Timetable and Budget
| Description | Deadline/Limit |
|---|---|
| Deadline for Stage 1 Applications | 11 July 2023, 1 PM |
| Notification of outcome of Stage 1 Application | October 2023 |
| Deadline for Stage 2 application | 28 November 2023, 1 PM |
| Notification of outcome of Stage 2 Application | April-May 2024 |
| Project Start | July 2024 |
| Project Duration | 18 Months |
| Budget | £250,000 |
Introduction
The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a realist review of risk assessment and management planning across adult secure mental health services in England to understand what works, describe what is happening in practice and determine how a more collaborative approach could be effectively and consistently implemented to improve patient experience and the way decisions are made about their care.
Background
Background to the forensic mental health pathway and adult secure services
Adult secure services provide specialised care and treatment for men and women with mental and/or neurodevelopmental disorders who are detained under the Mental Health Act (MHA) 1983, and whose risk of harm to others and risk of escape from hospital cannot be managed safely within other Mental Health (MH), Learning Disability (LD) or Autism (A) settings.
The forensic pathway can be complex and there are many interdependencies with other services and organisations. In England, adult secure inpatient services are commissioned across three levels of security - high, medium and low - based on patients’ need. Specialist forensic community teams provide ongoing care for patients discharged from adult secure services.
Patients enter the forensic pathway from a variety of sources including the courts, the community, prisons and general adult mental health, learning disability and autism services. Patients will typically progress through the system to lower levels of security before being either remitted back to prison or discharged with ongoing supervision and support in the community.
NHS England (NHSE) spends circa £1.3 billion annually on adult secure services and is the accountable commissioner for these services.
Specified commissioning responsibilities are delegated to NHS-led Provider Collaboratives (PCs) for most adult medium and low secure services, plus any community forensic services that NHSE is accountable for, excluding the more specialised services. There are 15 Adult Secure PCs nationally.
Lead Providers take on pathway management, placement oversight, quality assurance tasks and budgetary responsibility for their patient population with a renewed clinical and experience focus.
High secure services and the more specialised medium and low secure services (secure Acquired Brain Injury (ABI), secure D/deaf, and Women’s Enhanced Medium Secure Services (WEMSS)) are commissioned directly by NHSE.
Collaborative risk assessment and management planning
Collaborative risk assessment and management planning requires patients, their clinical teams, and where relevant their families and carers to work together to understand the patient’s risks and develop a mutually agreed care plan to optimise safety and recovery. Risks include harm to others, harm to self, self-neglect, iatrogenic, psycho-social and environmental.
Such patient-centred care seeks to maximise autonomy and involvement in decision making processes aligning with the NHS Long Term Plan and the National Institute for Health and Care Excellence [1, 2]
Collaborative risk assessment and management planning has the potential to improve outcomes, including reduced reoffending and rehospitalisation, shorter lengths of stay and better quality of life. Greater engagement and participation of patients in the process helps to create a greater sense of responsibility, which leads to more sustained changes in behaviour. Acknowledgement and mobilisation of patients’ strengths, in addition to their vulnerabilities, mean that individuals are better equipped to cope with stress, leading to better risk management.
Previous initiatives have attempted to foster consistent use of a collaborative and recovery orientated approach across services nationwide. For example:
- Between 2014-2016 a Commissioning for Quality and Innovation (CQUIN) scheme across adult medium and low secure services in relation to collaborative risk assessment, involved services providing evidence of co-production in the development and implementation of this approach including jointly delivered and received training for patients and clinicians. This was implemented with some variation nationally and also not sustained in some services beyond the timescale of the CQUIN.
- My Shared Pathway, a recovery-based tool developed collaboratively with patients, commissioners and providers that seeks to enhance patient involvement in decisions about their care, including issues of safety and risk. Although My Shared Pathway has been used in some adult secure services for the last decade, it has not been implemented consistently nationally or formally evaluated.
Although there is limited research about collaborative risk assessment and management planning, there is evidence supporting the feasibility of patient involvement. Collaboration needs to be meaningful for all parties involved and different stakeholders may have very varying perspectives on what this involves. Despite being a policy priority, and evidence that involvement of patients improves risk management and outcomes, not all clinicians/providers are as convinced of its importance. Furthermore, there may be gaps between what services say they do and what happens in practice.
If collaborative risk assessment and management planning can be effectively and consistently implemented across adult secure mental health services in England this could have a profound impact on patients’ experience and the way that decisions are made about their care. This would include when decisions are made and on what basis e.g., decisions around which level of security a patient should be in and the granting of leave, and eventual discharge, from hospital.
Research priorities
A programme of research, in the form of a realist review, is needed to understand what works, describe what is happening in practice and determine how a more collaborative approach could be effectively and consistently implemented. This has several specific components:
- What approaches to collaborative risk assessment and management planning are available across the adult forensic mental health pathway in England, and do they improve outcomes such as reoffending, re-hospitalisation, length of stay and patient quality of life?
- What happens in practice in terms of collaborative risk assessment and management planning across the adult forensic mental health pathway in England, are these approaches being effectively implemented and are they leading to improved outcomes?
- What are the barriers and facilitators to collaborative risk assessment and management planning across the forensic mental health pathway in England?
- What is the impact of collaborative risk assessment and management planning on the confidence of community teams to support patients in the community, (a priority within the Long Term Plan , i.e., reduced reliance on inpatient beds) and therefore on length of stay and ultimately use of resources.
Anticipated use of the research
It is anticipated that the research could result in recommendations by commissioners, or even mandating through the contract to ensure a standardised approach to collaborative risk assessment and management tools for use in clinical practice.
Case studies of best practice could be used as templates to help to reduce unwarranted variation between providers and enable more seamless transition across the pathway.
The results will inform future reviews of service specifications and the annual review of quality indicators within contracts. The quality dashboards for adult secure services in particular offer a very helpful mechanism to implement the findings of the research, for example by considering inclusion of specific metrics around collaborative risk assessment and management planning which providers are mandated through the contract to report on.
The research will support the wider efforts to identify and address health inequalities by highlighting the differential approaches to risk assessment and management planning, including the use of restrictive practice for some groups, thus helping reduce institutional bias and negative outcomes for these groups. For those patients who need to access adult secure services with a diagnosis of Learning Disability and /or Autism, the outcome of this research could support a number of the priorities within the Long Term Plan.
The research also has the opportunity to impact related parts of the health and justice systems which interact with adult secure mental health services, particularly the interface between adult secure services and prisons. This would include the potential to improve throughput to and from prison (specifically supporting confidence levels around remissions), and how risk assessments are carried out by MH services in prisons. It will also support Mental Health Casework Section (MHCS) (Ministry of Justice) collaboration and transparency, specifically for those patients who are restricted by the Secretary of State. Beyond adult secure mental health services there is also the potential impact on other services from the proposed approach to the research. For example, learning from this research could be applied to the general adult mental health pathway or to Children and Young People’s (CYP) secure and non-secure services. This approach would be particularly helpful in strengthening the transition pathway.
The National Specialised Commissioning Team (Adult Secure) has an established interface with policy teams across DHSC and MOJ (including strategic links to the MHCS and HMPPS), as well as at the Quality Network (Royal College of Psychiatry) and at the Care Quality Commission (CQC). These existing relationships provide ample opportunity to engage and involve (where appropriate) other significant policy teams, and share the interim and final learning from this research.
New Guidance on Health Inequalities data collection within NIHR PRP Research
Inequities and inequalities in the provision, access to and experience of health and care services is a high priority area within the Department of Health and Social Care and the NIHR and is present in the majority of funded projects. We are now assessing all NIHR research proposals in relation to health and care inequalities. NIHR asks researchers to explore issues of inequality and inequity in the research being proposed.
Our goal is also to facilitate more widespread and consistent reporting of data on health and care inequalities relating to the primary outcomes of NIHR funded research. Applicants should, if feasible, collect or analyse data related to health and/or care inequalities, we request that this stated in the proposal. This is a new request from the NIHR PRP and we will be continuing to monitor queries and make any necessary clarifications, as needed.
We understand that research projects may employ different methodologies, and focus on different populations. We ask that you please clearly identify in the research plan section of the application whether your application has a health and care inequalities component. If the project uses quantitative methods, please include detail of the core set of data that will be collected or analysed. Submission of the data collection will be a condition of final reporting that will need to be submitted to NIHR PRP when the grant has finished. If a health and/or care inequalities component is not included, please explain clearly why this does not fit within your research.
Specifically for this project, it may be useful to consider whether any particular groups are particularly impacted by discharge delays, and whether interventions have any differential impact for different groups. This may include consideration of local / regional variation, deprivation or characteristics covered by the Equality Act.
A recording of the Health Inequalities in NIHR PRP Research Q&A Event which was held on 19 September 2022 is available online, this may be useful to refer to as it provides additional information.
Further details about this new request can be found in Appendix A.
Eligibility
Eligibility for the NIHR PRP is laid out in our Standard Information for Applicants and applies to all calls unless otherwise stated in the individual research specification.
Technical requirements / Expertise required
- Forensic Mental Health
- Risk assessment and planning
- Offender Health
- Community Mental Health
- Mental Health Act
- Mental health services research
Outputs
Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resource needs to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.
Budget and duration
Applications will be assessed on value for money, we would not expect them to cost more than £250K.
The duration of the project should be as short as is consistent with delivering a high-quality study.
Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.
Management arrangements
A research advisory group including, but not limited to, representatives of DHSC, NHSE, other stakeholders, including Experts by Experience and a member of the NHSE Adult Secure Clinical Reference Group and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:
- Provide regular feedback on progress
- Produce timely reports to the advisory group
- Produce a final report for sign off
Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.
The application
[No specific requirements for this call]
References and key documents
NHS Long Term Plan, 2019.
Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research
Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk.
Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.
For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group.
For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.
We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used.
We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section.
* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.
** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.
*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.
Example data table for submission at the end of the funded research project
(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.
| Variable | Outcome (an appropriate average for this subgroup, usually the mean) | Number of observations | Additional information about variation if appropriate, e.g. range, standard deviation |
|---|---|---|---|
| Age | 0 | 0 | Additional information |
| Sex | 0 | 0 | Additional information |
| Gender | 0 | 0 | Additional information |
| Disability | 0 | 0 | Additional information |
| Ethnic Group | 0 | 0 | Additional information |
| IMD Group | 0 | 0 | Additional information |
| Region | 0 | 0 | Additional information |