there is no place for research in clinical practice: an nhs service manager perspective on the...
TRANSCRIPT
‘There is no place for research in clinical practice’:
an NHS service manager perspective on the CLAHRC-NDL specialised
depression service RCT.
Anne Garland, Nurse Consultant in Psychological Therapies, Nottinghamshire Healthcare NHS Trust
CLAHRC-NDL
Focus of this presentation
My context….
• Employed full-time in NHS
• Job role:• 50% clinical practice• 20% research• 10% education• 20% professional leadership
The context continued……..
• My role in CLAHRC-NDL• Grant holder alongside Professor Richard Morriss• Clinical Lead and main CBT therapist in the specialist depression service (RCT)• Diffusion Fellow
• The focus of the research• RCT testing the efficacy and effectiveness of a specialised depression service
with treatment as usual in secondary care mental health services • 5 year trial-three centres Nottingham, Derby and Cambridge• Implementing NICE recommended pharmacological and psychological (CBT)
treatments for depression
What motivated me to collaborate in CLAHRC?
A 14 year journey from 1994-2008 and the announcement of CLAHRC
• Newcastle-Cambridge RCT• Managed Innovation Network-PRiDe • Pilot Study• The potential promise of what CLAHRC’s could deliver to people who
suffer with chronic depression-a permanent service
‘There is no place for research in clinical practice’• The response of the Specialist Services Directorate service manager
where the RCT was based (also a nurse by profession) to a request for her support of the research project.
• When the original research bid was submitted a different service manager, now redeployed elsewhere, supported the bid.
• Over the five years in which the trial has been conducted the service where the RCT is based has had four different managers, all from a nursing background.
My solution……..
A theoretical lens through which to reflect…Mertens (2007):
• Proposes Transformative Research Paradigm
• Aim is to address social injustices and inequalities
• Thus the researcher is encouraged to articulate the issues of social justice that require redress in the context of the research being undertaken.
In the Trust where CLAHRC-NDL depression RCT resides….
Observed inequalities and injustice from presenters perspective: • Lack of access to NICE recommended pharmacological and
psychological treatments for people experiencing chronic and recurrent depression.
• A highly vocal and powerful anti-CBT/anti-evidence based practice/anti RCT nursing and clinical psychology voice (which gained significant momentum following inception of IAPT in 2007)
Back to the theoretical lens…..
Mertens (2003):• observes knowledge is not neutral and is influenced by human
interests.
An example: • Research does not necessarily serve the interests of those who
consent to become participants but often the interests of the academic community.
A reflection from the presenters own experience… • My time working in a university department as a clinical research associate. • This role involved working as a cognitive therapist in RCT • 4 year trial funded by grant from a very prestigious awarding body• The RCT demonstrated that cognitive therapy in comparison to treatment as
usual was protective in preventing depressive relapse. • The outcome paper was published in an equally prestigious international
journal with a high impact factor. • In discussion with one of the grant holders I enquired how we were going to
implement the research findings in clinical practice. • The reply came that this was not the plan, a more important plan was to apply
for the next grant.
So then what……..
• Somewhat disillusioned by this stance I moved back to clinical work in the NHS believing that here there would be opportunity to implement these research findings.
• I secured a job in a primary care service led by the profession of clinical psychology.
• On explaining recent experience of skills developed as a trial therapist and wanting to use these skills in clinical practice the reply came:
• ‘chronic depression is not treated in the primary care service but secondary care and only clinical psychologists are able to work in secondary care’.
Mertens (2007)………….
In such transactions we need to consider the different social realities that have been constructed
• How is reality defined? • By whom is it defined in this way? • Whose reality is given privilege?
Which social realities compete in the NHS?
Examples:• Professional discipline• Psychological therapies modalities• Job role i.e. clinician; manager; project lead• Job title i.e. CPN; clinical nurse specialist; healthcare assistant; peer support worker• Researcher• Research paradigm• Service User • Carer One person may straddle two or more of these social realities
Which social realities were relevant in my encounter with this service manager?
• Mental Health Nursing (shared)• Women (shared) similar age
• Operational manager same pay
• Clinician (nurse consultant) grade
• Cognitive Behavioural Psychotherapy (presenter) (NICE recommended treatment)
• Gestalt Therapy (manager) (not a NICE recommended treatment)
Back to the theoretical lens…..
• Thus how social realities, which serve particular ‘human interests’ interact will influence co-production in any culture or organisation
• ‘Power is an important determinant of which reality is privileged’ (Mertens 2007)
• In the nursing profession power resides in operational management
Tall Poppy Syndrome (Faugier)
Farrell, G. A. (2001) From tall poppies to squashed weeds: why don‘t nurses pull together more? Journal of Advanced Nursing 35 (1) 26-33
‘A social phenomenon in which people of genuine merit are resented, attacked, cut down, or criticised because their talents or achievements elevate them above or distinguish them from their peers’
The important factor in the transformative paradigm…
• To engage the participant community, paying attention to the most vulnerable groups whose voice may be drowned out by the voice of the social reality that has more privilege.
• Whose voice is being drowned out? –that of Gestalt Therapy and managers? NICE recommended treatments? CBT clinicians?
• Which social reality has more privilege? –NICE recommended treatments? Local anti-CBT lobby? Managers?
• Where are the service users/patients in all of this?
What does privilege versus vulnerability means in relation to those who suffer with chronic and recurrent depression?
A common view among staff: Depression both acute and chronic are ‘mild illnesses’ of the ‘worried well’. • Patients with chronic and recurrent depression are not allocated key
workers. • A higher commissioning tariff is allocated to those mental illnesses
defined as ‘severe and enduring illness’- chronic and recurrent depression is not classified in this way
• Yet depression is the most commonly occurring mental illness, which for a small but significant proportion of people it will take a lifetime course.
To return to our theoretical lens…
Mertens (2007):
• It is in knowledge and how it is used where power exerts its greatest influence
• Pay heed to the sources of knowledge that inform the research process and what research data is acted upon (or not)
Local anti-evidence based practice and anti-CBT lobby
• Within local secondary care mental health services staff there has been a backlash against evidence based practice and CBT
• This policy is seen to serve economic interests and contravenes the interests and wellbeing of service users, whom, are being disempowered and disenfranchised by commissioners taking a stance of prioritising evidence based psychological treatments
• This reality ignores the experience of many sufferers of anxiety disorders and depression, namely CBT can be for some, a highly effective psychological treatment that can transform their lives
Local anti-evidence based practice and anti-CBT lobby
We can reflect on:
• Whose interests the local anti-evidence based practice, anti-CBT lobby serves?• Which social reality and power base is taking precedence when decisions are
taken not to include NICE recommended treatments in service delivery models?
• Thus, in not accessing evidence based treatments service users are also disenfranchised and disempowered
A word from Tony Blair……
Tony Blair famously observed:
‘The NHS is run for the benefit of the staff who work within it and not the patients those staff are employed to serve’
There is some truth in this statement….and the managers stance can be viewed from this perspective
How did it all turn out…………did we find a route to co-production?
• Sadly not: ‘Asylum Mentality’ took hold • Tried to remove administrative support• Refused to pay my travel expenses for any CLAHRC activity • At year 2 a decision was taken to put my post to the cost
improvements-which would bring the whole project to an end• The Chief Executive intervened-for the sake of the CLAHRC….
How did it all turn out…………
• My post and the RCT were moved into the Adult Mental Health (AMH) Directorate
• The Chief Executive directly instructed the service manager and general manager to support the RCT 100%
• We completed the study in September 2013 • We now have a permanent specialist depression service in
Nottinghamshire Healthcare NHS Trust for people who suffer with chronic and recurrent depression delivering NICE recommended pharmacological and psychological treatments within a collaborative care model
What have I learned…..?
Finally…..
References:• Mertens, D.M. (2007) Transformative Paradigm: Mixed Methods and Social
Justice Journal of Mixed Methods Research vol. 1 no. 3 pp. 212-225 • Mertens, D.M.(2003) Mixed Methods and the Politics of Human Research: The
Transformative Emancipatory Perspective. In A. Tashakkori and C. Teddlie (Eds.), The Handbook of Mixed Methods in Social and Behavioral Research (pp. 135-164). Thousand Oaks, CA. Sage.