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The implementation of integrated psychological medicine services in Devon: An ethnography of change

Sarah Eddy (Student)

Supervisors: Dr Jo Day, Dr Iain Lang, Professor Chris Dickens 

Implementing change to improve practice and outcomes in healthcare can be complex and challenging. Obstacles to achieving anticipated goals may be encountered on multiple levels ranging from aspects of the change (intervention) to be made and how they are interpreted, through individual, team, and organizational problems, to system-level difficulties such as norms and expectations of professional behaviour.

The focus of this project will be on the implementation of an integrated psychological medicine service in Devon. We know anxiety and depression are approximately three times more common in people attending hospital than in the general population. The significance of this comorbidity lies not only in the greater misery, fatigue, and fearfulness experienced by those affected but in its association with poorer medical outcomes; among populations with long term conditions, depression and anxiety are associated with a doubling of morbidity and mortality, worse health-related quality of life, increased use of unscheduled care and increased healthcare costs. A related problem is that of “medically unexplained symptoms”, which can be challenging to address and resolve. Together, poor mental health in people with long-term physical health problems and poor management of medically unexplained symptoms are estimated to cost the NHS in England more than £11 billion a year (Naylor et al 2016).

Like most acute providers, medical and surgical care within the Royal Devon and Exeter Hospital (RD&E) have historically focused on the delivery of excellent physical healthcare and not on providing high quality psychological care to people attending hospital. NICE Guidance (2018) on how to manage these problems now exists and the RD&E is now working with Devon Partnership Trust and academic partners to develop and implement an Integrated Psychological Medicine service that will run alongside routine medical and surgical care. The project has been underway for several months and is currently running in a small number of departments, partially implemented in others, and there are plans for more departments to adopt it.

The aim of this PhD is to explore the models available for integrated physical and psychological care and to gain an in-depth understanding of the experience of implementing a model, in one local hospital setting, focusing on the key influences on how decision-making and action occur to implement and sustain a new way of working. This PhD will include Patient and Public involvement. Our objectives are:

1. To carry out a scoping review of the literature on models of integrated physical and psychological care comparable to that being adopted locally.

2. To study the implementation of the local model using a mixed methods ethnographic approach (drawing on interviews, observations, and documentation) in order to understand (a) what influences decision-making on the adoption and implementation of new ways of working in hospitals? (b) How does adaptation of planned interventions occur? (c) Which aspects of implementation (from intervention and individual, through teams and departments, to organizations and systems) lead to changes being both routinised and sustained?

This PhD research will provide an opportunity to further the empirical understanding of the implementation of integrated mental and physical health services and the management of care for patients presenting with medically unexplained symptoms. The insights from this project will provide significant transferable learning of the nuances and experiences of those involved in undertaking a major change to improve holistic service delivery for the benefit of patients.    

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