In this Papers Podcast, Ari Peters-Corbett, Dr. Sheryl Parke, Dr. Holly Bear, and Dr. Tim Clarke discuss their co-authored CAMH review paper ‘Barriers and facilitators of implementation of evidence-based interventions in children and young people’s mental health care – a systematic review‘ (https://doi.org/10.1111/camh.12672).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- A definition of key terms, including ‘evidence-based practice’, ‘implementation science’, and ‘implementation framework’.
- The motivation behind the study.
- The types of organisation barriers, including funding and costs.
- The types of clinician and individual level barriers, including perception and attitude around evidence-based practice.
- The types of organisation facilitators
- The types of clinician and individual facilitators, such as openness to change and access to resources.
- The importance of the findings for making recommendations for the future.
- Implications of the findings for researchers.
- Advice for clinicians and practitioners on how best to use the findings from the paper.
- Insight into a case study that highlights some of the take-home messages from the study.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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I am a trainee clinical psychologist at the University of Cardiff, and I previously worked as an assistant psychologist in children and young people services. I have a particular interest in research and the implementation of evidence in mental health.
Sheryl works as a clinical psychologist at Norfolk Community Health and Care NHS Trust and at the University of East Anglia as a Clinical Lecturer on the Clinical Associate in Psychology programme. Within her roles, she is keen to promote inter-disciplinary working to support the most beneficial approaches for clients, including understanding the most up to date approaches and supporting services to explore these and to put them into clinical practice quickly. Sheryl is involved in research projects exploring staff wellbeing and service provision, and has an interest in neurorehabilitation and exploring how music can be used as part of rehabilitation.
I am a senior postdoctoral researcher in the Department of Psychiatry. Using mixed methods, my research focuses on the evaluation, implementation, and sustainability of mental health and wellbeing interventions for young people, with a particular focus on digital and school-based interventions. I am leading the Bridging the Gap Project to investigate the barriers and facilitators of implementing research into practice in child and adolescent mental health settings in order to make recommendations across clinical, commissioning, and academic settings. (Image and bio from Department of Psychiatry, University of Oxford)
I am a Principal Research Clinical Psychologist working in Norfolk for children and young people’s mental health services. I really love working on developing research in this field which includes designing, adapting, testing and implementing psychological interventions. I am really interested in how we improve services by adapting and implementing interventions from the evidence base / research literature to individual contexts. For my implementation fellowship I am working with a federation of primary schools in Norfolk to implement parent guided CBT for child anxiety. (Image and bio from ARC East of England)
Transcript
[00:00:01.439] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association of Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant and today’s interviewer. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances. If you’re a fan of one of our Papers Podcast series, please subscribe on your preferred streaming platform, and let us know how we did, with a rating or review, and so share with friends and colleagues.
Today, I’m delighted to be interviewing Ari Peters-Corbett from the University of Cardiff, Sheryl Parke from the University of East Anglia, Tim Clarke from Norfolk and Suffolk NHS Foundation Trust, and Holly Bear from the University of Oxford. They’re the co-authors of a paper entitled, “Barriers and Facilitators of the Implementation of Evidence-Based Interventions in Children and Young People’s Mental Health Care – a Systematic Review.”
If we could start with, maybe, some introductions. Ari, could you start us off first?
[00:01:10.909] Ari Peters-Corbett: Hi, I’m Ari. I’m a Trainee Clinical Psychologist at the University of Cardiff and I previously worked as an Assistant Psychologist in Children and Young People Services. And I have a particular interest in research and the implementation of evidence in mental health.
[00:01:24.030] Mark Tebbs: Sheryl.
[00:01:25.030] Dr. Sheryl Parke: Thank you. Yeah, hi, everyone, I’m Sheryl. I’m a Clinical Psychologist and Clinical Lecturer working at the University of East Anglia and also Norfolk Community Health and Care Trust. I completed my final placement with Tim, who you’ll hear from shortly, looking at supporting research to be implemented into practice more quickly and more freely and now consider this in my clinical and academic roles.
[00:01:45.770] Mark Tebbs: Holly.
[00:01:46.790] Dr. Holly Bear: I’m a Postdoctoral Researcher at the University of Oxford, with an interest in the evaluation and implementation of mental health interventions for adolescents and young people, with a particular focus on digital and school-based interventions.
[00:01:58.030] Mark Tebbs: Thank you, and last, but not least, Tim.
[00:02:00.530] Dr. Tim Clarke: Yeah, hi, Mark, it’s great to be here with you. Thanks for having us. I’m a Research Clinical Psychologist, really a kind of, clinical academic, and love working at the interface between clinical services and research within Children and Young People’s Mental Health Services. And it’s been a pleasure to collaborate with all of these wonderful people.
[00:02:18.360] Mark Tebbs: I wonder whether that’s where we could start, Tim. How did you come to be working together on the paper?
[00:02:23.420] Dr. Tim Clarke: Well, it feels like years in the making, this kind of work. We’ve, kind of, come together by chance, so – by the fact that Sheryl has been on placement with me, and Ari worked with me as an Assistant Psychologist. And Holly and I met by chance, really, and then just started having a random conversation about our, kind of, academic interests, whereby we realised that we were both really interested in implementation science and implementing evidence into practice. And we shared, probably, it’s fair to say, Holly, some of the same frustrations, I think, of working, often in randomised controlled trials, where those results aren’t always translated into practice as quickly as possible.
So, we, kind of, came together with those, kind of, mutual interests and that led us to collaborate together. We also had the pleasure of doing an editorial piece for the CAMH Journal, which was a bit of a call to action around implementation of evidence in Children and Young People’s Mental Health Services. So, through that, we’ve, kind of, harnessed this, kind of, mutual interest.
[00:03:17.860] Mark Tebbs: Ari, would you be able to, kind of, kick us off, just by giving an overview of the paper?
[00:03:23.130] Ari Peters-Corbett: So, the paper is a systematic review and as Tim, kind of, just mentioned, it came out of part of the work that we did as an output of our Special Interest Research Group that was focusing around this topic. And we know that there’s lots of effective evidence-based practices for Children and young people’s mental health, but the actual use and uptake of it is very slow and very low, meaning that the evidence that we do have isn’t getting to the people who need it, and so, it’s not necessarily being used effectively.
When we were looking for evidence of, kind of, what helps and what hinders implementation of research in children and young people’s mental health, we found the current literature was both quite limited, and, also, like, scattered geographically. And so, we decided to pull all of that information together into one place and synthesise it into a systematic review to understand what those barriers and facilitators of implementing evidence in this population is. And, also based on that, make some kind of informed recommendations of what to do and be able to, kind of like, aid future research around the topic.
We didn’t limit ourselves, sort of, to one geographic location, as I said, ‘cause we found that the kind of evidence that we were seeing was quite diffuse at this stage. We used, also, an implementation framework to help assess the information that we were gathering from that literature, and then, we matched the barriers and facilitators into implementation of evidence-based practice in children and young people’s mental health. And in doing that, we, kind of, looked at organisational level barriers and facilitators, as well as individual and Clinician level barriers and facilitators. So, we looked at those two different levels of evidence when we were synthesising everything. And then, based on our findings, we made recommendations for practitioners, Commissioners and Researchers.
[00:05:02.289] Mark Tebbs: Before we, kind of, get into a little bit more detail, I’m just wondering whether it would be useful to just define some of those terms that we have, kind of, mentioned already. So, I noticed, kind of, evidence-based practice, implementation in science, implementation in frameworks. So, I don’t know, Holly, whether you’d be able to just define some of those, kind of, key terms that we’re going to be using?
[00:05:22.620] Dr. Holly Bear: Of course. I think that’s a very important point, ‘cause often, there are similar, yet slightly different definitions for these terms. And concepts can mean quite different things to different people, which can make it tricky to decipher whether we’re all talking about the same thing.
So, I think there’s no single agreed upon definition for many of these things and different people may prefer different definitions, but I guess for our purposes, for evidence-based practice, we’re talking about scientific knowledge about services practices. So, for example, referral assessment and case management, or about the impact of clinical treatments or services on the mental health problems of children and young people. And I guess different types of evidence is helpful in different contexts. So, it may be that evidence is generated from service evaluation, clinical audit, feasibility studies or randomised controlled trials or meta-analyses. There’s certainly a kind of, spectrum or pyramid of evidence that may be useful in different ways at different times.
And then, by implementation, we mean the systematic uptake, integration and imbedding of evidence-based practices into routine practice, to improve the quality and effectiveness of mental health services and care for children and young people. And then, finally, implementation frameworks is really just, kind of, conceptual models that help us operationalise implementation. So, what are the, kind of, key determinants or drivers of implementation and what is the process of implementation?
[00:06:39.080] Mark Tebbs: Great, and that’s really, really helpful. Getting back to the study, so, could you describe a little bit about your original motivation, what made you want to study this area? Sheryl, I don’t know whether you could expand on that a little bit for us?
[00:06:52.590] Dr. Sheryl Parke: So – and as you’ve heard Ari mention, there was a Special Interest Research Group, known as BRIDGE, and as part of that work, we were bringing together people from all over the country who were experts within this area. And part of that was really trying to understand what are the barriers and facilitators to implementing evidence-based interventions in the area of children and young people’s mental health? And what we were seeing was that there was a gap in the literature, so we didn’t understand what those barriers and facilitators were, but also, there was this implementation bottleneck. So, we know that there’s lots of work being done around the world, but actually, it takes such a long time for it to get out into clinical practice. So, we really wanted to understand, why is that happening, and how can we, kind of, almost, try and break through that a bit?
And actually, what that means with that bottleneck happening, is that many children and young people are not having access to the interventions that are going to be most helpful and that they need in the moment. So, therefore, as an output of that group, we decided it would be beneficial to bring together, systematically, in a review, that literature, have a look at it, understand the qualities of it, but also the weaknesses of it, and think about exploring why those evidence-based practices don’t, and – but also do, get implemented.
[00:08:05.330] Mark Tebbs: Thank you. So, how did you go about undertaking the study?
[00:08:09.260] Dr. Sheryl Parke: So, as I mentioned, we went for a systematic review approach. So, we knew that there was already lots of important work happening in this area, across the world, and that different groups were publishing their findings on, kind of, implementing interventions into practice. However, what was missing, really stood out, is that, kind of, collation and that review of those studies as a whole, and then, really understanding, what are the barriers and facilitators that each piece of research is indicating across those different study groups?
So, we searched the literature across the past ten years, and we found 26 studies, after all of our exclusion and screening, and from there, we used the Paris Framework, which is an implementation framework, to identify the barriers and facilitators to that implementation. And we sought to bring together all of the information from the different studies to understand if any of the barriers or facilitators were particularly unique to the children and young persons’ settings. And from this, as Ari mentioned earlier, we then went on to provide clear recommendations to Clinicians, organisations, Researchers and other key stakeholders who might be thinking about looking into what new evidence could be, but then, really helping them to think about, okay, what’s that next stage of implementation? So, we can try and reduce that length of time of that bottleneck.
[00:09:23.339] Mark Tebbs: Great. So, what were the key findings? What are the things that stood out to you? Ari maybe could lead us off on that.
[00:09:30.019] Ari Peters-Corbett: So, as I said, we, kind of, looked at organisational level, as well as Clinician and individual levels. The organisational barriers that we found were quite common across the studies and they included things like lack of resource, lack of access to funding, high service demand, and a lack of clinical capacity was also something that was found. Funding and cost were, kind of, the most significant and the least changeable of the barriers. The Clinician and individual level barriers were found, sort of, around Clinician perception and attitude towards the evidence-based practice, so, for example, manuals being, like, very rigid and difficult to use. And it was also found that Clinicians can have, like, a resistance to change and innovation, and that’s, potentially, due to, like, lack of positive evidence around that.
Competing demands and high caseload were also found to be a barrier, but I think it’s important to note that a high caseload isn’t unique to children and Young People’s Services. There’s also, kind of, a perceived disparity between research trials and actual service settings. So, research, like, versus real life, and – which was found to be a barrier, as well as Clinicians, kind of, being unclear around why the evidence-based practice was being implemented. And, also, things like a lack of accessibility to information about that, as well.
Notably, kind of like, structure was not only an organisational level barrier, but an individual level one, as well. So, things like lack of accountability and responsibility and lack of infrastructure to support Clinicians was also a barrier, as well as things like high staff turnover, also created a barrier. And when we’re thinking about the organisational level facilitators, they were mainly, kind of, essentially, found to be the reverse of the barriers. So, things like access to funding and resource was a facilitator and where the lack of it was a barrier. Funding was found repeatedly throughout the studies, as a facilitator. That was a really significant findings.
Connectedness of organisational resources, also, and those resources being easily accessible, that was an important facilitator, as well. Having innovation, kind of like, as a high priority within organisations was also important, as one of those facilitators, you know, relative to other competing demands. Supervision and leadership around evidence-based practice is important, as well, and also, having adaptability and flexibility, with good communication, with internal, kind of, innovational leaders, as well as having, like, a good perceived fit with the organisational ethos, were found to be important, as well.
And then, the Clinician and individual level, kind of, facilitators, were again, largely, the reverse of what was found to be the barriers. So, for example, attitudes and perception from Clinicians around the evidence-based practices, openness to change, having skills and competence, as well as good leadership support, and that was found to be particularly significant. Positive relationships between, you know, knowledge around the evidence-based practice and previous experience of, like, self-efficacy was found to have an effect on the willingness to adopt change or innovation.
Also, things like ongoing training and education, as well as access to resources, those were all facilitators, and administrative support was also found to be really key in terms of the evidence-based practice being delivered. And then, adaptability and flexibility were also found to be, you know, important facilitators at this level, as well as simplification of process to fit in with service users and with Clinicians.
[00:12:47.100] Mark Tebbs: Was it the first time that facilitators and barriers had been, kind of, put together in this way?
[00:12:53.170] Dr. Tim Clarke: Yeah, specific to children and young people’s mental health, Mark, I think probably yes. Hence the reason why we embarked on this journey in the first instance. But as Ari was, kind of, suggesting, that there wasn’t loads there that was unique just to children and Young People’s Mental Health Services. So, many of the frameworks and theories that we’ve, kind of, alluded to, around implementation in healthcare, particularly, also summarise very similar, kind of, barriers and facilitators.
What’s unique about this paper is that, obviously, we’re exploring it in the context of children and Young People’s Mental Health Services. So, there are some nuances, but broadly speaking, I think this is an issue across lots of healthcare settings and probably not just CAMHS, across adult mental health and other mental health settings, as well. But what’s great about this paper is that it really, a) puts it in the context of CAMHS, and also, is hopefully, going to influence how we provide services going forwards. That’s our hope, anyway.
[00:13:44.120] Mark Tebbs: Just picking up on that last point, then. So, the paper, kind of, moves from those, sort of, findings, to making a number of recommendations for the future. Could you tell us a little bit about why they’re important?
[00:13:55.220] Ari Peters-Corbett: Yeah. So, based on the evidence that we found, we wanted to make sure that we were making clear recommendations for everybody that’s responsible, in the implementation of evidence-based practice in children and young people’s mental health. So, that’s people like Commissioners, practitioners, Researchers, Academics, policymakers. Just to go through them. Firstly, it’s crucial that funding’s made available and accessible for implementation in children and young people’s mental health, and also, that funding should be ringfenced specifically for that and prioritised within budgets, based on that. That could, you know, mean things like supporting roles such as Psychology Graduates, Assistant Psychologists, Healthcare Librarians, to support with those things.
Also, those involved with research, such as Academics, should be prioritising implementation beyond the end of research trials and that’s really key in making sure evidence-based practices don’t get lost or forgotten about. So, when this happens, the evidence-based practices, they’re not getting to those that need them and then, that has a knock-on effect in children and young people’s services and the service users within them.
Academics and research funders should also be encouraged to, you know, increase their adoption of implementation research designs, so that implementation outcomes are prioritised along with things like effectiveness outcomes, as well. Clinical institutions should prioritise training and upskilling staff to really understand the importance of integrating evidence-based practice as part of the ethos of the service and to create buy-in from the ground up. That should be both on the organisational and the individual level, that should be job planned into specifically identified staff roles. And training around evidence-based practice should be routinely included in mental health staff training, so that that knowledge already exists when it comes up, when it comes to, like, delivery of clinical care.
Implementation leaders should be appointed within services to uphold the importance and accountability and responsibility around using evidence-based practices. And that could be done in conjunction with academic institutions, such as universities, as well. With the right training and funding, Academics and Researchers who designed and evaluated evidence-based practices, are really well equipped to play a key role in working closely with Clinicians and other stakeholders to provide advice and support on how to adapt interventions, to the context of those real world clinical settings.
Another recommendation that we made, as well, was around co-production and the use of service users and parents and carers, and how these people can be – should be prioritised when services are considering how best to implement those new evidence-based practices and adapt to their contexts. So, attention must be paid to the facilitation and the qualities of those supporting the implementation of evidence-based practices around, you know, training, supervision, consultation, what’s available to develop a shared sense, kind of, across clinical teams. And that should also be a priority to make sure it’s really valued and the value of that is optimised, as well.
Importantly, clinical and operational models and service specification and policies to support development and delivery of children and Young People’s Mental Health Services need to explicitly include the importance of implementing evidence-based practices and have recognition, kind of, on its potential to improve outcomes. To do this, case studies on implementation in children and young people’s mental health could be collected and knowledge should be shared to help increase awareness and uptake the successful use of evidence-based practice in this area.
Finally, in order to optimise the facilitation of evidence-based practice in children and young people’s mental health care, capacity should be created in job plans. And that might mean focusing on de-implementation of other practices which already exist, which might not be as effective.
[00:17:33.900] Mark Tebbs: Thank you for that. Holly, I wonder whether there’s anything to add about the implications of the study from the research side.
[00:17:43.000] Dr. Holly Bear: Yeah, so, as Ari just mentioned, I think with the right training and with the right funding, Researchers are actually very well equipped and well placed to play a key role in working alongside Clinicians and other stakeholders to provide advice and support on how to adapt interventions for real-world settings. And in terms of the research itself, I think a key thing for me is around prioritising research that’s timely, relevant, and responsive to the needs and context of children and young people’s mental health. And this includes intervention and implementation, evaluation, in real-world, naturalistic settings.
So, I think to address some of the limitations of these, kind of, really lengthy and expensive RCTs, the evaluation of existing interventions and practices in CAMHS, and in schools, actually, is an important step in generating some, kind of, useful observational data and evidence of effectiveness. I think, as I said, Researchers can play a key role in helping to support these evaluations, providing research, design and analysis consultation and oversight to collaborators. I think evaluations can help identify what works and why it works, provide learning to improve effectiveness, highlight good practices, as well as insights about which elements may require, kind of, adjustments or improvements. While, kind of, circumventing starting an RCT from scratch, which we know can take several years. And there’s so much good practice happening already, so it’s a shame not to, kind of, measure that and, kind of, capitalise on that.
And then, I think a top one for me, and I know Tim and I talk about this a lot when we’re presenting this work, is thinking around prioritising implementation from the outset of research. So, when designing and testing new interventions in research, it’s important to think about implementation from a very early stage in the process. So, that may include what we call hybrid trial designs, where we’re measuring implementation, but also clinical effectiveness. So, including key implementation determinants, things like acceptability, feasibility, costs, and keeping those things in mind from the outset and not waiting until it’s too late in the process. ‘Cause that, kind of, contributes to this long process of implementation that we’ve been discussing.
[00:19:35.809] Mark Tebbs: Yeah, that makes so much sense. We’ve got Clinicians and practitioners working in the field at the moment who are listening to the podcast. Is there any advice to those, kind of, people working on the frontline about how they’d use these findings to best effect?
[00:19:52.120] Dr. Tim Clarke: Yeah, I think I’m in a good position, maybe, to answer that, Mark, because I do clinical work within a CAMHS setting, as well, and work closely with Clinical Services. And I don’t know, just listening – I’ve read the paper many times, but just listening to Ari and to others talk, again, it really resonates with me that generally, in CAMHS services, we’re not great at doing this kind of stuff. And, you know, really assessing what the latest emerging evidence is, what the latest trials are suggesting, and then, having mechanisms to, kind of, put that into place.
And I think Ari’s really highlighted well just some simple things that we might be able to do as Clinicians, and as services, and also as Commissioners, such as ensuring that research and implementation of evidence is part of our induction programme or as part of training profiles, and that it’s job planned into our roles, or to specific roles, perhaps. Not everybody’s, but, you know, if we had somebody whose role it was to really assess the results of the latest research and the applicability to our service. And then, to be able to share that with the team and to start to explore naturally with the team about how we put that into practice, that would make a big difference.
There’s something for me about instilling this, kind of, curiosity in teams that we’ve got away from because of the busyness of clinical settings. So, we know that it’s a really tough time at the moment in CAMHS services, clinically. You know, high demand, low capacity, things are really, really hard, and I think we can get into this cycle of just doing more of the same, which, kind of, makes sense, doesn’t it? And we, kind of, have to. And I’m not suggesting that’s wrong, but what that limits us doing is really thinking about what’s new and innovative, or that might actually help us save time, or actually help improve our services and help offer new, emerging interventions to children and young people and their families, that we’re not currently offering.
And if we don’t have that knowledge and we don’t have that thinking space, and we don’t have the expertise to implement into practice, and that’s what we’re talking about here, specific conscious strategies to implement evidence into practice, then we are just going to end up doing more of the same, which isn’t always a bad thing. But we need to learn to innovate and implement emerging evidence a bit more into practice, using some of those simple techniques and facilitators that Ari’s summarised already.
So, I think it is really important that we listen to this type of research and that we find a way, as Clinical Services, to be curious and to assess the latest emerging evidence. Whether that meets the gaps within our service provision and the clinical needs that young people are presenting with, and then, piloting how we might put that into practice and thinking about how it might change our, kind of, provision, as well.
So, we need to ensure that we’re aware of the emerging evidence base and the established evidence base, you know. Because often, many of us would’ve worked in CAMHS services for a long, long time and may not even be aware of new recommended evidence or research that we should be aware of and be putting into practice. And, also, have more confidence and more self-efficacy, that, kind of, belief that we can actually change things, we can influence change, as Clinicians and as practitioners. And evidence and research, I think, is a really powerful tool in which we can do that. So, we can have those types of conversations with our Service Managers, with our leaders, with our Commissioners locally, with NHS England, to be able to say, “Why aren’t we doing this?” You know, the evidence and research suggests this might be a good thing, but we’re not doing it, and we can’t wait 15 years, so we need to think about a way of doing it now. So, I actually think we’re quite uniquely placed, as Clinicians and as Clinical Academics, to help bridge that gap a bit more.
So, I think what the paper really demonstrates, too, is that we have to approach things differently, like I say, and that it gives us the permission to have a stronger voice as Clinicians. This is another thing in our toolkit that we can use to improve mental health services for young people. And in essence, it’s not just knowing what’s out there, but it’s knowing how we put into practice what’s out there, as well, and that’s, again, what the results of this particular paper sum up really neatly, as well. And, you know, as a Clinician, as a Clinical Academic, I have had the privilege of putting some of this into practice. So, I have used some of what Ari and Sheryl and Holly have been talking about and that our paper talks about. I’ve used that to inform implementation of new evidence into practice, and it really works. Just, you know, using some of those, kind of, simple strategies, helps to quickly translate research into practice and has led to good outcomes.
[00:24:07.000] Mark Tebbs: I think that’s really well, sort of, summarised. I’m just wondering, is there anything else from the paper that you would like to highlight?
[00:24:14.090] Ari Peters-Corbett: I think, really, I’m just going to echo some of what Tim has already said, but it’s that, kind of, staff engagement that’s highlighted as that facilitator, I think is really important to note. So, if staff are well supported and they’re supported to have the time and thinking space to engage in exploring what’s new out there and exploring their own curiosities around the evidence-based practices, then that, in itself, will already be helping supporting the implementation into their clinical practice and therefore, benefitting the children and young people that they’re working with. As we’ve already described, unfortunately, the current working climate doesn’t always feel like there’s that space and time and support and that can limit that staff’s ability to engage in that implementation of new practice.
So, I’m recently – fairly recently newly qualified. So, I think what stood out for me is that importance of staff support, to have that time, but also that wider strategic plan. So, thinking about, okay, how do we get this embedded into routine clinical practice? How does this become part of the daily offer? And thinking about things like the time in job plans, but also, how do we remove those practices that maybe aren’t as effective now, because we’ve learnt something else that perhaps has become a bit embedded and ingrained in our practice? So, really, supporting that time for clinical reflection and review, thinking about, what am I doing and why am I doing it, but then, what else is out there and how can I bring that in?
And finally, the importance of sharing what’s happening on the ground. So, through those case studies and through the smaller bits of research that we found as part of our review, that really supports the dissemination of that evidence-based practice, and that’s really something that I’m going to take forward into my clinical work. Often, that can be viewed as less important research, but actually, we need to hear what’s happening on the ground before we can take it forward.
[00:26:00.880] Mark Tebbs: Yeah, I think that’s a lovely description about the importance of bridging the different worlds and what can be gained through that. Are you planning any follow-up research? Is there anything in the pipeline that you’d like to share with us?
[00:26:13.500] Dr. Holly Bear: I guess this review is really one, yet key, aspect of a much larger programme of research that we’re working on. And the findings of this review provided us with some really important insights which helped us inform a larger Emerging Minds Network funded project, called, “Bridging the Gap” that Tim and I lead. Where we are trying to move beyond a lot of learning and scoping that we’ve already achieved and that’s already been described in the podcast today and in the paper, and develop some solid, kind of, practice recommendations from there.
So, in that study we explored professionals’ experiences very broadly across research, clinical and commissioning settings. And that was quite important, actually, because the young co-Researchers and the Young People and Parents Steering Group members, were integral in setting the direction of that project and its outputs. So, we co-produced an animation with young people, which is available online, and the young people, parents and other professionals told us that the process of commissioning services to help children and young people’s mental health can be quite confusing, especially when it comes to translating research into practice. So, we co-produced a, kind of, Quick Guide to Commissioning, which talks through what commissioning is, the challenges faced, as well as the potential solutions. And the link to the animation is on the Bridging the Gap Project webpage, on the Emerging Minds website, so, watch this space for the paper. It’s coming soon from that work, and I think I’ll pass to Tim. He might have something to add to that, as well.
[00:27:30.030] Dr. Tim Clarke: Oh, thanks, Holly. Yeah, well, we want to work together on this forever, don’t we? We want to continue to collaborate on this kind of work, ‘cause we feel it’s so important. You know, in addition to the work that Holly’s described, what we have noticed, there’s been more emphasis on implementation, and from research funders, as well, which is great. So, we’ve talked about Emerging Minds, and we work really closely with them, but the National Institute of Health Research, as well, NIHR, have also got a programme of work. Currently, that work is called the MHIN Project. So, that stands for Mental Health Implementation Network.
So, we’ve been lucky enough to be successful on a grant for some funding from the MHIN Network. Just a small pot of funding, but it’s furthering, kind of, our research in this area and we’re using the results from this paper and from the work that Holly and I have been doing with the Bridging the Gap Project, to train up pastoral workers within primary schools in a evidence-based intervention. So, parent-led CBT for child anxiety, and the new online version that’s been developed by Cathy Creswell and her team at the University of Oxford. So, we’re using the Mental Health Implementation Network funding, together with the results from the work that you’ve heard about today, to implement very, very, very quickly, those interventions within primary schools. So, that’s a really exciting piece of work, which, kind of, is a bit of a culmination of the things that we’ve been talking about today and something we hope to expand further. And that’s called the “Working on Worries Project.”
[00:28:48.440] Mark Tebbs: Thanks, Tim. So, we’re coming to the end of the podcast. Tim, if there’s a particular case study you’d like to use that highlights some of the take home messages, that would be great.
[00:28:57.160] Dr. Tim Clarke: Yeah, the take home messages are, essentially, we need implementation of evidence and research into practice to be everybody’s business. So, we need to be thinking about it together. Academics need to be thinking about it more as part of the research process, and part of the research design, and we need Commissioners to really be thinking about it, too. And we need Clinicians and services to be considering how they appraise and assess what we currently offer, and whether that’s evidence-based and whether there might be something that’s new or emerging that could replace something that perhaps isn’t as impactful as we would hope it to be. So, first of all, we need to impress the importance that it’s everybody’s business. It’s not just the Academics, it’s not just the Clinical Academics or the Clinicians.
And we have to continue to use research and evidence base to continually improve our services for children and young people. Otherwise, we’re doing a disservice to our local populations and to our young people. And this means that we need to ensure that research is accessible, that implementation is thought about from the very conception of research ideas, or developing novel interventions, right the way through to the frontline. That we do implementation at every stage by working with those with lived experience and that we make time for implementation across all roles. And we have specific roles which focus on implementation of evidence and research into practice.
We’ve also got to champion the need for resources and funding specific to implementation activities, as we’ve been hearing about today. We have to work better together across all disciplines, including research, clinical, policymakers and Commissioners, as well. We have to value each other’s roles and what we bring to implementation, and we have to remember that a lot of implementation is quite relational. It’s about making those connections across the systems, across disciplines, across academia and the clinical world and the commissioning, and the policy world, and connecting with each other. And I think that’s part of what we do, as a group, really well, is that we think about the groups, the research groups, that are doing great research. We think about what our clinical needs are, and we try and marry the two together as quickly as possible, and all of that is, kind of, quite relational.
And as well, we have to remember that it’s not one size fits all. That we need to adapt, often, the research and the evidence into the context of our services, and that’s okay, that’s part of implementation. So, we have to, kind of, consider it – that, too. It’s not just as simple as taking a research trial intervention and slotting it straight into a CAMHS service. It takes quite a conscious effort.
And in terms of a case study, Mark, well, we’ve touched on the Working on Worries Project, which is where we’re training pastoral workers up in parent-led CBT and something called Online Support Intervention. So, that’s OSI, for short. What we try and do, actually, in the East of England, is that we try and look at what the clinical needs of services are. So, as an example, in the aftermath of COVID and during COVID, we saw many more, kind of, crisis presentations of children and young people with mental health difficulties. Lots of children and young people, unfortunately, attending Accident & Emergency Departments and acute hospital settings, as well. And we also know that the policy landscape is one of implementing brief crisis interventions. That’s one of the functions that we should be doing within our community settings. But when we ask the question, “What are, kind of, brief crisis interventions for children and young people?” not many people could really tell us that. And “What’s the evidence base of brief crisis interventions for children and young people’s mental health?”
So, we ask sensible questions like that, really, and then we go off and we have a look at the published literature, the grey literature, emerging evidence, and we bring and synthesise that together, and this is an example that we did with brief crisis interventions. And then, we deploy and disseminate that information in, you know, nice, accessible, kind of, summaries, over to our, kind of, Clinical Teams and our Commissioning Teams. And then, we ask whether services would like support with implementation and implementation support. So, would they like us to work with them to think about what intervention might suit their particular needs and their local populations? And then, we help them to put that into practice.
So, with the brief crisis interventions, we were able to work with the team in the East of England. We looked at the literature. We looked at their context of the service. We looked at what some of the new interventions were that were emerging. There was one particular intervention that was developed in Australia and the team thought, “Oh God, that would really fit well with our service context here, and we could see our staff doing this.” So, we looked at the characteristics of that trial and the intervention. Seemed to have a good match with style of interventions that they offer, and then, we developed an implementation plan with them, which also included contacting the team in Australia, commissioning the team in Australia to deliver training to that team. And now, the team are, kind of, putting that into practice as part of, kind of, one of their provisions. Now, that wouldn’t happen, I don’t think, without that conscious implementation thought. So, that’s just one quick example.
[00:33:30.570] Mark Tebbs: It’s a great example, actually. You can see how it would reduce the bottleneck and lag of implementation. So, great place for us to finish.
Thank you so much for your time. It’s been a really, really interesting podcast. For more details on Ari, Sheryl, Tim and Holly, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.
