Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation.

Background: People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives: The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design: This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting: The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants: Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes: Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results: Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations: The availability and quality of data imposed limitations on the reliability of some analyses. Future work: Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration: The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

People who experience mental health crises often go to a hospital emergency department and can be admitted to a psychiatric hospital. Emergency departments and psychiatric wards are not always the best environments for supporting people in a crisis. Emergency departments are overcrowded and waits can be very long; psychiatric wards are also very busy. Psychiatric decision units have been introduced to reduce pressure and improve experiences of crisis care. Psychiatric decision units are short-stay hospital-based units where people can be assessed and signposted to the most appropriate care. This study aimed to evaluate the effect of psychiatric decision units on emergency department visits, psychiatric admissions and the cost of mental health care, and to consider the best way for psychiatric decision units to be structured. We looked at research on similar units internationally and identified all psychiatric decision units in England. We evaluated the impact of psychiatric decision units four mental health NHS trusts on emergency department visits and psychiatric admissions by examining electronic patient records in the 2 years before and after units opened, and by comparing records in areas with and without psychiatric decision units using data from NHS Digital. We compared mental health services used by people in the 9 months before and after their first psychiatric decision unit stay. We interviewed people about their experiences of the psychiatric decision unit and crisis care. We also interviewed staff working on and referring people to psychiatric decision units. There were some reductions in psychiatric admissions, emergency department visits and wait times following opening of psychiatric decision units. The resulting cost savings were small and did not outweigh the costs of running psychiatric decision units. People mostly found units safe, calming and supportive, except where they were discharged too quickly. Psychiatric decision units worked best to reduce psychiatric admissions and improve quality of crisis care where stays were longer and staffing levels higher. Psychiatric decision units had more impact on emergency departments where they were larger and stays were shorter.

Recovery in Mind: A Recovery College's journey through the Covid-19 pandemic.

INTRODUCTION: The Covid-19 restrictions of 2020-2021 are known to have undermined the UK population's mental health. Working alongside staff, peer trainers and students at Recovery in Mind (RiM), a Recovery College (RC) in West Berkshire, England, this mixed-methods study is amongst the first to investigate how an RC has responded to the pandemic. METHODS: Working in co-production with RiM staff and peer-trainers, this study employed a mixed-methods design, gathering Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) well-being outcome measures by questionnaire and student experience, learning and co-production by interviews. FINDINGS: This research found that RiM continued to produce demonstrable improvements in student mental health. Students welcomed the way that RiM adapted to offering online and socially distanced provisions. Students valued the skills that RiM taught and the way that RiM courses reinforced prior learning; above this, however, they valued the mutual support and sense of community that participation provided. CONCLUSION: This study underlines the value of RCs maintaining 'hidden curriculums' of peer support and community involvement. This research emphasizes co-production as not only a tool for empowerment or service improvement but as a valuable skill for personal mental health recovery. Even when operating under the most unforeseen or challenging of conditions, RCs should always endeavour to prioritize and maintain co-production. PATIENT OR PUBLIC CONTRIBUTION: In accordance with the RC ethos, this was an entirely co-produced study, with academic researchers and RiM staff and peer trainers working democratically in partnership with one another to design and manage the study and to write up and disseminate findings. To ensure the independence and rigour of findings, data analysis was undertaken by external academic researchers.

A meta-ethnography of participatory health research and co-production in Nepal.

As global health research seeks to decolonialise, democratise, and become more culturally engaging, researchers are increasingly employing participatory and co-productive methods. Working from post-structural perspectives, this meta-ethnographic review explores how such health research in Nepal engages with the epistemological, methodological, and ethical questions it encounters. Five databases including Nepali NepJOL were searched for studies from inception to March 2021. The review included seven studies covering women's group co-production, interviews guided by photo-elicitation, observational methods to explore maternal and child health, mental health, and environmental determinants of health. This meta-ethnography identified that, against the background of a pluralist heritage of health practices, global collaborations involving Nepali researchers and practitioners used participatory research methodology to work with the local populations to improve health and co-production seek primarily to promote Western biomedical and psychosocial interventions. Both advantages and disadvantages were acknowledged. Empirical verification and global acceptance of Western biomedical and psychosocial knowledge were seen as beneficial. Moreover, Western biomedicine was perceived by some as more effective than some local practices in improving health; nevertheless, Nepal faces many challenges that neither can address alone. For participatory and co-productive approaches to become epistemologically enculturated within Nepali health research, researchers need to co-develop more local models and methods which are culturally sensitive and appropriate. Meaningful and effective participatory research can promote active involvement of people who deliver as well as people who use the community-based health care support. These are crucial to optimise sustainable change that global health research partnerships set out to achieve. This meta-ethnography recommends that researchers engage at a deeper level with the epistemological differences between themselves and the communities with whom they seek partnership. Cross-cultural research teams should discuss and address the power differentials which might affect them.

Menopausal symptoms and work: a narrative review of women's experiences in casual, informal, or precarious jobs.

Governments, employers, and trade unions are increasingly developing "menopause at work" policies for female staff. Many of the world's most marginalised women work, however, in more informal or insecure jobs, beyond the scope of such employment protections. This narrative review focuses upon the health impact of such casual work upon menopausal women, and specifically upon the menopausal symptoms they experience. Casual work, even in less-then-ideal conditions, is not inherently detrimental to the wellbeing of menopausal women; for many, work helps manage the social and emotional challenges of the menopause transition. Whereas women in higher status work tend to regard vasomotor symptoms as their main physical symptom, women in casual work report musculoskeletal pain as more problematic. Menopausal women in casual work describe high levels of anxiety, though tend to attribute this not to their work as much as their broader life stresses of lifelong poverty and ill-health, increasing caring responsibilities, and the intersectionally gendered ageism of the social gaze. Health and wellbeing at menopause is determined less by current working conditions than by the early life experiences (adverse childhood experiences, poor educational opportunities) predisposing women to poverty and casual work in adulthood. Approaches to supporting menopausal women in casual work must therefore also address the lifelong structural and systemic inequalities such women will have faced. In the era of COVID-19, with its devastating economic, social and health effects upon women and vulnerable groups, menopausal women in casual work are likely to face increased marginalisation and stress. Further research is need.

The psychosocial implications of social distancing for people with COPD: some exploratory issues facing a uniquely marginalised group during the COVID-19 pandemic.

Chronic obstructive pulmonary disease (COPD) is an illness associated with intersectional poverty and stigma in old age; people with COPD are susceptible to anxiety, loneliness and isolation. People with COPD who contract COVID-19 are at high risk of serious complications, intensive medical needs and death and are, therefore, required to socially distance particularly assiduously. This paper offers an embodied phenomenological analysis of the emerging theoretical literature exploring the impact of social distancing upon people with COPD. Firstly, people with COPD are aware of how respiratory illness feels, are anxious about COVID-19 and afraid of being denied care. Future research might consider how people with COPD may be susceptible to "coronaphobia" and mental health consequences of the pandemic. Secondly, COPD tends to affect older people within the most intersectionally marginalised socioeconomic groups. Future research should remain mindful that people with COPD may be among the most lonely and least able to access health and social care services online than others. Thirdly, pandemics are known to intensify pre-existing social stigmas. Researchers and practitioners alike should be conscious that people with COPD may become increasingly stigmatised, especially those from intersectionally disadvantaged minorities.

'To more than I can be': A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease.

Anecdotal experience and qualitative accounts suggest that singing groups, classes or choirs specifically for people with COPD (henceforth referred to as COPD-SGs) are effective in improving health. However, this is not reflected in the quantitative evidence. This meta-ethnography deployed phenomenological methods to explore this discrepancy. Analysis identified the phenomena of being together, being uplifted and being involved as central benefits of COPD-SGs. When viewed through the phenomenological lens of body-social as distinct from body-subject and body-object, findings demonstrated that the qualitative effectiveness of COPD-SGs is greatest on a collective basis. Qualitative research into the effectiveness of COPD-SGs offers more favourable results because phenomenological approaches can identify collective benefits that quantitative methods cannot. COPD-SGs should seek to maximise these collective benefits by rediscovering their cultural and artistic heritage within the national and global Arts in Health (AiH) movement, which has long emphasised the radical creative and healing power of group activity.

Insiders and incomers: how lay public health workers' knowledge might improve public health practice.

Since 2005, health trainers and other lay public health workers (LPHWs) have been increasingly active in the UK. Although elsewhere in the world LPHWs are expected to come from the communities within which they work and know that their knowledge is valued, neither is the case for LPHWs in the UK. This study sought to discover the lay knowledge of health trainers and other LPHWs, aiming to ascertain how this knowledge might more effectively be utilised within UK public health services. This paper describes a participatory and ethnographic case study research project undertaken on an anonymised urban estate in North East England. Findings were generated by a range of means including by participant observation and semi-structured interviews. Seven LPHWs took part, as did 32 other community members. This study found that the lay health knowledge of an individual UK LPHW is determined primarily by his or her position within, or in relation to, the community within which he or she works. Insider LPHWs possess an embodied knowledge and incomer LPHWs possess an experiential knowledge which, although different from one another, are essentially interpersonal in nature. Lay health knowledge can take different forms, and different LPHWs can provide different forms of lay health knowledge. Public health structures and services in the UK should make better use of all forms of LPHW knowledge, and should seek from LPHWs training on how to engage the most 'hard-to-reach' or 'difficult-to-engage' groups. Services recruiting LPHWs should decide whether they are seeking embodied insider LPHW knowledge, experiential incomer LPHW knowledge or a mixture of both.