Report - Health Foundation · Web viewDemonstrated feasibility of offering collaborative...

Shine 2014 final reportDeveloping Psychological Services following facial injury within the Centre for Oral and Maxillofacial Surgery Trauma Clinic, Royal London Hospital

Institute of Psychotrauma, East London NHS Foundation Trust & Centre for Oral and Maxillofacial Surgery, Barts Health NHS Trust

25 September 2015

The Health FoundationTel 020 7257 8000www.health.org.uk

Part 1: Abstract

Project title: Developing psychological services following maxillofacial injury within the Centre for Oral and Maxillofacial Trauma Clinic, Royal London Hospital

Lead organisation: Institute of Psychotrauma, East London NHS Foundation Trust

Partner organisation: Centre for Oral and Maxillofacial Surgery, Barts Health NHS Trust

Lead Clinician: Dr Naomi Wilson

Research by the Institute of Psychotrauma and the Centre for Oral and Maxillofacial surgery trauma clinic (2013) demonstrated 40% of patients met diagnostic criteria for either depression, Post-traumatic Stress Disorder (PTSD), anxiety, alcohol or substance misuse or were presenting with facial appearance distress. Most facial injury patients were not receiving mental health assessment or treatment and the maxillofacial team did not have direct access to psychological services.

The project aimed to address this need by: Offering collaborative medical and psychological care for all facial injury patients Providing brief screening, assessment and early psychological intervention Training the medical team to better recognise and respond to psychological distress

The team were not aware of any other collaborative service of this type in the UK, therefore successful innovation had the potential for national scale-up.

A clinical psychologist and research assistant joined the maxillofacial trauma team between September 2014 and September 2015. All facial injury outpatients attending clinic completed a psychological screening questionnaire and were given information about coping after facial injury. The clinical psychologist met or phoned all patients whose responses on the screening questionnaire indicated psychological distress. They were either given further self-help information, signposted to mental health services or offered immediate brief psychological treatment.

Key achievements and impact:

Demonstrated feasibility of offering collaborative psychological care within a busy oral and maxillofacial trauma clinic

Systematic and reliable identification of psychological need; over 600 facial injury outpatients were screened for psychological difficulties in clinic

Positive feedback about the beneficial impact of psychology service from patients, family members and medical team

Robust support from senior management within Barts Health NHS Trust and East London NHS Foundation Trust

Psychological consultation to the team resulted in improved understanding of psychological need in patients and raised profile of collaborative psychological care across the oral and maxillofacial department

Research expertise of clinical psychology service resulted in collaboration with medics to write two research papers for submission to peer-reviewed journals

Positive media coverage about the maxillofacial trauma clinic, including the psychology service: http://www.standard.co.uk/lifestyle/london-life/fix-your-bike-face-

Shine 2014 final report 2/15

http://www.standard.co.uk/lifestyle/london-life/fix-your-bike-face-how-the-royal-london-hospital-are-repairing-our-broken-cyclists-9957295.html?origin=internalSearch

how-the-royal-london-hospital-are-repairing-our-broken-cyclists-9957295.html?origin=internalSearch

National dissemination of pilot to other stakeholders – well received oral presentation delivered at the British Oral and Maxillofacial Surgery annual conference, July 2015

Psychology service reach extended beyond the original aims, to include: family support, neuropsychological consultation and complex case management

Development of a robust bid for on-going commissioning of psychology service Impetus to extend the service model to other maxillofacial trauma units in the UK,

through a national oral and maxillofacial trauma special interest group

Key challenges and learning points:

Personnel changes mid-way through project as the clinical psychologist and research assistant both went on maternity leave. Efficient recruitment of new post-holders meant negligible impact on service provision

Evaluation of the project required additional resources. Honorary psychology research assistants were recruited to this end

Sourcing clinical space within the oral and maxillofacial trauma clinic for confidential psychological consultations was an on-going challenge

Accessing electronic patient records could have been better integrated across Trusts Psychological needs of patients extended significantly beyond that reported in

original research project, and included; risk assessment (self-injury, violence towards others, injury through domestic violence, neglect and lack of appropriate psychological service at critical recovery points, e.g., in brain injured patients), liaison with family members who were traumatised and/or had become carers, neuropsychological assessment and co-ordination of mental health care for patients with complex needs

Evaluating the economic impact of an early intervention service was challenging in the absence of longer-term follow-up data

Commissioning the project beyond current funding stream during financial austerity Responsiveness to patient or medical team feedback and service user involvement

led to iterations in the service structure that resulted in improved design, acceptability and effectiveness of service

Part 2: Quality impact: outcomes

Two clinical psychologists (Band 8b, 0.1wte, and Band 8a, 0.6wte) and a research assistant (RA) (Band 5, 0.2wte) were recruited. The 8b Clinical Psychologist was project lead and supervisor of other staff. The 8a Clinical Psychologist spent 50% of their working time in the oral and maxillofacial trauma clinic (all day Mondays and Thursday afternoons). Their role was to administer self-report screening questionnaires, interpret these and respond to patients who needed immediate assessment and intervention - either in clinic or within a few days. The role of the RA was to support in the administration and interpretation of the screening tool when clinical demand was high and to support the evaluation of the project. A screening questionnaire (see Appendices) that took approximately five minutes to complete was devised and administered to all outpatients. This was based on already validated psychometric questionnaires (e.g., HADS, PCPS) that asked about depression, anxiety, PTSD, alcohol and drug use, risk to self (suicidal ideation) and facial appearance distress. It also asked if patients wanted and consented to psychological consultation. As the clinic was extremely busy and a significant proportion of patients were urgent new cases that were not pre-booked (e.g., had attended A&E over the weekend) systematic liaison with the reception and nursing staff was required to ensure that all patients were screened. At the point of screening patients were also given psychoeducation about common psychological

Institute of Psychotrauma & Royal London Hospital, Oral and Maxillofacial Trauma Clinic

SHINE 2014 Final Report 3/15



responses and helpful coping strategies following traumatic events (see Appendices). The surgeons also liaised with the clinical psychologist and vice-versa in cases of particular need or risk.

All patients who scored above cut-off on any of the subscales in the screening tool were approached by the clinical psychologist and briefly assessed to determine their psychological needs. A range of self-help leaflets (see Appendices) were written, e.g., anxiety, low mood, PTSD, were available to give to patients in clinic and brief psychological treatment was provided about how to cope with common psychological difficulties. Some of these patients were also offered follow-up calls, emailed, or seen at follow-up appointments in clinic so further advice could be given and a significant number were signposted (for self-referral) or referred to mental health services or non-statutory organisations (e.g., Headway (https://www.headway.org.uk/home.aspx), Changing Faces (https://www.changingfaces.org.uk/Home) who could support them. This sometimes required significant and occasionally urgent liaison (phone calls, letters, emails) on the part of the clinical psychologist, e.g., with GPs, local IAPT services, liaison psychiatry, specialist mental health services and charities, to ensure appropriate pathways of care.

All data from completed screening measures and patient contact notes were entered on to electronic databases within East London NHS Foundation Trust. Any letters sent regarding patients were copied to the oral and maxillofacial surgeons.

No significant changes were made to the service during its running, however the following minor adjustments were implemented:

Screening tool was amended to include patient date of birth, address and GP to minimise need to cross-referencing with medical notes for follow-up contact

Additional self-help leaflets were devised in response to patient need, e.g., sharing difficult information with children

As the service evolved, the clinical psychologist noted a significant number of patients who had more complex psychological need than those common mental health difficulties as assessed through screening. These were identified through face-to-face or phone contact and included: risk assessment (self-injury and suicidality, violence towards others, child protection issues, vulnerable adult safeguarding, injury through domestic violence, lack of appropriate psychological service at critical recovery points, e.g., in brain injured patients), liaison with family members who were traumatised and/or had become carers for facially injured patients, neuropsychological assessment and co-ordination of mental health care for patients with complex needs.

Primary data was collected as follows:

Demographic profile of patients presenting to psychology service Prevalence of psychological distress Number of patients who received follow-up assessment and intervention, and the

type and extent of psychological treatment provided

Secondary data was collected as follows:



https://www.changingfaces.org.uk/Home

https://www.headway.org.uk/home.aspx

Almost 10% of patients were followed up by phone. The screening tool was re-administered and patients were asked about their experience of the psychology service (see Appendices).

Ten patients were interviewed in greater depth about their facial injury, the psychological consequences of this and the impact of the psychology service on their recovery. These were audio or video recorded for case studies (See Appendices for two brief case studies).

The oral and maxillofacial surgical team (medics and nurses) were individually interviewed using a semi-structured interview (see Appendices) about their experience of the psychology service

Negligible adjustments were made to the outcome measures from those originally implemented.

The source of all data was either patients or medics within the oral and maxillofacial trauma clinic. Access to this data was relatively straightforward, although it required systematic and proactive work on the part of the clinical psychologist and research assistant to collect the qualitative data, as the time needed for this was significant. Good relationships with both sets of stakeholders facilitated this data collection.

The validity and reliability of the data was believed to be high. The screening tool was based on previously validated psychometric questionnaires routinely used in primary care mental health settings and additional questions added based on the prior research experience of the team with this population. There was baseline data for over 600 patients, which the team were very satisfied with. The clinical psychologist and research assistant had high-level research skills (up to doctoral level) therefore both the quantitative and qualitative follow-up data was robustly and reliably collected and analysed.

Primary data:

Seventy-three per cent of patients screened were men, and 27% women. Other demographic details can be found below.

3%

40%

30%

11%

7%6%

3%

Patient age groups

Under 18 years18-29 years30-39 years40-49 years50-59 years60-69 years70+ years



61%20%

10%

2%6%

Patient ethnicity

White or White BritishAsian or Asian BritishBlack or Black BritishMixedOther

Geographical spread of patients screened at the Oral and Maxillofacial trauma clinic across the UK and in London (n= 577 – not all patients had an identifiable postal address)

491 patients (85%) lived in a London Borough and 86 (15%) lived outside London.



44%

20%

29%

3% 3%

Source of Facial Injury

AssaultFallAccidentSportOther



The presenting psychological difficulties as screened in clinic were as follows. (NB: ‘Facial distress’ = distress or anxiety about facial appearance, and ‘Daily functioning’ = negative impact of facial injury on day to day functioning

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Positive screen for psychological condi-tions at first contact (n = 642) and in fol-

low-up group (n = 51)

All patients initially screened

Follow-up group

NB: ‘Facial distress’ = distress or anxiety about facial appearance, and ‘Daily functioning’ = negative impact of facial injury on day to day functioning



9%

63%

26%

1% 1%

Level of psychological intervention received by pateints

Screening only, n = 59Brief intervention in clinic, n = 398In-depth intervention in clinic and onward referral, n = 165Complex case requiring extensive liaison outside clinic, establishing pathway of care, n = 5Specialist psychotherapy with psychologist outside clinic, n = 8

There was a correlation between the degree of psychopathology and the amount of psychological intervention received by patients, i.e., those with more presenting difficulties required greater contact with the service. In addition, of those patients followed-up at three months, 25% of those who had received only brief intervention had not returned to work whereas of those who had needed more in depth intervention, 36% had still not returned to work.

Secondary data:

Psychological difficulty at follow-up in this sub-group of patients, indicated that overall there was a reduction in morbidity from 79% to 58%. The largest improvements were in distress about facial appearance and improvements in daily functioning. This might be expected, given that recovery and healing of the acute facial injury would be most rapid in the immediate weeks post injury. Depression and PTSD symptoms had also dropped, however drug use and anxiety had increased. This indicated that psychological need in this patient group was on-going at least over the medium-term.

The data below was collected from 8% of patients followed-up by phone, and the medical team.

Of those patients who received any psychological intervention 78% said that the psychology service either slightly or significantly improved their experience of attending the maxillofacial trauma clinic.



“[It] helped me to think more

rationally, I was too distressed

to do that on my own”

“[The psychologist] helped

address my drinking, helped

me offload and feel validated”

Core qualitative themes from patient feedback were as follows:

Positive feedback:

- Having someone to talk to about the psychological impact of their injury; being proactively approached within clinic, receiving empathy, validation, support, hope and having problems normalised was valued

- Patients felt the psychology service was highly relevant to their presenting needs- Patients had an improved understanding of psychological difficulties, found tools for

managing psychological distress helpful

- Patients believed that their recovery would have been significantly worse without psychological input

Areas for improvement:

- Patients wanted greater access to the psychologist; more private clinic space for consultations, earlier contact (for patients whose injuries pre-dated the start of the service and were seen at follow-up consultations)

Core qualitative themes from medical team were as follows:

Rapid, flexible, integrated psychological care was beneficial to patients

Addressing psychological issues facilitated medical recovery

Families reported that they had also found psychological support very beneficial

Their awareness of the psychological impact of facial injury had increased and they would value more training in this area



“Patients find it helpful. They ask where the

psychologist is” “I now have more awareness of the

domino effect of trauma on a patient’s life”

“Formerly I would make an urgent referral to the GP to

help the patient access local services – which never happened or happened slowly”

“It is good to know the patient is being taken care

of as a whole. Psychological problems

can be dealt with efficiently which means they’ll recover [physically]

sooner”

“[Having the psychologist in clinic means] I can ask

them for their opinion and it frees me up to see another

patient in a busy clinic”

The impact of the psychology service was uniformly agreed among all stakeholders (medical team, patients and psychologists) to be high. The introduction of comprehensive, expert, patient-centred screening and psychological assessment into the clinic was a fundamental change in service delivery team.

The reach of the psychology service was substantial. Unintended consequences of the intervention were the provision of the following services by the clinical psychologist:

Complex packages of care and liaison with secondary care mental health services with a minority group of patients, e.g., where there was substantial risk to self or others, multiple diagnoses ore pre-existing mental health problems

Brief neuropsychological assessment and referral to neurological services Family and systemic work, e.g., with parents, partners, friends or children of patients,

who had been directly or indirectly affected by the facial injury, e.g., were traumatised by witnessing the patient be injured or who had become carers for them

Two case studies illustrate the type and level of complex care required by a significant minority of patients (see Appendices).

Part 3: Cost impact

Key cost measures were the employment of clinical psychology staff that was calculated based on NHS Agenda for Change salary scales (see Addendum – Project Finance), standard administrational costs and the cost of initial dissemination.

Two issues with respect to project costs were:

i) Use of unpaid ‘Honorary’ psychology assistants (psychology undergraduates or graduates) as additional staff who worked in the following areas; scoring screening tools in clinic when exceptionally busy, production of clinical materials, carrying out follow-up calls for evaluation purposes and analysis of evaluation data.

ii) Increased Clinical Psychology (8b) time to 0.2wte at times of staff turnover when recruitment tasks increased. This cost was absorbed by the Institute of Psychotrauma.

Implementation costs such as staff training and change management activity were accommodated within the supervision time offered by the 8b Clinical Psychologist and within RA hours.

Evaluating the economic impact of the innovation was not a primary aim of the project. This was challenging to measure in an early intervention service whose aim was prevention and rapid identification of treatment needs and where no comparison group was available to compare medium or long-term outcomes between those who had received psychological input and those who had not.

Qualitative feedback from the medical team and patients consistently reported that the psychology service had positively benefited medical and psychological recovery, and that they anticipated this would have been slower or even severely disrupted in the absence of psychological input.



There is substantial research evidence that indicates those with long-term physical health conditions also have mental health problems, which was corroborated by our clinical experience. A significant minority of oral and maxillofacial trauma patients come within this category, e.g., those with brain injury, chronic pain, on-going need for reconstructive surgery (sometimes up to years), disability due to sight loss or other functional loss and permanent disfigurement. A recent report by the King’s Fund Centre for Mental Health (2012) concluded the following, all of which are pertinent to the oral and maxillofacial trauma clinic patient cohort and our innovation:

By interacting with and exacerbating physical illness, co-morbid mental health problems raise total healthcare costs by at least 45% for each patient with a long-term condition and co-morbid mental health problem(s), after controlling for severity of physical illness

There is evidence that the relationship between having multiple long-term conditions and experiencing psychological distress is exacerbated by socioeconomic deprivation

A significant part of the explanation for poorer clinical outcomes is that co-morbid mental health problems can reduce a person’s ability to actively manage their physical health conditions

Detection of co-morbid mental health problems in those with long-term health conditions is not done to a consistently high standard, and often goes undetected

Innovative forms of collaborative care (as modelled within this Shine project) demonstrate that providing support for co-morbid mental health needs can reduce physical health costs in acute hospitals and integrated treatment for mental and physical health has better outcomes than overlaying mental health interventions on top of medical treatment

Clinical commissioning groups should prioritise integrating mental and physical health care more closely as a key part of their strategies to improve quality and productivity in health care

Part 4: Learning from your project

The key aims of this project were met which was to successfully introduce collaborative psychological care within an oral and maxillofacial trauma outpatient service in a busy London secondary care hospital.

The enablers that helped us to achieve this were:

i) Pre-existing relationships between Institute of Psychotrauma and oral and maxillofacial department (through prior two-year research project) meant mutual respect, confidence and trust between teams was high. This facilitated rapid implementation of service and each team had clear, shared expectations for service model

ii) Highly competent clinical psychology staff that included clinical psychologists with service development and entrepreneurial skills, the ability to liaise and lead the MDT to implement service changes, high level communication skills, the capacity to function independently and autonomously within non-mental health setting, the ability to creatively respond to and find solutions to barriers to the service and devise research and disseminate the pilot project at a high level



iii) Commitment, enthusiasm, openness and buy-in from lead oral and maxillofacial surgeons and medical team

iv) Culture of collaborative and consultative working within the oral and maxillofacial team

v) Inclusion of research staff within team to facilitate evaluationvi) Active engagement from patient representatives that informed service iterations

and leant service development ecological credibilityvii) MDT buy-in was enhanced over time through responsiveness to clinical need;

clinical psychologist ‘going the extra mile’ for particularly complex patients, e.g., occasional in-patient assessments, regular board meetings and rapid communications around these and research expertise of psychology team to support publication output

viii) Organisational culture of both services was innovation driven and proactive so ‘match’ of teams was highly congruent

The key project aims were achieved. However, there were some aspects of organisational culture that acted as a barrier to service implementation at times. As clinical psychology staff were employed by a local mental health Trust but working in a hospital run by an acute Trust, communication and co-ordination was somewhat compromised by IT systems that were not inter-operable, and access to useful patient data was not routinely facilitated for the clinical psychologist. This meant some replication of communication, e.g., medics had to receive paper copies of letters or reports about patients written by the clinical psychologist.

Similarly the clinical psychologist had a relative lack of influence within the acute NHS Trust that was also financially vulnerable and with high turnover of senior staff, including at Board level. This meant that targets for internal dissemination were difficult to identify and gaining leverage for on-going commissioning was difficult within the acute Trust.

Securing protected, confidential and accessible clinic space was also problematic, and both patients and medics recognised this limitation. Future service development would be dependent on this being provided.

Staff changes were a significant challenge. Both the Band 8a clinical psychologist and RA left the project part-way through the year due to maternity leave although the project lead (who had also run the prior research project) remained in post. This leant the project continuity and the project lead oversaw recruitment of new staff, induction and integration in to team. This resulted in an agreed break in the full psychology service for one month (with urgent referrals from oral and maxillofacial surgeons only accepted I this time period), and an extension to the project end-point by one month.

It is felt that our original ambitions were realistic given available resources and timescales

Specific learnings included:

Need for highly qualified staff due to multiple skill set needed to establish service, work autonomously and manage volume and complexity of work

Relationships between services and among Board members were primary to success. The lack of felt hierarchy among those delivering a collaborative service leant the innovation energy as ideas and changes were valued and welcomed from all.

Part 5: Plans for sustainability and spread



A business plan has been drafted to submit to commissioners within Barts Health and to NHS England, in order to sustain the innovation beyond the funding period. There is support for this from the Business Development Units at Barts Health NHS Trust and East London NHS Foundation Trust.

Plans to spread the innovation beyond the original site include the following;

A number of patients have been interviewed and video or audio recorded, such that their case studies can be included in research papers and further dissemination / spread. There is an agreement to write up two papers for submission to the British Journal of Maxillofacial Surgery. These will include i) a write-up of the psychology service innovation and ii) a series of case studies highlighting the range and complexity of psychological need in patients presenting to oral and maxillofacial trauma services beyond that identified in the original research project.

Attendance and presentation of innovation at an international BAOMS conference in 2016

To designate the psychology service within Barts Health NHS Trust as a UK centre of excellence for collaborative mental health care in oral and maxillofacial trauma clinics

To run an open / training day for other oral and maxillofacial trauma specialists about the psychology service

To develop webinar training materials about how to replicate the psychology service provision at other sites

Opportunities for media coverage (TV, newspaper, online news) via the communications department of East London NHS Foundation Trust and media contacts at Sky have started.

With respect to other resources, the team are applying for dissemination and spread monies from the Health Foundation, for which there are funds of up to £30k for this purpose.

Dissemination already completed:

An oral presentation about the Shine innovation was delivered at the British Association of Oral and Maxillofacial (BAOMS) annual conference in July 2015 (See Appendices). A video of the presentation being delivered at the conference can be accessed here: http://we.tl/swqS4TeDdg. Three associated research papers were taken as poster presentations (See Appendices for primary research paper). A medical audience received these very positively, and numerous queries were made about how to develop similar provision in other oral and maxillofacial trauma clinics. The lead clinical psychologist has since liaised with one other service in Glasgow who are looking to develop similar provision. Communication is also on going with the trauma special interest group within BAOMS for the presentation (including video of this) to he shared with all members at a national level.

The service was featured in a London Evening Standard article, ‘Fix your bike face: how the Royal London Hospital are repairing our broken cyclists’ 25 January 2015, which specifically mentioned the importance of the psychological provision patients received (See Appendices).



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