On the basis of clinical experience and empirical evidence, it is clear that users of mental health services often find themselves in areas of care that are not best suited to their mental health needs and that sometimes can be counterproductive. Members of our team (i.e. clinicians, service users and researchers) have carried out research into the factors influencing clinicians’ decision making in acute mental health scenarios. Whereas it would be expected that decisions would be based primarily on clinical factors, our research demonstrated that this is not necessarily the case. We found that non-clinical factors play a major role in decisions, which can have a dramatic impact on service users’ experiences of contact with mental health services. Our team is currently undertaking a parallel evaluation exploring the experience of such clinical decisions from the perspective of the service user.

This proposal relates to an intervention which it is intended will reduce the influence of adverse ‘extraneous’ factors and facilitate the role of positive factors. We propose piloting this intervention at the point when decisions are made about whether or not to admit a service user to hospital. We anticipate that our model, which is designed to address the underlying problems identified, will not only ensure that service users’ needs are more appropriately met and that their experience of this point in the pathway will be a more positive one, but it will also lead to a more efficient use of available resources and reduce unwarranted variation in practice.

The proposed model has been designed to facilitate the role of certain factors in decision-making. These are the ‘service-user based factors’, which include (a) the wishes of the service users and carers, (b) the areas of clinical need, (c) the strengths and protective factors, and (d) the risks. Surprisingly there is little guidance, even at a national level, on how these factors should be taken into account when clinical decisions are made. The proposed model will involve the shaping of more specific guidance for day to day clinical practice which it is anticipated will reduce unwarranted variation and make decision-making more predictable for service users and clinicians. In contrast to the usual ‘top-down’ approach, the development of this guidance will be draw primarily on service user and carer experience and on the experience of clinicians who are currently making such decisions and will be supplemented by the evidence base that is available.

At the same time, this model aims to reduce the influence of factors which are considered to be potentially interfering or negative. For the purposes of this pilot, the model will focus on three overarching themes.

1. Firstly, our research uncovered a group of factors which relate to the dynamics between different clinicians involved in the decision-making (‘clinician-clinician dynamics’). We found significant variability in decision-making which was not necessarily resolved on the basis of outcome evidence. Rather, other interfering factors were influential (e.g. the forcefulness with which preferred choices are presented, the stage in the process when decisions are communicated with service-users, and perceptions of decision-making hierarchies). The more specific guidance described above will be the basis for reducing the influence of these factors, but critical to the model is ensuring agreement across the pathway and adherence over time to the agreed guidance.
2. Secondly, so-called ‘clinician-service user dynamics’ refer to issues that can arise within the assessment process, such as clinicians making assumptions about the service user’s motives which can in turn influence the level and type of engagement in the assessment and in shared decision-making.  Within this model, informed peer supervision will be provided to reduce the impact of unhelpful dynamics.
3. Thirdly, ‘threat/fear factors’ are those which relate to anticipated criticism for decision-making or consequences of the ‘worst case scenario’. The model will pilot the use of the guidance as a set of standards by which to review practice in the event of problems. We believe that agreeing standards in advance allows a focus on positive outcomes and reduces the influence of fear-based decision-making.

To develop the model and draw together the service user and clinician contributions, we propose recruiting a part time (23 hours a week) band 6 mental health practitioner who will be supported with an in kind contribution by members of our team (including a service user representative and researcher for the service user evaluation, a clinical lead and director in the field of mental health crisis services, and a consultant psychiatrist). The post-holder will be tasked with (i) leading the development of the decision-making guidance, (ii) developing relationships with professionals across the pathway including in other crisis services (e.g. police, ambulance, accident and emergency, social care, mental health), (iii) providing peer guidance and support to relevant professionals across the pathway in line with the guidance, and (iv) monitoring adherence to guidance.