One of the greatest challenges for researchers who hope to influence policy is the short duration of the policy cycle, with researchers often having little prospect of generating new evidence in time for deadlines. Likewise, this is a significant frustration for policy makers, many of whom are interested in principle in evidence, especially in areas such as health economic modelling, if it is relevant and accessible. Lead times while funding is awarded and contracts set up mean that new research commissioned to inform a policy decision might not even have begun by the time the decision has to be made.
In the case of the Independent Review of the Mental Health Act (MHA Review), the cycle has been particularly short. It was announced at the Conservative Party Conference in October 2017; an interim report was published in May 2018 and the full report launched on 6th December 2018. Despite this timetable, the MHA Review has also been distinguished by quite a close relationship to research. The main source of this has been the new NIHR Mental Health Policy Research Unit (MHPRU), introduced to readers of the Mental Elf at the time of its launch just over a year ago. The MHPRU, whose lead centres are UCL and King’s, but with a national multidisciplinary network of partners and collaborators, has been commissioned to deliver evidence to inform mental health policy. It’s one of a national network of PRUs, some of them focused on areas such as child health or maternal health, others more on methods. Ours is the first PRU to be commissioned in mental health; the others will also often have work on mental health within their programmes.
It was already clear at the time of the launch that the most pressing needs over the first year of the MHPRU’s life would arise from the Review of the MHA over which Sir Simon Wessely has presided, and so it has proved. Research on evidence-based policy making repeatedly identifies close links and relationships between researchers and policy makers as key (Government Office for Science, 2011; Economic and Social Research Council, 2018). It has certainly been our experience that this is very important. The pieces of work done by the PRU, mainly evidence synthesis, with some collation and analysis of data that already exists, have emerged from lively and collaborative discussions between researchers and the Mental Health Act Review team.
There has been substantial input from the PRU’s Lived Experience Working Group, a group of 14 people with personal experience of using mental health services or supporting family members who do so, who contribute to all PRU projects. An innovation that we have made with them is that members of the group are writing comments on all our papers from a lived experience perspective: the first of these has already been published embedded in a Lancet Psychiatry paper (Barnett et al, 2018).
Mental Health PRU work for the Mental Health Act Review
The pieces of work we have been able to produce to inform the Review are:
- A systematic review and meta-analysis of the effectiveness of compulsory community treatment.
- A systematic review and meta-analysis of the effectiveness of advance statements in reducing compulsory admissions.
- An analysis of routine data regarding compulsory admissions in two London Trusts, extracted using the CRIS tool (https://www.slam.nhs.uk/research/cris).
- A qualitative meta-syntheses of service users’ experience of compulsory admission.
- A qualitative meta-syntheses of family carers’ experience of compulsory admission.
- A rapid evidence synthesis of evidence on whether a range of psychosocial interventions reduce compulsory admissions.
- A paper comparing rates of compulsory admission and legislative systems internationally, and exploring how legal, social and service factors relate to national detention rates.
- A paper developing and testing the evidence for an explanatory model for the rising rates of compulsory admissions in England.
- A systematic review on social and clinical predictors of compulsory admission.
Full scientific papers are pending for these pieces of work, with one exception: a systematic review and meta-analysis of compulsory community treatment is already available as an open access publication (Barnett et al, 2018). Most scientific papers have now been submitted, and summaries of all of them appear as annexes to the MHA Review report. A substantial number of the review’s conclusions and recommendations have a clear relationship to our findings. Examples are the emphases on promoting the use of advance statements and joint crisis plans; the key importance of choice, autonomy, the inpatient environment and person-centred care to people’s experience of compulsory admission; and the need to closely monitor outcomes of reformed Community Treatment Orders, with a requirement to evidence greater effectiveness in order to justify their continued existence.
While we see this large-scale attempt to provide evidence to shape policy as a success overall, there are also considerable limitations. A challenge to the researchers and research funders among you is that the research evidence relevant to compulsory admissions really is very disappointing. Although there are papers on what it’s like being a detained patient on a ward, but there is hardly any literature on the experience of becoming compulsorily assessed and conveyed to hospital. Only a tiny proportion of trials of complex interventions have compulsory admission as an outcome, so that our knowledge about what prevents admissions remains very short-term and limited. Obtaining and conducting analyses based on official data remains challenging. There is much to do. We were aware also of the many other valid influences on policy making, which can limit the influence of conventional academic evidence: people with relevant lived experience and mental health practitioners were understandably in the foreground of this enquiry.
As well as informing the MHA Review, the published papers from the PRU research programme will identify priorities for future research and research funding, to help address the gaps in current knowledge. The PRU faced an early challenge in supporting such a major policy initiative immediately it was set up: the learning from this process and developing relationships with policy-makers will help ensure the PRU can contribute to supporting evidence-informed policy making in mental health in the years to come.
Conflict of interest
Sonia Johnson is Director and Bryn Lloyd-Evans is Deputy Director (UCL) of the NIHR Mental Health Policy Research Unit. These are their personal reflections on the process of supporting the Mental Health Act Review rather than a formal output from the Policy Research Unit.
Department of Health and Social Care (2018) Modernising the Mental Health Act – final report from the independent review. Published 6 Dec 2018.
Wessely S, Lloyd-Evans B, Johnson S. (2018) Reviewing the Mental Health Act: delivering evidence-informed policy. The Lancet Psychiatry, Published:December 07, 2018 DOI: https://doi.org/10.1016/S2215-0366(18)30477-2
Government Office for Science (2011) Engaging with Government: Guide for Academics (PDF). URN 11/390 (web resource).
Economic and Social Research Council (2018) Impact toolkit.
Barnett P, Matthews H, Lloyd-Evans B. et al (2018) Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. The Lancet Psychiatry 2018: 5(12) 1013-1022