Respect for the journey: a survivor-led investigation of undergoing psychotherapy assessment

PURPOSE

Psychotherapy assessments are key decision points for both clients and services, carrying considerable weight on both sides. Limited research indicates that assessments have immediate and long-term impacts on clients, particularly where trauma has been experienced, affecting engagement with therapy. Understanding assessments from clients' perspectives can inform service development and improve client experience.

METHODS

This is a survivor-led exploration of clients' experiences of undergoing assessment for talking therapies. Interviews were conducted with seven people who had undergone assessment for psychological therapies in third sector and NHS services. Interviews were recorded, transcribed and analysed thematically.

RESULTS

The core theme was 'respect for the journey' reflecting the need expressed by participants for their life experiences prior to the assessment to be given full respect and consideration. Six sub-themes were identified: trauma and desperation, fear of judgement, search for trust and safety, sharing and withholding (a balancing act), feeling deconstructed, and finding hope.

CONCLUSIONS

The findings highlight the heightened emotional power surrounding psychotherapy assessments, reflecting the journey participants had undertaken to reach this point. The dilemma facing clients at the heart of an assessment-how much to share and how much to withhold-demonstrates the importance for services and assessors of treating the journey a client has made to the assessment with care and respect. Findings indicate the value of services and practitioners undertaking a trauma-informed approach to assessment encounters.

Correction to: Respect for the journey: a survivor-led investigation of undergoing psychotherapy assessment

The original version of this article contained references to articles and authors that were blinded.

Predictors of engagement with peer support: analysis of data from a randomised controlled trial of one-to-one peer support for discharge from inpatient psychiatric care

BACKGROUND

A range of evidence for the effectiveness of one-to-one peer support in mental health services is emerging. Levels of engagement with peer support vary with limited studies showing few individual participant characteristics predicting engagement. Implementation factors that might predict engagement have not been considered.

METHODS

Data were analysed from the intervention arm of the ENRICH trial of one-to-one peer support for discharge from acute psychiatric inpatient care. Two outcomes were considered: (1) a measure of 'engaged with peer worker'; (2) number of face-to-face contacts with peer worker post-discharge. Two sets of independent variables were analysed against each outcome: (1) pre-randomisation participant characteristics; (2) implementation factors measured pre-discharge. Analyses used logistic and zero-inflated negative binomial regression models according to outcome structure.

RESULTS

Data were analysed for 265 participants randomised to peer support who had a known peer worker. Non-heterosexual participants had increased odds of engaging with peer support compared to heterosexual participants, OR = 4.38 (95% CI: 1.13, 16.9, p = .032). Longer duration of first contact with peer worker (OR = 1.03, 95% CI: 1.00, 1.04, p < .001) and more relationship building activities in the first contact (OR = 1.4, 95% CI: 1.13, 1.85, p = .004) were associated with greater odds of engaging with peer support. Analysis of number of contacts post-discharge showed consistent findings.

CONCLUSIONS

Implementation of peer support should include a focus on relationship building in the first session of peer support. The potential for peer support to break down barriers to accessing mental health services experienced by people from marginalised communities warrants further investigation.

Survivor-led guidelines for conducting trauma-informed psychological therapy assessments: Development and modified Delphi study

BACKGROUND

Psychological therapy assessments are a key point at which a person is accepted into a service or referred on. There is evidence of service users experiencing harm, dropping out of services and potentially experiencing poor outcomes because of inadequate assessment practices. Approaches to assessment tend to be developed by individual services, with a lack of research identifying what makes a good assessment.

METHODS

This survivor-led study, based in England, aimed to generate guidelines for conducting trauma-informed psychological therapy assessments. The study was guided by a Service User Advisory Group and a Clinician Advisory Group. The study was conducted in three key stages: (i) identifying, modelling and drafting guideline content (ii) modified Delphi study and (iii) guideline finalization. Stage 1 was informed by literature reviews, qualitative research, data workshops with Advisory Groups and an expert consultation. Fifty-nine people with relevant experiences then participated in a single-stage modified Delphi (Stage 2). The guidelines were finalized through an analysis of Delphi open comments and a final expert consultation (Stage 3).

RESULTS

The guidelines evolved through each stage of the process, and all items were deemed important by >90% of Delphi participants. The final trauma-informed guidelines contain eight principles, including 'focus on relationships', 'from systems to people' and 'healing environments'.

CONCLUSIONS

Experiential knowledge was key in generating the guidelines and conceptualizing content, with a consequent focus on areas, such as recognizing power differentials, understanding oppression as trauma and the relational aspects of assessments. Future research should focus on guideline implementation and investigate whether this impacts service user dropout, engagement with therapy, and outcomes.

PATIENT OR PUBLIC CONTRIBUTION

This study is an example of survivor research, with several authors, including the study lead, identifying as survivors. We consider the ways in which our identities as survivor researchers impacted the study findings.

The impact of working as a peer worker in mental health services: a longitudinal mixed methods study

BACKGROUND

Peer workers are increasingly employed in mental health services to use their own experiences of mental distress in supporting others with similar experiences. While evidence is emerging of the benefits of peer support for people using services, the impact on peer workers is less clear. There is a lack of research that takes a longitudinal approach to exploring impact on both employment outcomes for peer workers, and their experiences of working in the peer worker role.

METHODS

In a longitudinal mixed methods study, 32 peer workers providing peer support for discharge from inpatient to community mental health care - as part of a randomised controlled trial - undertook in-depth qualitative interviews conducted by service user researchers, and completed measures of wellbeing, burnout, job satisfaction and multi-disciplinary team working after completing training, and four and 12 months into the role. Questionnaire data were summarised and compared to outcomes for relevant population norms, and changes in outcomes were analysed using paired t-tests. Thematic analysis and interpretive workshops involving service user researchers were used to analysis interview transcripts. A critical interpretive synthesis approach was used to synthesise analyses of both datasets.

RESULTS

For the duration of the study, all questionnaire outcomes were comparable with population norms for health professionals or for the general population. There were small-to-medium decreases in wellbeing and aspects of job satisfaction, and increase in burnout after 4 months, but these changes were largely not maintained at 12 months. Peer workers felt valued, empowered and connected in the role, but could find it challenging to adjust to the demands of the job after initial optimism. Supervision and being part of a standalone peer worker team was supportive, although communication with clinical teams could be improved.

CONCLUSIONS

Peer workers seem no more likely to experience negative impacts of working than other healthcare professionals but should be well supported as they settle into post, provided with in-work training and support around job insecurity. Research is needed to optimise working arrangements for peer workers alongside clinical teams.

Rescue of cardiac function in obese type-2 diabetic mice by transfer of a human longevity gene

Background

Healthy longevity is the result of the interaction between favourable environment and unique genetic makeup. We showed that horizontal transfer of a longevity-associated gene variant (LAV-BPIFB4) improves endothelial function and accelerates the recovery from ischemia.

Purpose

To determine if the benefit of LAV-BPIFB4 gene therapy can be extended to diabetic cardiomyopathy.

Methods and results

We confirmed that human diabetic patients with heart failure (n=13) show a decreased cardiac expression of BPIFB4 compared with healthy subjects (n=10). Obese db/db mice received a systemic injection of adeno-associated viral vector (AAV9)-LAV-BPIFB4, AAV9-wild type (WT)-BPIFB4 (both 100 μL at 1×1012 GC/mL) or vehicle before the onset of cardiomyopathy, and were euthanised four weeks later for histological, metabolic and transcriptional analyses. Echocardiographic evaluation (n=8/group), performed at baseline and after gene therapy, showed that LAV-BPIFB4 treatment, despite not resolving hyperglycaemia, improved left ventricular function compared with the other groups. Histological analyses of the hearts (n=5 to 10/group) revealed that LAV-BPIFB4 reduced myocardial fibrosis and increased angiogenesis compared with vehicle and WT-hearts; moreover, LAV increased the expression of the alpha-isoform of the cardiac myosin heavy chain, which is associated with a superior cardiomyocyte contractility. Interestingly, LAV-BPIFB4 treatment induced an increase in cardiac SDF1 expression compared with WT and vehicle, despite the mechanism linking the two events is still unknown. The oral administration of the CXCR4 antagonist AMD-070, given at 2 mg/kg/day for four weeks, abolished several of the beneficial effects exerted by the LAV-BPIFB4 therapy in the obese diabetic mice, as assessed by echocardiography and histology (n=7/group).

At the molecular level, next-generation RNA sequencing (n=3 to 4 /group) showed 8 genes were differentially expressed by LAV-BPIFB4-hearts compared with vehicle-hearts. These genes are associated with mitochondrial and metabolic functions. Among them, changes in the UCP3, HMGCS2, CS, ATPB and TOMM20 expression were also validated at the protein level by western blotting. Lipidomics using ultrahigh-performance liquid chromatography-mass spectrometry (n=6 or 7/group) showed 63 metabolites differentially expressed by LAV-BPIFB4- compared with vehicle-hearts, with only 3 (two cardiolipins and one glycerophospholipid) returning close to the non-diabetic phenotype following LAV-BPIFB4 treatment.

Conclusions

This study newly shows the possibility of transferring the benefit of salutary polymorphic gene variants to protect the cardiovascular system from metabolic pressure. Rather than combating pathogenic mechanisms, the strategy activates alternative pathways overriding disease risk factors.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation project grant “Longevity-associated BPIFB4 gene therapy for treatment of ischemic disease”

The social underpinnings of mental distress in the time of COVID-19 - time for urgent action

We argue that predictions of a ‘tsunami’ of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health.  Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services.  However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations.  Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care.  Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater.

Peak Aerobic Fitness of Visually Impaired and Sighted Adolescent Girls

This study compared the aerobic fitness of 10 visually impaired and 10 sighted girls who performed a discontinuous incremental treadmill test to exhaustion. It found that there was no significant difference between the peak oxygen intake of the two groups. The results indicate that visually impaired children can attain aerobic fitness levels similar to those of sighted children.

'Dignity and respect': An example of service user leadership and co-production in mental health research

This paper explores the methodological aspects of a user‐led study investigating mental health service user experiences of targeted violence and abuse (often called 'hate crime'). 'Keeping Control' was a 16‐month qualitative study, undertaken in the context of adult safeguarding reforms in England. By collecting data on service user concepts and experiences, the research sought to address a gap in research and practice knowledge relating to targeted violence, abuse and hostility against people with mental health problems. In this paper, we discuss the significance of the design and methodology used for this study, with a particular focus on the interviews with service users. The research was both user‐led and carried out in collaboration with practitioners and academics, a form of research co‐production. Our aim is to inform researchers, practitioners and policymakers about the value of user leadership in co‐productive research with practitioners, particularly for a highly sensitive and potentially distressing topic.

"Keeping Control": A user-led exploratory study of mental health service user experiences of targeted violence and abuse in the context of adult safeguarding in England

The situation for people with mental health problems as a group of disabled people who experience targeted violence and abuse is a complex one. Disabled people, particularly those with mental health problems, are at higher risk of targeted violence and hostility with few effective evidence-based prevention and protection strategies. Achieving effective safeguarding for adults with mental health problems is characterised by differential attitudes to and understandings of abuse by safeguarding practitioners, as well as systemic issues arising from multi-agency working. "Keeping Control" was a 16-month user-led, co-produced exploratory qualitative study into service user experiences of targeted violence and abuse that was examined in the context of Care Act 2014 adult safeguarding reforms in England. User-controlled interviews of mental health service users (N = 23) explored their experiences and concepts of targeted violence and abuse, prevention and protection. Preliminary findings from these interviews were discussed in adult safeguarding and mental health stakeholder and practitioner focus groups (N = 46). The data were also discussed via two facilitated Twitter chats (responses N = 585 and N = 139). Mental health service users' experiences and concepts of risk from others, vulnerability and neglect can be different to those of practitioners but should be central to adult safeguarding. Histories of trauma, multi-factorial abuse; living with fear and stigma as well as mental distress; the effects of "psychiatric disqualification" and individual blaming should be addressed in adult safeguarding in mental health. Fragmented responses from services can mean a person becomes "lost in the process". Staff can feel disempowered, afraid or lacking in confidence to "speak up" for individuals in complex service systems with poor communication and lines of accountability. Adult safeguarding practitioners and stakeholders need to be confident, accessible and respond quickly to service users reporting incidents of targeted violence and abuse particularly in closed environments such as wards or supported housing.

Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: a cross national comparative mixed methods study

BACKGROUND

Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care.

METHODS

A cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users (n = 301) and staff (n = 290) and embedded case studies involving interviews with staff, service users and carers (n = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method.

RESULTS

For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.

CONCLUSIONS

There is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning. This paper arises from a larger study published by National Institute for Health Research (Simpson A, et al, Health Serv Deliv Res 5(26), 2017).

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

Cross-national mixed-methods comparative case study of recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings (COCAPP-A)

Background

Mental health service users in acute inpatient wards, whether informal or detained, should be involved in planning and reviewing their care. Care planning processes should be personalised and focused on recovery, with goals that are specific to the individual and designed to maximise their achievements and social integration.

Objective(s)

We aimed to ascertain the views and experiences of service users, carers and staff to enable us to identify factors that facilitated or acted as barriers to collaborative, recovery-focused care and to make suggestions for future research.

Design

A cross-national comparative mixed-methods study involving 19 mental health wards in six NHS sites in England and Wales included a metanarrative synthesis of policies and literature; a survey of service users (n = 301) and staff (n = 290); embedded case studies involving interviews with staff, service users and carers (n = 76); and a review of care plans (n = 51) and meetings (n = 12).

Results

No global differences were found across the sites in the scores of the four questionnaires completed by service users. For staff, there was significant difference between sites in mean scores on recovery-orientation and therapeutic relationships. For service users, when recovery-orientated focus was high, the quality of care was viewed highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Across all sites, staff’s scores were significantly higher than service users’ scores on the scale to assess therapeutic relationships. Staff across the sites spoke of the importance of collaborative care planning. However, the staff, service user and carer interviews revealed gaps between shared aspirations and realities. Staff accounts of routine collaboration contrasted with service user accounts and care plan reviews. Definitions and understandings of recovery varied, as did views of the role of hospital care in promoting recovery. ‘Personalisation’ was not a familiar term, although there was recognition that care was often provided in an individualised way. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.

Conclusions

Our results suggest that there is positive practice taking place within acute inpatient wards, with evidence of widespread commitment to safe, respectful, compassionate care. Although ideas of recovery were evident, there was some uncertainty about and discrepancy in the relevance of recovery ideals to inpatient care and the ability of people in acute distress to engage in recovery-focused approaches. Despite the fact that staff spoke of efforts to involve them, the majority of service users and carers did not feel that they had been genuinely involved, although they were aware of efforts to keep them safe.

Future work

Future research should investigate approaches that increase contact time with service users and promote personalised, recovery-focused working; introduce shared decision-making in risk assessment and management; and improve service user experiences of care planning and review and the use of recovery-focused tools during inpatient care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Do trainee surgeons have an adverse effect on the outcome after total hip arthroplasty?: a ten-year review

AIMS

The long-term functional outcome of total hip arthroplasty (THA) performed by trainees is not known. A multicentre retrospective study of 879 THAs was undertaken to investigate any differences in outcome between those performed by trainee surgeons and consultants.

PATIENTS AND METHODS

A total of 879 patients with a mean age of 69.5 years (37 to 94) were included in the study; 584 THAs (66.4%) were undertaken by consultants, 138 (15.7%) by junior trainees and 148 (16.8%) by senior trainees. Patients were scored using the Harris Hip Score (HHS) pre-operatively and at one, three, five, seven and ten years post-operatively. Surgical outcome, complications and survival were compared between groups. The effect of supervision was determined by comparing supervised and unsupervised trainees. A primary univariate analysis was used to select variables for inclusion in multivariate analysis.

RESULTS

There was no evidence that the grade of the surgeon had a significant effect on the survival of the patients or the rate of revision (p = 0.987 and 0.405, respectively) up to 12 years post-operatively. There was no significant difference in post-operative functional HHS or total HHS among consultants, junior and seniors up to ten years post-operatively (p = 0.401 and 0.331), respectively. There was no significant difference in hospital stay (p = 0.855) between different grades of surgeons. There was no evidence that the level of supervision had an effect on the survival of the patients or the rate of revision (p = 0.837 and 0.203, respectively) up to 12 years post-operatively. There was no significant difference between supervised and unsupervised trainee groups in post-operative functional HHS or total HHS up to ten years post-operatively (p = 0.213 and 0.322, respectively). There was no significant difference in the mean hospital stay between supervised and unsupervised trainees (p = 0.908).

TAKE HOME MESSAGE

This study suggests that when trainees are appropriately supervised, they can obtain results comparable with those of their consultant colleagues when performing THA.

Ordinary risks and accepted fictions: how contrasting and competing priorities work in risk assessment and mental health care planning

Background

Communication and information sharing are considered crucial to recovery‐focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.

Objective

Using data from our cross‐national mixed‐method study of care planning and coordination, we examined what patients, family members and workers say about risk assessment and management and explored the contents of care plans.

Design

Thematic analysis of qualitative research interviews (n = 117) with patients, family members and workers, across four English and two Welsh National Health Service sites. Care plans were reviewed (n = 33) using a structured template.

Findings

Participants have contrasting priorities in relation to risk. Patients see benefit in discussions about risk, but cast the process as a worker priority that may lead to loss of liberty. Relationships with workers are key to family members and patients; however, worker claims of involving people in the care planning process do not extend to risk assessment and management procedures for fear of causing upset. Workers locate risk as coming from the person rather than social or environmental factors, are risk averse and appear to prioritize the procedural aspects of assessment.

Conclusions

Despite limitations, risk assessment is treated as legitimate work by professionals. Risk assessment practice operates as a type of fiction in which poor predictive ability and fear of consequences are accepted in the interests of normative certainty by all parties. As a consequence, risk adverse options are encouraged by workers and patients steered away from opportunities for ordinary risks thereby hindering the mobilization of their strengths and abilities.

Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study

BACKGROUND

In the UK, concerns about safety and fragmented community mental health care led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require service users to have a care coordinator, written care plan and regular reviews of their care. Processes are required to be collaborative, recovery-focused and personalised but have rarely been researched. We aimed to obtain the views and experiences of stakeholders involved in community mental health care and identify factors that facilitate or act as barriers to personalised, collaborative, recovery-focused care.

METHODS

We conducted a cross-national comparative study employing a concurrent transformative mixed-methods approach with embedded case studies across six service provider sites in England and Wales. The study included a survey of views on recovery, empowerment and therapeutic relationships in service users (n = 448) and recovery in care coordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117) and a review of care plans (n = 33). Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and framework method.

RESULTS

Significant differences were found across sites for scores on therapeutic relationships. Variation within sites and participant groups was reported in experiences of care planning and understandings of recovery and personalisation. Care plans were described as administratively burdensome and were rarely consulted. Carers reported varying levels of involvement. Risk assessments were central to clinical concerns but were rarely discussed with service users. Service users valued therapeutic relationships with care coordinators and others, and saw these as central to recovery.

CONCLUSIONS

Administrative elements of care coordination reduce opportunities for recovery-focused and personalised work. There were few common understandings of recovery which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work. Research to investigate innovative approaches to maximise staff contact time with service users and carers, shared decision-making in risk assessments, and training designed to enable personalised, recovery-focused care coordination is indicated.

Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP)

Background

Concerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment.

Objective(s)

We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research.

Design

A cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33).

Review methods

A meta-narrative mapping method.

Results

Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments.

Limitations

Limitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers.

Conclusions

The administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.

Future work

Research should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Study protocol: cross-national comparative case study of recovery-focused mental health care planning and coordination (COCAPP)

BACKGROUND

The collaborative care planning study (COCAPP) is a cross-national comparative study of care planning and coordination in community mental healthcare settings. The context and delivery of mental health care is diverging between the countries of England and Wales whilst retaining points of common interest, hence providing a rich geographical comparison for research. Across England the key vehicle for the provision of recovery-focused, personalised, collaborative mental health care is the care programme approach (CPA). The CPA is a form of case management introduced in England in 1991, then revised in 2008. In Wales the CPA was introduced in 2003 but has now been superseded by The Mental Health (Care Co-ordination and Care and Treatment Planning) (CTP) Regulations (Mental Health Measure), a new statutory framework. In both countries, the CPA/CTP requires providers to: comprehensively assess health/social care needs and risks; develop a written care plan (which may incorporate risk assessments, crisis and contingency plans, advanced directives, relapse prevention plans, etc.) in collaboration with the service user and carer(s); allocate a care coordinator; and regularly review care. The overarching aim of this study is to identify and describe the factors that ensure CPA/CTP care planning and coordination is personalised, recovery-focused and conducted collaboratively.

METHODS/DESIGN

COCAPP will employ a concurrent transformative mixed methods approach with embedded case studies. Phase 1 (Macro-level) will consider the national context through a meta-narrative mapping (MNM) review of national policies and the relevant research literature. Phase 2 (Meso-level and Micro-level) will include in-depth micro-level case studies of everyday 'frontline' practice and experience with detailed qualitative data from interviews and reviews of individual care plans. This will be nested within larger meso-level survey datasets, senior-level interviews and policy reviews in order to provide potential explanations and understanding.

DISCUSSION

COCAPP will help identify the key components that support and hinder the provision of personalised, recovery-focused care planning and provide an informed rationale for a future planned intervention and evaluation.

Stem cell therapy for cardiovascular disease: the demise of alchemy and rise of pharmacology

Regenerative medicine holds great promise as a way of addressing the limitations of current treatments of ischaemic disease. In preclinical models, transplantation of different types of stem cells or progenitor cells results in improved recovery from ischaemia. Furthermore, experimental studies indicate that cell therapy influences a spectrum of processes, including neovascularization and cardiomyogenesis as well as inflammation, apoptosis and interstitial fibrosis. Thus, distinct strategies might be required for specific regenerative needs. Nonetheless, clinical studies have so far investigated a relatively small number of options, focusing mainly on the use of bone marrow-derived cells. Rapid clinical translation resulted in a number of small clinical trials that do not have sufficient power to address the therapeutic potential of the new approach. Moreover, full exploitation has been hindered so far by the absence of a solid theoretical framework and inadequate development plans. This article reviews the current knowledge on cell therapy and proposes a model theory for interpretation of experimental and clinical outcomes from a pharmacological perspective. Eventually, with an increased association between cell therapy and traditional pharmacotherapy, we will soon need to adopt a unified theory for understanding how the two practices additively interact for a patient's benefit.