PARTNERS2

PARTNERS2 was a five year National Institute for Health and Care Research (NIHR) funded research programme.

The multi-site project was being conducted by a national team of experts lead by Professor Max Birchwood and hosted by Birmingham University and Solihull Mental Health NHS Foundation Trust. There were work streams in Birmingham, Manchester and Devon.

The focus of the research was to enable primary care (GP) and secondary care (community-based mental health services) to work more closely together and to develop an evidence-based model of collaborative care to support individuals with schizophrenia and bipolar disorder.

70% of adult service users who have a diagnosis of schizophrenia or bipolar are seen in primary care alone. PARTNERS2 aimed to develop a model of collaborative care for primary care with secondary care support.

A research intervention was undertaken to test the model of care and at the end of the five-year programme the study team identified whether collaborative care for people with schizophrenia and bipolar disorder was likely to work.

Research findings were drawn from the views of people (including service users) involved in setting up and using the intervention, how well those who receive it were feeling, the quality of their lives and recovery and the costs involved in running the intervention.

People with schizophrenia and bipolar disorder often live very different lives from the general population. Around 66% live in poverty and isolation, most rate their quality of life as poor, and only 12% are employed. These disparities are related to poor mental health, the side effects of medicines on both physical and mental functioning and ongoing prejudices towards mental illness.

Previous research suggests that many individuals with lower levels of need have minimal and poorly co-ordinated primary (GP) and secondary (specialist community mental health service) care. Service users and professionals often feel that too much focus is placed on medication rather than wider aspects of health and societal life. Once stabilised on medication, services don’t always then focus on supporting these individuals to take the next steps in their recovery and fulfil their potential. PARTNERS2 aimed to help primary care and community based mental health services work more closely together and focus on such aims.

The PARTNERS2 team developed a system of collaborative care based in GP surgeries. The focus was for service users to be seen regularly by an experienced mental health worker who acted both as overall co-ordinator (supporting individuals to access other services and activities) and therapist. This person saw the service user regularly, helping them to help themselves and facilitate recovery in the broadest sense and, where required, call on the talents of other parts of the health service, particularly secondary mental health care and voluntary organisations. This simple idea needed to be carefully developed and tested and then set up as a pilot trial to see if it made a difference to the care provided. This was achieved through a series of work streams that drew on a variety of research methodologies and outcome measures.

Professor Richard Byng , University of Plymouth
Site Principal Investigator
University of Plymouth Community and Primary Care Research Group (CPCRG)

Professor Nicky Britten, University of Exeter
Principal Investigator
University of Exeter Medical School

Lynsey Williams , University of Plymouth
Research Assistant
University of Plymouth Community and Primary Care Research Group (CPCRG)

Dr Ruth Gwernan-Jones, University of Exeter
Qualitative Research Fellow
University of Exeter Medical School

Charley Hobson-Merrett , University of Plymouth
Research Assistant
University of Plymouth Community and Primary Care Research Group (CPCRG)

Professor Max Birchwood
Chief Investigator
Research Director, Youth Space & Professor of Youth Mental Health, University of Warwick
Mental Health and Wellbeing
University of Warwick
Email: m.j.birchwood@warwick.ac.uk

Dr Humera Khan (Meena)
Programme Manager, PARTNERS2 Programme, University of Birmingham
Primary Care Clinical Sciences
University of Birmingham
Email: h.s.khan@bham.ac.uk
Tel: +44 121 414 6947

Details of the wider multi-site study team along with special advisors can be found at the central study website.

The study was undertaken as a two-stage programme across six work streams with research undertaken in Birmingham, Lancashire and Devon.

The first stage involved developing a model of collaborative care using evidence from service users, carers, GPs, Trust clinicians and commissioners. Evidence was also gathered from secondary community mental health teams and their linked primary care (GP) practices to understand the nature of current care. The second phase involved a randomized controlled trial to examine the effectiveness and acceptability of the new model. The research was divided into six work streams.

Purpose: to describe the process of current care, help better target those who would most benefit from collaborative care and assess potential risk and safety issues.

Methodology: observational retrospective cohort study (notes review), development of an economic decision analytic model and focus groups with service users and carers.

Purpose: to develop a core outcome set and measures for use in mental health trials involving people with schizophrenia or bipolar disorder in a community based setting.

Methodology: currently there is no gold standard for the development of core outcome sets. Our approach is therefore based on current practice and includes focus groups with key stakeholders, a Delphi process, systematic review and stated preference survey.

Purpose: to define and develop the key components of collaborative care for people with schizophrenia or bipolar disorder in an English context.

Methodology: iterative development of the model building on the team’s recent Cochrane review using a range of qualitative and quantitative data.

Further details of work streams one – three can be found on the wider study site.

Purpose: to test the feasibility of patient and practice recruitment and commissioning.

Methodology: qualitative work involving semi structured interviews, and patient and practice structured surveys.

Purpose: to draw the findings of the previous four work streams into a pilot trial protocol and process evaluation.

Methodology: data synthesis and economic analysis.

Phase two (31-60 months)

Purpose: to establish the proof of concept of the intervention, estimate effects within a pilot trial and inform the design a definitive trial of collaborative care.

Methodology: pilot cluster randomised controlled trial and process evaluation.

The study team are working in collaboration with the McPin Foundation.

McPin are developing and delivering a public and patient involvement (PPI) programme for the study in collaboration with the research team. This will involve working alongside people with lived experience.

Ruth Sayers is the Public Involvement in Research coordinator for the study at McPin via contact@mcpin.org.

PPI was integral to this research study. PPI co-ordinators and service user researchers were also employed to work across each site. These important contributions wove through the whole programme, and fed directly into each work package through a combination of service user researchers’, lived experience research panels and PPI co-ordinators working across the three sites.

Service user research associates were employed to work in each site.

Study advisory groups and focus groups (made up from people with lived experience) were set up in Birmingham, Lancashire and Devon.

The study of records showed that care for individuals under secondary care is variable and substantial and people are seen every two weeks on average. The updated Cochrane review showed that collaborative care interventions were highly variable and no reliable conclusions can be drawn about effectiveness.

The PARTNERS model incorporated change at organisational, practitioner and individual levels. Coaching was selected as the main form of support for individuals’ personal goals. In the formative evaluation we showed that more intensive supervision and ‘top up’ training was needed to achieve the desired shifts in practice.

A Core Outcome Set was developed for bipolar and measures were selected for the trial. We developed a stepped approach to recruitment including initial approach and appointment.

The trial was conducted in four areas. 198 participants were recruited from 39 practices randomised. Participants received either the PARTNERS intervention or usual care. The follow up rate was 86% at 9-12 months.

Mean change in overall MANSA score did not differ between the groups (0.25 (s.d.0.73) for intervention vs 0.21 (s.d.0.86) for control). We also found no difference for any secondary measures. Safety outcomes (e.g. crises) did not differ between those receiving and not receiving the intervention. While the costs of intervention and usual care were similar there is insufficient evidence to draw conclusions about the overall cost-effectiveness of PARTNERS.

The mixed methods process evaluation demonstrated that a significant proportion of individuals did not receive the full intervention. This was partly due to care partner absence and also participant choice. The in-depth realist informed case studies showed that participants generally appreciated the support, some describing having a ‘professional friend’ as very important. For some people there was evidence that delivery of the intervention led to specific personal changes.

The phase one records study provided insights into usual care which had not been previously documented. The realist informed complex intervention development was both theoretical and pragmatic. The trial continued through the COVID-19 pandemic with high levels of follow up. The process evaluation had the depth to explore individual changes in participants’ response to the intervention. Weaknesses in the trial methodology included suboptimal implementation, outcome measures which may not have been sensitive to changes patients most appreciated, and difficulties collecting some outcomes.

While PARTNERS was not shown to be superior to usual care, the change to PARTNERS care was not shown to be unsafe. Full intervention implementation was challenging, but this is to be expected in studies of care including those with psychosis. Some individuals responded well to the intervention when psychological support in the form of individualised goal setting were flexibly deployed, with evidence that having access to a ‘professional friend’ was experienced as particularly helpful for some individuals.

Key components of the PARTNERS model could be developed further and tested, along with improved supervision in the context of ongoing community mental health care change.