Innovation and Research

About ENHANCE

Final paper on ENHANCE -  Quality of life, wellbeing, recovery, and progress for older forensic mental health patients [pdf] 1MB

This is the website for a research project entitled: ‘Older adult forensic mental health patients: defining barriers, facilitators and ‘what works’ to enable better quality of life, health and wellbeing, reduced risk, and lower levels of security’. The project will be known as ENHANCE.

ENHANCE  is being carried out by Dr Chris Griffiths, Dr Kate Walker, Dr Jen Yates, Professor Tom Denning, Professor Birgit Völlm, Dr Jack Tomlin, and Andrew Lowe, between September 2019 and November 2021. It is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1217-20028).

Why are we doing this research?

Forensic psychiatric services work with people with mental illness and who pose a risk to themselves or others deemed sufficiently high to require confinement to secure facilities, or risk assessment and management in the community. Specialist forensic inpatient services are also required specifically for older adults experiencing mental disorder who pose a risk to themselves or others and their needs and requirements are likely to have changes as they have aged.  Older forensic psychiatric patients (defined as aged 55 or over) typically have complex histories having experienced many different types of trauma such as childhood neglect/abuse, substance abuse, poor health self-management, psychiatric admission, homelessness and violence. It has also been found that due to common histories that include poor health management and substance abuse, people with long term mental health disorders experience the challenges associated with old age earlier, and have significantly reduced life expectancy. It is important that psychiatric services offer suitable and appropriate treatment to all patients to enable recovery and better levels of health, wellbeing and quality of life and lower levels of risk to themselves and others. However, it is not known if this is being achieved with older forensic mental health patients, or what the barriers and facilitators to progress are for this group. We know that there is an increasing proportion of older people in secure settings now, but we are unclear how well and effective treatments are with this group of people. The aim of this project is therefore to discover this by undertaking research with service users and service providers, in order to get an in-depth understanding of their needs, requirements, and an insight in to what works for these patients to enhance their quality of life and reduce risk to themselves and others. The research will be used to make recommendations and to inform service provision and policy.

Who we are?

Dr Chris Griffiths:

Dr Chris Griffiths has co-ordinated NIHR, charity and industry funded mental health and forensic research and experienced as a principle investigator. He leads the project, ensuring delivery in line with protocol, on time, within budget and to a high standard. He leads collaboration with co-applicants, collaborators, recruitment sites and PPI lead (ensuring the project’s PPI requirements are fulfilled). He will lead full team meetings and be involved in interpretation of data and will lead synthesis study module, reporting, development of recommendations and dissemination.

Dr Kate Walker:

Dr Walker is a Research Associate, and an experienced qualitative researcher in the fields of intimate partner violence and sexual offending. She will be responsible for the day-to-day running aspects of the research for the duration of the project. She plays a key role in connecting with service users, inviting them to participate in the research and gathering the data over time. She will also analyse the data and write up the final findings and reports in collaboration with the other investigators on the project and the Lived Experience Advisory Panel.

Professor Birgit Völlm:

Prof Völlm is a Professor in Forensic Psychiatry and Director of the Forensic-Psychiatric Hospital and Outpatient service in Rostock, Germany. Previously, she was Professor of Forensic Psychiatry at the University of Nottingham and a Consultant Forensic Psychiatrist in the Personality Disorder service at Rampton high secure hospital. Prof Völlm has extensive experience in conducting research in forensic settings in senior roles, including the management of large, multisite projects, both nationally (including NIHR) and internationally. She will attend full team meetings and will be involved in interpretation of data and contribute to the project’s synthesis module, final report, development of recommendations and dissemination. She will also provide mentorship to the chief investigator.

Dr Jack Tomlin:

Research Fellow, Klinik und Poliklinik für Forensische Psychiatrie, Universitätsmedizin Rostock.

Dr Tomlin is a Research Fellow who conducts and publishes research on forensic mental health. He will lead the project’s quantitative module and will direct the analysis and interpretation of the obtained psychometric data. He will attend full team meetings. He will contribute to the project’s data synthesis module, final report, development of recommendations and dissemination.

Professor Tom Dening:

Professor Dening, an academic old age psychiatrist with over 25 years consultant experience, leads the Centre for Dementia, Institute of Mental Health, Nottingham, and is the Dementia clinical lead, NIHR CRN East Midlands. Research interests include dementia and technology; the arts and dementia; and services for people living with dementia, including clinical trials, psychosocial interventions, care homes and forensic settings. He will attend full team meetings and contribute to all stages of the research.

Dr Jen Yates:

Dr Yates is an assistant professor of mental health and an experienced qualitative researcher in the fields of older people, dementia, and health services delivery. She brings experience in collecting, managing, and analysing qualitative data from both staff and service user perspectives. She will provide qualitative methodology research expertise and will lead the qualitative module. Jen will attend full team meetings and contribute to project’s data synthesis module, final report, development of recommendations and dissemination.

Andrew Lowe:

Andrew is a Lived Experience Advisory Panel member and Co-Applicant for the ENHANCE project. He has previous experience working on several other research projects, such as a Nottinghamshire Healthcare NHS Trust project, examining the effectiveness of individual placement and support in improving employment rates and associated psychosocial outcomes in forensic psychiatric populations.  He will be involved with the research throughout the project.  His role will include: advising on what is important to patients; practical aspects of recruitment; ethical and patient acceptability factors; input into project patient facing materials; interpreting both the staff and patient data; assisting with plain language summaries; and promoting the study in recruitment and dissemination events.

Expert Advisory panel:

Dr. Aamir Ehjaz

Dr Aamir Ehjaz is a Consultant Forensic Psychiatrist employed by Northamptonshire Healthcare NHS Foundation Trust (NHFT), where he was also the Clinical Director for Forensic Mental Health Services between 2011 and 2014.  His qualifications are MBBS (London, 2002), LLM in Medical Law (University of Northumbria, 2005), MRCPsych (Royal College of Psychiatrists, 2007), and MSc in Forensic Mental Health (St George’s Medical School, London, 2012).  Since 2010 he has also been the visiting psychiatrist at HMP Rye Hill.  In 2019 he has been elected as a Fellow of the Royal College of Psychiatrist (FRCPsych). He will provide expert advice regarding forensic mental health psychiatry.

Dr. Vivek Furtado

Dr Vivek Furtado is an Associate Clinical Professor in Forensic Psychiatry at the University of Warwick and Honorary Consultant Forensic Psychiatrist to an enhanced rehabilitation medium secure service in the West Midlands. He studied Medicine at the Christian Medical College and Hospital in Vellore and completed his basic and specialist training in Old Age Psychiatry in Leeds. He was awarded an NIHR Academic Clinical Fellowship to research long term care in forensic psychiatric settings and completed further specialist training in Forensic Psychiatry. His research interest spans forensic psychiatry, terrorism, extremism and radicalisation, old age psychiatry, prison psychiatry and old age forensic psychiatry. He will provide expert advice regarding old age forensic mental health psychiatry and contribute towards recruitment strategies, development of recommendations and dissemination.

Dr Jonathan Waite

Dr Waite was a Consultant in the Psychiatry of Old Age in Nottingham. Before he retired in 2018 he was a clinician for forty six years working as a community and liaison psychiatrist. He was Clinical Lead for Dementia for NHS East Midlands, and Lord Chancellor’s Medical Visitor for East Midlands and East Anglia. He is author of Dementia Care (OUP 2009) and co-editor of The ECT Handbook (CUP 2019).  He will provide expert advice regarding old age forensic mental health psychiatry, dementia and contribute towards data collection strategies, development of recommendations and dissemination.

Tracy Oliver

Tracy Oliver is a Community Forensic Psychiatric Nurse and Queen’s Nurse, working as a care-co-ordinator and social supervisor in Northamptonshire Community Forensic Team.  Prior to this she worked as an Inpatient Nurse in medium secure environments. Tracy will offer expertise on the project in relation to community mental health services and provision, psychiatry and contribute towards recruitment strategies, development of recommendations and dissemination.

Patient and Public Involvement

The project has a Lived experience Advisory Panel (LEAP) which comprises current and ex-service users who have been invited to help shape the project from inception to delivery and beyond. All literature and research methods have been devised with the LEAP group, and they have helped develop the questionnaires for participants. They will also be responsible for assisting and guiding with data collection, analysis and interpretation of findings. Finally they will be involved with dissemination by helping with the design and development of key messages and through attending and presenting at conferences and roadshows.

Funder:

This independent research is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1217-20028). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

What are our research questions?

R1. What are the levels of wellbeing, recovery related quality of life, cognitive functioning, and health related quality of life in older (aged 55 and over) secure inpatients and those based in the community and how can this inform development of adequate service to address their needs?

R2. From a staff and patient perspective, what are the barriers and facilitators to progress in terms of quality of life, health, wellbeing, risk and lower levels of security? How can these barriers be addressed to facilitate progress?

R3. From a staff and patient perspective, what interventions do and do not work, how, when, why and for who to enhance progress in terms of quality of life, health, wellbeing, risk and lower levels of security?

How will we do it?

Over 20 months, we will work with advisory teams, service users, service providers, and with members of the public, in order to better understand the needs and requirements of older forensic mental health patients. We will do this in four main ways:

STEP 1

Firstly, we will look at existing research and bring it all together to see what it says about service provision and interventions for older forensic mental health patients. This will help guide our research focus and the questions we ask. We will also undertake a policy review to understand what is already in place for older forensic mental health patients.                                                                                                               

STEP 2

With their consent we will interview 36 service users, from high, medium and low risk units as well as those in the community. We will:

• Ask about their wellbeing, recovery related quality of life, cognitive functioning, and health related quality of life;
• Question them on their experiences of service provision and interventions, what they feel works and what does not work, and their views and perceptions on what helps and hinders their progress;
• Examine their case files for background information; and
• Ask them to fill in some questionnaires about quality of life, health and wellbeing in order to understand the characteristics and contextual factors associated with this population.

Alongside this we will also interview 35 people who provide service and/or care for older forensic mental health patients, e.g., psychiatrists, psychologists, nursing staff, social workers, and occupational therapists. We will ask them from their perspective what are the barriers and facilitators to progress in terms of quality of life, health, wellbeing, risk and lower levels of security, and their views about service provision and interventions. This will give us multiple perspectives across different settings.

STEP 3

We will analyse all the data that we have collected from service users and service providers. We will work with our advisory panels to analyse, interpret and write up the findings from the research.

STEP 4

The final phase of our project will bring the various threads together and identify key ‘messages’ from the findings. We will share these with those who: commission services for older forensic mental health patients; deliver day-to-day services; work with this population; and who could benefit from understanding the needs and requirements of this population. We will deliver this in various ways such as through journal articles and reports, conferences and workshops, and roadshows and exhibitions.

The timeline:

So why?

There is very limited research around the experience and the added challenges of ageing in secure forensic psychiatric settings. This is the first UK-based study to examine in detail the barriers and facilitators to progress for older forensic mental health patients, and understand well being recovery and quality of life. The increasing prevalence rates, the longer stay in secure care and the preliminary evidence around the unique barriers to recovery experienced by older patients require that this research is conducted. The proposed research is timely to inform service guidance and standards and decisions on future service design and funding.

What our project is creating?

Enhance research project - powerpoint[pdf] 769KB

Enhance Project Activities Infographic[pdf] 101KB

Enhance dissemination event - 20 January 2022

The Enhance project hosted a dissemination event which aims to help define needs, barriers, facilitators and what works for older adults forensic mental health patients.

Download the Synthesis infographic which will give you more information on what the team is up to [pdf] 431KB

The agenda for the event:

• Welcome, introduction and background - Dr Chris Griffiths

• Qualitative research: ENHNACE study, patient and staff data - Dr Kate Walker and Dr Jen Yates

• Questions from the audience: Chaired by Dr Jen Yates

• LEAP experience - Ronald McDonald

• Questions from the audience: Chaired by Dr Kate Walker

• Quantitative research: Patient questionnaire data - Dr Jack Tomlin

• Questions from the audience: Chaired by Jack Tomlin

• Recommendations and implications - Dr Chris Griffiths 

• Q&A panel session - Chaired by Prof Tom Dening and Prof Birgit Völlm

Research papers

Walker, K., Furtado, V., Yates, J., Dening, T., Völlm, B. & Griffiths, C. (2022). Systems and Processes that Enable Progress for Older Forensic Mental Health Patients, International Journal of Forensic Mental Health, Published online: 26 May 2022 https://doi.org/10.1080/14999013.2022.2080304

Walker, K., Yates, J., Dening, T., Völlm, B., Tomlin, J., & Griffiths, C. (2022). Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study. Journal of Health Services Research & Policy,OnlineFirst, https://doi.org/10.1177/13558196221094512

Walker, K., Yates, J., Dening, T., Vollm, B., Tomlin, J., & Griffiths, C. (2022). Older adult forensic mental health patients’ views on barriers, facilitators and ‘what works’ to enable better quality of life, health and wellbeing and to reduce risk of reoffending and harm to self and others. East Midlands Research into Ageing Network (EMRAN), 46 https://doi.org/10.17639/36pc-f722

Tomlin, J., Walker, K., Yates, J., Dening, T., Völlm, B. & Griffiths, C. (2022). Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life. NIHR Open Res, 2, 9. (https://doi.org/10.3310/nihropenres.13248.1)

Walker, K., Griffiths, C., Yates, J., & Völlm, B. (2020). Service provision for older forensic mental health patients: a scoping review of the literature. The Journal of Forensic Psychiatry & Psychology, 1-22. https://doi.org/10.1080/14789949.2020.1817525