning in practice.

The meaning of ‘place’ in families’ lived experiences of paediatric outpatient care in different settings:a descriptive phenomenological study

Health service reforms in the United Kingdom have sought to ensure that children and young people who are ill receive timely, high quality and effective care as close to home as possible. Using phenomenological methods, this study examined the experience and impact of introducing new, community-based paediatric outpatient clinics from the perspective of NHS service-users. Findings reveal that paediatric outpatient ‘care closer to home’ is experienced in ways that go beyond concerns about location and proximity. For families it means care that ‘fits into their lives’ spatially, temporally and emotionally; facilitating a sense of ‘at-homeness’ within the self and within the place, through the creation of a warm and welcoming environment, and by providing timely consultations which attend to aspects of the families’ lifeworld.

Adversarial interpreting – a forensic linguistic perspective

Interactions with second language speakers in public service contexts in England are normally conducted with the assistance of one interpreter. Even in situations where team interpreting would be advisable, for example in lengthy courtroom proceedings, financial considerations mean only one interpreter is normally booked. On occasion, however, more than one interpreter, or an individual (or individuals) with knowledge of the languages in question, may be simultaneously present during an interpreted interaction, either monitoring it or indeed volunteering unsolicited input. During police interviews or trials in England this may happen when the interpreter secured by the defence team to interpret during private consultation with the suspect or defendant is present also in the interview room or the courtroom but two independently sourced interpreters need not be limited to legal contexts. In healthcare settings for example, service users sometimes bring friends or relatives along to help them communicate with service providers only to find that the latter have booked an interpreter as a matter of procedure. By analogy to the nature of the English legal system, I refer to contexts where an interpreter’s output is monitored and/or challenged, either during the speech event or subsequently, as ‘adversarial interpreting’. This conceptualisation reflects the fact that interpreters in such encounters are sourced independently, often by opposing parties, and as a result can rarely be considered a team. My main concern in this paper is to throw spotlight on adversarial interpreting as a hitherto rarely discussed problem in its own right. That it is not an anomaly is evidenced by the many cases around the world where the officially recorded interpreted output was challenged, as mentioned in for example Berk-Seligson (2002), Hayes and Hale (2010), and Phelan (2011). This paper reports on the second stage of a research project which has previously involved the analysis of a transcript of an interpreted police interview with a suspect in a murder case. I will mention the findings of the analysis briefly and introduce some new findings based on input from practising interpreters who have shared their experience of adversarial interpreting by completing an online questionnaire. I will try to answer the question of how the presence of two interpreters, or an interpreter and a monitoring participant, in the same speech event impacts on the communication process. I will also address the issue of forensic linguistic arbitration in cases where incompetent interpreting has been identified or an expert opinion is sought in relation to an adversarial interpreting event of significance to a legal dispute. References Berk-Seligson (2002), The Bilingual Courtroom: Court Interpreters in the Judicial Process, University of Chicago Press. Hayes, A. and Hale, S. (2010), "Appeals on incompetent interpreting", Journal of Judicial Administration 20.2, 119-130. Phelan, M. (2011), "Legal Interpreters in the news in Ireland", Translation and Interpreting 3.1, 76-105.

Mental health pharmacists views on shared decision-making for antipsychotics in serious mental illness

Background People diagnosed with serious mental illnesses (SMIs) such as schizophrenia and bipolar affective disorder are frequently treated with antipsychotics. National guidance advises the use of shared decision-making (SDM) in antipsychotic prescribing. There is currently little data on the opinions of health professionals on the role of SDM. Objective To explore the views and experiences of UK mental health pharmacists regarding the use of SDM in antipsychotic prescribing in people diagnosed with SMI. Setting The study was conducted by interviewing secondary care mental health pharmacists in the UK to obtain qualitative data. Methods Semi-structured interviews were recorded. An inductive thematic analysis was conducted using the method of constant comparison. Main outcome measure Themes evolving from mental health pharmacists on SDM in relation to antipsychotic prescribing in people with SMI. Results Thirteen mental health pharmacists were interviewed. SDM was perceived to be linked to positive clinical outcomes including adherence, service user satisfaction and improved therapeutic relations. Despite more prescribers and service users supporting SDM, it was not seen as being practised as widely as it could be; this was attributed to a number of barriers, most predominantly issues surrounding service user’s lacking capacity to engage in SDM and time pressures on clinical staff. The need for greater effort to work around the issues, engage service users and adopt a more inter-professional approach was conveyed. Conclusion The mental health pharmacists support SDM for antipsychotic prescribing, believing that it improves outcomes. However, barriers are seen to limit implementation. More research is needed into overcoming the barriers and measuring the benefits of SDM, along with exploring a more inter-professional approach to SDM.

Gestão e mapeamento de processos nas instituições públicas: um estudo de caso na Diretoria de Administração de Pessoal da Universidade Federal do Rio Grande do Norte

The new management models have led to the reorganization of institutions today. Much is made in improving the delivery of public services entities, and they have sought to adopt these new initiatives in order to improve the quality of the product or service offered to users. The modernization of the management model at the Federal University of Rio Grande do Norte (UFRN) strengthened by the accession of the institution to GesPública Program, which focuses on the management modernization leading institutions to seek ways to fit to meet the demands proposed the Program. Therefore, the Department of Personnel Administration (DAP) has structured its processes and procedures using the mapping tool processes. This research starts from the question: what were the results obtained with the implementation of the management and process mapping of PAD? It is proposed as a general objective to analyze the management and the mapping of that Board processes, identifying the possible benefits in improving the quality of the services provided to users. The specific objectives to achieve results, are pointed out: describe how you carried out the implementation of the management and process mapping in DAP and how it is working at the moment; examine the line in the relationship between the actions developed by the DAP and modern theories of this theme; identify the evolution of the sector with the measures adopted and the results obtained with the implementation of the mapping tool. In the theoretical framework, it was approached a brief history of the evolution of public administration in Brazil, GesPública program and its importance for process management in public institutions as well as the Management and Process Mapping. The context of the study was the DAP, and participants were managers of the institution in the survey. Data collection was done through the study of the institution's documents, bibliography analysis available on the topic, questionnaires and semi-structured interviews with professionals of the institution involved with the object of study, since its inception until July 2015, when it was finished the search. As a result, were listed: the motivation, importance, benefits and innovations that management and the mapping of processes brought to the institution, point out what has been improved in the service users and the tools used. We also analyze the main problems identified during the implementation of the mapping. As a suggestion, it was analyzed how these procedures can, if possible, be extended to other sectors of UFRN.

Gestão e mapeamento de processos nas instituições públicas: um estudo de caso na Diretoria de Administração de Pessoal da Universidade Federal do Rio Grande do Norte

The new management models have led to the reorganization of institutions today. Much is made in improving the delivery of public services entities, and they have sought to adopt these new initiatives in order to improve the quality of the product or service offered to users. The modernization of the management model at the Federal University of Rio Grande do Norte (UFRN) strengthened by the accession of the institution to GesPública Program, which focuses on the management modernization leading institutions to seek ways to fit to meet the demands proposed the Program. Therefore, the Department of Personnel Administration (DAP) has structured its processes and procedures using the mapping tool processes. This research starts from the question: what were the results obtained with the implementation of the management and process mapping of PAD? It is proposed as a general objective to analyze the management and the mapping of that Board processes, identifying the possible benefits in improving the quality of the services provided to users. The specific objectives to achieve results, are pointed out: describe how you carried out the implementation of the management and process mapping in DAP and how it is working at the moment; examine the line in the relationship between the actions developed by the DAP and modern theories of this theme; identify the evolution of the sector with the measures adopted and the results obtained with the implementation of the mapping tool. In the theoretical framework, it was approached a brief history of the evolution of public administration in Brazil, GesPública program and its importance for process management in public institutions as well as the Management and Process Mapping. The context of the study was the DAP, and participants were managers of the institution in the survey. Data collection was done through the study of the institution's documents, bibliography analysis available on the topic, questionnaires and semi-structured interviews with professionals of the institution involved with the object of study, since its inception until July 2015, when it was finished the search. As a result, were listed: the motivation, importance, benefits and innovations that management and the mapping of processes brought to the institution, point out what has been improved in the service users and the tools used. We also analyze the main problems identified during the implementation of the mapping. As a suggestion, it was analyzed how these procedures can, if possible, be extended to other sectors of UFRN.

A produção do cuidado no período gravídico-puerperal: experiência de mulheres usuárias de serviços públicos de saúde

Despite numerous government projects aimed at reorganizing and qualifying obstetric and neonatal care in Brazil, it remains problematic, with repercussions for maternal and newborn mortality and humanized care of both the mother and child. The objective of this study was to analyze the care provided to women during the pregnancy-puerperium cycle, based on reports of public health service users regarding their pregnancy and delivery experiences, using comprehensiveness and humanization as reference. The study applied a qualitative approach and the methodological strategy consisted of listening to the women, in order to identify, based on the meanings of their discourse concerning their experiences with health services, continuities and discontinuities of care during the pregnancy-puerperium cycle. Study participants were women who gave birth at a municipal public maternity, residents of Natal, Brazil, who at the time of the interviews, were between 10 and 42 days postpartum. Seven women reported their pregnancy and delivery experiences at public services. As interviews and observation took place, the material produced was also analyzed, in order to achieve simultaneous production and data analysis. Using systematization, a dialogue was established between the women’s discourses and production in the field of Collective Health, with respect to concepts and discussion about obstetric and neonatal care as well as the Comprehensiveness and Humanization of such care. Participant discourses underscored aspects related to prenatal care starting at pregnancy and its repercussions as well as prenatal monitoring by health services; aspects associated with care during labor and delivery, as well as those involved in postpartum in the maternity, both with respect to newborn and maternal careç and lastly, puerperium care after discharge from the maternity. Analysis of results sought to identify lines of continuity and discontinuity in the comprehensiveness and humanization of care. Based on these lines and as final contributions of the study, the following paths were proposed to achieve comprehensive and humanized production of health care for women during the pregnancy-puerperium cycle: Path 1- Reassess care in the maternal and newborn health network, aimed at comprehensiveness in terms of guaranteeing access to the various services and technological resources available to enhance health and life. Path 2- Reorganize work processes in order to attain comprehensive and humanized care for women in the pregnancy-puerperium cycle. Path 3 – Qualify the professional-user relationship in care management during the pregnancy-puerperium cycle. Path 4 – Invest in the qualification of communication processes in the different dimensions of care during the pregnancy-puerperium cycle.

A produção do cuidado no período gravídico-puerperal: experiência de mulheres usuárias de serviços públicos de saúde

Despite numerous government projects aimed at reorganizing and qualifying obstetric and neonatal care in Brazil, it remains problematic, with repercussions for maternal and newborn mortality and humanized care of both the mother and child. The objective of this study was to analyze the care provided to women during the pregnancy-puerperium cycle, based on reports of public health service users regarding their pregnancy and delivery experiences, using comprehensiveness and humanization as reference. The study applied a qualitative approach and the methodological strategy consisted of listening to the women, in order to identify, based on the meanings of their discourse concerning their experiences with health services, continuities and discontinuities of care during the pregnancy-puerperium cycle. Study participants were women who gave birth at a municipal public maternity, residents of Natal, Brazil, who at the time of the interviews, were between 10 and 42 days postpartum. Seven women reported their pregnancy and delivery experiences at public services. As interviews and observation took place, the material produced was also analyzed, in order to achieve simultaneous production and data analysis. Using systematization, a dialogue was established between the women’s discourses and production in the field of Collective Health, with respect to concepts and discussion about obstetric and neonatal care as well as the Comprehensiveness and Humanization of such care. Participant discourses underscored aspects related to prenatal care starting at pregnancy and its repercussions as well as prenatal monitoring by health services; aspects associated with care during labor and delivery, as well as those involved in postpartum in the maternity, both with respect to newborn and maternal careç and lastly, puerperium care after discharge from the maternity. Analysis of results sought to identify lines of continuity and discontinuity in the comprehensiveness and humanization of care. Based on these lines and as final contributions of the study, the following paths were proposed to achieve comprehensive and humanized production of health care for women during the pregnancy-puerperium cycle: Path 1- Reassess care in the maternal and newborn health network, aimed at comprehensiveness in terms of guaranteeing access to the various services and technological resources available to enhance health and life. Path 2- Reorganize work processes in order to attain comprehensive and humanized care for women in the pregnancy-puerperium cycle. Path 3 – Qualify the professional-user relationship in care management during the pregnancy-puerperium cycle. Path 4 – Invest in the qualification of communication processes in the different dimensions of care during the pregnancy-puerperium cycle.