Impact case study database

DIALOG+, developed by Queen Mary’s Profs Priebe and Healey, turns routine patient-clinician meetings in mental healthcare into therapeutically effective interventions. In 2016, it was shortlisted for the Health Service Journal national ‘clinical research impact’ award. The award recognises research with a substantial impact on actual patient care in the NHS.

Changing clinical guidelines: DIALOG is now recommended as the outcome measure used by all early intervention in psychosis (EIP) services nationally

In 2018, The Royal College of Psychiatrists’ College Centre for Quality Improvement (CCQI) developed a comprehensive set of standards for EIP, incorporating key standards on access, waiting times and NICE-recommended treatment. This framework sets out how progress should be measured and provides the detail by which EIP services will be evaluated [5.1]. The access and waiting time standard for EIP recommends DIALOG+ as one of three outcome tools “chosen because they have been well-researched and cover a wide range of relevant outcomes while being brief and practical to use in routine clinical settings” [5.2]. The Five Year Forward View for Mental Health [5.3] also encourages local health authorities to “align their framework with outcomes linked to specific mental health conditions or pathways of care” and recommends the DIALOG scale for measuring clinical effectiveness. DIALOG has recently been included in the NHS Outcomes Programme 2019-2020 as a core reporting standard for EIP services [5.4]. Finally, in 2019, the Welsh National Clinical Audit of Psychosis, commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit and Patient Outcomes Programme, recommended that quality improvement leads should work with EIP teams to “develop ways to use DIALOG outcome data to monitor and improve the quality of care they deliver to people with early psychosis” [5.5].

Uptake into routine clinical practice

Although the intervention was published only in 2015, its app version is freely available in the App Store and Google Play Store for different platforms, including smart phones and in >17 languages [5.6]. The app has been downloaded over 700 times and has been used in over 5,000 sessions (note that downloads are by care teams, therefore, numbers are not comparable with mass-market apps for individuals). The app also provides comparisons with previous ratings, explanations for each of the four steps, and the full manual for DIALOG+. The next generation of the app is fully integrated with the clinical records system RiO, providing a step change in the way care planning meetings are conducted.

DIALOG+ has been taken up regionally (East London NHS Foundation Trust (ELFT) for all secondary services with >8,000 patients at any time [5.7] across London, Luton and Bedfordshire, Norfolk and Suffolk) and nationally across all health boards in Wales (~600 patients). As of June 2019, a service evaluation indicated that more than 18,000 DIALOG+ sessions had been completed, with over 7,700 patients in East London alone. The intervention is now recommended for all patients in London’s secondary mental health services, which has resulted in substantial improvements to quality of life for >100,000 patients. Nationally the scale component of the intervention is recommended for evaluation in all EIP services, currently >18,600 patients, and internationally (as a core principle of establishing community mental health care in several low and middle-income countries), with the potential to improve the quality of life of millions of patients worldwide. To support wider intervention uptake, the Healthy Partnerships London website, which features all of the DIALOG+ tools used in routine mental health care including videos and training materials, was launched October 10th 2019 [5.8]. The intervention has been implemented and/or tested in >18 countries.

Improving patient mental health and quality of life

Using DIALOG+ in routine monthly meetings over a six-month period [3.4]:

• Improves patients’ quality of life (with effect size at least as large as specialised interventions such as cognitive behavioural therapy)

• Reduces symptoms

• Has better outcomes for independent living, work and social relationships.

The changes (measured using the Manchester Short Assessment of Quality of Life) highlight subjective patient-rated improvements in areas such as physical health, job situation and relationships with family and friends. Improvements are also apparent in objective social living parameters, such as living situation (independent, sheltered), employment (full/part time paid employment, voluntary) and friendships (having a close friend).

A service evaluation conducted in June 2019 on the routine use of DIALOG+ within ELFT indicated consistent improvements in quality of life. Analysing data from over 7,700 patients, all diagnostic groups, and across all different service types (inpatient, community recovery, perinatal, forensic) found that there were sustained improvements and that these were apparent for satisfaction with life domains, and treatment.

Improving health economics

Using DIALOG+ is not only cost-effective, but also reduces costs of care. The cost savings over a one-year period are approximately GBP1,300 per patient [5.9], which amounts to approximately GBP10,400,000 every year in the East London NHS Foundation Trust alone.