News

On the 25th of September 2013 the BioMedCentral update included a podcast from Prof. Kupfer regarding the new DSM.

"The recent publication of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) marks the end of a 20 year period of revision. We talk with the Chair of the DSM-5 task force, Professor David Kupfer, about the implications of the resulting changes in diagnosing and classifying mental disorders in the USA".

http://p5trc.emv2.com/LP/4A6weKw2PVe?utm_campaign=25_09_13_Biome_Update_Biol_BtG_HOUSE_Remaining&utm_content=7387477232&utm_medium=BMCemail&utm_source=Emailvision

The post below, written by Tom Dening, Professor of Dementia Research with the Institute of Mental Health,  has been invited to deliver an Inaugural Lecture for the University of Nottingham. The lecture will take place at the University’s A30 lecture theatre in the Arts Centre from 6pm on Thursday 10 October. Inaugural Lecture It is one of the expectations of a new Professor that he or she will deliver an inaugural lecture. The aim is to show off what you know but also to gather a broad audience and offer some entertainment too. This requires presumably some witty slides, the odd joke, and a clear narrative to set out your agenda for future research.

I think that’s where the auguries come in, i.e. as pointers to the future. I managed to lie low for a few months before eventually I was rounded up by the Vice Chancellor’s office and reminded of this serious obligation to scholarship and public education. Seized, as ever when faced with prospect of a speaking engagement, I managed to procrastinate for a while longer before bowing to the inevitable and agreeing to give it.

Several big issues immediately cropped up. One, the date. Two, the venue. Third, a snappy title is almost mandatory. Anyhow, the two problems were solved by the exhibition Art and the Asylum, which is currently running in the University’s Djanogly Art Gallery until early November, curated by my colleague Victoria Tischler. I warmly recommend this exhibition to anyone, by the way. We also worked out that the World Health Organisation’s Mental Health Day falls on 10^th October and this year the theme is Older People. Voila, there we have a date and a venue all in one.

The title was more of a challenge, but I knew that I would be talking about dementia and I conceive of the thing as telling a story, some of it personal and some of it about research in dementia and where that is taking us at the moment. So the subtext would be A Journey in Dementia or something like that. The catchy bit was harder but, for various reasons, I have settled on Mrs Finch and the Fishbowl as being the limits of the journey. Mrs Finch I am keeping under wraps so to speak but the Fishbowl is an interactive website designed to showcase dementia research in Nottingham. It uses a particular methodology, featuring fish (who write blogs), experts (who comment on the blogs), and the public (who can comment on any part of it). We also plan to launch the Fishbowl at the inaugural lecture.

In the last few days, we have ben deciding which of the Asylum Art exhibits we wish to use for the posters, invites and programmes. I went for an abstract dinosaur image rather than a Louis Wain cat. I thought that if we added a cat to finches and fishbowls, the metaphors would become overwhelming. Anyway, personally, I don’t like cats much.

All (?) that remains is to write the lecture. I have already been in touch with a blogger in South Devon to use one her excellent photographs of seagulls, so you can see that the key ideas are fermenting in there somewhere. I think I know what I want to say but we’ll have to see how it turns out. You’re welcome to attend, just email This email address is being protected from spambots. You need JavaScript enabled to view it. if you need further information and you will need to register as numbers are limited.

The Consortium of Therapeutic Communities Research & Development Group is hosting a research afternoon focusing on therapeutic communities (TC) and enabling environments (EE).  Come and hear about ongoing and recently completed research, discuss ideas, contribute suggestions.  The afternoon is free and open to all with an interest in TC and EE research.

Date: 26 September 2013

Time: 12:30pm (lunch and refreshment) for 1-4pm

Location: Community of Communities offices at the Royal College of Psychiatrists in London

Confirmed presenters include:
Robin Johnson and Peter Cockersell
Robin Johnson and Peter Cockersell will outline recent progress in the application of Enabling Environments thinking in UK homelessness resettlement services ( hostels, refuges, night shelters, foyers) - where it goes by the name of "Psychologically Informed Environments" (note that, by contrast to parallel developments in Criminal Justice, the "planned" in a "PIPE" is dropped, in order to accentuate continuous evolution.)

Official guidance recommending adoption of the PIE approach specifically commends "evidence-generating practice"; yet the stress in PIEs on reflective practice already begins to echo earlier debates in the TC movement over highly specified definitions of the TC, versus encouragement of a less teleological "culture of inquiry".

Elizabeth Bickford-Smith and Megan Wingfield
Elizabeth Bickford-Smith will present on her recently published paper in the Mental Health Review Journal about evaluating the usefulness of the step-down group run for members who have completed 18 months at Winterbourne House, Reading.  In conjunction with Elizabeth, Megan Wingfield will discuss a paper the support system at Winterbourne House.

Zoneera Akther
Zoneera Akther will be presenting her MSc thesis findings from the only prison-based DTC for female offenders.  Her thesis title is: An Exploratory Study of the Effectiveness of a Democratic Therapeutic Community for Female Offenders.

Jenelle Clarke
Jenelle Clarke will present an ongoing doctoral research project that explores everyday social encounters within TCs as an opportunity for social learning and the potential to experience positive change. The study adopts ritual theory as first suggested by Mead, Durkheim and Goffman, to address how, and to what extent, individuals use social interactions to facilitate self-transformation. These everyday interaction rituals are where social norms, social capital and power dynamics between clients and staff members are both explained and lived out.  The research utilises narrative ethnography involving participant observation of two therapeutic communities coupled with in-depth narrative interviews.

Nick Manning will provide concluding comments and discussion.

If you would like more information or to book a slot, please email This email address is being protected from spambots. You need JavaScript enabled to view it..

A re-post from the Centre for Mental Health's online blog, authored by Andy Bell, re. this week’s Panorama programme on the use of police custody in mental health emergencies, the Bradley Report, L&D services, prevention, etc.

http://blog.centreformentalhealth.org.uk/2013/09/10/a-continued-focus-on-prevention-early-intervention-and-recovery/

This week’s Panorama on the use of police custody in mental health emergencies painted a disturbing and distressing picture. It provided a graphic reminder of the risks of using police stations as “places of safety” under the Mental Health Act while illustrating the dilemmas police officers and mental health services face in being able to respond to the needs of people in a crisis.

During the programme, care services minister Norman Lamb described the picture it presented as a “national scandal” and it is hard to disagree. Despite the best efforts of both the police and mental health services, it is clear that, as a nation, our ability to respond to urgent care needs is inadequate.

Much effort is already being put into trying to resolve this situation. Spurred by previous reports of shortcomings in the system, the Home Office and Department of Health have already made clear their determination to see the NHS and police put better systems in place and to try out new approaches like street triage.

Separately, NHS England is now carrying out its own review of urgent care and the Department of Health is investing extra funding in A&E services. It is not, however, clear if these developments will be joined up and include the whole system of mental health crisis care. Yet this must now be regarded as a litmus test for parity between physical and mental health care.

While Panorama made clear that there are no easy solutions to the problems it laid bare, it was also plain to see that continued under-investment in mental health care is making it harder for anyone to improve the situation.

We also know some of the ways in which we could begin to do better. Completing the job of making a liaison and diversion service available, 24/7, to every police station in England is crucial. Recommended in the Bradley Report and committed to by the government, liaison and diversion can no longer be seen as an optional extra but a core role of all mental health services. Timely access to crisis resolution and home treatment services, appropriate places of safety and of course hospital places (or alternatives to admission) for adults and children are also key to building a whole system of mental health crisis care.

In general hospitals, meanwhile, there is growing evidence about the importance and the benefits of investing in liaison psychiatry services, again available 24/7, for people of all ages to ensure that those who seek help through A&E get effective mental health support alongside any physical health care they require.

Responding quickly, humanely and effectively to crises is fundamental to the mission of the NHS, and indeed of the police. Nobody can ignore the need to offer better care to people experiencing a mental health crisis: and not just the police and mental health services but general practice, ambulance services and A&E all need to be ready to respond.

Looking more broadly, while not all crises can be averted we need to keep focusing on prevention, early intervention and recovery: to ensure we are doing all we can to stop crises from happening at all and enable people with mental health problems to live without the fear that if they become unwell they will have nowhere safe to turn.

IMH Newsletter August 2013

The University of Nottingham has uploaded an edited film of the Inside Out of Mind play, recently staged at the Lakeside Arts Centre, onto its YouTube channel. The film can be seen at http://youtu.be/Kbir0cCQPYM on the YouTube channel ‘NottmUniversity’.  Inside Out of Mind played to capacity audiences during its run at Lakeside during 14-29 June 2013. The play is based on field notes collected by three health care assistants while working on an acute NHS dementia ward. The production was the brain child of Justine Schneider, Professor of Mental Health and Social Care within the Institute of Mental Health. It forms part of an official research project which Professor Schneider was commissioned to carry out for the Department of Health.  The video shows how the play has been used to raise awareness of dementia care and educate professionals involved in dementia care.

IMH Newsletter August 2013

Scientists from the Institute of Mental Health have shown that psychotic symptoms experienced by people with schizophrenia could be caused by a faulty ‘switch’ within the brain. In a study published in the leading journal Neuron, they have demonstrated that the severity of symptoms such as delusions and hallucinations which are typical in patients with the psychiatric disorder is caused by a disconnection between two important regions in the brain — the insula and the lateral frontal cortex.  The breakthrough, say the academics, could form the basis for better, more targeted treatments for schizophrenia with fewer side effects. The four-year study, led by Professor Peter Liddle and Dr Lena Palaniyappan, centred on the insula region, a segregated ‘island’ buried deep within the brain, which is responsible for seamless switching between inner and outer world. Dr Lena Palaniyappan said: “In our daily life, we constantly switch between our inner, private world and the outer, objective world. This switching action is enabled by the connections between the insula and frontal cortex. This switch process appears to be disrupted in patients with schizophrenia. This could explain why internal thoughts sometime appear as external objective reality, experienced as voices or hallucinations in this condition.” Visit the University of Nottingham website at http://www.nottingham.ac.uk/news/pressreleases/2013/august/schizophrenia-symptoms-linked-to-faulty-switch-in-brain.aspx for more information.

The House of Lords has recently established a Committee to review the Mental Capacity Act 2005 and the accompanying Deprivation of Liberty Safeguards.  They are examining many aspects (see the call for evidence here), but one thing that I really think needs reconsidering is the review mechanism.

Briefly, there are two mechanisms for review of a DoLS authorisation set out under schedule A1 to the MCA.  The initial approach should be an application for review to the supervisory body, which can request the review of any of the 6 qualifying criteria for the DoLS authorisation, to ensure they are still met.  The problem here, is that the supervisory body is the body which authorised the application in the first place; if they have done their job correctly, and not simply ‘rubber stamped’ the application, then they should have already checked that these criteria have been met.  If this is a case of disagreeing with the original assessments, rather than a review on the basis that the circumstances have changed (such as the individual regaining capacity), then this begins to seem like a weak process.  The supervisory body are not independent, and relies on good practice from everyone concerned.  As Mark and Steven Neary found out, the absence of external scrutiny on such a process, can result in collusion and abuse of the process.

The second route of appeal is directly to the Court of Protection.  This is an external mechanism, and as such should be unbiased and objective.  It is, however, costly and lengthy, and can take some time before anything is resolved.  Further, the court’s judgments on what constitutes a deprivation of liberty have been narrowing over the past few years (such as Cheshire West and P and Q), which the cynical amongst us could interpret as a policy decision to attempt to reduce the number of cases coming before an already-overworked court.

The right to a review of a deprivation of liberty is set out in the European Convention on Human Rights (ECHR), which is directly binding in domestic law by the Human Rights Act 1998.  Article 5(4) sets out that individuals who are deprived of their liberty ‘be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful’.  Recently, the European Court on Human Rights (ECtHR) has had cause to consider this provision in considerable depth, as it has heard a number of striking cases on issues of capacity and guardianship from Eastern Europe.

The recent cases are Kedzior v Poland, Stanev v Bulgaria, DD v Lithuania and Lashin v Russia.  All four applicants had a diagnosis of schizophrenia and had been found totally or partially incapacitated by a domestic court, and appointed a guardian.  The nuances of guardianship law are slightly different in each Member State, but the basic premise of incapacitation and guardianship is that the individual is no longer considered a legal person, and their guardian is their representative for the purposes of legal decision-making.  This includes the making of applications to a court of both their incapacitation and guardianship status, and their deprivation of liberty.

All four were found to be deprived of their liberty under article 5(1) of the ECHR, and that they had not had sufficient access to a review of that deprivation of liberty.  Mr Stanev was not permitted to bring a case for review of his placement in a social care home, as his guardian had not authorised his representation by a lawyer.  Though his guardian was not opposed to his making an application, the paperwork had not been completed correctly.  Ms DD was not permitted to make an application at all, only her guardian was permitted to do so; in her case, her guardian was opposed to her making any such application for review of her status.  The situation was similar for Mr Kedzior.  In the case of Mr Lashin, the Psychiatric Care Act in Russia provides for automatic review of the detention of people held under compulsory detention every 6 months.  Mr Lashin was considered a voluntary patient due to being placed there under consent of his guardian, and therefore did not have access to these automatic reviews.  He was not able to apply directly himself due to his incapacitated status.  In all four cases, the Court found a violation of article 5(4).

The position here is different to that in the ECHR cases.  The DoLS makes it very clear that the relevant person is automatically eligible to make a request for a review (para. 102((3) (a)), and the main MCA states in s.50 (1) (a) that an individual who lacks capacity does not require permission to make an application to the Court of Protection.  However, why there are no barriers in law, it must be considered whether, in practice and in reality, article 5(4) is met by the DoLS.  People who are subject to a DoLS authorisation may not be able to make an application themselves – they may have profound intellectual disabilities or advanced dementia, or another mental impairment which makes it difficult for them to communicate with others, and to formulate their objections.  In these instances, how can they ensure they have effective review of their deprivation of liberty?  Who is to take the complaint?

An individual subject to a DoLS authorisation is not alone; they have a representative, appointed as part of the authorisation process.  The individual themselves may also be supported by an IMCA, and s. 39D(8) requires that an IMCA must take steps to help the individual apply to court or for review by the supervisory body ‘if it appears to the advocate that P or R wishes to exercise that right’.  However, there are several problems with both of these mechanisms.  Firstly, the representative may well agree with the managing authority and the supervisory body as to the best interests of the individual.  Certainly, figures from the Department of Health suggest that just under a third of authorisations were reviewed last year, and only 3.3% of these were brought by RPRs.  Secondly, the IMCA support may only happen if an IMCA is appointed in the first place; s.39D(5) does require the appointment of an IMCA if the supervisory body does not feel that either the individual or their representative would be able to exercise their rights without such support.  On this basis, if it seems that the individual is protesting or objecting, then an IMCA should be appointed to help exercise their right to review or appeal.  However, this does not deal with the issue of those who appear passive, or are not objecting.  Either way, only 0.7% of the reviews were instigated by the individual themselves.

People who are subject to a DoLS authorisation may well be in the best place for them, but as the facts of Cheshire West show, the restrictions on their freedom of movement may be extreme, and should be subject to external scrutiny on a regular basis.  It is hard to understand why there is an automatic review mechanism for people with mental disorders, who may retain capacity to make an appeal themselves, and no parallel mechanism under DoLS, for people who arguably may be more vulnerable and in need of automatic review.  Even if they do not object, it is hard to understand why these restrictions should not be reviewed automatically, in the same way as they are for people detained under the MHA.

The justification, perhaps, for DoLS as opposed to the MHA is that someone deprived of their liberty under DoLS is not going to ‘get better’; if a deprivation of liberty is necessary at one time, it will always be necessary, as nothing is going to change.  Yet, the Code of Practice is very clear that authorisations should be issued for as short a time as possible, and everything should be done to reduce the restrictions to a level below the threshold of deprivation.

The recent ECtHR judgments should give us pause for thought.  While there are no direct legal bars on review of a deprivation of liberty by a court, there are a variety of practical restrictions which may make the exercise of that right difficult.  An automatic review process through the Court of Protection would be unwieldy and impractical, but we should consider an independent tribunal process, like that under the MHA.  It does not seem consistent for one form of deprivation of liberty to have this mechanism and not another.

 

Amanda Keeling

PhD Student, School of Law, University of Nottingham

This email address is being protected from spambots. You need JavaScript enabled to view it.

This week’s IMH Blog Post is from GOV.UK and was originally posted on 27 June 2013.   Mental health nurses to join police on the beat Mental health nurses will patrol with police officers in four new pilot sites to improve responses to mental health emergencies, Care and Support Minister Norman Lamb announced today at the Black Mental Health UK Conference.

The street triage scheme sees mental health nurses accompany officers to incidents where police believe people need immediate mental health support.

The innovative scheme, funded by the Department of Health and backed by the Home Office, helps people with mental health problems who are sometimes detained in the wrong environment.

Today the first four areas have been chosen to pilot the mental health scheme, which will start in the summer. The police force areas working with Department of Health are:

• North Yorkshire
• Devon and Cornwall
• Sussex
• Derbyshire

Two street triage services in Cleveland and Leicestershire have already shown that nurses and police can work together to achieve better results for patients by making sure they receive the treatment they need. This also reduced demands on valuable police time.

Last month, the Home Secretary announced that the Department of Health would be working with the Home Office to pilot ‘street triage’ with the police this year. This is part of a wider Department of Health and Home Office work plan on policing and mental health.

The Department of Health has secured further funding to extend this pilot scheme to more police forces and a number of further areas have already expressed an interest. More announcements are planned in the near future.

Care and Support Minister, Norman Lamb said: “In some areas the police already do an excellent job in terms of their handling of situations involving people with mental health problems and work well with health colleagues to make sure that mentally ill people in crisis get the care and attention they need, but we need to make that the reality everywhere.

“We are launching these pilots to make sure that people with mental health issues get the right care, at the right time and in the right place.

“We know the barriers often lie at the crossroads between police and health services. That is why we are working with the Home Office and leaders of the police to look at how we can improve services for the very vulnerable people involved.”

This work is part of wider work that the Department of Health and its stakeholders are making to improve crisis care for mental health patients. Other work includes:

• an urgent assessment of the availability of places of safety across England by mid-July
• an inspection of the quality of all places of safety by the Care Quality Commission
• reviewing the provision of ambulance services for mental health emergencies later this year
• a concordat in place this Autumn to improve the treatment of people with a mental health crisis

Minister of State for Policing and Criminal, Justice Rt Hon Damian Green said: “All too often the police encounter vulnerable people with mental health issues who need immediate care or longer term support which only the health service can provide.

“As the Home Secretary announced recently, the rollout of these street triage pilots are a step forward in our on-going work with the Department of Health and police to ensure people with mental health issues are dealt with by the right emergency service.”

Background Information

1. Places of safety should typically be hospitals, residential care homes or the home of a relative or friend of the person. A police station should only be used as a “place of safety” as a last resort.
2. For more information please contact the Department of Health press office on 0207 210 5317.

 

A new book which may be of interest to IMH members: 

Falling Into the Fire is psychiatrist Christine Montross's thoughtful
investigation of the gripping patient encounters that have challenged and
deepened her practice. The majority of the patients Montross treats in Falling
Into the Fire are seen in the locked inpatient wards of a psychiatric hospital;
all are in moments of profound crisis. We meet a young woman who habitually
commits self-injury, having ingested light bulbs, a box of nails, and a steak
knife, among other objects. Her repeated visits to the hospital incite the
frustration of the staff, leading Montross to examine how emotion can interfere
with proper care. A recent college graduate, dressed in a tunic and declaring
that love emanates from everything around him, is brought to the ER by his
concerned girlfriend. Is it ecstasy or psychosis? What legal ability do doctors
have to hospitalize-and sometimes medicate-a patient against his will? A new
mother is admitted with incessant visions of harming her child. Is she psychotic
and a danger or does she suffer from obsessive thoughts? Her course of
treatment-and her child's future-depends upon whether she receives the correct
diagnosis. Each case study presents its own line of inquiry, leading  Montross to seek relevant psychiatric knowledge from diverse sources. A doctor of uncommon curiosity and compassion, Montross discovers lessons in medieval dancing plagues, in leading forensic and neurological research, and in moments from her own life. Beautifully written, deeply felt, Falling Into the Fire brings us inside the doctor's mind, illuminating the grave human costs of mental illness as well as the challenges of diagnosis and treatment. Throughout, Montross confronts the larger question of psychiatry: What is to be done when a patient's experiences cannot be accounted for, or helped, by what contemporary medicine knows about the brain? When all else fails, Montross finds, what remains is the capacity to abide, to sit with the desperate in their darkest
moments. At once rigorous and meditative, Falling Into the Fire is an intimate
portrait of psychiatry, allowing the reader to witness the humanity of the
practice and the enduring mysteries of the mind.

An early review of the book from the Los Angeles Times can be read here:
http://www.latimes.com/features/books/jacketcopy/la-ca-jc-christine-montross-20130728,0,2386923.story

The book can be ordered via:
http://www.amazon.com/Falling-Into-Fire-Psychiatrists-Encounters/dp/1594203938/ref=sr_1_1?ie=UTF8&qid=1374950652&sr=8-1&keywords=falling+into+the+fire

Peer Support in Mental Health Care: is it good value for money?
by Marija Trachtenberg and Michael Parsonage(Posted by the Centre for Mental Health on 23 July 2013)

Peer support is the provision of practical and emotional help for people with long-term mental health problems by people with their own lived experience of such problems. The underlying idea is not a new one. For example, there is evidence going back to the 1840s of peer support in the old asylums, provided by Alleged Lunatic Friends (Hervey 1986).  Indeed, for as long as people have used mental health services, they have provided each other with friendship, mutual support and shared coping strategies, but it is only relatively recently that the value of such relationships has been formally recognised in the development of paid employment roles. Peer support workers may be employed in place of traditional staff, for example as case managers, or – more commonly – as additional members of a mental health team, fulfilling such roles as befriending, mentoring, social support and advocacy.

Increasing numbers of peer support workers are now being employed in mental health services, both in this country and elsewhere, but good quality evidence on the effectiveness of this form of service delivery is in short supply and even less is known about its cost-effectiveness. A recent Cochrane review was able to identify only 11 randomised controlled trials and came to largely agnostic conclusions (Pitt et al. 2013). Other reviews have taken a more inclusive approach, including evidence not derived from RCTs, and a number of broadly positive conclusions on effectiveness have started to emerge (Repper and Carter 2011). These include benefits not just for the service users who receive peer support but also for the peer workers themselves and at the organisational level, where the introduction of peer support is increasingly seen as a powerful way of promoting a more recovery-focused approach to mental health care. In no study has the employment of peer support workers been found to result in worse health outcomes for those receiving the service and, although not replicated in all studies, findings have been reported of improvements across a range of outcomes including: patients’ feelings of empowerment and self-confidence; self-reported physical and emotional health and clinician-assessed global functioning; satisfaction with services; community integration and social functioning; stability in employment, education and training; and reduced alcohol and drug use among patients with co-occurring substance abuse problems.

A first attempt at assessing whether peer support provides value for money is set out in a paper just published by the Centre for Mental Health (Trachtenberg et al. 2013) and launched at this year’s annual conference of the NHS Confederation. The analysis looks specifically at whether peer support workers can reduce psychiatric inpatient bed use, either by preventing admissions or by reducing length of stay. We chose to look at the impact on inpatient bed use partly for reasons of data availability but also because of the very high unit cost of hospital care and because this has been an area where service users’ experience of care has consistently been reported to be rather poor (Care Quality Commission 2009) and thus it seemed an area where the impact of peer workers might be particularly strong. If peer support can improve patients’ feelings of empowerment, self-esteem and confidence, this may help them to manage their lives in the community better, with a correspondingly reduced need for inpatient care.

We identified six studies in the research literature which give some evidence on the relationship between peer support and inpatient bed use. Five of these were from the US and one from Australia. Only two were RCTs, although three of the others did have some form of comparison group.  Study authors were contacted in all cases for additional information and on this basis we were able to produce estimates of the number of hospital bed-days saved per full-time equivalent peer support worker in each study. These figures on bed-days saved and peer worker input were then converted to £s using unit costs for England in 2011-12, resulting in a simple benefit:cost ratio of the following form: value of hospital bed-days saved per peer support worker divided by cost per support worker.

Four of the six studies show a benefit:cost ratio substantially in excess of one, i.e. the value of bed-days saved comfortably exceeds the cost of employing peer workers. In one study, the ratio is positive but less than one (some savings but not enough to fully offset the costs of employment) and in one the ratio is negative, implying that in this case the use of peer workers is associated with an increase rather than a reduction in bed use. Aggregated across all six studies, the benefit:cost ratio works out at 4.8:1 on a weighted average basis (with weights determined by the size of each study’s patient sample). The overall conclusion suggested by these figures is that peer workers bring about significant reductions in hospital bed-use among the patients they support, leading to savings which are well in excess of additional pay costs. These savings are of course over and above any positive impact on non-financial outcomes relating to the mental health and quality of life of service users.

A number of major limitations must be acknowledged. First, the evidence base is extremely modest, both in scale and in quality. Second, there is a good deal of variation between the studies in the nature of the intervention being evaluated (e.g. the roles played by peer workers, the amount of training they received and the frequency and duration of their contacts with patients). Third, no allowance is made for the possible impact of peer support on service costs other than hospital bed use. And fourth, none of the studies is from this country.

Notwithstanding these and other shortcomings in the analysis, our conclusion is that, overall, the available evidence is sufficient to justify continuing developments in the use of properly trained and supported peer workers in mental health teams, alongside more research evaluating their effects.

References
Hervey N (1986) Advocacy or folly: the Alleged Lunatic Friends Society, Medical History, 30, 245-275.

Pitt V, Lowe D, Hill S et al. (2013) Consumer providers of care for adult clients of statutory mental health services, Cochrane Database of Systematic Reviews 2013, issue 3.

Repper J, Carter T (2011) A review of the literature on peer support in mental health services, Journal of Mental Health, 20, 4, 392-411.

Trachtenberg M, Parsonage M, Shepherd G, Boardman J (2013) Peer support in mental health care: is it good value for money?, Centre for Mental Health, London.

Care Quality Commission (2009) Mental health acute inpatient services survey 2009, Care Quality Commission, London. 
Authors
Marija Trachtenberg is a graduate of the LSE Masters course in health economics and has worked as a research assistant at the Centre for Mental Health.

Michael Parsonage is Chief Economist, Centre for Mental Health.

This post was first published on the LSE Health and Social Care blog (July 15 2013)

The Consortium of Therapeutic Communities Research & Development Group is hosting a research afternoon focusing on therapeutic communities (TC) and enabling environments (EE).  Come and hear about ongoing and recently completed research, discuss ideas, contribute suggestions.  The afternoon is free and open to all with an interest in TC and EE research.

Date: 26 September 2013 Time: 1-4pm Location: Community of Communities offices at the Royal College of Psychiatrists in London

If you are interested in presenting, would like more information or to book a slot, please email This email address is being protected from spambots. You need JavaScript enabled to view it..

As part of the recently advertised 'Art in the Asylum' exhibition running from 7 September - 3 November 2013, there are a series of upcoming lectures, gallery tours and documentary film that may be of interest:

[caption id="attachment_982" align="alignleft" width="216"] Image: ‘I Spit on Life’ 1956 by William Kurelek (Adamson Collection, London © Estate of William Kurelek, courtesy of the Wynick/Tuck Gallery, Toronto)


Lectures 
All lectures are held in the Djanogly Art Gallery Lecture Theatre *unless stated otherwise
Admission free 
Friday 6 September 6.30-7.30pm
Followed by Preview

Crossovers
Dr. Esra Plumer and Dr. Victoria Tischler on the historic use of art in mental health institutions and the interplay between creativity and madness, introducing some of the spaces, places and key figures in the fascinating history of crossover between visual art and mental health care.

Wednesday 11 September 6-8pm Edward Adamson’s life and work: creativity and the evolution of art as therapy
Dr. Susan Hogan (University of Derby, author of Healing Arts: The History of Art Therapy 2001) with contributions from John Timlin (Adamson Collection) and Dr. David O’Flynn  (Consultant Psychiatrist & Chair of the Adamson Collection). The groundbreaking work of the ‘grandfather of art therapy’ Edward Adamson is considered alongside associations between therapy and Surrealism.
 
Wednesday 18 September 6.30-7.30pm
A hidden gem: Dr. W. A. F. Browne's collection of patient art at Crichton Royal Institution, Dumfries
Dr. Maureen Park (University of Glasgow, author of Art in Madness 2011) discusses the pioneering work of Dr. Browne and his collection of patient art, the oldest surviving collection of asylum art in the world.

Wednesday 2 October 6-8pm
Ancient and modern mental healthcare
Jules Evans (author of the bestselling Philosophy for Life: and other Dangerous Situations 2012) with Dr. Ben Di Mambro (Consultant Psychiatrist) and Dr. Arun Chopra (Consultant Psychiatrist). From ancient philosophy to Cognitive Behavioural Therapy (CBT), recent controversies in psychiatric diagnostics and the launch of the DSM-V, the speakers discuss how old and new approaches might interact in the provision of mental health care today.

Wednesday 16 October 6.30-8.30pm
*venue: Nottingham Contemporary
Book on-line www.nottinghamcontemporary.org
Looking into art from the asylum: Prof. Roger Cardinal (author of the seminal text Outsider Art 1972); and Richard Dadd and Asylum Art of the 19^th century: Dr. Nick Tromans, Curator, Watts Gallery, Surrey.

Artists whose approaches diverge radically from average expectation and from officially sanctioned approaches and styles are discussed alongside Richard Dadd, one of the best- known British asylum artists

 
Wednesday 30 October 6.30pm-7.30pm
Marat/Sade and the ‘theatre of cruelty’
Dr. Gordon Ramsay and Dr. James Moran (English Dept. University of Nottingham) consider Peter Brook’s 1964 production of Peter Weiss’s play Marat/Sade in the context of Antonin Artaud’s ‘theatre of cruelty’

Gallery Tours
Djanogly Art GalleryAdmission free

Thursdays 1-2pm:

12 September: Victoria Tischler, Curato
26 September: Rob van Beek, artist
10 October: Ruth Lewis-Jones, Learning Officer
24 October: Neil Walker, Curator, Djanogly Gallery

Please note that Gallery Tours are not seated events. Every effort will be made to accommodate elderly and disabled visitors.

Gallery Tour: New Perspectives on…
Djanogly Art GalleryAdmission Free

Thursday 17 October 7-9pm

A walkabout tour led by a relay team of six post-graduates researching at the University of Nottingham in a variety of disciplines who will each bring their expertise to bear on one work in the Art in the Asylum exhibition. Each speaker will have 8 minutes before handing the baton on to the next with an opportunity for a Q&A session at the end of the evening.

For all Lectures and Gallery Tours above (*unless stated otherwise) please book in advance by calling the box office on 0115 846 7777.

Film/Documentary
Broadway
14-18 Broad Street
Nottingham
Book at Broadway Box Office or on-line www.broadway.org.uk
Broadway ticket prices apply.

Wednesday 23 October 8.30pm All Divided Selves (2011) Dir. Luke Fowler 90 mins

Documentary on the radical Scottish psychiatrist R. D. Laing, author of The Divided Self 1960. Introduced by Dr. Joseph Berke, psychotherapist, who worked with Laing in the 1960s.

If you are interested in mental illness and gang membership, perhaps this BBC report and the related journal article may be of interest:

http://www.bbc.co.uk/news/health-23275139

"Young men in gangs are significantly more likely to suffer from a mental
disorder and need psychiatric help than other young men, says a UK study".

"Prof. Jeremy Coid, lead study author and director of the forensic psychiatry research unit at Queen Mary, University of London, explained the likely cause:

It is probable that, among gang members, high levels of anxiety disorder and psychosis were explained by post-traumatic stress disorder, the most frequent psychiatric outcome of exposure to violence".

This week the IMH Blog Editorial Team would like to highlight four blog posts published recently on health and mental health sites.  Three discuss the very timely issue of compassion within health and the fourth focuses on community budgeting to pool funds for services.  Have a read of each and let us know your thoughts!

Safe Care – The Fierce Urgency of Now 4 Compassionate Culture keeps us safeBy Dr Alys Cole King, Consultant Liaison Psychiatrist and Co-founder of Connecting with People training (Published on Knowing You Matter on 27 June 2013)

'The fourth blog in the Safe Care series is written by Dr Alys Cole King who is a Consultant Liaison Psychiatrist and Co-founder of Connecting with People training. Alys influences thinking around compassion in healthcare nationally and internationally powerfully collaborating with leading thinkers in the field.'  (continue reading...)

Power to the PeopleBy Paul Hodgkin, GP, chief executive of Patient Opinion (Published on E-Health Insider on 26 June 2013)

'Paul Hodgkin, a GP and chief executive of Patient Opinion, says that if the NHS really wants to regain compassion it is going to have to get a lot better at understanding where it comes from.' (continue reading...)

The Unexpected Benefits of Compassion for Business: Compassionate workplaces - good for employees AND the corporate bottom lineBy Emma M. Seppala, PhD,  Associate Director of the Center for Compassion and Altruism Research and Education at Stanford University (Published on Psychology Today, 22 April 2013)

'Managers often mistakenly think that putting pressure on employees will increase performance. What it does increase is stress—and research has shown that high levels of stress carry a number of costs to employers and employees alike.' (continue reading...)

Mental Health: The Whole Picture By Sean Duggan, chief executive of the Centre for Mental Health (Published on Centre for Mental Health Blog, 24 June 2013.  Originally published in Public Finance Magazine.)

'Community budgets that pool funding for services could dramatically improve mental health provision. This ‘whole place’ approach should be backed in the Spending review.' (continue reading...)

Each year, for selected exhibitions, Neil Walker, the Curator of the Djanogly Art Gallery throws out the following challenge to the PhD students of the University of Nottingham:
‘Can you create a short paper which links your own research area to a work of art currently being exhibited in the gallery?’

A few weeks ago Kezia Scales, whose PhD topic is the person-centred care approach, and Fiona Birkbeck, who is examining client/expert relationships in the NHS and Education, and who both recently presented papers at the IMH conference, joined the successful applicants. The six chosen PhD candidates received training and advice from Mark Rawlinson, Head of the Department of Art History and Eleanor Forward of the Graduate School on how to make and explain links from their own research to art works constructed entirely from paper and displayed in The First Cut exhibition, from 29th April to 9th June, 2013.

[caption id="attachment_975" align="alignright" width="187"] Figure 1 Upon the End of Your Feral Days Chris Jones 2011 Djanogly Gallery Photo Alan Fletcher


On the evening of the event, Kezia went first, standing beside her chosen work – ‘Upon the End of Your Feral Days’ by Chris Jones.  A powerful papier mache recreation of a motorbike in decay. It seemed broken and discarded, the colours murky, the shine all gone but as Kezia began to speak, the audience could see that the motor bike actually had shoots of regeneration, new life curling up from its base.

As she said, ‘On first impression, this title seems to say it all. Once, this bike might have been a symbol of speed, vitality, youth, freedom, sexuality, danger, power – but now? It has reached the end of the road. With its eroding edges and gaping holes, this bike seems to signify nothing but loss and decay.

Similarly, we often assume that older people living in a care home have reached the end of the road. No longer able to stay at home, dependent on the assistance of others, they are characterised primarily in terms of loss and decline: the loss of youth, independence, productivity, usefulness. Perhaps worse: the loss of dignity, individuality, identity.’

She encouraged us to look more closely, in order to see the tendrils of wire stretching upwards from the disintegrating body of the bike. ‘However tentative, these wires provide a reminder that life prevails,’ she said. ‘Out of the memory of what was, arises what is and what will be.’

[caption id="attachment_974" align="aligncenter" width="182"] Figure 2 Upon the End of Your Feral Days Chris Jones 2011Djanogly Gallery photo Alan Fletcher


Kezia went on to say that the motorbike with its memories and its still rakish stance, reminded her of a particular resident from her ethnographic research: Leo. Leo is living on a special dementia unit that is attempting to implement person-centred care. Recalling, as an example, Leo’s delight in a joke shared with a care worker as they sat in the sun together, Kezia told us that, ‘Leo clearly hasn’t reached the end of the road. He is still connecting with his environment, and the people around him – just as this static bike can stir feelings and responses in us as observers, Leo is still sharing with us his own pleasure in living.’ One care assistant has created a ‘memory book’ that shows photos of Leo in his navy uniform, but also shots of him as a husband, a father, an ordinary guy. Importantly, Kezia told us, the carer has also left blank pages so that new photos can be glued in – not from Leo’s past but from his present and his future.
Just like the motorbike, Leo still retains the capability of action, of ‘effect’, his capacity for ‘feral days’ is not over, although it may have changed.

‘And so,’ Kezia concluded, ‘this sculpture, as it relates to my research on person-centred care, reminds us that there is movement in stillness. There is strength in fragility. There is growth in decline. From loss arises new meaning. And thus, although we may come to the end of our feral youth, we should be careful not to see that as the end of the road.’

I was waiting to speak after Kezia, and, as the enthusiastic clapping died away, I directed the audience to turn and look at the floor.  For on it was spread the work of Andrea Mastrovito, entitled Exodus 8.13, and the subject of my paper. Although using simply cut paper as its medium, Exodus 8.13 is designed to elicit a series of complex responses from the viewer.

When I first saw the vast bed of exuberant flowers spread out on the floor of the gallery, my initial response was one of delight. Have they planted a bed of flowers actually inside this gallery? Ah no, of course, they are paper flowers.

[caption id="attachment_979" align="aligncenter" width="300"]
Figure 3 Exodus 8.13.Andrea Mastrovito 2012 Djanogly Gallery Photo courtesy of the Graduate School, University of Nottingham


But just after that initial response came another, more surprising, reaction. Fear. The flowers looked vulnerable, they had no protection from the feet of the gallery visitors; they were open to being examined, maybe picked over until they were destroyed. There was no sign advising us to be careful.

My area of research is into our public services, particularly health and education. The Consultants, Nurse Directors, GPs, Head Teachers and Senior Lecturers whom I have interviewed tell me of their fear – their uneasiness – that our services may be ‘viewed’ and ‘picked over’ until they no longer exist in any form that we will recognize.
Just as the paper frogs eat the paper flowers in the Pharaoh’s garden of Exodus 8.13, so practitioners fear that the very ethos of public service is being eaten away. League tables in schools and time targets for GPs may have unintended consequences. Our expert practitioners, who have always been keen to measure their own performance, are afraid that they are now being asked to tick the wrong boxes.

[caption id="attachment_977" align="aligncenter" width="300"] Figure 4 Exodus 8.13 Andrea Mastrovito 2012 Djanogly Gallery Photo Alan Fletcher


If, as a visitor to the gallery, you bend down to examine the ‘garden’ more closely, you will see that that it isn’t made of carefully crafted, hand painted flowers, as you might expect, but its illusion of bounty is taken from cheap, mass produced catalogues. Advertising made to entice us to believe that the glossy blossoms can be ours. This ironic twist in the art work echoes the comments of our doctors, nurses and teachers who tell me that glossy brochures may reflect the commodification of healing and learning in our society rather than tell the truth about the ‘products’ on offer.

However, as I walked away from the ‘flowers’ on that first day, I realized that they still made a splash of thrilling, uplifting colour. The flowers, whatever connotations they carry, create a real sense of joy - just as inspirational and compassionate practitioners in heath and education still manage to offer good care and teaching, to the benefit of us all.

Kezia and I enjoyed the time we spent with the Djanogly Gallery. For both of us, there seemed to be an immediately ‘good fit’ between our research and the works we chose. It was something we both wanted to explore. In a broad sense, both art and healing deal with the human condition and in various ways, creative work and mental health have always been inextricably linked.  As Mark Rawlinson told us on our first training session, ‘This is a great way of thinking about making your work accessible to different audiences. Of connecting. And, what’s more, it’s fun!’
And it was.

Fiona Birkbeck
PhD Research Student
Department of Education
University of Nottingham

The IMH Blog Team are pleased to announce an upcoming exhibition being held at Djanogly Art Gallery, Lakeside Arts Centre, University Park, Nottingham.  The exhibition begins Saturday 7 September 2013 and will run until Sunday 3 November 2013. Admission is free.

[caption id="attachment_982" align="aligncenter" width="216"] Image: ‘I Spit on Life’ 1956 by William Kurelek (Adamson Collection, London © Estate of William Kurelek, courtesy of the Wynick/Tuck Gallery, Toronto)

Art in the Asylum presents the first examination of the evolution of artistic activity in British psychiatric institutions from the early 1800s to the 1970s.

Highlighting key institutions and influential figures in the history of British mental healthcare, the exhibition traces the historical shift from invasive treatments of mental disorders to a more humane regime in which creativity played a significant role.

The exhibition also tells the story of the strong influence of continental psychiatry on British practice, and the wider recognition of patient artwork by leading modern artists.

Curated by Dr Victoria Tischler and Dr Esra Plumer.

Dates: 7 September - 3 November 2013 Location: Djanogly Art Gallery, Lakeside Arts Centre, University Park, Nottingham Admission: Free

Poster available for circulation: University of Nottingham Art in the Asylum

From the Vice-Chancellor's desk: ‘Inside Out of Mind’

One of the biggest challenges we face is our ageing population.

Modern medicine and general improvements in health have resulted in many more of us living longer. There are now 1.7 million more people over the age of 65 than 25 years ago, and the number of people over the age of 85 has doubled in the same period.

One consequence of increasing longevity is increased prevalence of chronic disease, not least dementia in its many forms. Currently it is estimated that some 800,000 people in the UK have dementia. The Alzheimer’s Society predicts this could be a million by 2021, more than 1.5 per cent of our total population.

Summary statistics like this mask the human side of a condition that is not well understood and which has devastating consequences for those affected by dementia and those who care for them. In 2006, in partnership with the Nottinghamshire Healthcare NHS Trust, we established The Institute of Mental Health (IMH) to promote interdisciplinary research and pioneering educational activities in this key area.

As well as conducting fundamental and translational research, the IMH promotes truly innovative outreach programmes. Inside Out of Mind, which is now being performed at Lakeside, our public arts centre, is a remarkable example of genuine innovation.

This original theatrical production is based on findings from research commissioned by the National Institute for Health Research, and led by Professor Justine Schneider. She and her team of ethnographers provided the raw material from intensive evaluation of carers and the cared for on three dementia wards, and playwright Tanya Myers “…humanised their data into drama…” Tanya also directed Inside Out of Mind.

The outcome is a strikingly powerful production: sometimes harrowing, sometimes humorous, but always sensitive and sharp in its insights on the lives of carers and cared for. It is educational, thought provoking and bursting with emotion. Unsurprisingly it is receiving a lot of attention, and in the process promoting open and welcome debate.

The production is underpinned by practical and financial support of more than a dozen organisations from the public and voluntary sectors. Each has played an indispensable part in bringing this performance to the stage, enabling 1,500 health-care staff to come and see how their working lives have been dramatized by Tanya Myers and her team.

The development and production of Inside Out of Mind has been an exciting journey of knowledge exchange between the arts, social sciences and health-care providers. It is our University at its very best: delivering innovation and excellence in research, working in partnership across different sectors, and building bridges between health, education, research and the wider public through the arts.

For many, this project would have been just too risky: not so for Lakeside, and Shona Powell and her colleagues are to be congratulated for taking it on.

Professor David Greenaway Vice-Chancellor

So Professor Arne Akbar, of University College London, summarised one of the key questions his research intends to answer. As Professor of Immunology, he was one member of a fascinating panel discussion at this year’s Cheltenham Science Festival. He was accompanied on stage by Dr Donald Palmer of the Royal Veterinary College and Professor Thomas von Zglinicki of Newcastle University, with Chair, Dr Suzy Lishman, Vice President of the Royal College of Pathologists.

I attended this discussion on the ageing immune system expecting a physical biological slant and wondering whether I would come away with ideas about diet or exercise that I could perhaps apply. But when someone asked whether there was anything we could do to foster an effective immune system into old age, the answer was resoundingly to avoid excessive stress. Whilst other factors such as diet were important, and genes and chance played the over-riding role in how well each of us will age, stress was top of the list of damaging lifestyle factors. As I understand it, the mechanism seems to be that high levels of stress hormones lead to inflammation which leads to a lowered immunity. It may be seen in cold sores, frequent colds and ultimately many more serious illnesses especially as we get old older. It can shorten our lifespan, and lead to miserable final years.

As an occupational psychologist, I am interested in stress, well-being and successful transitions, including ageing, in the working population. Many of my clients are in their forties and fifties, trying their level best to keep a successful career and family going whilst staying mentally and physically healthy. Most of them expect and hope for a long and active life. Many of them are also stressed – and see this as an inevitable aspect of a modern professional job.

Being mentally as well as we can be
This presentation brought home to me more clearly than ever before the link between mental and physical health. Mental ill-health in terms of stress affects us at a cellular level. And yet, so many of us continue to live lifestyles that dismiss the idea of actively looking after our day-to-day mental health.

I meet many clients who are well aware of looking after their physical health, through diet and exercise, with varying degrees of success when trying to fit this into a busy life. Most of us recognise that on-going struggle. But well-established factors relating to mental health, such as social support and connection, sleep and mindfulness, are very often swept aside as we pursue our work related goals and pass our weeks in juggling conflicting demands on our time.

The research is clear. Not only can that make us feel tired and ragged, irritable and worried, it can damage our cells. The very cells whose purpose is to protect us from harm.

My guess is that most of us are really not intending to do that. But somehow our prevailing culture has become one of ignoring the risks that we are running. Or worse, actively promoting behaviour that probably increases the amount of damage we are doing to those vital cells.

Is there a better way?
I think one of the most exciting aspects of the world becoming ever more connected is the synergy that happens when disciplines meet, to bring different perspectives on complicated problems. None of us has the answer on our own any more (if we ever did).

For me, I think that the issue of mental health at work could be one where sociologists, psychologists, economists, accountants and immunologists (to name a few) meet. Along with some designers and engineers perhaps. We probably need to invite others along too. Maybe even politicians.

We need to understand how groups work, how norms of unhelpful behaviour become established and how individuals can strengthen their own resolve and habits to look after themselves, as well as help each other. We need to grapple with how organisations deal with complex demands, and how that filters down to the cellular level of their employees. We need to educate people in how to look after their daily mental health and give them permission and mechanisms to prioritise it (which many organisations don’t, whether by design or accident). We need to know how to design or influence systems to work for our best interests rather than against them.

We need to pause a while and ask good questions. Collectively and individually.

We need to ask ourselves whether there is a better way to do our jobs. A way that is productive, engaging, rewarding, and motivating - and which doesn’t give us an unnecessarily short sell-by date.

Sarah Dale is an occupational psychologist, coach and author. Her self-help book for busy professionals, Keeping Your Spirits Up, is available on Kindle or as paperback, and her next book, Bolder and Wiser, will be published in the autumn. You can follow Sarah on twitter on @creatingfocus.

Professor Nikolas Rose recently gave a talk entitled, 'What is Mental Illness Today? Five Hard Questions', as part of the School of Sociology and Social Policy's Seminar Series (University of Nottingham).

The video of his presentation is now available: http://youtu.be/KxI6DmbEKQg.

Further information about Professor Rose and his lecture is below:

What is ‘mental illness’ today – five hard questions Nikolas Rose Department of Social Science, Health and Medicine King’s College London

Presentation Abstract In this talk I want to characterize the ‘territory’ of mental illness today by posing five hard questions that seem to me to represent genuine empirical, conceptual, professional and ethical dilemmas. My questions are: Is there an‘epidemic’ of mental disorder?; Does the path to understanding mental disorder lie through the brain?; What is the role of diagnosis and of diagnostic manuals?; Should we seek early identification of those at risk of future mental pathology? What is the place of patients, users, survivors, consumers in the mental health system? On the basis of this discussion, I will conclude by trying to draw out some lessons for the politics of mental health today.

Nikolas Rose Professor Nikolas Rose is one of our leading contemporary social scientists. Currently he is Professor of Sociology and Head of the Department of Social Science, Health and Medicine at King’s College, London. He was previously Martin White Professor of Sociology, and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society at the London School of Economics and Political Science. He is also co-PI for the EPSRC funded Centre for Synthetic Biology and Innovation (CSynBI). His most recent books are The Politics of Life Itself : Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton, 2006); Governing The Present (with Peter Miller, Polity, 2008) and Neuro: the New Brain Sciences and the Management of the Mind (with Joelle Abi-Rached, Princeton, forthcoming, 2012). He is a longstanding member of the Editorial Board of Economy and Society, co-editor of BioSocieties: an interdisciplinary journal for social studies of the life sciences, Chair of the European Neuroscience and Society Network, and a member of numerous advisory groups including the Nuffield Council on Bioethics.

Well, it finally launched, the patient feedback website that we created as part of the Patient Feedback Challenge. The evaluation section was part of a partnership with the Involvement Centre of Nottinghamshire Healthcare NHS Trust and the web design agency Numiko to build a website which can help us to collect feedback data, summarise and report on it and share the actions and learning which have resulted. Go have a look.

I'm going to talk a little bit about some of the thinking behind our approach on the Patient Feedback Challenge. Similar thinking has motivated recent developments within Nottinghamshire Healthcare NHS Trust as well as in the wider NHS but there is a long way to go before the whole NHS nationally embodies the approach being advocated here.

NHS data systems are, quite naturally, built around very strict data management which emphasise the security of data and ensuring accountability of data loss or misuse. This is right and proper. However, very frequently, clinicians, managers, auditors and evaluators do not need to access highly sensitive personal information. In certain cases, information can be shared freely over the internet, as with the data collected on patient experience within the Patient Feedback Challenge (survey responses, Patient Opinion stories, and specific extracts from the PALS database).

The skills and technologies to rapidly analyse and disseminate data of this kind where rights access is not an issue is presently lacking in many NHS settings. Data analytic solutions, where they exist, are often large and complex and are complex and expensive to set up and modify. Where solutions are brought in from private sector providers these tend to be inflexible and it can be difficult for an organisation to achieve the results they want using off the shelf technologies (for example, integrating and resharing different types of data, such as the survey, Patient Opinion, and PALS data involved within the Patient Feedback Challenge). A limitation in the data architecture of many NHS organisations is the tendency for data to exist in silos, with each department maintaining its own separate database with no capacity to combine or reshare any of the data. Often the existence and location of datasets is unknown to others working elsewhere in a Trust.

Another problem endemic in many NHS settings is Spreadsheet addiction (e.g. Burns, 2004). This has been given as a possible culprit in JP Morgan Chase's having lost 2 billion dollars in May 2012 (from http://goo.gl/SSAMS):

'James Kwak, associate professor at the University of Connecticut School of Law. noted some interesting facts in JP Morgan Chase's post-mortem investigation of the losses. Specifically, that the Value at Risk (VaR) model that underpinned the hedging strategy:

"operated through a series of Excel spreadsheets, which had to be completed manually, by a process of copying and pasting data from one spreadsheet to another", and "that it should be automated" but never was.'

The process of analysing and presenting Service User and Carer Experience survey data began in a similar fashion, with spreadsheets and macros being used to produce summary graphics, and reports manually cut and pasted together. Fortunately for us, before we lost 2 billion dollars this way there was a mishap and it became obvious that the process needed to be automated in order to meet the reporting timescales. An incremental approach was adopted, and each stage of automation brought more complex and better data summaries, so that within a few years reporting on survey data had gone from a task that was difficult for one person to perform quarterly alongside other tasks to a level of complexity that would demand more than one individual working full-time for the whole of each quarter just to meet each quarterly timescale.

The patient feedback challenge has allowed us (with our friends at Numiko) to clear the final hurdle and to remove the last vestiges of human effort from the regular reporting, which means that quarterly survey reports and custom extracts will be available 24 hours a day, 365 days a year to anyone in the world with an internet connection. Managers will be able to see the latest results from their area and anywhere else in the Trust at any point in the reporting cycle and service users and carers will be able to transparently query and scrutinise all of the patient feedback data that we collect.

All the technologies that were used are simple, free, and open source. Using free software such as R and reporting technologies such as HTML and LaTeX means that not only are there no costs associated with buying or licensing software but also that analysis and reporting technologies are simple to use straight away. In a process known as agile software development (Beck et al., 2001) all of the technologies that have been produced have been put to immediate use. Early on, automation was only possible of graphics and manual effort was required to put together the report and write textual summaries. Later graphics and text were both automated and only formatting and final edits were performed by a human being. With the completion of the Patient Feedback Challenge now the formatting can also be automated. But at each stage the results of the technology were being used live in order to meet the demands of the organisation. This has the twin benefit of giving an immediate payoff to investment in workforce costs developing the software as well as giving the opportunity for the technology to be refined in use. The results of each stage of development were obvious when each reporting cycle was complete and work has been undertaken throughout to better serve both the Involvement team who deliver the survey results as well as the clinicians, managers, service users, and carers who make use of them.

There were two bits of coding work that made up the majority of my contribution, the quarterly report function which summarises feedback at all levels of the organisation in a series of hyperlinked webpages and the custom search function which uses the very simple Shiny package to allow users to query different types of data and search by service type, demographic feature, keyword, etc. The code for both can be found at my GitHub page.


Dr Chris Beeley, Institute of Mental Health

References

Beck et al. (2001). Manifesto for Agile Software Development. Agile Alliance. Retrieved 20-8-2012

Burns, 2004. Spreadsheet addiction. http://www.burns-stat.com/pages/Tutor/spreadsheet_addiction.html Retrieved 16-5-2012