De-implementation of low value mental health care: a PhD update.

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 by Qandeel Shah

In July I presented a poster at the NIHR 6th UK Implementation Science Research Conference. The NIHR ARC South London co-hosted the conference with the University of Limerick in Ireland. The conference brought together researchers, clinicians, and policymakers from around the world to discuss the role of implementation science in developing and sustaining health and public services. There was a great mix of plenary lectures, oral presentations, and rapid poster presentations, covering a breadth of research topics. There was a special interest in research relating to the UN’s Sustainable Development Goals including health and wellbeing, education, climate change and reducing inequalities. In future years, there are plans for conference delivery to be shared across the different improvement and implementation science themes of the ARCs. Indeed, there is a Cross-ARC Implementation and Improvement Science theme network, set up by the improvement science theme which is led by Professor Rebecca Lawton. The network meets regularly to discuss current projects and capacity building activities, and to collaborate on projects. Examples include our shared work on co-production (check out our Improvement Science Snapshot on co-production and our publication) and a current scoping review distilling the benefits for health and social care staff of participating in applied health research.

The conference was a hybrid event, and I presented a poster during a ‘rapid- fire’ session. This involved a five-minute presentation followed by five minutes of questions from the audience. My poster was titled ‘De-implementation of low value mental health care’. The poster summarised the first stage of my PhD, identifying low value practices that are potential targets for de-implementation. Healthcare interventions that may harm the patient or have little benefit given the cost, available alternatives, and preferences of the patient are defined as low value care. There is growing interest in de-implementing low value care, but this has mostly focused on acute and primary care settings. With mental health services currently experiencing huge demands and limited resources, it has become increasingly important to de-implement mental health care practices that have no benefit for patients. A reduction in these practices could help free up the vital resources and time needed to deliver safe, high-quality care. Although recommendations like those produced by the choosing wisely campaign help raise awareness about low value care, interventions are needed to stop these practices. The most commonly identified barrier to de-implementation is the patient themselves. Thus, the patient perspective is paramount in this area of research.  

The aim of the study I presented on was to identify low value mental health care practices from the service user’s perspective, understand why these practices are considered to be low value and explore how they might be de-implemented. To do this, I conducted semi-structured in-depth interviews with mental health peer support workers. Peer support workers are people who have lived experience of mental health challenges and use this experience and empathy to support other people receiving mental health services. I analysed the data using abductive thematic network analysis. During the interviews, peer support workers discussed clinical and non-clinical practices they thought were not useful. They spoke about the benefits and harms associated with each practice and how they might be de-implemented. Some of the most commonly identified low value practices included overuse of medications like antidepressants; the unnecessary use of restraint in inpatient mental health services; and the use of enhanced observations in inpatient mental health services. 

As a PhD student, presenting my work to more senior researchers and experts in de-implementation was daunting, but the conference provided an excellent opportunity for me to communicate my research findings to a broad audience. Following the presentation, the audience asked some interesting questions and shared their thoughts, which was encouraging and helped me think more about specific aspects of my research such as methodology and dissemination. Following the conference, I revisited papers on de-implementation theory and considered how theory could be applied to future studies. I also took time to think about how to disseminate this study’s findings in an accessible way to peer support workers and service users.  

There are always pros and cons to hybrid events, but the main advantage of attending the conference in person was the informal networking. I was able to meet many early career researchers with similar interests and international experts in the area of de-implementation research. The conference was also an excellent opportunity to learn, I received lots of useful suggestions and advice from other researchers and attending ‘meet the experts sessions’ meant that I could listen to discussions and ask questions about topics that were of interest to me. This was the highlight of the conference for me! 

For anyone interested in learning more about de-implementation:

Please see our Improvement Science Snapshot on this topic and the further reading list.
Please see a presentation and publication by our colleague, Daisy Halligan, a research fellow within the Yorkshire and Humber Patient Safety Research Centre who recently competed her THIS Institute funded PhD on de-implementation.

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