‘Preventing suicide and self-harm’ theme in the NIHR GM PSRC

Professor Nav Kapur and Professor Roger Webb are co-leads for the ‘Preventing suicide and self-harm’ theme at the National Institute for Health and Care Research Greater Manchester Patient Safety Research Collaboration (NIHR GM PSRC). Here, they introduce the new theme.

“People at risk of suicide and self-harm are some of the most vulnerable and improving the safety of their care is essential. Patient safety research is a critical part of preventing self-harm and suicide in mental health services. Our new research programme is dedicated to making a difference to this area of healthcare by identifying, refining, and evaluating new ways of delivering services.

The work that we plan to do will build on what we have discovered about provision of psychosocial assessment following a self-harm episode and enhanced family involvement for patients in specialist mental health services.

Our research team in the GM PSRC includes people from a broad range of academic and clinical disciplines, including psychiatry, clinical psychology, primary care, health economics, health services research, epidemiology, statistics, informatics, and behavioural science.

Designing our programme of research

Researching this topic can be especially challenging.  When we were designing and developing our programme of research, we worked with people with lived experience and healthcare staff to gain a deeper understanding of some of these challenges.

Therefore, our research aims to improve patient safety by identifying interventions that help to prevent self-harm and suicide in mental health services. We recognise that there are many different ways to deliver mental health services and that some approaches may be better at reducing the risks of self-harm and suicide than others.

For example, our research will examine innovations in specialist mental health services, in secondary hospital emergency departments, and in general practice. We are committed to identifying which approaches have the most potential to reduce the risks of self-harm and suicide in these different healthcare settings.

Delivering our programme of research

To meet our objectives, we will be working closely with service providers and patients, carers and healthcare staff to investigate the most effective interventions and refine them further to increase their potential impact. This will involve large-scale studies which include several services and a high number of patients to ensure the results are relevant to a wide range of mental health settings. As a result, we aim to better understand any potential barriers to successfully rolling out the interventions that we’ll be testing.  This type of study can also provide us with valuable insights into how the interventions can be adapted to work well across different mental health services and settings.

Impact and outcomes

Our research has the potential to make a significant difference to patient safety. By identifying and implementing effective interventions, we can help prevent suicide and self-harm and improve the outcomes for people who are experiencing mental health illness. We want to assure affected individuals that there is support available and encourage them to seek help if they need it.

At the heart of our research is the recognition that mental ill health can affect anyone, and that everyone deserves access to high-quality care. Inequality in mental health services is a complex issue and can be influenced in various ways, including by social, economic, and cultural factors, as well as differences in how services are offered. For instance, people from ethnic minority backgrounds may be more likely to experience stigma and discrimination when accessing mental health services, while people from socially disadvantaged backgrounds may face other barriers that hinder their access to treatment. 

We are committed to identifying interventions that work for everyone, regardless of their background or circumstances. By identifying the most effective interventions and refining them, we can work towards reducing the risks of suicide and self-harm, improving patient safety, and ensuring that everyone has access to the effective care that they need.”

Development of a ‘best practice’ guide on the safe use of medicines after discharge from mental health hospitals

Richard Keers is a Senior Clinical Lecturer in Pharmacy at The University of Manchester with experience as a mental health pharmacist. He has been part of the Medication Safety theme at the Greater Manchester Patient Safety Translational Research Centre for a number of years. He will be working in the new Improving Medication Safety theme as part of the NIHR Greater Manchester Patient Safety Research Collaboration which begins on 1^st April 2023.

Richard’s work focusses on the safe use of medicines across different health settings and he has a particular interest in supporting patients with mental illness to use their medicines safely and effectively. His new study, ‘Developing a framework for medication optimisation and safety in primary care following discharge from mental health hospitals’ has been awarded funding from the NIHR School for Primary Care Research. The study will begin in summer 2023 and will run for 16 months.

In this blog, Richard explains why this project is needed and how the research will be carried out, as well as the impact it could have on how medicines are used safely by health professionals and people with mental illness after they are discharged from a mental health hospital.

What problem will this research address?

When people with mental illness are discharged from mental health hospitals, we know they may be more likely to be re-admitted or need care due to problems with their medicines. They may be leaving hospital with different medicines to when they were first admitted.

Patients, carers and health professionals need more support to work together to help patientsadjust to treatment changes after they’ve been discharged. Improving the safety of mental health hospital discharge and the use of medicines are therefore seen as important priorities for patients and health services.

However, there has been little research to:

1. Understand how patients and their carers use and understand their medicines in the community after discharge,
2. Find out what support patients, carers and health professionals need, and
3. Understand who they may ask for this support. Health professionals working in communities supporting patients may lack guidance on how best to work together. This is important, as mental health, general practice, community pharmacy and social care are now expected to work more closely together.

How will the research address the problem?

Our study aims to create a ‘best practice’ guide for health professionals and patients/carers to use in the community following discharge from mental health hospitals. This is designed to help them work better together so medicines are used in the safest and most effective way.

To do this, our study will be carried out in three stages and will be guided by people with lived experience who will join our research team and project steering group:

• Stage 1

We will interview patients, carers and health professionals to find out how medicines are used and what people feel could help or hinder their safe and effective use after mental health hospital discharge.

We are also interested in understanding what support is needed with medicines and if and where this can be found.

• Stage 2

Using the results of stage one of the project, we’ll host workshops that will bring together patients, carers, health professionals and policy makers to decide on the most relevant and important content for a ‘best practice’ guide. This includes thinking about different perspectives as well as other elements that are likely to make a difference.

• Stage 3

The ‘best practice’ guide will be created and we aim to make this available as separate versions for patients/carers and health professionals.

What impact is expected from this research?

The main outcome of our research will be the ‘best practice’ guide. We hope it’ll be available online for health professionals and patients.  

The separate versions of the guide should help our research to be better understood. They will provide opportunities for people to be empowered, learning more about medicines and how to work together to use them safely after hospital discharge.

We are looking forward to raising awareness of the research and will be sharing the guide at conferences, in academic journals and across social media.

If you have any questions about this work or would like to learn more, please email Dr Richard Keers or contact him on Twitter.

Hidden LIVE – a young person’s experience of creating a performance and podcast about mental health

A free immersive experience was first performed in May 2022 at The Royal Northern College of Music in Manchester. It is a project that’s funded by two National Institute for Health and Care Research (NIHR) research centres, the Applied Research Collaboration Greater Manchester (ARC-GM) and the Greater Manchester Patient Safety Translational Research Centre (GM PSTRC).

The research centres worked with not-for-profit organisation, Made by Mortals, to recruit ten young people who together created a podcast and performed the show.

One of the young people, Ashgan, 21, talks about their experience working on this project here.

“I personally heard about getting involved through an email that I was sent from the University of Manchester, so I found the Made By Mortals website and called the number about the opportunity. I was emailed with the details straight after our conversation! What excited me about the opportunity was that it was both something creative and to do with mental health. As someone studying Psychology at the time and who also does photography, it was perfect for me. It was an incredible opportunity to gain experience with such a profound organisation. I was also really enthusiastic at the prospect of working with other young people. I felt we needed our voices amplified, which is something I had in common with the other young people in the group.

When I found out we would be recording a podcast as part of the project, I was a bit worried as I’d never done this before. I later found out that it was completely different to what I thought we’d be doing. We made the story ourselves, and we didn’t need to worry about doing anything technical, as this was sorted for us.

We were all from a mixture of backgrounds. For example, Ameir studies Dentistry, Shuhaney is in college and wants to be a teacher, and Sadia works with the council, and, me, Angel, and Annie all studied Psychology at the time. There were differences between us, but lots of similarities, that we built into the storyline.

We all loved the diversity in the group, it really put everyone at ease. We were a mix of ages and genders and from different backgrounds and ethnicities. This really helped when we were creating the characters, and all of the details around their lives. We all had such a range of experiences from our real lives that we could draw on due to the differences in our cultures and unique backgrounds. For example, we decided on the name Adam as it was ethnically ambiguous, so anyone could listen to the podcast and relate to it. We all felt this was important.

The way we were eased into creating the podcast was great, it made the whole experience more fun and less daunting. At first, it was all meetings on Zoom, which was a good way to start and allowed us to bond before we met in person. It was very productive over Zoom, and it was easy to use. The team helped to ease meetings with relaxed introductions, and we had ice breakers to help people become more confident and open. For example, one of the games we played, involved making up a headline for a random image. It was a fun way to start the meeting because there wasn’t any pressure. There was also music to begin with whilst people were joining, so it was never awkward.

I remember being late to the first meeting because of another commitment, but everyone was so welcoming, it was a great environment. I think working in Psychology, Mental Health etc, can have that stereotype of everyone being ruthless and nonchalant, but it was the opposite. It was the most comfortable, caring, and understanding environment I have worked in, and I’m happy I was able to take part and meet amazing people who I’d probably not usually cross paths with.

Building the podcast story was set up in such a way that it almost felt like all we were having meetings, it was fun and we had relaxed conversations. We would talk about our lives, what we liked, who we spent our time with, the experiences we’ve had, and that subtly blossomed into a storyline. I remember Ameir was talking about how he and his best friend had bought cheap silver necklaces to commemorate their friendship. That was added to the script with Adam and his best friend doing the same thing. Another example was when we were talking about how we value our memories, and I mentioned how I hoard receipts from road trips. This found its way into the script as well. Having those personal experiences in there helps the story to feel real even though Adam himself is fictional.

Adam’s story is made up of all the experiences, we as a group, have been through. We felt this made the podcast so relatable for any audience because it’s realistic. Even when it was a potentially upsetting topic about mental health, we were supported and the conversation was so relaxed, it was easy to be open. In that sense, creating the podcast was so positively impactful towards our wellbeing, it was nice for everyone to share experiences in a judgment-free space. All of the little experiences were threaded together to create the podcast by Paul and Chris at Made by Mortals

We met in person for the first time to read through the script, which was exciting. Again, it was a really comfortable environment. I remember, I was fasting for Ramadan, and one of members of staff emailed me beforehand to make me aware that there was a prayer room if I needed to head out. She also let me know the times I could come so I wasn’t surrounded by everyone having their lunch if I wanted. Also, a wheelchair accessible taxi was ordered for Shuhaney. So many efforts were made to make sure we were comfortable, and we all appreciated it.

Listening to the script for the first time was very emotional. It was so original, and it was nice to spot personal experiences and everyone’s individual input. We were all treated like equals. It was clear that everyone had been thought of when putting the script together to ensure our voices were all equally represented. I could not believe that the script came together from all the little bits we talked about. It was surreal hearing it for the first time, and it still feels that way now. Because the conversations had been so casual, comforting and fun, it didn’t feel ‘significant’ enough to create an entire script. Sadia, one of our group, said: “It really made me aware that things like this don’t need to be formal, scary, and intimidating.”

With us all being incredibly happy and proud with the script, it was time to record it. Before recording, myself and the rest of our group expected a ‘traditional’ recording studio, and we were all worried we would mess the recording up. Tashinga, said, “I expected to be in a studio and alone in it, behind a screen, which sounded so awkward.” Sadia added that she “was relieved we were all sitting together, with mics and handheld recording devices. It was more fun!”. Andy, who helped us with the recording, was patient and comforting. Everyone was supportive. We all gave each other a mini applause after our first few recordings. It was a new experience, and I’m grateful I was able to do it in such a patient, supportive environment! There was no pressure, so we were able to record whilst actually enjoying the whole process.

The entire process was great, and the impact was huge. Seeing how other people benefitted from the podcast at the first performance was amazing. We heard how they felt like they could then be open about their experiences and the performance started a discussion between young people, families and professionals. This hugely boosted our confidence to get involved in projects like these, meet new people and share our experiences. Also, like I mentioned, creating the podcast itself and working with people with similar experiences really benefitted us in itself. Sadia spoke about it perfectly when she said it was like ‘indirect therapy’.

A huge thank you to NIHR ARC-GM, Made by Mortals, and everyone who was a part of the team, and thank you to the audience, we hope you enjoyed our immersive performance. We’re now taking it on tour and you can find details on how you can see it here: https://arc-gm.nihr.ac.uk/hidden-live

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The people involved in the podcast were: Ameir, Angel, Annie, Ashgan, Sadia, Shuhaney, and Tashinga.

New research reveals that a tool designed by researchers to help prevent self-harm is liked by those with lived experience

Behavioural Science researchers have worked with a group of people who have a history of self-harm to understand if a new online tool can help to reduce the urge to self-harm. The research aimed to understand their thoughts, feelings and experiences of using the tool, known as a volitional help sheet. It is the first study to apply the ‘theoretical framework of acceptability’ to understanding the acceptability of an intervention for self-harm.

This research forms part of a larger study that involved designing the tool and is funded by the National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre (NHIR GM PSTRC).

Researchers interviewed sixteen people with a history of self-harm, who had previously used the tool to make ‘if-then plans’ to try to reduce the urge to self-harm. An ‘if-then plan’ is normally used in psychology to help people to commit to doing a certain thing in a specific situation. It allows people to plan their response to a particular set of circumstances that may arise. For example, ‘if X occurs, ‘then Y will be done’.

The research, “Exploring the acceptability of a brief online theory-based intervention to prevent and reduce self-harm: a theoretically-framed qualitative study” was published in BJPsych Open.

As well as understanding if it was liked by those who used it, researchers also sought to understand when the tool could be most useful. Those interviewed agreed that healthcare professionals (particularly GPs and mental health professionals) could use the tool during medical consultations to complement existing healthcare that patients receive.

The study’s authors hope this intervention provides a useful tool for individuals to construct their own personalised ‘if-then plans’, and can form part of a longer-term support strategy delivered by healthcare professionals for preventing self-harm.

Dr Chris Keyworth, Lecturer in Psychology at the University of Leeds and lead for this study at the GM PSTRC, said: “Using a specific framework from behavioural science, the “Theoretical Framework of Acceptability”, allowed us to explore in detail peoples’ experiences of using our tool, the volitional help sheet.

“Specifically we were able to understand how a person thinks and feels about the tool, while also being able to recognise the effort needed to engage with it by making ‘if-then plans’. In taking a qualitative approach, we were able to identify specific ways that the tool could be used – both personally, and by healthcare professionals. Importantly, this also allows us to identify areas to improve it. For example, we could add more referral resources or signposting to support services in future versions.”

The tool was designed alongside a patient and public involvement and engagement (PPIE) group with lived experience of self-harm to ensure the intervention is as acceptable as possible and requires the lowest level of effort by those who use it. This has been reflected in the views of participants taking part in the study.  Researchers are now looking at ways of making the tool more widely available online.  

Free immersive show comes to Stockport and Salford raising awareness of challenges faced by young people struggling with their mental health

After a successful first performance at the Royal Northern College of Music, an immersive show that aims to highlight the challenges faced by young people who struggle with their mental health is going on tour across the North West.

The first date is Thursday 10 November at The Lowry Theatre, Salford, and further performances will follow in early 2023.

The performance has been created by two National Institute for Health and Care Research (NIHR) centres, the Applied Research Collaboration Greater Manchester (ARC-GM), and the Greater Manchester Patient Safety Translational Research Centre (GM PSTRC).

Ten young people from diverse backgrounds worked with researchers and not-for-profit organisation Made by Mortals to create a performance that encourages audience members to walk in the shoes of a fictional character, Adam. They recorded a podcast which is combined with a live performance to create the show.

Adam is 18 years old and transitioning from children’s mental health services to adults. Immersive sound and live action combine to give a real sense of what it’s like to be Adam. Audience members are encouraged to wear an eye mask to heighten the experience. A trailer has been created to give an insight into what it’s like to attend a performance.

One of the young people involved in the performance, said:

“All of us involved have different ethnicities, ages, genders, and backgrounds. It really helped when we were creating the characters, and all of the details around their lives, because we all had such a range of experiences from our real lives that we could draw on due to the differences in our cultures and unique backgrounds. For example, we decided on the name Adam as it was ethnically ambiguous, so anyone could listen to the podcast and relate to it, because we didn’t want anyone to feel limited and as though it couldn’t be applied to them.”

An actor plays the part of Adam’s mental health support worker, Shaun. He helps to guide the audience through the story and suggests they remove their eye masks at key points during the performance. Shaun speaks about his experiences of working with Adam. The script for this was created by working alongside parents and carers with lived experience of mental health services. Shaun speaks about his relationship with Adam, the support he is able to offer and how that is changing now that Adam has turned 18.

Prof. Karina Lovell, lead for Mental Health at ARC-GM and Professor of Mental Health at the University of Manchester, said:

“We believe the podcast that’s been created with young people and Made by Mortals gives an accurate portrayal of the challenges faced by young people struggling with their mental health. It’s a powerful performance and we hope it makes a difference to not only the people who come along to the live performance, but to those who read the resource we’ll be creating on the day.”

Shaun also highlights how the music, which was co-created by the young people involved, reflected the story. This included an eclectic mix of instrumentation representing the cultural heritage of the young co-creators, and Adam’s dialogue being transformed into beautifully lyrical melodies performed live by a violinist.

Paul Hine, Director at Made by Mortals, said:

“Coproduction is at the heart of this project and it’s this that helps us to create a sense of what it’s really like for young people struggling with their mental health. We are keen for as many people as possible to experience the performance and encourage anyone interested to register for tickets.”

The performance will be followed by an interactive session where audience members are encouraged to ask questions about the show to encourage discussion.  

One of the researchers, Dr Leah Quinlivan, who leads mental health research at the GM PSTRC, said:

“An important theme of our work is mental health and this includes developing interventions for adults as well as young people. We are therefore, delighted to be involved in this project, as it has the ability to reach a diverse audience and make a difference to young people struggling with their mental health.”

Further information and details on how to book tickets for the upcoming performance at The Lowry in Salford Quays can be found on the GM PSTRC website.

NIHR ALERT: People discharged from inpatient mental healthcare are at increased risk of dying

This blog post was originally published to the NIHR Evidence webpage.

People discharged from inpatient mental healthcare have a much higher risk of dying than the general population, research found. Their risk was particularly high in the 3 months after being discharged. The researchers say this highlights the need for improved follow-up and support for people returning to the community.

Working age adults were 191 times more likely to die by suicide than the general population in the first 3 months after discharge. The risk was most increased among those in the least deprived areas (compared to the most deprived), and among women.

Older adults were also at increased risk of suicide. In addition, in the first 3 months, they were 3.5 times more likely to die of natural causes (illnesses such as heart disease, or stroke) than people of the same age in the general population. This risk was highest in the most deprived areas.

The study was based on the GP and hospital records of a large group of adults in England. The data covered the year after they were discharged from inpatient mental healthcare.

A second study again looked at the risks of dying among people with serious mental health conditions discharged from inpatient care. This time they were compared to people with serious mental health conditions who had not recently been in hospital. It found that the risk of death from all causes was much higher in those discharged from inpatient care.

The research team calls for improvements to discharge planning, based on individual need.

What’s the issue?

Living in the community after spending time as an inpatient in a mental health ward can be difficult. People may still be unwell, and they may be returning to challenging and risky circumstances.

The risk of death by suicide is known to increase in the early weeks after discharge. However, studies have not compared the risk in this group of patients, to that in the general population.

People with serious mental health conditions are at higher risk of dying than the general population. People diagnosed with schizophrenia, bipolar affective disorder, or other psychoses have a life expectancy 10 to 20 years lower than the general public. This could be due to social risk factors, poorer access to healthcare, or side effects of medications. It is not known whether inpatient psychiatric care adds extra risk.

The research team monitored these risks over time. They considered whether gender, socioeconomic position, or age could affect the risk of death from different causes. They compared the risks among people discharged from inpatient mental health services, the general population and people with severe mental health conditions who had not recently been in hospital.

They hope their findings will help professionals support this vulnerable group.

What’s new?

First, the researchers looked at data on 100,000 people who had been discharged from an inpatient psychiatric unit in England between 2001 to 2018. Each was matched with up to 20 people in the general population who had not received inpatient mental healthcare. People were matched with others of the same gender, age and GP practice. This research included data on almost 2 million people in total.

It showed that in the first year after discharge, both working age and older adults (65+ years) had a higher risk of death than the general population. The risk was higher for each cause of death, including by suicide, related to drugs and/or alcohol, accidents, and natural causes (such as stroke).

The largest proportion of deaths (40%) in working age adults was by suicide. In older adults, most (94%) deaths were from natural causes. Compared to the general population:

• suicide risk was particularly high in the first 3 months of returning to the community; working-age adults were 191 times more likely to die from suicide; older adults were 125 times more likely
• risk of dying by suicide was greater among working age adults in the least deprived areas
• women’s risk of suicide after discharge increased more than men’s (although the absolute number of men who died by suicide remained higher than the number of women)
• older adults were 3.5 times more likely die by natural causes in the first 3 months after discharge, particularly those in the most deprived areas.

In the second study, the researchers looked at data from almost 24,000 adults who had been in inpatient mental health services. They matched each with up to 5 people with severe mental health conditions who had not received inpatient care. This gave a total of 119,000 adults.

People recently discharged from inpatient care had a higher risk of dying from all causes. Compared to those who had not recently been in hospital:

• suicide risk was almost 12 times higher in the first 3 months after discharge; the risk remained higher for 2 to 5 years
• the risk of dying by natural causes was raised in the first 3 months, and was highest in middle-aged people.

Why is this important?

Together, the studies show that adults of any age are at increased risk of dying after they are discharged from inpatient mental healthcare. The research highlights the need for careful discharge planning, particularly in the first 3 months. People need care that is tailored for them, and they need follow-up and support.

Mental health support to prevent suicides is needed for the whole group, regardless of gender. In contrast to trends in the general population, this research found that suicide was more likely in the least deprived areas. The researchers suggest that shame and stigma may be greater among less disadvantaged groups. Or it could be that services in deprived areas are better able to offer support.

Older adults need more support to improve their physical health, especially in more deprived areas. The researchers recommend holistic follow-up, including social support, physical health assessment, and adjustments to living arrangements. They say that the lower risk of suicide could be because older adults may have survived previous crises. It could also be that many in this group had dementia, and may not have been able to plan suicide.

For people with severe mental health conditions, being discharged from inpatient care increased their risk of death (compared with no inpatient care). This highlights the need for more mental and physical health support for this group. Psychosis support services typically target younger people, but these findings suggest that middle-aged people also need this support.

What’s next?

The findings support NICE recommendations for timely support after discharge from inpatient mental health settings. They are also in line with the NHS Long Term Plan for mental health. Yet the research demonstrates people’s ongoing risk. The researchers say we need a rethink on how people are supported throughout their hospital stay and once they return to living in the community.

This research described the increase in deaths soon after discharge from inpatient mental healthcare. It was not able to explain why. The researchers say it is possible that staying in hospital can reduce people’s autonomy and their ability to self-manage their condition. It might also be that people do not have their physical health assessed at discharge. Further research could explore whether these explanations hold true. For now, the researchers suggest that the inpatient environment should prepare people for their life after they leave hospital.

This study did not include people who are not registered with a GP, such as those who are homeless. Further research could look at these groups. It could also investigate how the severity of mental health conditions and social circumstances affect risk of death.

The same research team is now investigating how people access services and are supported by their GPs in the year after discharge. They are exploring whether people who die by suicide are less able to access care. Colleagues at the University of Manchester are researching what patient safety interventions are effective after discharge. They developed Safer Plus, a step-by-step guide to improve the quality of hospital discharges. Safer Plus has been included in Royal College of Physicians guidance.

You may be interested to read:

This NIHR Alert is based on:

Musgrove R, and others. Suicide and other causes of death among working- age and older adults in the year after discharge from in-patient mental healthcare in England: matched cohort study. British Journal of Psychiatry 2022;221:2

Musgrove R, and others. Suicide and death by other causes among patients with a severe mental illness: cohort study comparing risks among patients discharged from inpatient care v. those treated in the community. Epidemiology and Psychiatric Sciences 2022;31:e32

A plain language summary and a blog by the author are available.

The NHS and the charity Mind provide information on how to get help for mental health conditions.

The National Confidential Inquiry into Suicide and Safety in Mental Health 2021 includes a toolkit for mental health services based on ’10 ways to improve safety’.

Performance raised awareness of the challenges faced by young people struggling with their mental health

To mark Mental Health Awareness Week 2022, researchers at the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM), supported by the NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), created an immersive performance to raise awareness and highlight what it’s like to be a young person who is struggling with their mental health. It was put on as a show at The Royal Northern College of Music in Manchester for an audience of young people, parents, those involved in supporting young people (health and care professionals, third sector organisations) and researchers.

ARC-GM recruited young people with lived experience of mental health issues who worked with not-for-profit organisation, Made by Mortals, to create a unique performance. The show encouraged audience members to walk in the shoes of a fictional character Adam, who is 18 years old and transitioning from children’s to adult mental health services. The production involved immersive sound design, use of eye masks, and live action. At points during the performance, the audience were challenged to help Adam.

An actor played the part of Adam’s mental health support worker, Shaun. He helped to guide the audience through the story and suggested they remove their eye masks at key points during the performance. Shaun spoke about his experiences of working with Adam. The script for this was created by working alongside parents and carers with lived experience of mental health services. Shaun spoke about his relationship with Adam, the support he was able to offer and how that was changing now that Adam had reached 18 and therefore needed to be referred to Adult Mental Health Services.

Shaun also highlighted how the music, which was co-created by the young people, reflected the story. This included an eclectic mix of instrumentation representing the cultural heritage of the young co-creators, and Adam’s dialogue being transformed into beautifully lyrical melodies performed live by a violinist.

Paul Hine, Director at Made by Mortals, said: “Coproduction has been at the heart of this project. It’s a great example of what is possible when people with lived experience, health practitioners, research teams, and the participatory arts come together to support each other and bring about the shared change we want to see.

“This has been a fantastic collaboration with the final production becoming much more than the sum of its parts. We can’t wait to see what we can do together in the next phase of this project.”

The performance was followed by an interactive session where audience members were encouraged to ask questions about the show. This provoked a discussion where solutions were discussed. One attendee, said: “Adam needs to know he’s loved and he needs a purpose. He needs to feel valued. How do we put humanity back into the system? Adam needs that human-to-human connection.”

Another attendee, who works for a mental health charity, said: “GPs don’t always or aren’t able to pass the details on of the services we offer so people don’t always know about the support that’s available. A database where all this information could be held may work well.”

Throughout the show a visual minute taker captured the story and key discussions points from the audience.

Dr Leah Quinlivan, who works in the GM PSTRC mental health theme, said: “I put my eye mask on, like all the other audience members and was guided through a day in the life of Adam. As the audio was written by young people who have struggled with their mental health, there was a feeling that I was given a glimpse of what someone like Adam may go through. There was a real sense of how alone Adam felt and how frustrated his mental health supporter worker felt. It was very interesting hearing from the audience members, some of whom were the parents of the young people who took part. This was an important performance that has the ability to raise awareness and to flag some of the biggest issues faced by young people struggling with their mental health and those who support them.”

Organisers are planning to ensure more young people are able to experience the performance and are hoping to take the show to different areas across Greater Manchester in the Autumn. If you’re interested in learning more about these additional performances please contact: Alison Littlewood, NIHR ARC GM Programme Manager. 

Addressing health inequalities and local needs through research about health and social care: a workshop hosted by the NIHR GM PSTRC and ARC-GM

Tackling health inequalities is a key priority for Greater Manchester (GM) and recent experiences during COVID-19 have further highlighted this need. In spring 2022, two research centres funded by the National Institute for Health and Care Research (NIHR) held a workshop to explore health inequalities across Greater Manchester and to set out priorities for working in partnership to make a difference.  

The event brought together researchers from the University of Manchester working for the Applied Research Collaboration Greater Manchester (ARC-GM) and the Greater Manchester Patient Safety Translational Research Centre (GM PSTRC). Public contributors and people working in the Voluntary, Community and Social Enterprise (VCSE) sector also joined discussions. 

Professor Dame Nicky Cullum from ARC-GM highlighted how Gorton Monastery was a fitting location for the event. She explained how Gorton is one of the most deprived areas in GM with poorer health and lower life expectancy compared to the rest of the country. Yet, the restoration of the magnificent monastery building was only possible because of the collective action of local communities working together. This event was similarly focused on the value of working together with local communities to create positive action, and to tackle health inequalities and inequalities in patient safety through our research. 

Dr Luke Munford presented ‘A Year of COVID-19 in the North’ and highlighted the bleak picture around widening inequalities in the north of England during the pandemic in terms of life expectancy, the impact of COVID-19, and experiences of many long-term health problems.  

Professor Roger Webb (pictured second from left below) talked about inequalities in mental health during the pandemic, exploring the impact on how frequently people presented to healthcare services following self-harm.  

From the GM PSTRC (l-r):

Research Leads Prof Caroline Sanders & Prof Roger Webb

Director Prof Darren Ashcroft

Centre Manager Karen Considine

Dr Kelly Howells and Matt Amp (a researcher from the homelessness charity Groundswell) presented their work exploring healthcare access for people experiencing homelessness. They highlighted the benefits of working in partnership to ensure those with lived experiences of homelessness drive the whole research pathway from the earliest ideas to the final writing and dissemination.  

Stephanie Gillibrand finished the session discussing partnerships to ensure community voices were at the centre of research on inequalities during COVID-19 and the vaccination programme. Participants praised the participatory approach and co-production evident, sharing ideas on how we can ensure more projects adopt this way of working. 

Neil Walbran from Healthwatch Manchester talked about their work to ensure equalities legislation is put into practice. Paul Hine presented some work by Made By Mortals, a creative performance organisation. They use creative methods and podcasts to bring experiences to life, especially to those most affected by inequalities.    

Charles Kwaku-Odoi from the Caribbean and African Health Network (CAHN) discussed examples of CAHN’s work at the forefront of tackling ethnic health inequalities. We reflected back to a previous event they led two years earlier (also at Gorton Monastery), in partnership with GM PSTRC and others, to highlight the major inequalities in outcomes and experiences for Black and Asian women using maternity services. We did not know then, that the following month would bring a total lock down and change the lives and health of so many people.  

Community members and organisations presenting and participating at the event reflected many experiences of worsening health, hardship and social exclusion. Yet, much of the discussion also reflected passion, resilience and commitment that is inspirational in demonstrating what can be achieved in working together.  

Nasrine Akhtar, who leads a voluntary organisation called Awakening Minds and working with local communities in Oldham, aptly summed up how she views this work, saying “It’s not hard work, it’s heart work!” This sentiment was widely appreciated by others, representing the underlying values needed to drive future partnership working to address health inequalities.  

Further information and some of the presentations are available on this website and a report will be published soon.

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Research Fellow, Dr Lisa Riste, attended the ‘Addressing health inequalities and local needs through research about health and social care’ event and was inspired to write this poem giving her impression of what was discussed.

Health Inequalities need ‘heart work’

There's a life expectancy difference

A gulf between north and south

Twenty years less for northern men

That needs to be shouted about

The spending cuts and austerity

Biggest losses where health is worst

Mean some are disproportionately affected

Creating an awaiting tsunami of hurt

In engaging the local community

It plays to the strengths of us all

When academic and organisations join

It helps neighbourhoods once in free fall

But you can't bestow equality

I'm sorry that isn't your gift

Breaking down the old hierarchies

Is what we need to focus on and shift

So don't be afraid to make progress

Be cautiously optimistic about change

"It's not hard work, it's heart work"

Time for the systems to all re-arrange

Research explores the transition between young people’s mental health services and adult services

Dr Faraz Mughal is a GP, an NIHR Research Fellow at Keele University, and is supported by the GM PSTRC. He has been working with Dr Rebecca Appleton, a Research Fellow from University College London (UCL) who led a research study, published in the British Journal of General Practice, called ‘Young people who have fallen through the mental health transition gap: a qualitative study on primary care support’.

Why was the research needed?

Young people who are no longer able to receive specialist mental health support after reaching the upper age limit of child and adolescent mental health services (CAMHS) may be able to access ongoing mental health support from their GP which could improve the safety of the transition.  

This research enhances our understanding of how we can ensure safer transitions for young people with ongoing mental health needs.

Who was involved in the research?

This research included interviews with 14 young people and 13 parents of young people who had experienced poor continuity of care after reaching the point where they were too old to receive further support from CAMHS.

Participants were recruited from the West Midlands and London and were part of a larger study exploring the transition between child and adult mental health services across Europe (the MILESTONE project). A method called reflexive thematic analysis was used to analyse the data which helps to identify patterns or themes.

Young people and parents described frequently being discharged to their GP after reaching the upper age limit of CAMHS. Participants reflected on various experiences of accessing mental health support from their GP. Young people identified barriers including:

• Experiencing anxiety in the general practice environment (e.g., waiting room)
• The perception that GPs were unable to prescribe certain specialist medication
• Having to move to a new practice if they moved away from home for university.

Participants who reported positive experiences were more likely to have a long-term relationship with their GP and felt that their GP took the time to understand their needs and experiences.

What themes were uncovered?

Researchers identified that a major theme was ‘taking responsibility for the young person’s mental health care’. In some cases, participants said their GP took on responsibility for their care, as they were not eligible for support elsewhere. Parents described difficulties in trying to take responsibility for their child’s care if they were too unwell. This was because once that young person was over 18 it became more difficult for them to talk to services on their child’s behalf.

Young people reported having unmet mental health needs. In some cases, this was because referrals made by GPs to other services had been rejected, meaning their GP became the main provider of mental health care. However, some young people felt their GP did not have the necessary understanding of mental health problems to be able to offer appropriate support, which raises questions around GPs capability and training.

Disjointed care was also an important theme that was identified. Young people and their parents described having to navigate a complex health system, often with long waiting lists to access care. For example, some participants reported CAMHS discharging young people to their GP, and then the GP having to make an onward referral, which led to delays in accessing further mental health support. Disjointed care was also experienced by young people who had to change GP practices after moving away for university, as their new GP was often not aware of their previous mental health history.

What are the implications of this research?

Dr Rebecca Appleton, Research Fellow, Division of Psychiatry at UCL, and lead author of this research said: “Young people struggle to access support for their mental health once they reach the upper age boundary of CAMHS. This research indicates the need for improved communication between specialist services and GPs, to help GPs refer young people onwards, or to receive support to prescribe specialist medication.”

Dr Faraz Mughal, GP, NIHR Research Fellow, and affiliate of the NIHR GM PSTRC based in the School of Medicine, Keele University, said: “Our findings highlight the need for mental health and primary care services to work closer together for a safer transition process for young people who have ongoing mental health needs once reaching the upper boundary of CAMHS. Interventions should be tested to see how this process can be optimised.”

Understanding how to support GPs to deliver NICE recommended care for those who have harmed themselves

Behavioural science has been used to investigate why GPs follow or don’t follow existing guidelines from the National Institute for Health and Care Excellence (NICE) on self-harm. As a result, researchers were able to identify ways of helping GPs to follow the guidelines. NICE guidelines help health and social care professionals to prevent people becoming ill by setting out the recommended care that should be delivered.   

The first update to NICE guidelines on self-harm in 11 years is published in July 2022 and so it is important that researchers are able to identify ways of helping GPs to follow them. The research also highlights how supporting GPs to follow the guidelines could improve outcomes for people who have harmed themselves.

The research ‘Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework‘ was published in The British Journal of Health Psychology, and is funded by the National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC). The Centre is a partnership between The University of Manchester and Northern Care Alliance NHS Foundation Trust.

Jessica Leather, researcher at the GM PSTRC and lead author of the study, said: “GPs play an important role in assessing and managing self-harm, and as a result, they need a range of ways to support people who have harmed themselves. Previous research has shown that some GPs weren’t aware of the guidelines. For those who were aware of the guidelines we wanted to understand what stopped them or helped them, so our interviews concentrated on this group of GPs.

“This is hugely important given the volume of people seeking help from their GPs and the recent increases in the number of people who harm themselves.

”The study involved interviewing GPs and using a theory based framework to identify the reasons that either allowed GPs to follow (enablers) or not follow (barriers) the NICE guidelines. These can be categorised into five areas (known as theoretical domains).  In total there were 5 enablers and 7 barriers (summarised under each domain below).

1. Environmental context and resources (reported by 100% of GPs) Barriers – GPs worry that following guidance is difficult due to time pressures and a lack of access to mental health referrals. The format of the guidelines makes them difficult to access.  
2. Cognitive and interpersonal skills (reported by 86% of GPs) Barriers – GPs need strategies to communicate efficiently in high-pressure consultations.Enablers – GPs are trained to be highly skilled at communicating with patients sensitively.
3. Memory, attention and decision processes (reported by 67 % of GPs)Barriers – following the guidelines can be a distraction from watching for risk cues during consultations. GPs make decisions about self-harm based on their professional experience and the patient’s underlying mental health needs.  Enablers – Online alerts can prompt GPs to engage with NICE guidelines.
4. Beliefs about capabilities (reported by 67% of GPs) Barriers – GPs have clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral. Enablers – Guidelines provide confidence and reassurance.
5. Knowledge (reported by 62% of the GPs) Enablers – GPs are trained as junior doctors to have a good understanding of mental health risk assessment, but who had further mental health education felt better equipped to respond to self-harm.

Ms Leather, continued: “Our research identifies five domains and we believe there is an opportunity to tackle these individually or together through interventions. By doing this, GPs will be better equipped to follow the new guidance when it’s published.”

After identifying the domains researchers used the Behaviour Change Wheel to identify intervention strategies that could help GPs to follow the guidelines for self-harm. For example, poor access to resources and time pressures was a common reason for not following guidelines. The Behaviour Change Wheel suggests that a useful strategy to address this would be to change the environment that GPs work in to enable them to follow the guidance.

Professor Chris Armitage, lead for Behavioural Science at the GM PSTRC, said: “This study makes important recommendations for future interventions to change GPs’ behaviour to follow national guidelines for self-harm. These could include optimising the delivery of national guidance for quick reference, further guidance about long-term management in primary care, and enhanced training to address knowledge and skill gaps.”