No abstract

Medical Research Council guidelines recognise the need to optimise complex interventions prior to full trial through greater understanding of underlying theory and formative process evaluation, yet there are few examples. A realist approach to formative process evaluation makes a unique contribution through a focus on theory formalisation and abstraction. The Evaluation 25(2) success of an intervention is dependent on the extent to which it gels or jars with existing provision and can be successfully transferred to new contexts. Interventions with underlying programme theory about how they work, for whom, and under which circumstances will be better able to adapt to work with (rather than against) different services, individuals, and settings. In this methodological article, we describe and illustrate how a realist approach to formative process evaluation develops contextualised intervention theory that can underpin more adaptable and scalable interventions. We discuss challenges and benefits of this approach.

Good mentoring is particularly important for student support. Where there are high student numbers in placement, this can adversely affect students' placement learning.

ObjectivesTo determine if street triage is effective at reducing the total number of people with mental health needs detained under section 136, and is associated with cost savings compared to usual police response.DesignRoutine data from a 6-month period in the year before and after the implementation of a street triage scheme were used to explore detentions under section 136, and to populate a decision analytic model to explore the impact of street triage on the cost to the NHS and the criminal justice sector of supporting people with a mental health need.SettingA predefined area of Sussex, South East England, UK.ParticipantsAll people who were detained under section 136 within the predefined area or had contact with the street triage team.InterventionsThe street triage model used here was based on a psychiatric nurse attending incidents with a police constable.Primary and secondary outcome measuresThe primary outcome was change in the total number of detentions under section 136 between the before and after periods assessed. Secondary analysis focused on whether the additional costs of street triage were offset by cost savings as a result of changes in detentions under section 136.ResultsDetentions under section 136 in the street triage period were significantly lower than in the usual response period (118 vs 194 incidents, respectively; χ2 (1df) 18.542, p<0.001). Total NHS and criminal justice costs were estimated to be £1043 in the street triage period compared to £1077 in the usual response period.ConclusionsInvestment in street triage was offset by savings as a result of reduced detentions under section 136, particularly detentions in custody. Data available did not include assessment of patient outcomes, so a full economic evaluation was not possible.

BackgroundSubstantial policy, communication and operational gaps exist between mental health services and the police for individuals with enduring mental health needs.AimsTo map and cost pathways through mental health and police services, and to model the cost impact of implementing key policy recommendations.MethodWithin a case-linkage study, we estimated 1-year individual-level healthcare and policing costs. Using decision modelling, we then estimated the potential impact on costs of three recommended service enhancements: street triage, Mental Health Act assessments for all Section 136 detainees and outreach custody link workers.ResultsUnder current care, average 1-year mental health and police costs were £10 812 and £4552 per individual respectively (n = 55). The cost per police incident was £522. Models suggested that each service enhancement would alter per incident costs by between −8% and +6%.ConclusionsRecommended enhancements to care pathways only marginally increase individual-level costs.