Policy Research Programme - Research specification for access assessments for admission to adult medium and low secure services call

Introduction

1. The NIHR Policy Research Programme (PRP) invites applications to undertake research to inform decisions about the appropriate use of NHS resource and establish the principles of access assessments to adult medium and low secure services associated with the most effective use of these resources and to improve the interface across the whole pathway, including the Criminal Justice System (CJS) and secondary Mental Health (MH), Learning Disability (LD) and Autism services. Up to £400,000 in total is available for a single project judged to be of sufficiently high scientific quality and relevance.
   
   
2. In particular, we would welcome research that examines the use of structured assessment tools in these settings and evaluates the experience of professionals who make referrals, those who conduct assessments and patients who are experiencing the process.
   
   
3. This research is needed to provide a solid evidence base to inform effective decision-making ensuring patients are placed in the right services for them and to enhance the consistency, equitability and reproducibility of decision making to reduce variability across NHS-led Provider Collaboratives (PCs).

Background

4. The NHS spends circa £1.3 billion annually on adult secure services the majority of which is spent on medium and low secure services (circa. £1.1 billion.) Adult medium and low secure services provide care and treatment for men and women with mental and/or neurodevelopment 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 secure pathway can be complex and there are many interdependencies with other services and organisations.
   
   
5. NHSEI is the accountable commissioner for these services, however specified commissioning responsibilities are delegated to NHS-led PCs. PCs are groups of providers that taking collective responsibility for a specific type (or group) of service specialism(s), through a Lead Provider for their originating population. They manage the pathway and budget for their population and have responsibilities for quality assurance and service improvement. They are accountable to NHS England and NHS Improvement for decisions made and the quality of care. PCs have specific delegated commissioning responsibilities.
   
   
6. There are 15 Adult Secure NHS-led PCs, eight of these are live as of 1 July 2021 with the remaining seven to go live by 1 October 2021. This policy direction is described in the NHS Mental Health Implementation Plan.
   
   
7. 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. Within an NHS-led PC, the Lead Provider is a designated/agreed NHS provider organisation who will oversee the delivery of all services under the contract. Lead providers engage with all other providers within and outside of the Provider Collaborative, will sub-contract elements of the contracted services and ensure consistency and quality of services delivered. The lead provider is accountable to NHS England and NHS Improvement on behalf of the Provider Collaborative.
   
   
8. Central to the purpose and effective functioning of the PC model are access assessments for those identified as potentially needing access to adult secure services. The process for carrying out access assessments is outlined in appendix 2 of the Medium and Low Secure (Adults) specifications C02/S/a and C02/S/b. Referrals to adult secure services come from several sources, for example, the CJS or secondary MH, LD and Autism services. The access assessment is crucial considering the human, clinical and financial consequences of admitting a patient to these services.
   
   
9. The access assessment process is significant for those patients who need to transition across levels of security. This type of transition can take place as part of a progression through the pathway but can also be required when someone’s mental state deteriorates and their risk increases, leading to the potential need for access to higher levels of security. These decisions need to be made through robust assessments carried out by skilled and experienced clinical teams.
   
   
10. Despite national specifications and standards, there are local variations in the delivery of the access assessment, which can be inefficient, with duplication of processes. Structured Professional Judgement (SPJ) tools, for which an evidence base is only starting to be established, are available to contribute to access assessment decisions that can be anchored or modified by clinical judgement.
    
    
11. It is unclear as to the effectiveness of SPJ tools in admitting or allocating a patient to the correct level of security, or an alternative care pathway. As a result of this lack of evidence and other reasons, SPJ tools have not been universally adopted or their use standardised and often access assessments rely on clinical judgement alone.

Research needed

12. There is a paucity of literature on adult secure services generally with very little national or international research undertaken; much of the available evidence is not of high quality.
    
    
13. Research is needed to establish whether NHS resources are being used effectively and efficiently for adult medium and low secure services, insofar as adult secure services can manage the risk presented by patients following their admission, while maintaining the principles of least restrictive practice.
    
    
14. Research is also needed to understand and evaluate the experience of the professionals who make referrals to these adult secure services, those who conduct the assessments (with or without SPJ tools) and importantly patients who are experiencing the process. In addition, it is crucial to understand where any inequalities may be evident.
    
    
15. We would welcome research that evaluates the experience of:

• Professionals who make referrals
• Professionals who conduct assessments (with or without structured assessment tools)
• Patients who are experiencing the process

16. Indicative research questions include:

• How are SPJ tools being used in decision-making about who accesses adult medium and low secure services, if at all?
• Do such tools have evidence for adequate psychometric properties to be used in this way?
• What is the experience of referrers and assessors of using these tools in terms of acceptability, usability and confidence in these tools to help support decisions about who accesses these services?
• Does the use of such tools lead to more effective decisions and therefore pathways of care and outcomes for patients (it may be helpful to consider this in relation to specific secure service types e.g. male and female, medium and low secure, by diagnosis.
• Are assessments taking into consideration all relevant available information and ensuring the least restrictive environment is considered? What is the experience of patients, referrers and assessors of the access assessment process?
• What, if anything, does the evidence tell us about differences in the usage of SPJ tools in, experiences of, or outcomes from the assessment process for patients with protected characteristics?

17. All research should actively involve patients, their families and carers, and the public, and where feasible should be co-produced, from the inception of the application through to dissemination, as standard, working alongside relevant communities to understand people’s experiences and to highlight the narratives and views of those with lived experience.

Areas out of scope for this programme of work  

• This research should be focused on adult medium and low secure services commissioned in England for English patients only.

Technical requirements

• 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.

Budget and duration

• A budget of £400,000 is available for this research. The duration of the project should be as short as is consistent with delivering a high quality study.
• In assessing proposals, the Department will be seeking value for money as well as scientific excellence and the potential policy impact which is key.
• 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.
• In order to maximise the benefit from the findings, the research will need to commence as soon as possible following selection of the successful bid and placing of a contract. Capability to start promptly will be an advantage and for this commissioning round, applicants should demonstrate that projects can start by October 2021.

Timetable

Step	Date
Deadline for stage 1 applications	7 September 2021, 1 PM
Notification of outcome of stage 1	22 October 2021
Project start	November 2021

Governance and Research Requirements

• Applicants will need to describe how proposed studies will inform policy development in mental health and in relation to mental health legislation.
• 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.