CLAHRC-NDL Bi-Annual Newsletter Edition 3 - Spring 2011
Research making a difference to practice
What is the CLAHRC?
We are delighted to welcome our new Director Professor Rachel Munton, who met with our Service Users and Carers group to answer their questions - see page 18.
We are a health and social care partnership based at the University of Nottingham.
As well as updates from our six research themes, we throw the spotlight on one of our Diffusion Fellows and report on a new webbased Toolkit for Commissioning. Our new Engagement Fellow provides an overview of the Third Sector and the opportunities for closer working with CLAHRC-NDL. University and NHS leaders take part in our ‘What CLAHRC means to me...’ feature - look out for their contributions throughout the newsletter. We hope this overview of our work in the Nottinghamshire, Derbyshire and Lincolnshire region will lead you to find out more by contacting us, or by taking a look at our website: www.clahrc-ndl.nihr.ac.uk
We apply our research in primary care, stroke rehabilitation, mental health and children & young people to improve the quality and effectiveness of health and social care delivery across the East Midlands and beyond.
CLAHRC Associates Want to know more or get involved? Join our 600 associates and receive updates on: • • • •
Your area of interest Training and development opportunities Networking opportunities Details of conferences, lectures and seminars
See page 4 for more details.
Contents Research Themes
Mental Health 6 Readiness for treatment in people with
4 Beginner’s Guide to CLAHRC-NDL
personality difficulties, Work-focussed psychological support 7 Mood disorders study
Children & Young People 8 STAK does MAYFEST, GAPP and CATO
Primary Care 10 Preconception and Regular attenders studies 11 Understanding the impact of accidental injuries, Service user perspective: Trevor Jones
Stroke Rehabilitation 12 Home visits after stroke, Early supported
discharge Upper limb project, Return to work after stroke
Engagement 14 Regional employment retention workshop,
Everything you ever wanted to know about CLAHRC (but were afraid to ask!).
9 Brain scans show why children with ADHD have wandering minds 18 Professor Rachel Munton Q&A Our new Director Professor Rachel Munton
answers questions from our Service Users and Carers reference group
20 Engaging the Third Sector
Mat Rawsthorne, our newly appointed Engagement Fellow, outlines how he aims to stimulate relationships between CLARHC- NDL and the ‘third sector’.
Hosted on the CLAHRC-NDL website, a new toolkit will help commissioners and decision- makers target resources and interventions to specific populations.
22 New web-based Comissioning Toolkit
Children’s services integration a priority 15 Engagement by design, Personal health budgets 23 Implementation 16 Welcome Dr Carl Edwards, Implementation successes... 17 Diffusion Fellows in CLAHRC-NDL
CLAHRC Profile: Catherine Pope
Catherine is the Diffusion Fellow for the individual placement and support (IPS) for people with severe mental health problems study within the Mental Health theme. Here she updates us on the study’s progress, and discusses some of the challenges faced within Mental Health.
Dates for your diary Our successful training and learning series returns in 2011. Events planned for this year include:
Map of Medicine: assisting and promoting research evidence to facilitate commissioning
How to influence and engage commissioners
Developing a business case
Welcome I am delighted to have been appointed as Director of CLAHRCNDL following Graeme Currie’s appointment as Professor of Public Management at the University of Warwick Business School. I know you will want to join me in thanking Graeme for the strong foundations he has built for the CLAHRC and to wish him well in his new appointment. Good luck, Graeme! I am really looking forward to working with you and making sure we make the very best use of the funding and opportunities that CLAHRC affords us to improve the health and wellbeing of people in Lincolnshire, Derbyshire and Nottinghamshire – and to do this as a genuine collaboration between service providers, the University of Nottingham and the wider communities we serve. I have recently worked as a Director at NHS East Midlands and before that on the Board at Nottinghamshire Healthcare NHS Trust. I am combining the CLAHRC Directorship with the Directorship of the East Midlands Leadership Academy, a membership organisation developed to serve the leadership and development needs of the NHS organisations throughout the East Midlands. I am very aware of the incredible pressures that service colleagues are facing at this time, and yet the need to focus on high quality research and leadership is even more important when times are tough. I am also aware that, for some readers, there is a need to be really clear what the CLAHRC is actually all about, and to have an entry level guide for their reference and dissemination. So I have decided to use the following two pages to do just that – and for those of you who know all this already, please pass this newsletter to someone who doesn’t!
Professor Rachel Munton Director of CLAHRC-NDL & East Midlands Leadership Academy
Personality difficulties: development day
Communities of Practice: from theory to reality
You’ve collected your data, what next?
Further details on these and other CLAHRC events can be found on our website: www.clahrc-ndl.nihr.ac.uk/news-and-events www.clahrc-ndl.nihr.ac.uk
Beginner’s Guide to CL
What is it? What is its aim?
CLAHRC-NDL is a partnership between the University of Nottingham, Nottingham City Council and NHS organisations across Nottinghamshire, Derbyshire and Lincolnshire. We are one of nine CLAHRCs in England, and are funded by the National Institute for Health Research (NIHR). Our current clinical research themes include Children & Young People, Mental Health, Primary Care and Stroke Rehabilitation. We also have two themes that work across these areas: ‘Implementation’ and ‘Engagement, Synthesis & Dissemination’. We undertake high quality, applied, health and social care research and then translate that research into practice; improving services for patients across the East Midlands and beyond. To explain our name: we are Collaborating and Leading to Apply Health Research into Care.
Who is it for? Who can get involved?
To successfully translate our research into health and social care improvements we need to work with a variety of individuals, groups and organisations. To develop this collaborative working process we created Associate membership and invite you to join – to help us shape the future of health and social care together. An Associate can be anyone with an interest in CLAHRC-NDL; that could be our aims (putting research into practice), our partner organisations, or applied health research in general. You can have any level of knowledge, understanding or experience, be of any profession or none, be a service user, patient or carer, or you may know nothing at all and just want to know more.
Why should I be interested? What's in it for me?
We provide you with an assortment of opportunities for consultations, seminars and training. In addition, through involving yourself with our work you can network with others who promote high quality health and social care research. Our monthly updates will tell you about events and conferences. Perhaps most importantly, through your participation you will know that you are making a contribution to improving health and social care for patients and carers.
‘What CLAHRC means to me...’ ‘CLAHRC-NDL is a major component of our NIHR funded research portfolio, and enables us to exploit clinical research advances in everyday medical practice. Together with the Institute of Mental Health, these form the key vehicles for delivering the University of Nottingham’s research in the field of mental health’. Prof. Ian Hall, Dean of the Medical School, University of Nottingham
How will CLAHRC improve the quality of service to people who use health and social care?
We are working to promote Communities of Practice - also called Communities of Interest - around our research themes. These are networks of interested individuals working together to support innovative practice and new developments in health and social care. It is through such groups that the CLAHRC aims to sustain its programme of work in the longer term, in the interests of patients and carers. CLAHRC-NDL builds on existing clinical and research expertise in our four core research areas. Our cross-cutting themes help to ensure that the widest group of stakeholders is involved in the work the CLAHRC undertakes and that the barriers to implementing research are identified, explored and ultimately overcome.
If I want to get involved, what could this involvement look like?
You can contribute to our work in a number of valuable ways. We value any level of involvement, from simply showing your support through your membership to actively implementing health and social care improvements. Other possible contributions include: • Spreading knowledge, understanding and interest in the CLAHRC-NDL by learning more yourself; • Developing a network of contacts around the CLAHRC-NDL by making others aware and inviting them to become Associates too; • Providing us with feedback and information based on your own expertise and experience – helping us learn from you; and • Sharing our research with others to promote evidence-based service improvement.
I’m interested. How can I get involved?
If you would like to become an Associate or to find out more, please visit our website: www.clahrc-ndl.nihr.ac.uk/associates or call 0115 823 1253 for a paper form.
‘What CLAHRC means to me...’ ‘CLAHRC-NDL offers an opportunity to bring the most innovative, evidence-based research findings directly to those who benefit from them the most – our patients and service users. Secondly it allows NHS, University and Local Authority agencies to work in partnership across Nottinghamshire, Derbyshire and Lincolnshire – this has benefits that become apparent both inside and outside the research arena. The whole premise of CLAHRC is to bring research findings into practice quickly and this is being achieved in many areas. Our recent Director appointment, Professor Rachel Munton, brings a new service-facing energy which will only deliver improved outcomes for everyone, now and in the future.’
Prof. Mike Cooke, Chief Executive, Nottinghamshire NHS Healthcare Trust
Mental Health Research projects in the Mental Health theme are service-facing; they aim to improve standard clinical care in relation to best practice standards or to enhance usual care through innovation.
Readiness for treatment in people with personality difficulties Our Readiness to Change researchers are interviewing service users and practitioners in forensic and non-forensic services to identify the facilitators and barriers to engagement in psychosocial (‘talking’) therapies for people with personality difficulties. So far over 140 people have taken part in the team’s research. Their views are beginning to highlight a number of interesting characteristics of services, therapists, therapy programmes, and clients, which can promote or impede treatment engagement. With the assistance of practitioners and service users, we will build upon these findings to design an intervention to promote treatment engagement. This will be piloted in services for people with personality difficulties, to test its acceptability and usefulness.
Theme Lead: Professor Richard Moriss
We are also interested in finding out about how to assess engagement in psychosocial therapy. Having reviewed all the existing assessments of client engagement, none is suited to our research, so we have decided to design a new assessment of client engagement. We are currently testing the accuracy of this tool in forensic and non-forensic services for people with personality difficulties across Nottinghamshire, Derbyshire and Lincolnshire.
In the spring, we will hold a half-day developmental event on the topic of personality difficulties. For more information about this forthcoming event and further information, contact us.
Work-focussed psychological support The Individual Placement Support (IPS) study has completed its six month pilot phase. Clinical Psychologist Naomi Boycott has now developed a work-focussed therapy manual which provides additional support to selected participants. This consists of psycho-education and CBT, focussed on common psychological barriers to seeking employment. The intervention encourages clients to use a problem-solving procedure when they encounter difficulties at work or at home. Participants cover a range of topics including anxiety, depression, memory and concentration, selfesteem and stigma. Naomi Boycott explains: “I am currently seeing five participants on a weekly basis, and they are all making good progress with the programme. Follow-up measures about employment and personal outcomes, such as selfesteem, will be taken at six and 12 months post-intervention. A qualitative questionnaire concerning the experience of Contact: taking part in the intervention is also planned and will be email@example.com conducted after the person has finished the intervention”.
Mood disorders study CLAHRC research studies are specifically designed to innovate in clinical practice and embed evidence-based treatments in the ‘real world’ of mental health. The mood disorders study is beginning to do just that, as it tests out the effectiveness and impact of a specialised depression service for chronic and recurrent depression. This study was devised after clinicians observed that, despite there being a range of NICE-recommended pharmacological and psychological treatments for chronic and recurrent depression, these were generally not being accessed by service users. Our specialised depression service model utilises the principles of Collaborative Care and Recovery and offers evidence-based prescribing conjunction with a range of cognitive-behavioural therapy (CBT) treatments including Cognitive Therapy, Mindfulness, and Compassionate Mind based CBT. Our collaboration with Self Help Nottingham (see page 20) has enabled the development of user and carer support groups and access to social inclusion initiatives. An evaluation is comparing the specialised service to treatment as usual. The Collaborative Care model represents co-ordinated care planning and provision between psychiatrist and psychotherapist within the study and the referring team. The study is now in year two of actively receiving referrals and, whilst the research data cannot be looked at until the end of the trial in 2013, the following service based observations have been made: »» Every patient has said how much they valued the Collaborative Care model we are evaluating and their experience of the service model has been positive. »» Informal feedback from psychiatrists is that the study is ‘exciting’ because it is providing new psychological treatments for depression. Their view is that chronic depression may prove more amenable to treatment under this novel approach.
Mood disorders study recruiting Our mood disorders study is actively looking to recruit more participants. Are you a GP or Psychiatrist with patients on your caseload who may benefit from this service? We also accept self-referrals. Eligibility for the study is based on: »» a primary diagnosis of uni-polar depression; »» receiving treatment for depression for at least 6 months (either primary and/or secondary level); and »» a good enough command of English to participate in talking therapies. The referral process is simple; if you think you may be eligible to take part, or if people on your caseload fit the bill, then please contact the study team.
firstname.lastname@example.org T: 0115 823 2478 / 07771 944659
Children & Young Peop The C&YP theme focuses on child and adolescent mental health and issues of public health and service development. Early intervention, disruptive behaviour problems and obesity are key targets. Each project includes an implementation arm to identify the barriers and drivers that may prevent or help the uptake of research in practice.
Steps To Active Kids (STAK) does MAYFEST Each year the University of Nottingham throws open its doors and welcomes the community and alumni onto the campus to celebrate in its success. “What a fantastic opportunity”, we thought, “to showcase CLARHC and the Steps to Active Kids Project (STAK) to a community audience with a few alumni thrown in for good measure.” The event is being held on 7th and 8th May 2011 and the research team from the Steps to Active Kids project will be holding ‘street dance’ activity sessions throughout the day, based on the DVD designed and developed for the project. To add an extra dimension, visitors will be invited to complete a computer based task, designed to examine the effect of exercise on cognitive function, before and after taking part in the ‘street dance’ activity. A poster will be displayed outlining the STAK project and leaflets will be available for visitors to take away.
CATO and GAPP Stakeholder events Over 60 delegates including clinicians, nurses, commissioners and service users attended the Consensus Assessment and Treatment Outcomes (CATO) stakeholder event, held on 4th February 2011 at CLAHRC headquarters. The morning session focussed on assessment and outcome measures from a range of perspectives including Commissioners and members of the CAMHS Research Outcome Team (CORC). The afternoon session saw delegates, including a group of service users, split off into small groups to discuss assessment and outcome measure. The Group ADHD Parenting Programme (GAPP) stakeholder event took place on 18th November 2010. It was attended by key stakeholders from across the NDL region, including senior parenting practitioners from the local authorities, and parent programme facilitators from CAMHS. The event was a great success, allowing for networking across the NDL areas. The feedback received about the project was positive and many links have now been formed with interested parties. In addition, the event has informed key decisions within the project, particularly toward the development of the pilot study which is now well underway. It also allowed for community ] engagement, in terms of developing a mapping survey Contact: to illustrate the services currently available to parents STAK: email@example.com in the NDL region. Thanks to all who attended both CATO: firstname.lastname@example.org events!
ple ‘What CLAHRC means to me...’ ‘CLAHRC is the place where academics and the NHS come together to make sure evidence is used by the NHS and implemented into real change. CLAHRC is a protected place where we can overcome misunderstandings and cultural differences between the NHS and Universities to make sure our relationship is as productive and fruitful as possible. As a Phd and NHS manager I take a personal interest in this relationship and as an accountant I like that CLAHRC does this - in a tough economic climate - for quite realistic sums of money’. David Sharpe, Chief Executive, NHS Derbyshire County
Brain scans show why children with ADHD have wandering minds Brain scans of children with attention deficit hyperactivity disorder (ADHD) have shown for the first time why they sometimes have difficulty in concentrating. The study may explain why parents say that their child can maintain concentration when they are doing something that interests them but struggles with boring tasks. Using a ‘Whac-a-Mole’-style game, CLAHRC researchers working for the Motivation, Inhibition and Development in ADHD Study (MIDAS) group at the University of Nottingham found evidence that children with ADHD require much greater incentives – or their usual stimulant medication – to focus on a task. When the incentive was low, the children with ADHD failed to ‘switch off’ brain regions involved in mind-wandering. When the incentive was high, their brain activity was indistinguishable from that of a child without ADHD. ADHD is the most common mental health disorder in childhood and affects around one in 50 children in the UK. Children with ADHD are excessively restless, impulsive and distractible. Although no cure exists, symptoms can be reduced by medication (most commonly Ritalin) and/or behavioural therapy. Previous studies have shown that children with ADHD have difficulty in ‘switching off’ a network in their brains. This network is usually active when we are doing nothing, giving rise to spontaneous thoughts or ‘daydreams’, but is suppressed when we are focused on the task before us. Using a magnetic resonance imaging scanner, which can be used to measure activity in the brain, the team monitored both children with and without ADHD as they played a computer game designed to study the effect of incentives. By studying the brain scans, the researchers showed that the children without ADHD switched off the network in their brain whenever they saw an item requiring their attention. However, unless the incentive was high, or they had taken their medication, the children with ADHD would fail to switch it off and would perform poorly. The findings are published in the ‘Journal of Child Psychology and Psychiatry’. Children & Young People’s Theme Lead Professor Chris Hollis, who led the study, says: “The results are exciting because we are beginning to understand how in children with ADHD incentives and stimulant medication work in a similar way to alter patterns of brain activity and enable them to concentrate better. It also explains why in children with ADHD their performance is often so variable and inconsistent.” Dr Elizabeth Liddle, first author of the study, adds: “The common complaint about children with ADHD is that ‘he can concentrate...fine when he wants to’, so some people just think the child is being naughty when he misbehaves. We have shown that this may be a very real difficulty for them. The off-switch for their ‘internal world’ seems to need a greater incentive to function properly and allow them to attend to their task.” www.clahrc-ndl.nihr.ac.uk
Primary Care The Primary Care research projects highlighted on these pages reveal some of the new approaches being undertaken in this area.
Preconception study: Survey of GP practices Our preconception study is looking at how to improve preconception healthcare for women and their partners in disadvantaged white, South Asian and African Caribbean communities. These groups have worse mother and child health outcomes than the population as a whole. Principal Investigator Professor Joe Kai explains: “Preconception healthcare tends to be done opportunistically in general practice. There are currently no national guidelines or evidence on models that might be implemented and it is unclear to what extent preconception care is actually happening. We have just completed an online survey with general practices around Derby and Nottingham to find out more about their practice and attitudes towards preconception health. This will help develop a preconception health intervention”. The survey showed that preconception health care is provided in the majority of the practices, and tends to take the form of lifestyle advice on diet / weight management, smoking and alcohol consumption. The care tends to be informal (i.e. no protocols) and is mainly provided only if the opportunity arises. The main barriers faced by practices are a lack of personnel and time. Lack of training, high workload, and confusion over who should deliver the care also contribute.
Professor Joe Kai
Joe Kai again: “These findings will be used alongside those from focus groups with women from disadvantaged communities and primary care professionals from the Nottingham and Derby area, to inform the next phase of the research”.
Regular attenders update The regular attenders study is looking at whether the needs of people with mental health disorders who go to their general practice regularly can be helped with cognitive behaviour therapy (CBT). The study team are pleased to report that they have now recruited an additional two general practices based in Nottinghamshire County and Bassetlaw PCTs to work with them on the pilot study. Professor Richard Morriss, Principal Investigator, explains: “During the pilot phase of the study, which involves interviewing patients and offering those who would benefit a course of treatment involving CBT, we have become increasingly aware of the importance of training for GPs, particularly relating to patients with medically unexplained symptoms. The team are pleased to be Contact: collaborating with the Leicester CLAHRC on developing a Tracey George (Theme Manager) training package for GPs so they are better able to meet the Tracey.George@nottingham.ac.uk needs of such patients”.
Understanding the impact of accidental injuries The impact of injuries study is working to find out more about the effects of accidental injury on peoples’ lives. One part of the study involves interviewing patients about their recovery and experience of using healthcare services, as Principal Investigator Denise Kendrick explains: “Interviews with patients are ongoing; however the information we have received so far from injured patients has been extremely valuable. The interviews have given us a good understanding of what it is like to live with an injury, and we have some really interesting and varied information about peoples’ experiences in hospital related to waiting times, general care and attention, and dignity preservation”. People also talked about their experiences of returning home after injury and how it can affect every aspect of their lives and those of people around them. The team have also gained insights into patient experiences of service provision and the referrals process. “We are extremely grateful to participants for taking the time to talk to us and most have welcomed the chance to tell their story”, adds Denise.
Service user perspective: Trevor Jones I’m a service user representative working with the Impact of Injuries study team. My role is to bring the patient’s perspective to the design and conduct of the research. Following two separate accidental injuries, I can draw upon my experiences of Emergency Department care followed by periods of hospital admission and rehabilitation. I can consider how it may feel to be approached in the Emergency Department and be asked to participate in a piece of research in the immediate aftermath of an accident. Drawing on my experiences, I provide guidance on issues such as what difficulties a participant could experience in completing a complex questionnaire, or how to encourage participants to remain with the study. At project meetings I aim to play a constructive part by contributing the patient point of view to decision making. Other ways I have worked with the study team include reviewing Standard Operating Procedures for recruitment of patients and conduct of interviews, where there is a direct impact on patients. I have also worked through questionnaires to be used by researchers and taken the part of a patient during role play exercises as part of research training. As the study progresses, I will be involved in the interpretation of findings and forming of conclusions.
Stroke Rehabilitation Our Stroke Rehabilitation theme aims to increase the capacity of the stroke rehabilitation community to engage with and apply research findings. In doing this, we hope to produce an improvement in the delivery of care and evidence-based rehabilitation services for all stroke survivors.
Home Visits after Stroke (HOVIS)
Early Supported Discharge (ESD) in context
Since July 2010 the team have been recruiting patients and are on track to meet their targets by October 2011. They recently thanked the Derby stroke rehabilitation team for their commitment to the trial.
Stroke is the largest single cause of disability in a community setting with direct care costs for the NHS of over ÂŁ3 billion annually. Early rehabilitation of stroke patients at home following their care in hospital is seen as a way to reduce costs and promote good outcomes.
The qualitative aspect of the research is also going well, with all of the expert interviews now complete and 15 of the 20 senior occupational therapy interviews complete. Analysis is underway and the team hope to write up the outcomes of the expert interviews and submit for publication later this year. A questionnaire will now be sent to all stroke unit occupational therapy departments in England, to gather information on routine practice of predischarge home visits. This information, along with the data obtained from the occupational therapy interviews, will enable the team to report on current pre-discharge home visit practice for stroke patients and put the findings of the RCT into context.
Stroke Rehabilitation: A stroke survivor is helped in his own home by an Occupational Therapist (right)
In a recent paper in Neurology, Rebecca Fisher and Marion Walker point out that while the transfer of care from hospital to home is a particularly critical time for patients and carers, and there is good evidence to adopt early supported discharge, this needs to be seen as just one part of the stroke care pathway, where every stage requires a high level of co-ordination between services. Fisher R and Walker M. (2011). Early Supported Discharge: an essential part of the stroke care pathway. Geriatric Medicine. 41(2).
Experts agree on ESD guidelines The launch of a consensus statement on Early Supported Discharge marked an important milestone in the Stroke Themeâ€™s programme last October, when 80 people, including representatives from the Strategic Health Authority, East Midlands Cardiac and Stroke Network and the UK Stroke Association, heard how experts rated 56 statements about the key elements of an effective ESD service. Full results will be out soon in the journal Stroke. The ESD consensus has also been disseminated via the national Stroke Improvement Programme.
Upper limb project update
A considerable number of stroke survivors experience residual upper limb problems; of these it is thought between 55-75% will fail to regain the functional use of their affected upper limb. This negatively impacts on their quality of life and reduces their chances of returning to paid employment. Research has shown that a considerable amount of practice is required to achieve an improvement in upper limb ability. However, following discharge from hospital, access to sufficient rehabilitation is often difficult to achieve.
Credit: Matt Alexander, Nottingham Evening Post
To address this need for accessible and intensive rehabilitation, the upper limb team are investigating the feasibility of using a low cost, virtual reality device suitable for use within peopleâ€™s own homes. A system has been developed from components of the popular Nintendo Wii, which uses a virtual reality â€˜gloveâ€™ together with games specifically designed to elicit the movements required for completion of everyday tasks. The games will hopefully be engaging so the intensive exercises involved in rehabilitation can be more enjoyable. Following several key months of development, the team are now gearing up to start project recruitment. The final round of testing has ensured good reliability and usability of the virtual glove and games system. This involved repeated rounds of gaining both service provider and user feedback on the system from a series of workshops, and making appropriate changes as needed. In early 2011 the team will commence participant recruitment on the project with the help of the Nottingham University Hospitals Stroke Services. During the recruitment phase, participants will be able to have the virtual glove and games system to use in their own homes for ten weeks following their discharge from Stroke Services. Although research therapists will support the use of the system over this time, participants will be able to self-manage Contact: their daily use of this novel therapy. The team is now looking forward to recruiting their first participant to the project and email@example.com supporting them through this process.
What support to return to work? Less than half of all stroke survivors return to work. The Return to Work (RtW) study has found that employer misconceptions, the work environment, financial disincentives, limited rehabilitation and a lack of access to suitable support all contribute to unemployment following stroke. Many survivors also have hidden disabilities (like visual impairments) which are missed at the point of hospital discharge. Because their problems are not obvious, they also fail to access routine rehabilitation, where their difficulties might be detected and work focused services triggered. Guidelines from the British Society of Rehabilitation Medicine (2010) recommend how vocational rehabilitation should be organised and delivered, yet the provision of vocational rehabilitation services for stroke survivors has long been patchy and services poorly defined. Some services are provided by the NHS, some are linked to Job Centre Plus and others operate within the private or voluntary sector. The RtW study is looking into issues surrounding the commissioning, organisation and delivery of health based vocational rehabilitation for people with stroke in an Engagement Event on May 10th, 2011. We hope to explore issues around the opportunities for cross-sector partnerships, and also the timing of interventions, whether services are justified in the face Contact: of limited health resources and who should be prioritised for vocational firstname.lastname@example.org rehabilitation.
Engagement Employment retention workshop January 2011 saw 27 delegates from across the East Midlands attend our workshop on employment retention services. The half-day event looked at the barriers to job retention for people with mental health problems, and gathered examples of good practice. Delegates came from a range of organisations including Job Centre Plus, NHS Trusts and private and Third Sector employment support services. The afternoon started with presentations from three employment retention service pilots that are currently being delivered: the Lincolnshire IAPT Employment Advisor Pilot, the Leicester Fit for Work Pilot and the Nottinghamshire Fit for Work Pilot. Following group discussions, it was agreed that job retention services were very effective in keeping individuals in work, though early intervention was vital to success. The importance of partnership working between health care providers and welfare to work providers was also keenly stressed. Marion Blake, Mental Health and Employment Lead at the East Midlands Regional Development Centre, said: “The East Midlands has three retention pilots running. It was good to hear from all three leads and get the positive results to date from them. Clearly there is a need for this work to continue across the East Midlands in partnership with organisations in health and employment”. Event Chair Professor Justine Schneider commented: “It was great to hear first-hand about the successful pilot in Lincolnshire, where employment support was integrated with IAPT. It has definitely shown the benefit of promoting work as a goal alongside psychological therapy, and I’m glad Occupational outcomes: to learn that the approach is being email@example.com continued“. The outcomes will feed into the CLAHRCNDL cross-cutting theme of occupational outcomes and will help develop further research with our partners in the region.
Retention services pilots: Lincoln: firstname.lastname@example.org Nottingham: email@example.com Leicester: firstname.lastname@example.org
Children’s services integration a priority Researchers from the Engagement and Implementation themes are working to identify the priority areas for new research related to the children’s health and social care agenda. A Delphi consensus approach has been used to consult with children’s leaders across the NDL region. Experts who took part in the survey helped CLAHRC researchers to identify a total of 13 key topics, and to refine these through a Delphi process described in our last newsletter. Stakeholders identified ‘integration of health and social services and its impact on process and outcomes’, ‘factors affecting young peoples’ routes into (and out of) mental health and offending careers’ and ‘effects of staff training on CAMHS referrals to tier two and three’ as their top priorities for research in children’s services.
We will now take forward the priorities in three ways: identifying what is already known, undertaking rapid reviews of the literature, and developing new research proposals together with the people concerned.
Priestess of Delphi by John Maler Collier
FEATURE: Engagement by design... The model developed by the CLAHRC for the south west peninsula (PenCLAHRC) shows how professionals and the public can inform the research process, which in turn leads to implementation activity to improve services, and on to dissemination of the results.
Starting with the generation of questions through discussion between practitioners, researchers and service users, CLAHRC skills can be used to structure the question, as we have done through the survey on children’s services priorities described opposite. For some of these priorities the answers will be known, and can be found through consulting experts.
Personal Health Budgets – local pilot site Personal Health Budgets (PHBs) aim to make transparent the resources available for an individual’s care and to maximise patients’ choice on how best to achieve desired outcomes. PHBs are likely to be suitable for people with long-term conditions who are frequent users of healthcare. A pilot programme involving half the primary care trusts in England is currently underway to test out personal health budgets in the NHS. The programme will explore who will benefit most from personal health budgets, and how the NHS can make them work. One of the pilots is taking place in CLAHRCNDL’s partner organisation, NHS Nottingham City. This pilot focuses on personal health budgets for patients: »» »» »»
with neurological conditions referred to the new Community Neurology Service with memory problems referred to the Intermediate Care Service at the Willows who become eligible for fully funded NHS continuing healthcare or joint funded health and social care packages
A national evaluation of all the PHB pilots is being led by the PSSRU at the University of Kent. It will examine whether PHBs ensure better health and social care outcomes, and, if they do work, how they can be best implemented. Interim reports and updates are available from the evaluation team’s website: www.phbe.org.uk/index.php
PHB pilot Project Manager email@example.com
Implementation Welcome, Carl Dr Carl Edwards has joined CLAHRC-NDL as an Implementation Fellow, a role that is jointly funded by Nottingham University Hospitals NHS Trust and CLAHRC-NDL. Carl’s role is to facilitate the translation of our research into clinical pathways, as well as business and financial planning of services. Carl joins us from NHS Innovations East Midlands, where he was responsible for advising on intellectual property issues and commercial development of NHS ideas. Carl is Chair of the East Midlands HIEC, and Chair of Leicestershire, Northamptonshire and Rutland NHS Research Ethics Committee 1. Carl will work across all of our themes to build links with our NHS partners. Initially he will work with our Early Supported Discharge team (Stroke Rehabilitation theme) where he will be looking at the service changes and business cases created by the team, and creating more generalisable cases and lessons that may be applicable in other parts of CLAHRC-NDL. Carl will also be helping to deliver training and education events as part of our development and learning series programme.
Implementation successes... The Implementation theme has been collaborating with the Early Intervention programme team at Nottingham City Council to examine the relationship between parental mental health needs and the emotional wellbeing of children and young people. Evidence suggests a causal link between the two and advocates that a holistic approach should be taken. However, in reality service provision does not always follow this path. The aim of the project was to engage with local stakeholders about their views on how cohesively adults and children’s services work holistically, and scope potential ways forward. The CLAHRC team undertook a series of interviews with stakeholders to understand the common barriers and facilitators to the implementation of a holistic approach to parental mental health needs and the emotional wellbeing of children and young people, which has been termed a ‘think family’ approach. As a result of the work undertaken in this study, our recommendations led to a service redesign that will ensure that community based mental health need is managed holistically. This work has been taken forward by Nottingham City Council, who are working with a stakeholder task force to implement our recommendations.
For more success stories:
‘What CLAHRC means to me...’ ‘There is a wealth of published evidence about the healthcare interventions that are most effective in practice, but too few of these interventions are in widespread use across the NHS. As the service faces its toughest financial challenge, it is imperative that we get this evidence into practice – doing so will drive up quality of care and drive down costs. The CLAHRC has this philosophy at its core. The practical way in which it approaches breaking down the barriers to the adoption of evidence-based practice is applicable to all areas of healthcare. Not only is the CLAHRC beginning to produce impressive results in its current areas of focus, but it is generating a methodology that can transform healthcare delivery.’ Peter Homa, Chief Executive, Nottingham University Hospitals NHS Trust
Scrambling over fences – Diffusion Fellows in CLAHRC-NDL CLAHRC’s innovative approach to knowledge exchange is proving successful in many ways. We have approximately 30 Diffusion Fellows (DFs) seconded from our partner organisations, who are carrying out this role. Part of the Implementation Theme’s work is to research the role, and to learn lessons from the DFs’ experiences. DFs have already given us some vivid descriptions of what life is like ‘out there’, and one of the lasting images is of determined DFs scrambling over the fences encountered between organisations, departments, professions and individuals, in order to successfully diffuse knowledge and make a difference to practice. Following the successful presentation of our early work, we have been asked to present our approach and early findings to a group of SDO Management Fellows. More on this scheme and the current fellows can be found at: www.sdo.nihr.ac.uk/fellowships.html It is clear that this scheme closely parallels the aims of CLAHRC, working towards improving research and its effects. The Implementation Theme is currently piloting the next stage of our DF research, using an interview method that has been developed in-house. We are using creative interviewing in order to help DFs express the sensitive and political elements of their work, things that are so critical in achieving success or failure, but which are sometimes hard to describe in words. Once we have learned the lessons of the pilot we will be interviewing all the DFs about their experiences so far.
Rachel Munton Q&A Our Service Users and Carers Reference Group, led by Associate Professor Julie Repper, exists to advise and steer our research studies, to ensure that they remain relevent, responsive to frontline health and social care needs, and to keep them patient-focussed. Here Trevor Jones, a member of the group, puts questions to Rachel Munton, our Director who joined us in February 2011.
Rachel: Hi Trevor – thanks for agreeing to interview me – I hope I can answer the questions.
What skills and experience are you able to bring to CLAHRC-NDL?
Trevor: Welcome to CLAHRC-NDL. I’d like to start by finding out a bit about you. What’s your employment background?
I’m known as someone who puts patients and carers first, and I’m committed to inclusive approaches. I have experience in a variety of health and education settings and am energetic and committed to improving patient experiences. I think clarity and good governance are important – so I am likely to seek to influence the ways CLAHRC can work to make the best use of the talented individuals and finances at its disposal. I am also known for my sense of humour – work can be fun!
How do you see the future for research in CLAHRC-NDL?
The difference between the nine CLAHRCs funded in 2008, and other research approaches is the emphasis on translation of research findings into practice – the ‘so what’ factor as I like to call it. As this is the central aim of the CLAHRC approach, to pay little attention to implementation or translation is not acceptable.
Working in practice, as I have, you really need some help to navigate research findings, best practice and even simple nuggets of information from the literature are helpful. So I think it’s vitally important that CLAHRCs face the NHS and patients, and are able to be flexible and responsive to their needs.
I’m a nurse by background – and proud to be – I did my general nurse training in Nottingham and my mental health nurse training in London. I worked as a registered nurse at the City Hospital Nottingham and I’ve worked as a CPN and a CPN manager. I then worked at the University of Nottingham to lead a number of nurse education programmes.
More recently, I was the Director of Nursing at the Strategic Health Authority (SHA), and before that the Director of Nursing at Nottinghamshire Healthcare Trust. I joined the Trust in May 2006 from my former role as Interim Deputy Chief Executive at the Mental Health Act Commission.
Previously I worked at the Department of Health as Director of Mental Health Nursing, and as National Director for the Black and Minority Ethnic Mental Health Programme within the National Institute for Mental Health in England [NIMHE]. In August 2008 I was honoured to be awarded the title of Special Professor of the University of Nottingham, School of Nursing, Midwifery and Physiotherapy. So – a long career history that says a bit about my age!!
How do you think CLAHRC will be affected by the current policy changes in the NHS, for example reducing costs not seen as front line?
So, how can we best ensure that the research taking place in CLAHRC-NDL makes a difference to clinical practice? Do service users have a role to play?
Again, research needs to be contextualised current changes in the NHS are unprecedented, and naturally a preoccupation for those who work in services. If CLAHRCs conduct research without implementation, or research that seems remote, or ignore the cost pressures and reconfiguration in the NHS, we will look out of touch. We will more particularly fail to provide the offer we so clearly must – evidence to change and influence practice in the patient interest.
We need to be co-producing - that’s policy speak for doing things together - with our NHS partners so that we can see their priorities, and then build research around these.
This must involve grass roots staff of all disciplines, not just senior figures. It should be shaped around the needs of people who use services, and involve them throughout. And of course, we must remember that we are potential or actual patients and services users – the researchers and staff of CLAHRC are likely to be users of NHS services themselves. So a tidy division into ‘staff’ and ‘patients’ is naïve – we all need better services and the way to get them is to apply evidence into practice as swiftly and creatively as possible – the central aim of CLAHRCs.
With that in mind, how can service users be involved in helping to achieve high quality research in CLAHRC-NDL, making sure it is relevant to patient needs?
Service user / patient involvement is absolutely central – and we are doing pretty well I think. The work you are doing Trevor, on the Impact of Injuries study, means that your expertise by experience is embedded within projects, and can advise and steer them.
The NIHR (who fund the CLAHRCs) are very keen to see how service user perspectives are interwoven – and the Service Users and Carers Reference Group and POPULOS panel also have a role. The Health and Social Care Bill has restated the underpinning importance of the NHS Constitution – and of course this places the patient or service user at the centre of all healthcare activity and decision making.
Thanks Rachel. I’m pleased to see the emphasis you place on conducting research which is directed towards the real needs of patients and staff in the NHS, and also on how we should help NHS staff to translate research findings into improving care they provide for patients and their carers. I’m sure your track record of work in the NHS will help you to guide CLAHRC-NDL on how we can best achieve this. I wish you every success and I look forward to speaking to you again in a few months time to review progress. Thanks Trevor - let’s chat again in six months after the review we plan for CLAHRC-NDL to see how things are going then.
‘What CLAHRC means to me...’ ‘It is critical that the very best evidence is used to inform the services patients receive in our care. The translation of research into practice is essential to improving services, and this partnership approach is at the heart of CLAHRC. I look forward to a more visible, local presence moving forward so a wider range of my staff can get engaged – and so more people with mental health and learning disabilities can benefit’. Chris Slavin, Chief Executive, Lincolnshire Partnership NHS Foundation Trust
Engaging the Third Sec As our new Engagement Fellow tasked with stimulating relationships between CLARHC-NDL and the ‘third sector’, Mat Rawsthorne and Sarah Collis from Self Help Nottingham provide an insight into a sector whose definition is greatly debated, which has led some to conclude that there is no single ‘authentic’ third sector for which a single master plan can be drawn up...
FEATURE: Innovators, Fast Followers and Critical Friends To distinguish third sector organisations from the public sector they are sometimes referred to as nongovernment or non-statutory organisations; and to distinguish them from commercial market activity they are referred to as non-profit organisations. These definitions have wide currency, and to some extent add to the lack of understanding about what third sector organisations actually are as they tend to just state what they are not. Perhaps it is more helpful to identify what characteristics third sector organisations share as a way to understand their function and purpose. As a sector which is linked with civil society, they are value-driven, not for profit (i.e. they reinvest surplus to further their core objectives) and are incredibly diverse. The National Council of Voluntary Organisations estimate that there are around 170,000 charities in the United Kingdom, these together with social enterprises, small community groups, co-operatives and mutual organisations make up a sector engaged in civil society of upwards of 900,000 groups in total with a combined income of over £35.5b a year.
900,000 [third sector] groups...in the UK...have a combined income of over £35.5b a year...
In the CLAHRC-NDL region alone the sector employs over 35,000 people in organisations which have a range of objectives including social, environmental, health, education, culture and many more. Third sector organisations don’t all employ staff but most will rely heavily on volunteers either to run their services or to provide governance functions. When engaging with the third sector there is a huge diversity in size and structure including large charities with local branches such as the Stroke Association and Rethink, Social Enterprises such as Homecare Nottingham Ltd and the Impact Integrated Medicine Partnership and smaller specialist groups such as the Ear Foundations and Making Waves. Regardless of size, the sector is assuming an increasing role in relation to the delivery of services; strengthening community cohesion; providing a voice for under-represented groups; campaigning for change; and promoting enterprising solutions. The Third Sector is seen as having particular strengths in tackling the most entrenched social, environmental and health challenges through their ability to respond quickly to unmet need; they can be innovators and ‘fast followers’, able to implement new best practice quickly.
ctor Engagement with the third sector has great potential for the development of more efficient use of scarce resources (co-production), attainment of objectives which are of mutual interest (co-operation), and ultimately to the common aim of better patient care. Closer working between CLAHRC-NDL and the sector is supported by the direction of current policy imperatives, including user-led research, patient choice and selfmanagement.
Closer working between CLAHRC-NDL and the third sector...will ultimately [lead] to the common aim of better patient care...
As a critical voice third sector organisations can provide constructive input to current studies on steering groups for example, acting as a critical friend and providing an alternative viewpoint. Engagement is a two-way process which fosters knowledge transfer. Voluntary and not-for-profit organisations in the health and social care area play an increasingly important role in the translation of research evidence into practice.
Third sector organisations need to evidence the work they are doing and may be in a position to use CLAHRC research to demonstrate the impact they have. The barriers and facilitators to implementing research in practice will be identified and explored by involving the widest group of stakeholders.
By joining Communities of Practice to support innovation and new developments in health and social care, the third sector can support the CLAHRC aims to sustain its programme of work in the long term.
The experience of the third sector brings a realistic foundation to applied research design, and research in turn can bring valuable resources to develop and test new ideas. By identifying research projects which are mutually relevant and beneficial, greater co-operation between CLAHRC-NDL and the third sector will generate successful research bids, leading to improvements in care and wellbeing.
Find out how your research can benefit from Third Sector Engagement: firstname.lastname@example.org / email@example.com T: 0115 911 1662
Commissioning Toolkit Customer Insight for Intelligent Commissioning (CIIC) Toolkit
NHS Nottinghamshire County have led a project to develop an evidence-based process for identifying targeted social marketing interventions to tackle health problems. Social marketing enables commissioners and decision-makers to achieve positive behaviour change amongst targeted disadvantaged populations. The process has been developed into ‘The CIIC Toolkit’. The CIIC Toolkit is web-based and is hosted on the CLAHRC-NDL website. It will help commissioners and decision-makers to turn customer insight into intelligent commissioning. The RIF Project, from which the toolkit was developed, focused on childhood obesity but ‘The CIIC Toolkit’ can be applied to all health needs. PUBLIC
The project came about to address the specific problem of childhood obesity. The project team found that money spent on social marketing could be targeted more effectively if population characteristics were used. These include gender, race, age, income, education, employment status, and even location.
MOSAIC analysis & mapping populations
Literature search, review & analysis followed by critical review
Working collaboratively with the public, private and academic sectors across the East Midlands (see the logos below), the project Synthesis: The web-based resource benefits from public, private and academic expertise team sought to blend the ‘information worlds’ of academic evidence-based research and private sector consumer insight. The web-based resource developed from this work on childhood obesity enables commissioners and decision-makers to learn from industry and use consumer insight, underpinned by academic rigour, to address health need and improve how and where services are provided.
Project Manager Lisa Soultana explains the benefits: “This innovative toolkit will help commissioners and decision-makers target resources and social marketing interventions to disadvantaged populations and identify ‘hot spots’. Using consumer insight will lead to innovative, systematic, tailored and targeted local services that improve health outcomes which, in turn, will lead to more sophisticated commissioning, better use of health spend on prevention and management, and better use of social marketing funds”. The resource will be hosted on the CLAHRC-NDL website from April 2011: Left to right: Nyree Dawson (project advisor) and Lisa Soultana (Project Manager)
Background image: Demographic analysis of Nottingham, conducted by Experian using the Mosaic tool
CLAHRC Profile Catherine Pope is a Physiotherapist, employed as the Associate Director of Allied Health Professionals for Nottinghamshire Healthcare Trust. She is also the Director of Therapies on the Mental Health Network Board which is part of the NHS Confederation. Catherine is the Diffusion Fellow for the individual placement and support (IPS) for people with severe mental health problems study within the Mental Health Theme (see pages 6 - 7). Q: Hi Catherine. Could you tell us about your role as Diffusion Fellow on the IPS study? A: I’ve been involved with the study since February 2010. My role is to smooth the path for the researchers and promote the project with staff and service users. I also have a key role trying to ensure the goals of the study - prioritising employment as a realistic outcome for service users - are embedded in the Trust’s strategic plans.
Q: How is the study progressing – where are we at the moment? A: We are currently in the pilot phase, testing out the psychology intervention with a small group of service users before extending the scheme for the full study. We’re still struggling with recruiting sufficient numbers but are extending the scheme to a further team to help with this. We have also greatly improved recruitment within the existing team through some heroic efforts by key members of the research team. We had hoped to be Research is able to recruit focussed on more employment the everyday specialists to extend the study problems of across the Trust, service users... but the changes in health policy and the current financial situation mean that’s going to be an ongoing difficulty. Q: What are the big issues/challenges within Mental Health at the moment? A: Like every other public sector area we are challenged by the need to make efficiency savings. The financial pressures being experienced by local authorities also means a squeeze on their ability to fund projects and services
aimed at increasing employment opportunities, and of course rising unemployment makes it even more challenging to find jobs for people with severe and enduring mental health problems. However, that only highlights how essential this service is, and hopefully, with the help of CLAHRC, we can persuade our commissioners and GPs that the evidence base supports their investment in Individual Placement and Support as a means of preventing relapse and reliance on services.On a positive note the newly published mental health strategy “No health without mental health” (DH 2011) and the NHS Outcomes Framework 2011/12 (DH 2010) both highlight the importance of employment as an outcome for people with mental health problems.
I have been able to use the role to highlight the importance of employment throughout the Trust, linking it to the Trust’s Recovery strategy. I also sit on a number of local, regional and national committees for the Trust so can ensure that the The financial pressures project is linked to being experienced by strategic local authorities planning ...highlight how and is essential this service is... on the radar of appropriate influential people. I also hear of opportunities for funding or profile raising that we can access. I would therefore say that the role is about being able to see where you can add value to the project and then just getting on with it.
Q: Could you explain what the CLAHRC-NDL Diffusion Fellow role means to you?
Q: Has the CLAHRC model helped you to apply research findings into practice?
A: That’s an interesting question - I don’t
A: Definitely, even as a non-clinician,
think there is a defined role as such. The people who are working as Diffusion Fellows each bring their individual strengths and networks and apply them to the specific needs of the project they are involved in. I think I have been most effective in influencing change, finding solutions to operational problems and acting as a negotiator between the needs of the researchers and those providing the operational service. Sometimes that is very challenging as the priorities and demands on the researchers and clinicians can be very different and even contradict each other. Somehow, by managing to keep everyone focussed on the shared end result of finding jobs for service users, most of these problems can be surmounted.
being part of the CLAHRC has enabled me to use the evidence to change practice and raise the profile of employment as a desirable outcome for service users. It has given much more weight to negotiations with clinicians, managers and commissioners in our efforts for employment to be seen as part of the Trust’s core business. I think without it we would be struggling to have our message heard in the current financial climate. It is really important to me that research is seen to be happening in the real world – with all the problems that creates, and which I have to help negotiate – it means the research is focussed on the every day problems of service users, and therefore makes the practical applications that much easier to explain and to embed in the longer term.
To find out more about our Diffusion Fellows, including contact details, visit: www.clahrc-ndl.nihr.ac.uk/diffusion-fellows
CLAHRC events 2011 14th April:
Commissioning Conversations An event for all CLAHRC Associates, Diffusion Fellows and staff.
7th + 8th May: 10th May:
University of Nottinghamâ€™s MAYFEST Our Children & Young Peopleâ€™s theme present STAK.
Return to Work after Stroke Engagement Event Contact firstname.lastname@example.org
For details of these and more events and learning opportunities, visit our website or follow us on Twitter.
NIHR CLAHRC Nottinghamshire, Derbyshire and Lincolnshire Sir Colin Campbell Building University of Nottingham Innovation Park Triumph Road Nottingham NG7 2TU Tel: 0115 823 1253 Fax: 0115 823 1289 Email: email@example.com www.clahrc-ndl.nihr.ac.uk www.twitter.com/CLAHRC_NDL
This document can be made available in large print and other formats including translations upon request.
In this spring 2011 edition of Engage we welcome our new Director Professor Rachel Munton, who met with our Service Users and Carers group t...