Optimising the delivery of ‘Early Intervention in Psychosis’ services
Research type
Research Study
Full title
Optimising the delivery of ‘Early Intervention in Psychosis’ services: a qualitative exploration of associations between components of care and outcomes.
IRAS ID
331282
Contact name
Mike Crawford
Contact email
Sponsor organisation
Imperial College London
Duration of Study in the UK
1 years, 6 months, 1 days
Research summary
Summary of Research
Psychosis is a severe mental health condition characterised by hallucinations and paranoid beliefs. Psychosis can be very confusing and upsetting, and interfere with study, work and relationships. More than 1 in 100 people will suffer from psychosis during their lifetime.
There are effective treatments for psychosis, including medications and psychological therapies. Support for patients’ families, and practical help with education and employment are also important. To try to ensure that all people who develop psychosis get the best available treatment, specialised services called ‘Early Intervention in Psychosis’ (EIP) teams were set up throughout England. Studies have found that people who are treated by EIP teams have better outcomes than those who are not.
In 2019 a national audit found large differences in the care provided by EIP teams. For instance, only half of people received a recommended psychological therapy called Cognitive Behavioural Therapy, and only a third of patients’ families received proper support. Currently, we do not know what the reasons are for these differences, or how they impact service users’ experience of care or future health.
We plan to conduct a study of EIP teams in England to answer some of these questions, by interviewing people who use and provide EIP services. We aim to gain a better understanding of how the care that people receive affects their mental health and their future use of health services. We also aim to identify reasons why there are differences in the care provided by different EIP services.
We will include a wide range of people from different social and ethnic backgrounds in this research. We will be advised by a group of people who have used EIP services who will make sure that the questions we ask are meaningful and important to the people we are trying to help.
Summary of Results
We would like to thank everyone who took part in this study. We are very grateful for the time and experiences participants shared with us.
What was the study about?
The study was called “Optimising the delivery of Early Intervention in Psychosis services.”
Early Intervention in Psychosis (EIP) services support people experiencing psychosis, particularly during the early stages of their difficulties. They provide medical, psychological and social support.
Previous research suggests that EIP services can improve outcomes. However, services differ in how they organise and provide care.
One important difference is the number of people supported by each care coordinator. This is known as their caseload. Previous research suggested that smaller caseloads might be linked with better outcomes, but it was unclear why.
We therefore wanted to understand what makes EIP care helpful from the perspectives of people who receive, support and provide it. We were particularly interested in how care coordinator caseloads might affect people's experiences of care.
Who carried out and supported the research?
The research was led by researchers at Imperial College London, working with researchers and clinicians from other UK universities and NHS organisations.
Imperial College London sponsored the study. The research formed part of a National Institute for Health and Care Research (NIHR) Doctoral Fellowship awarded to Ryan Williams.
How were members of the public involved?
A group of people with recent experience of EIP services, including a carer, advised the research team. They were involved during the development, analysis and interpretation of the study.
Their advice influenced the interview questions, recruitment and interpretation of the findings. For example, they encouraged us to include people from groups that have sometimes been under-represented in research.
Who took part?
We interviewed 45 people from six EIP services in England:
13 people who had used EIP services;
four carers; and
28 healthcare professionals.We selected services with different care coordinator caseloads and different rates of hospital admission. This helped us explore a range of experiences.
What happened during the study?
This was an interview study. Participants did not receive any new treatment or intervention as part of the research.
Participants took part in an individual interview about their experiences and views of EIP care. Interviews lasted around 40–75 minutes and took place face-to-face, by telephone or by video call.
The interviews were recorded, transcribed and anonymised. We then looked across the interviews for important patterns and differences in participants' experiences.
What did we find?
Participants described helpful care in broad terms. They valued care that supported recovery, wellbeing and personal progress, rather than focusing only on symptoms or hospital admission.
Four closely connected features of helpful care stood out:
Continuity meant having ongoing contact with staff who knew the person and understood their circumstances. This helped people develop trust and avoid repeatedly explaining their story.
Flexibility meant adapting care to people's changing needs and preferences. This included changing when, where and how support was provided.
Inclusivity meant recognising that people's needs and experiences differ. Helpful care responded to factors such as trauma, neurodiversity and cultural differences.
Co-production meant people being actively involved in decisions about their care. Participants valued being listened to and working with staff towards goals that mattered to them.
Why did caseloads matter?
Caseload size appeared to affect how easily staff could provide these forms of care.
Smaller caseloads gave staff more opportunity to build relationships, respond flexibly and provide individualised support. They also created more opportunities for people using services to be involved in decisions about their care.
Larger caseloads could make this more difficult. Participants described care becoming more rushed, fragmented or protocolised when staff were under greater pressure.
However, caseload size was not the only factor. Having a smaller caseload did not automatically guarantee good care, and helpful care could still occur in services with larger caseloads.
Team organisation, staff experience, leadership and service culture also appeared important.
What might services do when resources are limited?
Participants described several approaches that might help services maintain good care when staff are under pressure.
These included staff sharing responsibility for supporting an individual, rather than relying entirely on one care coordinator. Short but regular contacts could also help maintain relationships between longer appointments.
Participants also valued staff with particular expertise in areas such as culture, trauma or neurodiversity. Peer workers with their own experience of using mental health services could also help people feel understood and navigate services.
These approaches were suggested by participants and observed in some services. The study did not test whether they improve outcomes, so further research is needed.
Were there any medical problems caused by taking part?
This study did not provide participants with medicines, treatments or other healthcare interventions. We therefore did not study adverse reactions to a treatment.
Participants were asked about their experiences of mental healthcare during an interview.
What do the findings mean?
The findings suggest that relationships are an important part of helpful EIP care.
Having enough staff time appears to make it easier to provide care that is continuous, flexible, inclusive and collaborative. Care coordinator caseloads may therefore affect care partly through their impact on relationships between staff and people using services.
However, this was a qualitative interview study. It cannot prove that smaller caseloads directly cause better outcomes or identify an ideal caseload size.
The findings also come from six services in England. Experiences in other services or countries may be different.
How could this research help patients and services?
The findings provide information about what people using, supporting and delivering EIP services believe makes care helpful.
They suggest that decisions about staffing should consider not only which treatments services provide, but whether staff have enough capacity to build relationships and adapt care to individuals.
The findings also identify possible ways of protecting these qualities when services are under pressure.
What further research is needed?
Further research should examine whether these findings apply in other EIP services and how relationship-based care can be supported when caseloads are high.
Research is also needed to test whether changing caseload sizes improves outcomes. This could help establish what caseload sizes provide the best balance between quality of care, outcomes and cost.
Where can I learn more?
The findings have been shared with EIP teams, service-user groups and other organisations involved in improving EIP care.
REC name
London - Dulwich Research Ethics Committee
REC reference
24/LO/0216
Date of REC Opinion
19 Apr 2024
REC opinion
Further Information Favourable Opinion