De-implementation of low-value practices (clinical and non-clinical) in UK mental health services: A patient perspective

Background: Low-value care is a widely recognised issue that threatens the quality of patient care and the sustainability of healthcare systems. The majority of efforts to identify and stop the use of low-value care have focused on clinical practices such as unnecessary diagnostic tests, clinical treatments and surgical procedures. Little is known about non-clinical patient safety practices. Furthermore, there appear to be limited efforts to identify and de-implement low-value care in mental health services. Eliminating practices that are wasteful could free up the time and resources staff need to provide safe and high-quality care.
Aims: The overall aim of this PhD to identify low-value care practices in UK mental health services, examine how they could be de-implemented and understand the role of patients in this process.
Study 1: A systematic review and meta-analysis were conducted to examine the effectiveness of de-implementation interventions that target patients. The ‘active ingredients’ in successful interventions were also explored. The review highlighted the importance of the patient-clinician interaction in stopping low-value care and the paucity of de-implementation efforts in mental health settings.
Study 2: To identify mental health care practices that are perceived to be low-value, semi-structured interviews were carried out with people who have lived experience of mental health challenges. Four practices were identified as low-value. This included the overuse of antidepressants, risk assessments, physical restraint and enhanced observations.
Study 3: An established de-implementation framework was used to determine a priority practice for further exploration. The literature surrounding each practice was reviewed to explore existing efforts to de-implement these practices. Through this process, enhanced observation on mental health wards was identified as a potential target for de-implementation.
Study 5: To explore enhanced observations further, a rapid ethnographic study was carried out at three NHS acute female mental health wards. This study looked at how enhanced observations were experienced by staff and service users, how they are conducted, and how ward related cultural and contextual factors impact the use of this practice. Contextual summaries of each site and crosscutting themes were developed to summarise interviews and observational data.
Study 6: The final stage of this PhD involved developing recommendations to reduce the inappropriate use of enhanced observations. A four-stage stakeholder consultation process was used to refine a set of nine recommendations.
Conclusion: Study findings presented several novel insights about low-value mental healthcare practices. Evidence from this PhD provides a novel way of involving service users in the identification of low-value care and de-implementation. The findings also contribute to the development of de-implementation theory and understanding the patient's role in de-implementation.