Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust

Background Households in areas of socio-economic deprivation are more likely to consume diets low in fruit and vegetables. Fresh Street is a place-based fruit and vegetable voucher scheme with vouchers redeemable with local independent (non-supermarket) vendors. Paper vouchers are offered to all households in a geographical area regardless of household type, size, or income with no requirement to demonstrate need. The regular shareable vouchers are combined with recipes and dietary information to increase exposure to healthy food prompts, reduce food insecurity, increase fruit and vegetable consumption, improve dietary quality, and support healthy dietary habits. This study aimed to inform a randomised controlled trial (RCT) to assess the impact of Fresh Street on a range of public health outcomes. Methods The pilot cluster RCT took place in three inner city areas of high socioeconomic deprivation in England (Tower Hamlets, Bradford, and Doncaster). New systems for managing vouchers and doorstep delivering weekly envelopes to households were developed. Weekly envelopes containing vouchers (5 x £1), a healthy seasonal recipe and brief nutritional information were offered to all households in nine intervention streets. Nine control streets received no intervention. Household surveys collected information on fruit and vegetable consumption, diet quality, and household characteristics. Results The household survey response rate was below the 50% target for progression to the main trial. Most local fruit and vegetable vendors accepted vouchers. Three quarters or more of households regularly accepted the envelopes. The scheme was well received by households, local vendors and local public health teams. Household uptake of the scheme was highest in Tower Hamlets (75%) and Bradford (83%). The mean weekly voucher redemption was highest in Tower Hamlets (£3.26) and Bradford (£2.82), where the scheme ran longest, and where vendors were nearby. Conclusions This was the first pilot RCT of a place-based, household voucher approach. The newly developed system for securely printing and redeeming the vouchers worked well and is potentially scalable. Future trials should consider alternative methods of assessing the impact on households and explore more efficient ways to deliver the intervention e.g. through collaborative working with local resources such as community centres.

Despite the ubiquity of guided self-help (GSH) interventions in Primary Care psychological services, there have been no previous studies of the relationship between the competence of qualified practitioners and treatment outcomes. This study compared competence-outcome associations in two types of GSH. Competence and clinical outcome measures were drawn from a clinical trial comparing the efficacy of two types of GSH for anxiety disorders, based on cognitive behaviour therapy (CBT-GSH) or cognitive analytic therapy (CAT-GSH). These interventions were delivered over the telephone by qualified and supervised practitioners. Audio-recordings of GSH sessions (n=94) were rated using a validated competence measure. Clinical outcomes were anxiety, depression and functioning. Secondary outcomes were attendance and need for further intervention after GSH. Competence ratings were highly reliable. No significant associations were found between competence and clinical outcomes, treatment engagement or need for further intervention. In this clinical trial, GSH competence ratings were not associated with clinical outcomes. Directions for future competence-outcome research are provided for GSH interventions. Key learning aims• (1) Become familiar with the current empirical literature on therapist competence and associations with clinical outcome. • (2) Raise awareness of a recently developed alternative form of guided self-help based on the theory and principles of cognitive analytic therapy. • (3) Enhance understanding of the relationship between practitioner competence and clinical outcome in guided self-help for anxiety disorders.

Objectives Whilst cognitive analytic therapy (CAT) is increasingly used as an indirect intervention, there is little evidence of how the approach can be applied to reflective practice. This study sought to develop a process model of cognitive analytic reflective practice (CARP) groups. Design Constructivist grounded theory approach supplemented by quantitative measures of helpfulness and group cohesion. Methods Twenty‐four participants, working within four staff teams in a secure children's home, attended four CARP groups over a 1‐year period. Sessions were audio recorded, transcribed and checked for model fidelity and then analysed using grounded theory. Theoretical sampling was achieved via conducting focus groups with teams informed by the emergent categories, and using sessional measures of group cohesion and helpfulness to confirm theoretical saturation. Results The model constructed had three interrelated main categories: ‘facilitator processes: establishing a reflective space’, ‘group processes: widening awareness of the self, others, and system’ and ‘outcomes: changing relational dynamics and finding exits.’ The model was validated by evidence from the measures. Conclusions The model offers an empirical understanding of how CAT informs reflective practice through a better understanding of reciprocity in the dynamics of care systems.

Everyone should have the opportunity to participate in decisions about their health, including people living with dementia. People with dementia typically bring a companion to medical appointments, so most care decisions are made in interactions involving three parties. To make decisions about their care, patients with dementia must have the opportunity to take a turn-at-talk in conversations where decisions are made. However, negotiating who speaks next in triadic talk is a complex task, especially when dementia-associated language and/or memory problems impact communication. Findings show that using second person (“you”) pronouns assist people with dementia in responding to queries, yet third person (“she/he”) can exclude them from the interaction, although this near-canonical pronoun use can be overridden by sequential placement, gesture, and gaze. We also demonstrate how midturn pronoun switching often only provides for tokenistic inclusion, though this again is dependent on sequential placement and embodied interaction. Data are in English.

Objectives Given the ubiquity in routine services of low‐intensity guided self‐help (GSH) psychological interventions, better patient selection for these brief interventions would be organizationally efficient. This study therefore sought to define who would respond best to two different types of GSH for anxiety to enable better future treatment matching. Methods The study used outcome data from a patient preference trial ( N = 209) comparing cognitive analytic therapy‐guided self‐help (CAT‐GSH) with cognitive behavioural therapy‐guided self‐help (CBT‐GSH). Elastic Net regularization and Boruta random forest variable selection methods were applied. Regression models calculated the patient advantage index (PAI) to designate which GSH was likely the most effective for each patient. Outcomes were compared for those receiving their PAI‐indicated optimal and non‐optimal GSH. Results Lower baseline depression and anxiety severity predicted better outcomes for both types of GSH. Patient preference status was not associated with outcome during either GSH. Sixty‐three % received their model indicating optimal GSH and these had significantly higher rates of reliable and clinically significant reductions in anxiety at both post‐treatment (35.9% vs. 16.6%) and follow‐up (36.6% vs. 19.2%). No single patient with a large PAI had a reliable and clinically significant reduction in anxiety at post‐treatment or follow‐up when they did not receive their optimal GSH. Conclusions Treatment matching algorithms have the potential to support evidenced‐based treatment selection for GSH. Treatment selection and supporting patient choice needs to be integrated. Future research needs to investigate the use of the PAI for GSH treatment matching, but with larger and more balanced samples.

What are the impacts of physical health problems upon the person’s mental health? There is no easy answer to this as there are lots of things that can impact. These vary from person to person and every person’s experience will be unique to them. This chapter will look at the impacts of some of these factors on the child and adult using the experiences of a person who has grown up with physical and mental health problems throughout childhood and into adulthood. Using the person’s case study, the main times of distress will be formulated to understand the impact that situations have had on the person’s mental health and physical health, alongside biopsychosocial concepts.

Background Research pooling data from UK university counselling services (UCSs) has allowed UCSs to compare their outcomes and demonstrate their effectiveness in improving student mental health. During the COVID‐19 pandemic, UCSs moved to remote delivery. Consequently, it was necessary to understand how this impacted students' outcomes. Aims This evaluation aimed to (1) understand how the therapeutic outcomes of a UCS compared with established norms in UK UCS literature, and (2) understand whether delivering therapy online affected student outcomes compared with UK norms from in‐person therapy. Method Sessional outcome data from 627 students who attended the UCS in the 2020/2021 academic year were gathered. Descriptive analyses of students' initial clinical data (determined by the CCAPS‐34) were conducted. Paired sample t ‐tests determined differences between the pre‐ and post‐therapy scores. The effect size of this difference was derived. Results Students presented with high levels of academic distress, social anxiety, generalised anxiety and depression. The initial severity of mental health concerns was lower than that reported in previous literature. The largest improvements were evidenced for depression and general anxiety and 25% ( n = 112) of students achieved reliable reductions in distress. Compared with existing literature, the UCS showed similar levels of improvement over therapy. It is suggested that remote therapy increased service accessibility. Conclusion The delivery of remote therapy produced results consistent with norms in the UK data, highlighting the effectiveness of online therapy for university students. Further large‐scale evaluations of student outcomes from remotely delivered therapy are recommended.

Unilateral tonsillar enlargement (UTE) generally prompts suspicion of malignancy and tonsillectomy is often performed for histological diagnosis. This may be unnecessary in asymptomatic patients. We performed a retrospective study of all patients who had asymptomatic UTE and underwent tonsillectomy over a 5-year period. We found no malignancies in our cohort of 78 patients. 22 out of 74 (29.7%) patients had a difference of 50% or more in the size of their tonsils. Around 1 in 4 patients had an inaccurate clinical diagnosis of UTE compared to the final size of their tonsil specimens. In a comprehensive literature review, only 2 out of 1152 patients (0.17%) were found to have lymphoma with UTE as the only presenting symptom and no other suspicious features. There can be huge variability between the size of normal tonsils. UTE alone without any other concerning features should prompt clinicians to consider other management options such as a period of observation rather than diagnostic tonsillectomy.

Aims Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) has 28 Promises as part of its Strategy. Promise 16 is to: Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year. This audit in November 2023 looked at the practice of using outcome measures for CAMHS patients in order to highlight areas of development for the service to work toward achieving the promise. Methods We wanted to understand if young people were having outcome measures completed and if so, when, what and how often. We achieved this by using a dip sample of five patients each across the three different localities (Rotherham, Doncaster and Scunthorpe). A report was generated to include all patients discharged from CAMHS in the preceding three months to September 2023. Young people who had been with the service less than six months were excluded from the audit. Five patients were chosen randomly from each locality and their electronic patient record on System One was studied. Information in the patient records was compared against the audit standards and recorded in Excel so the data could be analysed. Results The results showed that 11 of 15 young people had an outcome measure completed at some point during their episode of care. All five young people in Scunthorpe had an outcome measure recorded in their clinical records however this tended to only happen at the very start, meaning there was no basis for comparison. Four out of five patients in Doncaster had outcome measures in the clinical record and these were undertaken throughout the episodes of care. In Rotherham, two of five young people had outcome measures recorded in the clinical records. The most frequently used outcome measure was the RCADS but the SDQ was also used. Conclusion There is work to be done to ensure the use of outcome measures becomes routine, and also to standardise both the type and frequency of use. The Trust is aiming to increase their use by utilising SystmOne's capabilities to interface with service user mobile devices to send out outcome measures to patients. There is also a plan to inform staff within the service about the expected use of outcome measures. This audit will be repeated in 2024 to see if the Trust are moving closer to delivering their promise.

Aims The 2016 Junior Doctor’s contract offers guidance as to the rest periods needed during non-resident on-calls (NROCs). The Rotherham, Doncaster and South Humber (RDaSH) NHS Foundation Trust currently works on a NROC trainee rota. NROC work undertaken is monitored via a log form, returned by the trainee after their shift. A retrospective audit was completed with only a 28% return rate of log forms. Though anecdotal evidence suggested inadequate rest and high workloads during on-calls, due to low engagement in monitoring formal data was lacking. Therefore, a trainee-led prospective audit was designed to formally monitor on-call workload over a period of 4 weeks. The main aim of this project was to review the average amount of hours worked during an NROC shift and compare achieved rest periods against agreed standards (derived from 2016 contract). These standards indicate that 90% of shifts should achieve 8 hours rest in 24 hours and 5 hours continuous rest between 22:00–07:00. In order to accomplish this we first aimed to increase the return of completed on-call log forms to 75%. Methods Work was predominantly concentrated around increasing return rate of the log forms including: running teaching sessions, regional promotion, and sending daily reminder emails to return the forms. These forms were then reviewed and analysed. Results Across the 4 week audit period, the return rate of log forms was 95%, compared with the previous return rate of 28%. Average hours worked across all three localities exceeded the expected hours by RDaSH. When compared with the standards outlined, 1 in 3 shifts in Rotherham, 1 in 5 in Doncaster and 1 in 4 in South Humber did not achieve contractual rest periods. Out of these, not reaching 5 hours continuous rest was the most common reason for not meeting contractual rest periods. Conclusion RDaSH worked collaboratively with trainees to generate a number of interventions to mitigate the breaches in rest periods including: creation of a new clinical role to filter calls, reviewing the suitability of the NROC rota and increasing pay to reflect the increased workload. There is currently work underway to redesign the rota. This audit highlights the importance of prioritising regular reviews of NROC work to ensure the safety of both staff and patients through achieving adequate rest periods.

Community-based intensive home treatment (IHT) is delivered as an alternative to psychiatric hospital admission as part of crisis resolution services. People receiving IHT present with complex mental health issues and are acutely distressed. Home treatment options are often preferred and there is evidence of service fidelity, although less is known about psychosocial care in this setting. Underpinned by a critical realist epistemology, this study aimed to explore psychosocial care in the context of home treatment from the perspectives of staff, service users and family carers. Data were collected using individual interviews and focus groups in two NHS organisations in England. An inductive qualitative thematic analysis resulted in five themes focused on (1) the staffing model and effective care provision, (2) the organisation of work and effective care provision, (3) skills and training and service user need, (4) opportunities for involvement and personal choice, and (5) effective communication. Findings suggest that co-production may improve congruence between IHT service design, what service users and carers want and staff ideals about optimal care. Service designs that optimise continuity of care and effective communication were advocated. Staff training in therapeutic interventions was limited by not being tailored to the home treatment context. Evidence gaps remain regarding the most effective psychosocial care and related training and supervision required. There is also a lack of clarity about how carers and family members ought to be supported given their often-crucial role in supporting the person between staff visits.

Background Self-harm is a prevalent behaviour that has a major detrimental impact on a person’s life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context. Method An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria. Discussion CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm. Trial registration The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).

A growing number of older people remain in custody each year resulting in an increasing number of common mental and physical health concerns. No prior evidenced-based targeted psychological interventions support this group of people, and little is known about their needs, current activities, and health-related problems. We addressed these gaps through a project involving older prisoners, prison staff and a project advisory group in one male and one female prison site in the North of England. Systematic review evidence supports the development of an implementation tool kit addressing strategies to develop and deliver interventions that are sustainable, acceptable, and feasible in the prison environment. Prison strategies need to specifically address the needs of older people in custody. Relatively inexpensive activities, with some thought to delivery and flexibility have the potential to benefit common mental and physical health, increasing quality of life, reducing high economic and social cost, mortality, and reoffending in this age group.

Objectives To compare idiographic change during two formats of guided self‐help (GSH); cognitive‐behavioural therapy guided self‐help (CBT‐GSH) and cognitive analytic therapy guided self‐help (CAT‐GSH). Design Qualitative inductive thematic analysis. Methods Semi‐structured interviews with N = 17 participants with a reliable change outcome on the GAD‐7 after completing GSH for anxiety. Changes were categorised and themes extracted. Results No differences between CAT‐GSH and CBT‐GSH were found regarding types of change reported. The five overarching themes found were personal qualities of success, enlightenment through understanding, specific tools and techniques, changes to relationships and tailoring support. Four themes maximally differentiated between the two different types of GSH; CAT‐GSH enabled relational insight and change whilst CBT‐GSH enabled better understanding of anxiety, new coping techniques and supportive relationships. Conclusions Both common and model‐specific factors contribute to patient change during GSH. Whilst all forms of GSH are grounded in the psychoeducational approach, separate theoretical foundations and associated methods facilitate different types of ideographic change.

Background: Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. Methods: This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. Results: Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5%) or medium (41.9%) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40%, while for follow-up it was 36%. Pooled rates for ≥50% improvement in seizure frequency were 66% and 75%. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d=0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. Conclusions: The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Background Well-designed evaluations of psychological interventions on psychiatric intensive care units (PICUs) are a rarity. Aims To evaluate the effectiveness of cognitive behaviour therapy for intrusive taboo thoughts with a patient diagnosed with bipolar affective disorder admitted to a PICU due to significant ongoing risk of harm to self. Method This was a four-phase ABC plus community follow-up (D) mixed methods n =1 single case experimental design. Four idiographic measures were collected daily across four phases; the baseline (A) was during PICU admission, the first treatment phase (B) was behavioural on the PICU, the second treatment phase (C) was cognitive on an acute ward and the follow-up phase (D) was conducted in the community. Four nomothetic measures were taken on admission, on discharge from the PICU, discharge from the acute ward and then at 4-week follow-up. The participant was also interviewed at follow-up using the Change Interview. Results Compared with baseline, the behavioural and the cognitive interventions appeared effective in terms of improving calmness, optimism and rumination, but the effects on sociability were poor. There was evidence across idiographic and nomothetic outcomes of a relapse during the follow-up phase in the community. Eleven idiographic changes were reported in the interview and these tended to be unexpected, related to the therapy and personally important. Discussion Single case methods can be responsive to tracking the progress of patients moving through in-patient pathways and differing modules of evidence-based interventions. There is a real need to implement robust outcome methodologies on PICUs to better evaluate the psychological aspects of care in this context.

A major effort of the pharmaceutical industry has been to identify and market drug treatments that are effective in ameliorating the symptoms of psychotic illness but without the limitations of the current treatments acting at dopamine D2 receptors. These limitations include the induction of a range of adverse effects, the inadequate treatment response of a substantial proportion of people with schizophrenia, and the generally poor response to negative and cognitive features of the disease. Recently introduced drug treatments have gone some way to avoiding the first of these, with a reduced propensity for weight gain, cardiovascular risk and extrapyramidal motor effects. Despite claims of some small improvements in negative symptoms, these drugs have not demonstrated substantial increases in efficacy. Of the drugs currently in development as antipsychotic agents, several are misleadingly described as having novel ‘non-dopaminergic’ mechanisms that may offer improvements in addressing the limitations of adverse effects and efficacy. It will be argued, using the trace amine-associated receptor 1 agonist as an example, that several of these new drugs still act primarily through modulation of dopaminergic neurotransmission and, in not addressing the primary pathology of schizophrenia, are therefore unlikely to have the much-needed improvements in efficacy required to address the unmet need associated with resistance to current treatments.