The National Institute for Health and Care Excellence (NICE) recommended psychological therapies for severe mental health problems. Mental health trusts prioritise spending money for therapy on outpatient services instead of inpatient services, as ward staff often think that inpatients are ‘too unwell’ to benefit from talking-based treatments. In this blog, Katherine Berry and colleagues explain how this negatively affects inpatients and outline new policies for mental healthcare. 

• Inpatient services play a key role in delivering care to those experiencing mental health difficulties during an acute crisis. However, acute inpatient care has been heavily criticised for being non-therapeutic, leading to low levels of patient satisfaction.
• A key area of dissatisfaction is due to limited treatment choice, with an over reliance on medication and limited access to psychological therapies.
• Benefits to implementing psychological therapies on acute mental health wards would include increased patient satisfaction and improved patient outcomes, such as reduced readmission rates and improvement in mental wellbeing.

Inpatient psychological therapy: Is it possible?

The Mental Health Task Force (2016) advocated that NHS Trusts in England should deliver timely, evidence-based psychological therapies on acute mental health inpatient wards. Current research shows that medication is the main form of treatment, with many UK acute psychiatric wards typically having a day or less of weekly input from a qualified psychologist. This prevents addressing many root causes of mental health issues, as well as limiting coping strategies which psychological therapies could target.

Talk, Understand, Listen for In-Patient Settings (TULIPS) is a research project funded by NICE, which works in partnership with patients, healthcare professionals and research academics from The University of Manchester; with the overall aim to increase access to psychological therapy on mental health inpatient wards. Expanding over 5 years, the project seeks to draw upon previous research and current experiences in acute mental health services. Along with a review of 40 studies that attempted the delivery of psychological approaches on acute mental health wards, we interviewed 50 patients, staff and carers to comprehend what helped and hindered service delivery and to understand experienced stakeholder views on how best to deliver therapy.

The second phase of the project (January- December 2019) saw a pilot scheme, involving two half time clinical psychologists, trialled on two wards in Greater Manchester NHS Trusts. The support provided by the scheme included psychologists working alongside nursing staff to understand patients’ needs, as well as both professionals providing inpatient therapy. Finally, staff were interviewed with regard to their experiences of the pilot scheme and the impact it had on the number of serious incidents on the ward.

Although the pilot was too small to draw any firm conclusions, there was evidence to suggest the level of serious incidents decreased on those wards taking part in the scheme. The information collated from the literature reviews, interviews and pilot study was presented to a group of 20 stakeholders in acute care (patients, staff and carers), and together we drew up detailed plans and policy recommendations regarding how best to deliver therapy and overcome the current barriers.

Policy Recommendations 

Based on the current findings of the project we propose the following policy recommendations to increase access to psychological therapies and improve care on acute mental health wards in the UK.

1. All acute mental health wards should have access to a dedicated ward-based psychologist. It is important for wards to have their own psychologist, allowing for the development of good relationships between patients and staff.
2. Acute wards must be able to provide a private room on the ward specifically for the purpose of delivering therapy. Wards can be busy and chaotic environments, thereby patients need an opportunity to experience therapy in a private space without needing to leave the ward (which might not be possible for some).
3. To ensure continuity of care between inpatient and community services, mechanisms must be put in place to allow psychologists to work closely with colleagues in the community, feeding back work developed during the inpatient admission. 
4. Long waiting lists and times in the community must not be used as an excuse to avoid delivering therapy to inpatients, as inpatient admission may provide an ideal opportunity to seek mental health support that is needed. Patients who experience high levels of distress and concentration difficulties may benefit from talking and being heard. 
5. All acute mental health nurses and ward staff must receive training and regular supervision in psychological models of care, covering the psychosocial causes of mental health problems (including the role of trauma and childhood adversity in the development of psychosis) and psychological formulations. Supervision should aim to build staff confidence in delivering psychological approaches.
6. All acute mental health staff should have access to support from a psychologist in managing stress and distress arising from their job role. Studies show there is an increased risk of burnout and compassion fatigue among acute mental health staff. Therefore, The CQC have urged for increased support to aid better staff wellbeing in order to provide effective quality care on these wards.

TULIPS next steps: UK trials

The therapeutic model from the first stage of this research is now being evaluated in a larger study. Beginning in October 2019, a larger trial is currently taking place throughout the Greater Manchester Mental Health NHS Foundation Trust (leader of the research). The project aims to recruit a total of 34 acute mental health wards across the UK to measure the effect of increasing access to therapy for patients, staff, wards; while determining the health economic outcomes, under a randomised controlled trial. Measures will be collected at baseline, 6-months and 9-months, with wards being randomised to receive intervention and usual care, or simply usual care. The findings will be analysed to determine the effects on: patient well-being, serious incidents on wards and multiple secondary measures such as staff burnout.

COVID-19 Impact 

COVID-19 impacted the way we ran our study. Many of our participating wards were faced with outbreaks of the virus, and our study and face-to-face research activity was paused from Mid-March to August 2020.

Despite the challenges this brought, we sought ethics approval for several amendments to continue research activity remotely, for example follow ups conducted via the telephone. Recruitment started again in August 2020, however progress has been slowed down by vaccine studies taking precedent at some of our intended study sites. We are in discussion with several sites and hope to meet our recruitment quota of 34 wards by mid to late 2021, with the trial reaching completion in December 2022. If you are a Trust who may like to participate in the TULIPS study please get in touch. For more information about our study and progress please visit: https://sites.manchester.ac.uk/tulips/.  Alternatively, please visit our twitter @TULIPS_Project.

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