Impact case study database

In Scotland, ~1600 new psychosis presentations occur each year. UofG research has been at the forefront of supporting innovative clinical approaches and models to address this clinical need. In a REF2014 case study , we described research on CBT in psychosis, and the co-development and implementation of the cognitive interpersonal therapy (CIT) approach to emotional recovery and relapse prevention within the Glasgow Early Intervention Centre (ESTEEM) [3.1–3.3, 3.5]. This work led to ESTEEM’s expansion across NHS Greater Glasgow & Clyde and provided the key basis for a commitment in the Mental Health Strategy for Scotland 2012–2015 to promote the development of early intervention services for first episode psychosis.

In the current REF2021 window, this UofG research has led to:

1. continued benefits to early intervention services and service users in Scotland—within the ESTEEM service in Glasgow and an early intervention service in Edinburgh; and provided the basis for a renewed and enhanced policy-level commitment and funding to propagate early intervention services for first episode psychosis across NHS Scotland;

2. new research on CFT [3.4] has led to this approach being taught to, and used by, mental health professionals across the world; and,

3. the CIT approach [3.3], together with new understandings of relapse detection [3.6], has contributed to strengthening capacity for Community Mental Health teams to implement psychosocial interventions for psychosis.

1. Early intervention services and Scottish Government Mental Health Strategy 2017–27

In July 2014, Gumley completed a prospective three-year evaluation of ESTEEM’s Integrated Care Pathway during which time ESTEEM implemented the CIT and CFT approaches co-developed with UofG [5.A, 3.iii]. The results showed very high rates of psychiatric and emotional recovery, and low rates of psychiatric admission and detainment over 12-months among the 130 people who entered the service during the evaluation [5.A]. The positive findings led to the routine implementation of: (a) assessments of service user, carer and clinician engagement; (b) identification of individuals at high risk of arrested recovery, reflected in poor engagement ratings by mental health staff; (c) use of a compassion focussed approach to address cognitive-interpersonal mechanisms of recovery and relapse; and (d) development of a formulation based approach to multidisciplinary intervention.

Since 2014, ESTEEM has continued to implement Gumley’s approach to assessing engagement and focus on multi-disciplinary team formulation to inform care planning and delivery. Between August 2014 and December 2020, an estimated 800 service users have passed through this ICP [5.B] (benefitting from the CIT and CFP research) and spending half the number of days as inpatients than they might have had the service not been available [3.5]. Benefits of the CIT approach has also been reported in a two-year prospective study within the Edinburgh Early Psychosis Support Service. 79 teenage service users, treated with the CIT approach [as per ref 3.3] compared with treatment as usual, showed greater reductions in psychotic symptoms and depression; and improvements in quality of life across physical health, psychological, social relationships and environment domains [5.C].

A Centre for Mental Health report (p.19, para 6) calculated that the total health care costs of patients supported by an early intervention service are 20–50% lower than those receiving standard care. This reduces the cost of per patient mental health care by £5,493 in the first year of psychosis and by £15,742 over three years [5.D]. On this basis, for the 800 service users who have used the ESTEEM ICP since 2014, estimated cost savings may amount to ~GBP4.4 million in the first year of psychosis.

Policy support for early intervention continues to strengthen. The Scottish Mental Health Strategy 2017-2027 builds on the Mental Health Strategy for Scotland 2012–2015, which first introduced a policy commitment to early intervention services based on Gumley’s research with ESTEEM [3.5]. The updated policy advances the commitment to early intervention services with ‘Action 26’: to ensure the propagation of best practice for early interventions for first episode psychosis [5.E, 5.F]. To support this new Action, in April 2019 the Scottish Government established a new national clinical network—the National Early Intervention in Psychosis Improvement Network [5.F, 5.G]. It provided £400,000 to support Healthcare Improvement Scotland to lead a Needs Assessment for how early intervention for psychosis services can be delivered in different settings, to map implementation and promote practice development [5.G]. The Principal Medical Officer (Psychiatry) for Scotland said, “ Prof Gumley’s involvement in the above is both in creating an initial evidence base to inform policy and then using that to help shape strategic decisions and operational delivery plans in an ongoing way” [5.F]. Following the Covid-19 pandemic, the Scottish Government issued a Mental Health Services Transition and Recovery plan, which highlighted the increase in first episode psychosis during the pandemic, and further emphasising their commitment to early intervention in psychosis [5.G].

2. International propagation of Compassion Focussed approaches for psychosis recovery

Professor Gumley’s CFT model of emotional recovery/relapse and the associated responses to these factors have been disseminated internationally via professional training centres and service providers:

• The Senior Clinical Psychologist and team leader of a leading early intervention centre based in Melbourne Australia described how Prof. Gumley’s work on attachment; CFT; and wellness planning have been core parts of their team’s training provision and is influencing clinicians across Australia [5.H]. The research is included in training workshops that they deliver to mental health clinicians from across Australia and overseas (Canada, Hong Kong, Japan, New Zealand). The centre has run 90 workshops since 2014 to over 2,000 attendees, with published evaluation of these training courses revealing the significant increase in knowledge that attendees gain from this training provision [5.H].

• A leading international trainer in CFT, and Director of Balanced Minds Ltd (Edinburgh & London) said, “ With the help of Professor Gumley’s ground-breaking academic (theoretical and research) contributions, the CFT approach to psychosis has received growing international attention, especially in the last five years”. Drawing upon Prof. Gumley’s CFT research, between 2016–2020 the trainer delivered 12 training events to clinicians in USA, Canada, Australia, Russia and Ireland [5.I]. “ There are clearly high levels of implementation among the teams who have specifically requested (and funded) ongoing consultation”, which includes six mental health teams (five in USA and one in Ireland). Where ongoing consultancy isn’t provided, feedback requested 4–5 weeks after training indicates comparable implementation, e.g. in feedback from 42 Canadian clinicians following a workshop, 90% stated that they had implemented changes in practice as a result [5.I].

3. Strengthening capacity to address psychosis in Community Mental Health Services

Professor Gumley’s research [3.3, 3.4, 3.6] has also influenced the development of secondary mental health services (Community Mental Health Services) in Scotland. Between 2014–18, NHS Education for Scotland (NES) commissioned Prof Gumley (together with Prof Hamish McLeod, UofG) to provide three training events to representatives from each mental health service in Scotland. These were attended by 59 senior staff, psychologists, psychiatrists, nurses and occupational therapists working with people with psychosis, who can disseminate CBTp in their local areas, and provide supervision and clinical governance of staff trained in a planned roll-out of a NES national training programme called Psychosocial Interventions for Psychosis (NES-PSIp) [5.J].

In 2015, Prof. Gumley’s CIT approach shaped the model adopted to train Community Mental Health Staff across Scotland in the NES-PSIp. This programme was developed in collaboration with stakeholders across Scotland, including service user groups (Glasgow Mental Health Network and CAPS Advocacy Services, Edinburgh) and NHS Boards, and used a ‘train-the-trainer’ approach. The training involving e-learning and workshops underpinned by UofG research [3.1–3.6] [5.J]. Following an initial pilot in the Lothian region in 2017, this programme trained 51 trainers from a range of mental health professional backgrounds in five Scottish Health Boards, completing in May 2018. 90% of participants found the training highly acceptable and were prepared to roll out training within their boards. Between May 2018–May 2019, trainers within five NHS boards delivered 14 training events to 290 staff (including mental health nurses, allied health professionals, psychiatrists and social workers) [5.J].

NES conducted a survey of 24 mental health staff who had completed NES-PSIp training to ascertain translation of training into practice. Mental health staff had an average of 17 service users with psychosis on their caseload and reported that they had used their NES-PSIp training with 41% of their caseload with psychosis. Thus, the 341 NES-trained staff (51 senior trainers and 290 mental health professionals) potentially reach 5,500–6,000 service users with psychosis and employ their training with around 2,250 service users. Respondents also reported that 66.7% of service users now had an Advanced Statement that expresses a user’s preference for treatment in the event of a mental health crisis or losing capacity; these statements had previously been very difficult to implement. Furthermore, 71% of staff stated that the training had changed the conversations they had with their service users ‘a lot’ or ‘a great deal’ and 67% stated that it had improved collaboration ‘a lot’ or ‘a great deal’. One mental health nurse reflected how her service users had “opened up about their symptoms, and recognized that they are not alone, not "mad", that this is a real illness and there is help…. It feels like we are on their journey together, they feel understood and validated. Our conversations are structured, the workbooks help to maintain focus for the session and open opportunities for questions” [5.K].

The value of the NES-PSI programme is highlighted in smaller health boards such as NHS Highland. They have identified Action 26 of the Mental Health Strategy 2017–2027 as a priority, but are unable to support a specialist Early Intervention unit. Instead, they refer those presenting with first episode psychosis to Community Mental Health Teams or Child and Adolescent Mental Health Services. This is only possible when staff in these services have been trained to provide care. As of June 2019, 36% had completed NES-PSIp training [5.G].