With the people, for the people: applying mental health research

Imagine a 17-year-old man with a learning disability arriving in A&E with suspected appendicitis. By the time he’s been treated, he will have navigated a system complex enough to challenge anyone. A web of interactions will have been woven involving A&E, surgery, social services and mental health services, and complicated by the fact that, at 17, the young man faces transition from adolescent to adult services.

Professor Peter Jones, Director of the Collaboration for Leadership in Applied Health Research and Care for Cambridgeshire and Peterborough (CLAHRC CP), cites this young man as an example of one of the many highly vulnerable people who must traverse what he describes as pinch points in mental health services: “such gaps, despite vast efforts on the part of those carrying out the services, can sometimes place individuals with mental health problems in an impossible situation.”

Each year, around one in four adults in Britain will experience some kind of mental health problem, a condition that also affects children and the elderly. CLAHRC CP, a five-year, £23 million collaboration between the University of Cambridge, the National Institute for Health Research (NIHR) and six health and social care providers (see panel), is focusing applied health research on the urgent needs of patients at the front end of mental health service delivery. Three years into the CLAHRC, the work is having demonstrable beneficial outcomes to patients and clinicians.

Found in translation

CLAHRCs (there are nine around the country) have their origins in the 2006 Cooksey Review commissioned by the UK government, which identified two major gaps in the translation of health research into health care: the translation of basic research into products (often called ‘bench to bedside’ or type 1) and the implementation of these products into clinical practice (type 2). CLAHRCs, funded by the NIHR, were established to bridge the type 2 gap.

It’s not a straightforward matter, as Jones explained: “The type 2 gap involves a great many players and an understanding of how to move ideas around a system. In fact, it’s a sophisticated systems engineering and management problem.”

No wonder that Jones attributes a crucial part of the success of CLAHRC CP to the involvement of Cambridge’s Engineering Design Centre (EDC), Judge Business School (JBS) and Institute of Public Health: “We can look back now and see that much of our thinking began to change in the early stages as a result of these cross-cutting conversations. What we’ve learned is that there are principles to short-circuiting having an idea and getting it into the hands of people who can use it.”

Invention to innovation

The research strands of CLAHRC CP focus on the mental health of children and adolescents, adults with disorders, and old-age and end-of-life care (see panel). “Much of the research is highly technical but with close co-operation between researchers and the consumers – patients, clinicians and service managers – we’ve been able to make sure the findings are rapidly available and implemented,” explained Jones. “You could say that co-production is the essence of CLAHRC.”

Many of the research projects (26 at last count) demonstrate how involving consumers at an early stage not only helps to shape the work but also enables the consumers to plan for implementation. Jones likens the situation to a process in which the research is ‘pulled through’ by the end user: “When you have liaised with the consumer very early on, you know that their question is your question and they’re eager for your results.”

One example has been the Transfer of Care at 17 (TC17) study led by Professor Ian Goodyer, aimed at understanding the factors that facilitate or hinder successful outcomes when young people leave the care of the local authority. Adolescence is a complex period of rapid change for all young people but it’s also a critical period of vulnerability for developing mental health problems: approximately 50% of all lifetime mental disorders begin in the middle teenage years and 75% by the mid-twenties.

After discussion with Cambridgeshire Social Services, the TC17 researchers realised that describing the mental health needs of children in care was almost completely unchartered territory. Little was known of mental illness influences on personal and social adjustment in those leaving care, and adolescents revealed a reluctance to seek help. In association with young people, the team developed a tool to assess barriers to care and, partly in response to the findings, Cambridgeshire Social Services are undergoing a restructuring exercise to cater for 44 new units with an emphasis on family well-being and mental health.

The project has also led to the development and piloting of a new mental health training package for foster carers to help them identify core symptoms of emotional distress through close observation during a child’s first two weeks in care. “Both Cambridgeshire County Council and Peterborough County Council are enthusiastic about the pilot, along with the Looked After Children Psychology Service,” explained Goodyer. “If the results are positive it could lead to a fundamental change in how the foster carers are educated and supervised to help children in their care.”

“The greatest impact of the CLAHRC to date has been, and continues to be, the gradual enlightenment on the part of our local authority, voluntary sector and clinical colleagues of the potential value of high quality research to their work,” added Jones.

The main aim of CLAHRC-CP is to increase the value of services and what they can do for patients and their families. Often, improved services also result in cost savings, as is the case for the outcome of a research project on Improving Access to Psychological Therapies (IAPT).

The IAPT programme, provided by the NHS, offers psychological therapy to people suffering from mild to moderate depression and anxiety disorders, where previously medication and a long wait on a list for a counsellor had been the only option for GPs. Each year in England, mental health conditions cost approximately £105 billion due to loss of earnings and associated treatment and welfare costs.

Working with the East of England Strategic Health Authority, CLAHRC researchers, led by Jones, investigated whether the programme was meeting the needs of the local population. Having analysed data from over 100,000 consultations, the team showed that simply offering therapy by telephone rather than face to face was just as effective and yet much more cost-effective and convenient. It also opened up the service to people otherwise unable to access support owing to their remote location, physical disability, employment status or their avoidance of talking about their condition in person.

Alison Watson, IAPT Research Associate, explained the impact of the study: “It’s definitely a case of invest to save. For every patient who recovers from depression or anxiety, the NHS is saving over £1,000. IAPT is designed to prevent that ‘revolving door syndrome’. People are taught the skills to self-manage their condition, which leads to long-term sustained recovery. Access to the talking therapies over the telephone has been a real innovation in service delivery, which has helped services meet the needs of their local population.”

Boundary spanners

Ultimately, the key to translating invention into innovation sustainably, believes Jones, are boundary spanners – individuals who can understand both research and clinical practice. The CLAHRC Fellowship scheme, developed over the past year, has now trained 27 individuals from health and social care in research methodology, service redesign and change management. Already CLAHRC Fellows are making an invaluable contribution, acting as local ‘research champions’, and helping the CLAHRC connect with health care practitioners in the community.

Looking forward, Jones reflected on what he finds most exciting about the CLAHRC: “It’s the ability to be reactive to co-production and to be flexible enough to take on emerging areas in mental health, because if the consumers really want an answer, then it will happen more quickly and you’ll have more impact.”