Background: Mental health policy is crucial for enhancing mental health and well-being. Despite the significant contribution of mental disorders to the global burden of disease, 68% of the countries possess a comprehensive mental health policy. This review aimed to identify similarities and differences between low-income countries' (LICs) and lower middle-income countries' (LMICs) mental health policies, along with key gaps, limitations, and strengths, to inform Pakistan's mental health policy.

We conducted searches on Google, the WHO Mental Health Atlas, and the country's Ministry of Health website for mental health and general health policies. Recent mental health policies were included from LMICs that were available in English, whether published or unpublished. Scholarly articles, commentaries, books, and health policies that did not address mental health were excluded. Data extraction covered document title, policy status, country, policy formulation process, human resources, suicide prevention, finances, health service delivery, governance, leadership, involvement of ministries, and implementation plans. We synthesized the data through a comparative narrative review in both text and tables.

Fifty percent (8/16) of LICs and sixty-five percent (17/26) of LMICs have health and mental health policies in English. These policies cover topics like psychiatric disorders, psychotropic drugs, forensic mental health, substance abuse disorders, and communicable and non-communicable diseases. Approximately 65% of LMICs' policies outline the structure of their federal or national government, and 59% provide information on provincial and local government structures. Most LICs include their vision, mission, and objectives in their policies.

Mental health is often neglected in the healthcare policies of LICs and LMICs. To reduce the burden of mental illness and prevent self-harm, suicide, and substance misuse disorders, the implementation of evidence-based mental health policies in line with the Sustainable Development Goals (SDGs) is crucial.

At Chelsham House – an older adults, acute inpatient dementia mental health ward – morning handover meetings (‘huddles’) lacked structure and consistency, resulting in extended, inefficient patient handover discussions and unclear task allocation. These issues consumed valuable clinical time and impacted the continuity and effectiveness of care. Recognising these challenges, a need to revamp the huddle format emerged, prioritising clear communication, effective task distribution, and team cohesion to enhance patient safety and care efficiency.

This project aimed to improve the efficiency and effectiveness of morning huddles at Chelsham House by reducing their average duration by 10% and enhancing multidisciplinary team (MDT) staff satisfaction regarding patient handover dialogues, task distribution, and accountability within 2 weeks.

The intervention streamlined the huddle format by assigning a rotating MDT chairperson and task allocator, setting a strict 2-min per patient discussion target. New segments, such as a ward safety check and focused discussions on risks and discharge barriers within patient updates, were added. A task allocation board was implemented in the meeting room for assigning tasks. Staff surveys and data on meeting duration were collected pre- and post-implementation.

The implementation led to a 16% reduction in huddle duration (from 64 to 54 minutes) and a 21% decrease in time spent per patient discussion (from 4.09 to 3.23 minutes). Staff surveys showed a significant increase in satisfaction regarding safety discussions (21%), task clarity (23%), and discharge planning efficiency (26%). The effectiveness of mental and physical health discussions was maintained, with a high average Likert score of 4.64 post-implementation, on a scale where 1 is ‘Strongly Disagree' and 5 is ‘Strongly Agree'.

This QIP achieved a notable 16% reduction in huddle duration, enhancing clinical operations on the ward. The progress, combined with improved staff satisfaction and maintained quality of discussions, underscores the QIP's success in boosting clinical efficiency and offers valuable insights for future initiatives in similar settings.

People with Functional Neurological Disorder (FND) exhibit diverse symptoms, ranging from motor and sensory issues to non-epileptic attacks, potentially causing reduced functioning and quality of life. East Kent Neuropsychiatry Service developed written and video resources to educate patients about FND. We aim to improve patient education on FND through increasing resource options and identifying optimal implementation of the materials within the care pathway.

We implemented an existing symptom self-management psychoeducation booklet and novel video resources as part of a quality improvement project (QIP). The first QIP cycle trialled the resources across different treatment pathways using three groups, each of seven patients. Group 1 received the booklet first, then the video two weeks later. Group 2 received the video first, then the booklet after two weeks. Group 3 received both resources at the same time. After 4 weeks, patient feedback was collected by 4 medical students by telephone. Qualitative and quantitative data was obtained from 8 patients. Quantitative feedback was obtained using a 5-point Likert scale. In the second QIP cycle, 10 patients received both resources simultaneously, with improvements made to resource accessibility and readability.

The first QIP cycle highlighted that the videos were helpful in explaining FND, with 75% of patients rating the videos the same or higher than the booklet. Qualitative responses commented that videos were more personal and easier for family members to understand. Across both video and booklet resources, 67% of patients agreed or strongly agreed the resources were useful for explaining FND and their experience. One patient, in group 1, stated the resources improved their symptoms. 54% of patients agreed that they received the resources at the appropriate time; a common theme across all groups was the desire to access the resources earlier within the pathway. In the second QIP cycle (8 patients, 25% response rate), all agreed the resources improved FND understanding and self-management strategies.

Our study highlights that video resources are a valuable addition to FND psychoeducation, with benefits for patients, carers and family members. Both booklet and video resources were helpful in improving patient education on FND. Our findings emphasise the need for early integration of psychoeducation in the care pathway. Future developments could include collaborating with other specialties involved in the care of FND patients, such as neurology and emergency departments, to enable early integration of psychoeducation resources, empowering clinicians to effectively communicate about FND and enhancing patient psychoeducation.

Additional authors: Mr Alan Dunlop, Ms Wendy Collison and Professor Rafey Faruqui.

Fourth-year medical students from Manchester University undergo a four-week Psychiatry rotation in Stockport as part of their curriculum. Placed in both community and inpatient teams within General Adult and Older Adult Psychiatry services, this placement offers a unique opportunity for students to gain clinical and educational experience in Psychiatry, potentially shaping their perception of the field. This quality improvement project aimed to enhance the overall experience of medical students during their Psychiatry placement in Stockport.

A retrospective review of quantitative and qualitative feedback from the March to April 2023 cohort (n = 4) involved a 5-point Likert scale and comments covering 10 domains. The feedback focused on aspects such as induction, orientation, learning objectives, patient assessment, procedural skills, supervisor feedback, access to resources, timetables, and the overall experience. An average total score was calculated.

Subsequently, strategies were implemented for the April to May 2023 cohort based on the feedback. Weekly check-ins, updated timetables, team introductions, additional teaching sessions, and opportunities for case presentations were among the interventions.

Quantitative and qualitative feedback from the April to May 2023 cohort (n = 4) were collected and compared with the previous cohort's feedback.

The feedback scores demonstrated improvement, with the average total score increasing from 4.1/5 (82%) in March – April 2023 to 4.7/5 (94%) in April–May 2023. Students praised the helpful staff, opportunities to present cases, and the tailored and useful nature of the placement. Feedback on improvements included addressing vague timetables, unannounced cancellations of teaching sessions, and limited opportunities for case presentations.

This quality improvement project demonstrated that the targeted interventions helped enhance the educational experience of medical students during their psychiatry placement. The increased feedback scores underscore the positive impact of targeted interventions. The findings emphasize the importance of continuous quality improvement in medical education, ensuring a more positive and enriching experience for medical students in Psychiatry rotations.

The aim of our project is to support health literacy in patients and carers under the Nottinghamshire Intellectual and Developmental Disabilities (IDD) service. To achieve this aim, we will produce a 20 page newsletter, containing updated and accessible research on mental health disorders that are common in the IDD population. We will also utilise a Trust webpage to publish the newsletter and produce a video/ podcast for the webpage, showcasing individuals with intellectual disabilities discussing and interacting with the articles.

Research into the relevant articles included a search on Google Scholar and PubMed, and a list was written up. Final research articles to be included in the newsletter were selected after consultation with the consultant peer group within the Intellectual and Developmental Disability team within Nottinghamshire Healthcare NHS Foundation Trust. Easy read forms of all the articles were drafted by researchers, which will be sent to relevant authors to verify that this is an accurate representation of their research. An accessible 20-page newsletter will be produced, and an IDD focus group will review the content of the newsletter, discuss the articles and relevant videos/ podcasts will be made of these interactions. A webpage on the trust website will be created to publish the newsletter and allow users to interact with the articles electronically (using the standard electronic accessibility tools) and this will also contain the videos/podcasts produced. Feedback will be obtained electronically via a QR code and via traditional means e.g. an easy read reply slip.

The key outcomes of our project are producing 10 easy read articles within our newsletter. These articles need to be useful and accessible to the IDD population, which will be verified by small focus groups consisting of patients with IDD, carers and staff to review literature before publication as well as the feedback after publication. Another key outcome is the use of coproduction to involve people with IDD in production of the newsletter and webpage, in order to recognise the value of their lived experience, improve the quality of the project and drive success.

Successful publication and feedback will pave a way for exploring a second edition the following year for printing via Trust communications. If successful, this project could be used as a template for an effective way to share research findings that contribute to the understanding of assessment and treatment pathways for people with an Intellectual and Developmental Disability.

The project's aim is to record up-to-date BMI readings of 70% or more of our service users by September 2024. We have identified barriers limiting current data collection, such as challenges weighing wheelchair bound clients or limited availability of weighing scales, and will action our change idea methods to reach our target in this time period.

Significant health inequalities have been identified in the learning disability population, with men and women in our cohort dying 23 years and 27 years younger respectively compared with the general population. Furthermore, people with learning disabilities are at increased risk of being overweight or obese compared with other cohorts, which itself leads to a range of health and social complications. A recent audit of our psychiatry caseload revealed the need to improve weight monitoring and subsequent management for our service users, to help reduce health inequalities identified.

We have weekly project meetings with our MDT including psychiatrists, dietetics, occupational therapists, nurses and psychologists. We have arranged stakeholder involvement by inviting service users to these weekly meetings to contribute their own ideas to the project, and have organised focus groups for service users, carers and staff. We intend to generate change ideas by using quality improvement methodology to identify primary and secondary drivers. One of these already incorporated into the project is a machine in our waiting room monitoring our clients’ weight, height and blood pressure. Having identified obstacles in our service users obtaining their weight, we have successfully bid for funding for one of these machines.

We will use Plan Do Study Act (PDSA) cycles to evaluate the effectiveness of our change ideas. Convenient sampling of our psychiatry caseload showed only 26.7% of 71 service users have an updated weight and BMI, and identified that we don't have a robust process for monitoring patients' weights (total project caseload is 1264).

During the development of this project, we identified a variety of approaches to improve health outcomes for our service users including educating staff on incorporating weight monitoring into consultations and how to manage the results. This project comprises one part of East London Foundation Trust's overall Triple Aim: to improve population health; improve the quality and improve value for the system. Going forward, our intention is to incorporate weight management into our routine reviews and ensure staff are educated in the importance of regular weight monitoring, the health benefits and how to refer.

Incidents involving patient violence and aggression are a common occurrence on the neurosciences wards. Many staff do not know how to de-escalate or manage such incidents, leaving them vulnerable and unsupported. This project was designed to increase mean staff confidence by at least 2 points (on a scale of 1–10) regarding confidence and satisfaction in managing patient violence during a 6-week period.

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, we carried out a preliminary survey on 2 neurosciences wards. Multidisciplinary staff were interviewed about their confidence (on a scale of 1–10) in managing violence. The survey and interview assessed which measures were already in place on the wards, such as Datix reporting and referral pathways. The first intervention focused on preventing patient violence with informative posters on referral pathways and verbal de-escalation techniques; these were distributed throughout the wards and staff were notified via email. Follow-up surveys were collected, enquiring whether staff had seen the posters and how their confidence levels have changed. The second intervention was implemented 2 weeks later and focused on post-incident support. We distributed leaflets on Critical Incident Staff Support and sent an email link to a verbal de-escalation playlist. Follow-up surveys were collected again to track changes in staff confidence and satisfaction. Weekly electronic clinical record searches were recorded to track the number of incidences of patient aggression during the same 6-week period.

Staff confidence (N = 24) in verbally de-escalating violence and aggression increased by 1.1 and 1.75 points for Wards A and B, respectively. Of the 6 staff members who were followed up, only 1 experienced a 2-point increase from baseline in confidence in verbal de-escalation; 1 staff member experienced a 1-point increase, 3 experienced no change, and 1 reported a 1-point decrease. Staff satisfaction in management of violence on their wards increased by 1.04 and 1.75 points for Wards A and B, respectively. Staff confidence in knowing which team to refer patient violence to increased by 1.167 and 1.07 points for Wards A and B. Incidences of patient violence reported on EPIC decreased by 8 episodes for Ward B and increased by 2 episodes for Ward A.

Low-cost, simple intervention techniques are largely ineffective in improving staff confidence in handling violence. During verbal feedback, most staff agreed that training and simulation-based days would be useful. Ward managers should seek to include well-structured training to improve staff confidence.

The burgeoning focus on climate change has emerged as a prominent area of both interest and concern. As the importance of sustainable healthcare practices gains momentum, there is a heightened focus on tackling environmental issues and promoting planetary health. In a noteworthy achievement, the NHS became the world's first health service in October 2020 to commit to achieving carbon net zero.

Bradford District Care NHS Foundation Trust (BDCT) has been a strong advocate for sustainability and planetary health (S&PH) initiatives, driven by the committed leadership of the BDCT Sustainability department. While the non-clinical senior leadership displayed active involvement in these initiatives, there appeared to be, at least anecdotally, a somewhat limited participation from the clinical teams. This project aimed to investigate and analyse this perceived gap, utilising the findings to guide future initiatives.

Aims and Objectives:

The primary objectives of this research are to assess, evaluate, and empower medical staff at BDCT in sustainable healthcare practices. The specific aims include:

1. 1. Assessing the current awareness levels of S&PH among medical staff.

2. 2. Evaluating the extent of medical staff involvement in existing S&PH initiatives within the NHS and BDCT.

3. 3. Identifying barriers and challenges faced by medical staff in actively participating in sustainability and environmental initiatives.

4. 4. Contributing insights to broader S&PH initiatives within BDCT.

5. 5. Developing strategies to empower clinicians, service users, and communities to actively engage in environmental and sustainability initiatives.

We focused on three key themes: the staff, the patients, and the access to green spaces.

A research tool was developed to conduct this project. This entailed an online, semi structured proforma which was disseminated across the medical staff group in BDCT. The medical staff group included consultants, trainees, SAS/Trust Grade, and LAS doctors.

The proforma consisted of 18 questions and examined the following three themes:

• • Staff: Staff Knowledge and Awareness of S&PH

• • Patients: How do staff facilitate patients' awareness of S&PH?

• • WorkPlace: Access to green spaces.

Total 18 responses gathered via the semi structured proforma. 55% (n = 10) responses were from inpatient setting, 33.3% (n = 6) from community setting; 2 from other settings. 72.2% (n = 13) were in full time occupation while rest (n = 5) were less than full time.

Genders had almost equal representation.

Only a minority (27%) of staff were aware of the sustainability champion within BDCT, while only 22.2% were aware about the BDCT Green Plan initiative.

The common suggestions about methods to improve the awareness about the Green Plan and Sustainability were email, intranet page, sessions on the topic, posters, monthly update amongst various others. Email newsletter was overrepresented as a common theme (24%).

A majority of employees (78%) noted a significant change in the mileage which was a reduction (78% noted a reduction) as expected before and after Covid Pandemic.

Some of the suggestions received were innovative and interesting including cycle scheme, working from home, hybrid working amongst others. However, almost all responses were able to appraise the advantages of flexible working and the associated barriers.

The last segment explored the green spaces and their effect on mental health which was very encouraging.

This research project aligns with the RCPsych's vision of sustainability and nature, emphasising the critical role clinicians play in advancing sustainable healthcare practices. Some of the findings are really encouraging, however there is a still a significant gap in understanding the role of sustainability champion and the Green Plan.

By exploring awareness levels, involvement, and challenges faced by medical staff, this study seeks to provide actionable insights that not only enhance practices within BDCT but also contribute to the broader discourse on sustainability and planetary health in healthcare settings.

The findings are anticipated to catalyse strategies that empower clinicians and communities, fostering a culture of active engagement in environmental and sustainability initiatives.

Clozapine is a well-established and widely practiced treatment for treatment-resistant schizophrenia. Due to its significant side effect profile, it requires intense monitoring, including monthly blood tests and medical reviews. A patient's attitude towards clozapine can impact compliance with treatment and its monitoring process. This survey intended to identify the community mental health patients' perception of the clozapine treatment and its monitoring process and to help improve current practices of the service.

A structured survey with 17 questions was administered to patients registered at the community clozapine clinic via face-to-face or phone conversation at an Australian Community Mental Health Service by the principal researcher and clozapine coordinators.

17 out of 25 eligible patients (68%) participated; the mean age was 39.7 years. There were nine female and eight male participants. 94% of patients were on clozapine for more than one year. 70.5% agreed that clozapine helped to improve mental health, and they understand clozapine side effects and monitoring process. 76.5% agreed that the treating team provided psychoeducation. Seven participants reported clozapine improved side effects compared with previous medications. Three disagreed that clozapine improved side effects, and six remained neutral. Hypersalivation (35.2%), constipation (23.5%) and weight gain (17.6%) were identified as the worst side effects. Nine (52.9%) participants reported that they make healthy life choices. Factors affecting motivation for a healthy lifestyle are mental health symptoms (47%), finances (47%) and physical health well-being (52.9%). Only 35% identified motivation from others as necessary for a healthy lifestyle. Fatigue/poor motivation (47%) and mental health (35.2%) prevent them from making healthy choices. Side effects and finances equally (23.5%) impact healthy choices. Eleven participants (64.7%) felt clozapine monitoring was a positive experience, and 88.2% felt they had enough support during the clozapine monitoring process and were adequately informed about their treatment plan. Two participants disagreed that they were informed of their treatment plan. The majority (82.3%) said no change was needed in the monthly medical officer-led clozapine clinic or six-monthly psychiatrist-led clozapine clinics. Text messages (88.2%) and phone conversations (47%) were the most preferred method for treating team communication about treatment.

The majority of patients identified that clozapine helped to improve mental health, and the monitoring process was a positive experience. Most participants were aware of clozapine and its monitoring process. Psychosocial support will be essential to improve quality of life and might improve the negative perception of clozapine's side effects.

Early Intervention Services (EIS) are in a unique position to assess patients presenting with their first episode of psychosis. The possibility that an organic disorder may be underlying their presentation must be ruled out, often necessitating neuroimaging and/or input from neurology and neuropsychiatry.

We aim to improve the management of neuropsychiatric presentations in EIS. We will determine the incidence of cases, from the London Boroughs of Sutton and Merton, which warrant referral to neurology, neuropsychiatry and neuroimaging. We will then review referral pathways and provide justification for community services, such as EIS, to autonomously request referrals and neuroimaging.

We retrospectively reviewed the complete caseloads of EIS for Sutton and Merton (n = 121). We considered the neurological comorbidities of patients to determine the incidence of cases which warranted a referral to neurology, neuropsychiatry and/or neuroimaging. We reviewed how requests were made and the subsequent results.

15% of the EIS caseload had a neurological comorbidity. Migraine was the most common condition (8.3%), followed by traumatic brain injury (3.3%), headache (2.5%), and seizure (1.7%). There was one case each of epilepsy, stroke, transient ischaemic attack, cavernoma and cerebral venous thrombosis. 83% of patients with a neurological comorbidity had received neuroimaging and all imaging results were either normal or confirmed known pre-existing neurological disease. The 17% of patients who did not receive neuroimaging had only migraine as a neurological comorbidity. One patient was reviewed by neurology and diagnosed with psychosis presumed to be secondary to paraneoplastic syndrome. All patients that fulfilled criteria for a neuropsychiatry referral had this completed electronically. However, there was no clear pathway to request a review by neurology, and Sutton EIS had difficulties autonomously requesting and accessing the results of neuroimaging, delaying provision of appropriate care.

There is a small but significant burden of neurological comorbidity among EIS patients. In our brief study, we found one patient whose symptoms of psychosis were likely attributable to an organic cause. Accessible pathways to refer patients for neuroimaging, and subsequently to neurology and/or neuropsychiatry if indicated, are crucial in the assessment and management of first episode psychosis where an organic cause is suspected. Access to these resources should be efficient and autonomous for EIS. We are in the process of implementing referral guidance alongside a direct electronic referral process to request neuroimaging and further input from neurology and/or neuropsychiatry, to optimise care for patients and our service.

To improve the visibility and accessibility of secure inpatients’ physical health needs by measuring staff satisfaction levels towards physical health information and monitoring.

Through purposive sampling we conducted a five-point Likert Scale on members of the multidisciplinary team (MDT) on one medium-secure forensic ward, within Oxleas NHS Foundation Trust, which provides 124 forensic inpatient beds to southeast London. We collated physical health data from across electronic patient records to create a single-point-of-access workspace on Microsoft OneNote, accessible to all members of the MDT contemporaneously, comprising past medical history, psychotropics requiring close monitoring (e.g. lithium, clozapine, valproate), vital signs, weight, bloodwork, electrocardiogram findings, hospital appointments/results and cancer screening.

We re-sampled members of the ward MDT after the workspace had been created and implemented.

Nine members of the multidisciplinary team were sampled before and after the OneNote workspace was implemented.

• • Pre-intervention, 56% disagreed that they were confident in quickly viewing recent investigation results. Post-intervention, 99% of users agreed/strongly agreed, with no negative responses.

• • Pre-intervention, 67% disagreed or strongly disagreed that they were confident in knowing what physical health appointments were scheduled. Post-intervention, 100% of respondents agreed/strongly agreed.

• • Pre-intervention, 78% disagreed or strongly disagreed that they were happy with the availability of past medical history information. Post-intervention, this increased to 99% agreed/strongly agreed.

• • Pre-intervention, 89% disagreed/strongly disagreed that they knew where to see patients on psychotropics requiring close monitoring. Post-intervention, this increased to 100% strongly agreed.

• • Pre-intervention, 66% disagreed/strongly disagreed being able to see single-point, up-to-date physical health information, at baseline. This increased to 99% agreed/strongly agreed post-intervention.

Physical health information is often overlooked in secure inpatient settings. Due to the limitations of the electronic patient record, it can be difficult to find relevant physical health information quickly. This can lead to dissatisfaction and a lack of confidence in the MDT, as shown in the baseline data.

After the Microsoft OneNote dashboard was introduced, there was a marked improvement in staff confidence, happiness, and awareness of physical health requirements for each patient.

Further data needs to be collected to assess for sustainability of these improvements. We intend to expand the scope of this system across the secure inpatient units in the Trust.

The Personality Disorder Service in the Northern Health & Social Care Trust was originally set up to deliver evidence-based treatment for people with the diagnosis of personality disorder. This group of people historically have been stigmatised, excluded and let down by services, despite their complex needs and frequent history of childhood trauma. The team developed a Mentalization Based Therapy (MBT) programme originally commencing in 2013.

To identify recent completers of the MBT 2 18 month programme and to assess whether there was any reduction or change in pattern to the number of days spent as inpatient both during and after having completed the programme, whether there was a reduction in the frequency of same day assessments with community mental health teams or unscheduled care and finally whether there was any reduction in terms of volume of crisis assessments and presentations to Emergency Department.

Using validated Quality Improvement Methods, a Plan Do Study Act Cycle was commenced which involved identifying patients who had begun and finished the MBT programme and minimum of 12 months had passed since completion in order to follow-up.

We then broke down this data into 3 domains. By using EPEX, Paris and Electronic Care Record computer systems, it was possible to analyse days spent as inpatient, same day assessments and crisis assessments as well as Emergency Department attendance.

For these periods of time, they were split into pre-commencement of programme (18 months), during programme (18 months) and post-completion of programme (12 months) to see if there was any tangible decrease in these numbers.

19 service users were identified that had initially been referred to Personality Disorder Service between 2016 and 2018 and who subsequently began MBT2 programme between 2017 and 2019. Given the length of completion of the programme, this allowed us to gather a full set of data with regard to these patients up to completion of programme in 2021. Subsequent period of 12 months was then analysed post-completion of treatment taking us up to 2022.

The average time spent in inpatient admission days prior to starting therapy for 18 months (n = 19) was 21.74 days, this decreased to 6.53 during therapy and 3.68 post-therapy (12 month follow-up) = 5.52 adjusted for 18 months. This represents a reduction of 74.61%.

The average number of same day assessments and unscheduled care (n = 8) seeking prior to admission was 1.38. This decreased to 0.75 during therapy and 0.88 post-therapy adjusted to 1.32 for 18 months, which represents a small decline of 4.35%.

Finally, the average number of Crisis contacts and Emergency Department assessments were 2.63 in the 18 months before commencing therapy, 1.26 during therapy and 0.58 in the 12 months post-therapy, 0.87 adjusted for 18 months. This represents a reduction of 66.92%

It is clear from analysis of the data that there has been a substantial decrease in time spent as admitted inpatient as well as number of contacts with Crisis Assessors and Emergency Departments in association with completion of the MBT 18 month programme.

This demonstrates that, by using an evidence-based and well-established programme, which carries a high time commitment for both service users and practitioners, it is possible to considerably reduce use of other, more acute services and keep patients with a diagnosis of EUPD out of hospital longer and on a sustained basis and also to reduce presentations to Emergency Departments which was often on the basis of self-harm and/or overdoses.

The dual result is that it can be validated objectively that service users are suffering less distress after having completed the programme, which will lead to better quality of life, whilst also reducing the burden on costly inpatient services with the end result being an important investment in mental health services in Northern Ireland and the prototype for the developing regional service.

To improve the quality of junior doctor handover in the Tyrone and Fermanagh hospital. The hospital is spread across a number of inpatient sites making it difficult to complete an in-person handover. Each day the handover is completed on a Word document and sent via trust email to relevant staff. Issues were identified with the quality of information shared and how the outstanding tasks were handed over.

A PDSA cycle was implemented to explore outstanding issues with the handover and consider how change might be implemented. Junior doctors identified various issues including the lack of a common format, the amounts and relevancy of information shared and identifying an individual or team to conduct the outstanding tasks.

A baseline audit for a 3 month period (July–September 2023) was completed. Results were reviewed and a driver diagram was established. Suggestions identified for improvement included the use of new template and an in-person handover.

A new template for recording information was drawn up and agreed by the group. It included basic demographic prompts such as staff member on shift and the date of handover. The template included prompts for key patient information identified from initial audit as frequently forgotten.

The template was emailed to doctors on the rota and was also highlighted to new staff at junior doctor changeover points. This new template was the intervention chosen for re-audit between November 2023 and January 2024.

Following the application of our intervention, completion of the handover improved. From an information governance perspective the identification of staff and shift dates improved (to 98% & 99% respectively). The security of information shared improved through use of password (69% to 91%).

The quality of information sharing also improved with the percentage improvement of key demographics increasing, such as patient initials (29.4%), Healthcare number (9.2%), MHO status (15.46%), patient summary (19.76%) and working diagnosis (34.91%) and finally an increase of 88.74% in identifying the person for following up outstanding tasks.

The use of a handover template has improved the quality of information shared across a number of key areas. The identification of person for handover has improved significantly with this tool and is felt to represent an improvement in patient safety. Following re-audit cycle, other areas were identified for further changes such as adjusting prompts on the template and a secure folder for storing the handover. These changes could be easily implemented in a subsequent audit cycle.

The assessment, diagnosis, and management of memory problems in older adults are routinely undertaken by memory assessment services (MAS) typically following referral from a GP. Mental health liaison teams (MHLT) newly identify many older people in acute hospitals with memory problems. Delirium is often diagnosed acutely and should be managed prior to any consideration of dementia diagnoses, however many of these people still have histories which also suggest underlying undiagnosed dementia. Referral policies advise of 3 months delay between delirium and MAS review to avoid misdiagnosis of dementia. MHLT therefore often request GP to refer at 3 months if still indicated. It is felt that some patients may be lost to follow-up via this route; our aim was to explore this further with a view to establishing a more robust direct referral pathway if indicated.

Electronic records of patients under the care of MHLT aged over 65 from June 2022 to June 2023 were reviewed. This excluded patients who were referred and discharged from MHLT after a single assessment. We collected retrospective data for 8 months during this 12-month period. For any patients with memory concerns, we recorded where MAS referral was recommended and whether they were subsequently referred and seen.

108 patients over the age of 65 under the care of MHLT were identified. 69 patients had memory problems, 28 of whom already had established diagnoses or were already under MAS and 41 had newly identified memory problems. Of these 41 patients, 15 were felt to need MAS referral due to possible dementia. 3 were referred directly to MAS by MHLT and were seen. 5 were later referred to MAS by GP on MHLT recommendation and were seen. 7 were not later referred to MAS despite it being recommended.

All 3 patients whom MHLT were able to refer directly to MAS were seen, whereas 7 out of 12 (58%) patients for whom 3-month delayed referral by GP was requested were not seen. The policy of 3-month delay avoids misdiagnosis due to delirium, but in practice also leaves some patients with missed opportunities for diagnosis and management of dementia. There is a need for a more robust delayed referral pathway to memory assessment services from mental health liaison teams. We hope to use these findings to improve our local referral pathways and share this information to support other localities.

The project aimed to review the Trust Medical Appraisal policy and offer a platform to update the Trust policy locally and align it to a National recommendation in the Medical Appraisal Guide besides gathering consensus for change for other relevant issues to the Trust.

The project was undertaken as a part of the ‘Leadership and management fellowship Scheme’ sponsored by the Tees Esk and Wear Valley NHS Foundation Trust and conducted in collaboration with the Royal College of Psychiatrists, UK and Faculty of Leadership and Management, UK 2022–23 with data collection lasting from January till August 2023. The methodology consisted of drafting a document comparing the information from the review of the existing Trust medical appraisal policy and the guidance in the Medical Appraisal guide, drafting a questionnaire which covered the complex issues in the appraisal process and where the Trust medical appraisal policy was identified as having gaps which required further opinions to be generated for a possible revision to the policy, and gathering consensus opinions from focus group discussions for different groups of staff which included appraisers who are not managers, consultants who are not appraisers, medical managers who are not appraisers, consultants who are appraisers and SAS doctors who are not appraisers. The focus groups were conducted virtually as well as face to face groups and consensus opinions were then synthesised with information available from the guidelines to draft recommendations. The recommendations were then presented to the senior managers in the Trust appraisal process to seek feedback and approval.

The main recommendations that followed from the review were: to promote supportive and developmental nature of the appraisal process by making the process less document intensive by modifying appraisal portfolio and appraisal sections, educating staff on not duplicating information, promote verbal reflection, and modifying corporate supporting information section to reduce burden on doctors; maintaining 3 year appraiser turnover; avoiding line manager to be the appraiser of the appraisee; not sending appraisal summary to the line manager and considering how to facilitate communication and input of the line manager to the revalidation decision; clarifying requirements of supporting information for appraisal of particular group of doctors (Trust doctors, International Medical Graduates (IMG), academics, and on zero hour contracts); expand corporate supporting information to include General Medical Council (GMC)/Trust disciplinary and low level concerns; to promote wellbeing discussion by adding prompt for doctor to comment on their wellbeing; adding a wellbeing statement to the appraisal template and finally to add trainer accreditation statement to the appraisal template to facilitate reporting of trainer accreditation. Most of the recommendations were accepted by the Trust except one on expanding the corporate supporting information for doctors and addition of a wellbeing template in appraisal section.

The project served as a significant leadership experience in my training role to undertake a project driving a Trust-wide change in medical appraisal policy based on participative leadership, generating consensus and developing a phased action plan towards implementation.

An April 2022 Electroconvulsive Therapy Accreditation Services (ECTAS) review of electroconvulsive therapy (ECT) services in the Southern Sector of the Western Health and Social Care Trust highlighted that the follow up of service users' memory and cognitive side effects post-ECT needed to be improved to deliver safer and more effective care. The aim of this MDT quality improvement project was to transform the follow-up process from a baseline of 13% of service users receiving memory assessment 1–2 months post ECT to 100% of service users receiving memory assessment 1–2 months post ECT over a 16 month period.

In June 2022, an MDT working group was established with key stakeholders from inpatient and community mental health services. Using driver diagrams, opportunities for improvement were collectively identified and innovative ideas proposed to overcome these barriers. The primary drivers for change were communication, resources, and education. Systems were established and PDSA cycles used to review our data and decide whether we needed to make a further change. 17 service users received ECT and were followed up within the 16 month period. Our third change brought about the most significant and sustained improvement to the process; establish ECT champions within community teams. The ECT champion's role was to improve communication between inpatient and community teams in regards to service users needing memory follow up post ECT.

The introduction of three ECT champions within the community teams significantly improved communication between the inpatient and outpatient teams resulting in an improvement in the standard of care to our service users. Initial figures show 100% of service users having memory assessment follow up at 1–2 months post ECT in July 2023, October 2023 & December 2023. No service users required follow-up within the service in August/September/November 2023. Performance monitoring is ongoing as part of the service's governance meeting.

In conclusion, by improving communication, utilising resources more effectively and educating through ECT champions, the percentage service users receiving memory assessments at 1–2 months follow up post ECT achieved ECTAS standard of 100%. This will benefit our service users by enabling us to identify those who need further input. Looking into the future, we need to undertake a clinical audit to assess for a sustained improvement and ensure that no unintended consequences have been introduced from this QIP. We have shared our learning within the wider trust and plan to spread and scale our changes across a wider area.

Clinical coding (CC) is the translation of medical terminology into a coded format that is recognised both nationally and internationally. NHS trusts must record the clinical care given to inpatients and the resources used for inpatients while they are in hospital care. CC ensures accurate patient records, communication and data exchange between providers and can aid in epidemiological research, healthcare planning and quality as well as cost control. An audit was carried out in a mental health inpatient unit to assess whether CC was completed as per the local and national CC guidelines, followed by an intervention to improve compliance.

2 inpatient wards were identified, 1 male and 1 female, and 10 patients from each ward were selected at random on the 15th of December 2023. Their notes were assessed to determine whether: the CC has been updated during their current admission, CC has been updated if new diagnosis, CC had been completed on last discharge, physical health conditions were included in the CC and the number of physical health diagnosis changes and their documentation. Intervention was carried out and a re-audit completed on the 31st of January 2024.

Out of 20 patients: 5 (25%) had a completed CC during their admission and 4 had a diagnosis change but only 1 (25%) CC was updated. 9 had a physical health diagnosis but only 3 (33%) were included on CC. 16 (89%) had a completed CC on last discharge and 2 were admitted for the first time.

Doctors on the wards were informed about CC, how to access the form on the system and the importance of updating CC. This was communicated in teaching sessions and doctor communication groups.

The re-audit showed some improvement. Out of 20 patients: 10 (50%) had a completed CC during their admission, 4 had a diagnosis change and 3 (75%) CC were updated. 7 had a physical health condition and only 2 (29%) were included on CC. 12 (75%) had a completed CC on last discharge and 4 were admitted for the first time.

The audit showed a lack of awareness of CC and its importance. The intervention helped to improve compliance of CC in current inpatients. Further intervention and improvement is required for physical health CC and can be attempted with posters in the doctor's rooms and regular reminding during group sessions.

Patients should have a comprehensive understanding of the side effects, and monitoring requirements of the medications prescribed to them. Making the patient aware of serious side effects is important for patient safety and informed consent. Patients should know when and how to seek help for side effects. Health literacy also increases patient autonomy and shared decision making.

As an inpatient, a psychiatric patient’s medications are closely monitored, and there is frequent contact with healthcare professionals who can identify any health needs. Within our trust, there is a side effect checklist to be completed by community staff each time a community patient has clozapine monitoring. However, in our clinical practice, we have observed that some patients have needed prompts regarding need for re-titration if dose missed for 48 hours.

We aimed to assess medication safety information awareness in a small sample of patients open to forensic community team who are prescribed clozapine.

A 26-point questionnaire was used to assess the participant's depth of knowledge of clozapine. A combination of 3 open and 22 closed questions were used. Patients were scored for their answers to the closed questions, using a predetermined marking scheme, being awarded 1 point per appropriate answer. We set the standard as maximum score of 22.

All participants (n = 7) were male and had been prescribed clozapine for at least one year.

All participants were able to accurately state why they were prescribed clozapine. The mean score was 16. Zero participants scored 22. Lowest score was 14. One participant omitted two questions (Do you know what to do if you take more clozapine tablets than you are supposed to? Do you know what to do if you forget to take clozapine?). He stated that he was very careful regarding his medication and therefore, will not forget or miss any doses.

71% of patients were unsure what they should do if they were to accidentally take more tablets than prescribed.

Five out of seven participants were able to cite at least one side effect of clozapine without prompting.

Two patients were not able to spontaneously recall the monthly blood test requirement.

There was a range of knowledge deficits about clozapine in our sample. After including reminders of safety information about clozapine at quarterly care coordination reviews, we plan to re-assess in a year's time.

With recruitment and retention of NHS doctors an increasingly topical issue, the facilitation of a supported Return To Work (RTW) following a period of leave is particularly important. That the support provided takes a holistic approach to the wellbeing of the individual and their family unit is necessary if it is to be of the greatest success, especially with regards to new parents. The World Health Organization recommends breastfeeding until 2 years of age but in the UK just 0.5% of parents are breastfeeding at 1 year and, perhaps more significantly, 90% of breastfeeding parents stop before they would like to. Under the 2010 Equality Act, breastfeeding is a protected characteristic and legally, upon RTW, a breastfeeding parent must have a Breast-Feeding Risk Assessment (BFRA). The Health and Safety Executive have set out factors to be considered when completing BFRAs which enable the identification, mitigation or removal of risks that threaten breastfeeding, often via impacting the physical and mental health of the parent and child.

Our aim was to explore the experiences of both JDs and clinical supervisors in accessing and completing BFRAs in order to identify whether further work was required on this subject.

A survey was sent to psychiatry JDs across the West Midlands inviting those who had RTW whilst breastfeeding to share their experiences. Another survey was sent to leads and supervisors across the region, exploring their confidence with BFRAs and their recommendations.

20 JDs responded. 16% received a BFRA with 5% being undertaken prior to RTW (best practise). For most of those who received one, it was a positive experience and 81% of those who did not receive one reported that they would have liked to but were either unaware that they existed or that they apply to children over 1 year.

36 consultants responded. 31% were aware of BFRAs with 9% feeling confident in completing one and none having had any training to do so. There was a strong sense that BFRAs should have a multi-disciplinary approach which contrasted with what occurred in reality.

Identifying a lack of knowledge, as well as doctors’ need and desires regarding BFRAs, has resulted in a multifactorial approach to raising awareness of their existence, content and potential impact. Sessions for JDs and supervisors have been organised regionally and locally and there has been engagement with each trust in order to create a more uniform breastfeeding policy.

The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provide acute care for the elderly with severe mental health conditions including dementia. Restraints are one of the methods employed in managing agitation in patients with dementia. The physical consequences of restraints are reduced mobility resulting in decreased muscle tone and mass, bone demineralisation, orthostatic hypotension, and atelectasis. This results in patients who are more prone to falls, aspiration pneumonia, deep vein thrombosis/pulmonary embolism and ulcers. The psychological consequences include aggravating agitation, feelings of humiliation, negative emotions like anger and despair. Hence, we embarked on a program to reduce the use of physical restraints in the management of agitation in patients with dementia.

Baseline restraint hours were collected from 7am to 9pm for all dementia patients who were restrained for agitation for a period of 5 months. Patients on Geri chair with seatbelt used primarily for fall prevention were not included. The Pittsburgh Agitation Scale was used to measure agitation.

The nursing staff were trained on the Enriched model for targeting behaviour and on the VIPS (Valuing people, Individualised care, Personal perspectives, Social environment) framework for person centred care. Restraint hours were collected post intervention as well as benzodiazepine usage data over both periods to monitor any changes in the usage.

The baseline data (preintervention) over a 5-month period determined that patients with dementia who were agitated were being restrained on an average for 3.33 hrs per day from the period of January to May 2021. Following the training of nursing staff on the enriched model of care and the use of VIPS framework for person centered care the restraint hours reduced to 1.48hr per day over 5 months from January to May 2022. Benzodiazepines usage went down from 0.34mg at baseline to 0.17mg per dementia patient per day post intervention.

Nonpharmacological interventions (enriched model and VIPS framework for person centered care) using a multidisciplinary team approach is effective in the management of agitation resulting from dementia and should be used as a first line in the management of such conditions.