Shine 2014 final report
Developing Psychological Services
following facial injury within the Centre for
Oral and Maxillofacial Surgery Trauma
Clinic, Royal London Hospital
Institute of Psychotrauma, East London NHS Foundation
Trust & Centre for Oral and Maxillofacial Surgery, Barts
Health NHS Trust
25 September 2015
The Health Foundation
Tel 020 7257 8000
www.health.org.uk
Part 1: Abstract
Project title: Developing psychological services following maxillofacial injury within
the Centre for Oral and Maxillofacial Trauma Clinic, Royal London Hospital
Lead organisation: Institute of Psychotrauma, East London NHS Foundation Trust
Partner organisation: Centre for Oral and Maxillofacial Surgery, Barts Health NHS
Trust
Lead Clinician: Dr Naomi Wilson
Research by the Institute of Psychotrauma and the Centre for Oral and Maxillofacial surgery
trauma clinic (2013) demonstrated 40% of patients met diagnostic criteria for either
depression, Post-traumatic Stress Disorder (PTSD), anxiety, alcohol or substance misuse or
were presenting with facial appearance distress. Most facial injury patients were not
receiving mental health assessment or treatment and the maxillofacial team did not have
direct access to psychological services.
The project aimed to address this need by:
 Offering collaborative medical and psychological care for all facial injury patients
 Providing brief screening, assessment and early psychological intervention
 Training the medical team to better recognise and respond to psychological distress
The team were not aware of any other collaborative service of this type in the UK, therefore
successful innovation had the potential for national scale-up.
A clinical psychologist and research assistant joined the maxillofacial trauma team between
September 2014 and September 2015. All facial injury outpatients attending clinic completed
a psychological screening questionnaire and were given information about coping after facial
injury. The clinical psychologist met or phoned all patients whose responses on the
screening questionnaire indicated psychological distress. They were either given further selfhelp information, signposted to mental health services or offered immediate brief
psychological treatment.
Key achievements and impact:
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Demonstrated feasibility of offering collaborative psychological care within a busy
oral and maxillofacial trauma clinic
Systematic and reliable identification of psychological need; over 600 facial injury
outpatients were screened for psychological difficulties in clinic
Positive feedback about the beneficial impact of psychology service from patients,
family members and medical team
Robust support from senior management within Barts Health NHS Trust and East
London NHS Foundation Trust
Psychological consultation to the team resulted in improved understanding of
psychological need in patients and raised profile of collaborative psychological care
across the oral and maxillofacial department
Research expertise of clinical psychology service resulted in collaboration with
medics to write two research papers for submission to peer-reviewed journals
Positive media coverage about the maxillofacial trauma clinic, including the
psychology service: http://www.standard.co.uk/lifestyle/london-life/fix-your-bike-face-
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how-the-royal-london-hospital-are-repairing-our-broken-cyclists9957295.html?origin=internalSearch
National dissemination of pilot to other stakeholders – well received oral presentation
delivered at the British Oral and Maxillofacial Surgery annual conference, July 2015
Psychology service reach extended beyond the original aims, to include: family
support, neuropsychological consultation and complex case management
Development of a robust bid for on-going commissioning of psychology service
Impetus to extend the service model to other maxillofacial trauma units in the UK,
through a national oral and maxillofacial trauma special interest group
Key challenges and learning points:
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Personnel changes mid-way through project as the clinical psychologist and research
assistant both went on maternity leave. Efficient recruitment of new post-holders
meant negligible impact on service provision
Evaluation of the project required additional resources. Honorary psychology
research assistants were recruited to this end
Sourcing clinical space within the oral and maxillofacial trauma clinic for confidential
psychological consultations was an on-going challenge
Accessing electronic patient records could have been better integrated across Trusts
Psychological needs of patients extended significantly beyond that reported in
original research project, and included; risk assessment (self-injury, violence towards
others, injury through domestic violence, neglect and lack of appropriate
psychological service at critical recovery points, e.g., in brain injured patients), liaison
with family members who were traumatised and/or had become carers,
neuropsychological assessment and co-ordination of mental health care for patients
with complex needs
Evaluating the economic impact of an early intervention service was challenging in
the absence of longer-term follow-up data
Commissioning the project beyond current funding stream during financial austerity
Responsiveness to patient or medical team feedback and service user involvement
led to iterations in the service structure that resulted in improved design, acceptability
and effectiveness of service
Part 2: Quality impact: outcomes
Two clinical psychologists (Band 8b, 0.1wte, and Band 8a, 0.6wte) and a research assistant
(RA) (Band 5, 0.2wte) were recruited. The 8b Clinical Psychologist was project lead and
supervisor of other staff. The 8a Clinical Psychologist spent 50% of their working time in the
oral and maxillofacial trauma clinic (all day Mondays and Thursday afternoons). Their role
was to administer self-report screening questionnaires, interpret these and respond to
patients who needed immediate assessment and intervention - either in clinic or within a few
days. The role of the RA was to support in the administration and interpretation of the
screening tool when clinical demand was high and to support the evaluation of the project. A
screening questionnaire (see Appendices) that took approximately five minutes to complete
was devised and administered to all outpatients. This was based on already validated
psychometric questionnaires (e.g., HADS, PCPS) that asked about depression, anxiety,
PTSD, alcohol and drug use, risk to self (suicidal ideation) and facial appearance distress. It
also asked if patients wanted and consented to psychological consultation. As the clinic was
extremely busy and a significant proportion of patients were urgent new cases that were not
pre-booked (e.g., had attended A&E over the weekend) systematic liaison with the reception
and nursing staff was required to ensure that all patients were screened. At the point of
screening patients were also given psychoeducation about common psychological
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responses and helpful coping strategies following traumatic events (see Appendices). The
surgeons also liaised with the clinical psychologist and vice-versa in cases of particular need
or risk.
All patients who scored above cut-off on any of the subscales in the screening tool were
approached by the clinical psychologist and briefly assessed to determine their
psychological needs. A range of self-help leaflets (see Appendices) were written, e.g.,
anxiety, low mood, PTSD, were available to give to patients in clinic and brief psychological
treatment was provided about how to cope with common psychological difficulties. Some of
these patients were also offered follow-up calls, emailed, or seen at follow-up appointments
in clinic so further advice could be given and a significant number were signposted (for selfreferral) or referred to mental health services or non-statutory organisations (e.g., Headway
(https://www.headway.org.uk/home.aspx), Changing Faces
(https://www.changingfaces.org.uk/Home) who could support them. This sometimes required
significant and occasionally urgent liaison (phone calls, letters, emails) on the part of the
clinical psychologist, e.g., with GPs, local IAPT services, liaison psychiatry, specialist mental
health services and charities, to ensure appropriate pathways of care.
All data from completed screening measures and patient contact notes were entered on to
electronic databases within East London NHS Foundation Trust. Any letters sent regarding
patients were copied to the oral and maxillofacial surgeons.
No significant changes were made to the service during its running, however the following
minor adjustments were implemented:
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Screening tool was amended to include patient date of birth, address and GP to
minimise need to cross-referencing with medical notes for follow-up contact
Additional self-help leaflets were devised in response to patient need, e.g., sharing
difficult information with children
As the service evolved, the clinical psychologist noted a significant number of
patients who had more complex psychological need than those common mental
health difficulties as assessed through screening. These were identified through faceto-face or phone contact and included: risk assessment (self-injury and suicidality,
violence towards others, child protection issues, vulnerable adult safeguarding, injury
through domestic violence, lack of appropriate psychological service at critical
recovery points, e.g., in brain injured patients), liaison with family members who were
traumatised and/or had become carers for facially injured patients,
neuropsychological assessment and co-ordination of mental health care for patients
with complex needs.
Primary data was collected as follows:
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Demographic profile of patients presenting to psychology service
Prevalence of psychological distress
Number of patients who received follow-up assessment and intervention, and the
type and extent of psychological treatment provided
Secondary data was collected as follows:
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Almost 10% of patients were followed up by phone. The screening tool was readministered and patients were asked about their experience of the psychology
service (see Appendices).
Ten patients were interviewed in greater depth about their facial injury, the
psychological consequences of this and the impact of the psychology service on their
recovery. These were audio or video recorded for case studies (See Appendices for
two brief case studies).
The oral and maxillofacial surgical team (medics and nurses) were individually
interviewed using a semi-structured interview (see Appendices) about their
experience of the psychology service
Negligible adjustments were made to the outcome measures from those originally
implemented.
The source of all data was either patients or medics within the oral and maxillofacial trauma
clinic. Access to this data was relatively straightforward, although it required systematic and
proactive work on the part of the clinical psychologist and research assistant to collect the
qualitative data, as the time needed for this was significant. Good relationships with both
sets of stakeholders facilitated this data collection.
The validity and reliability of the data was believed to be high. The screening tool was based
on previously validated psychometric questionnaires routinely used in primary care mental
health settings and additional questions added based on the prior research experience of
the team with this population. There was baseline data for over 600 patients, which the team
were very satisfied with. The clinical psychologist and research assistant had high-level
research skills (up to doctoral level) therefore both the quantitative and qualitative follow-up
data was robustly and reliably collected and analysed.
Primary data:
Seventy-three per cent of patients screened were men, and 27% women. Other
demographic details can be found below.
Patient age groups
3%
3%
6%
Under 18 years
7%
11%
18-29 years
40%
30-39 years
40-49 years
50-59 years
60-69 years
30%
70+ years
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Patient ethnicity
2%
6%
10%
White or White British
Asian or Asian British
Black or Black British
Mixed
20%
62%
Other
Geographical spread of patients screened at the Oral and Maxillofacial trauma clinic across
the UK and in London (n= 577 – not all patients had an identifiable postal address)
491 patients (85%) lived in a London Borough and 86 (15%) lived outside London.
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Source of Facial Injury
4%
3%
Assault
44%
29%
Fall
Accident
Sport
Other
20%
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The presenting psychological difficulties as screened in clinic were as follows. (NB: ‘Facial
distress’ = distress or anxiety about facial appearance, and ‘Daily functioning’ = negative
impact of facial injury on day to day functioning
Positive screen for psychological
conditions at first contact (n = 642) and
in follow-up group (n = 51)
90%
80%
70%
All patients initially
screened
Follow-up group
60%
50%
40%
30%
20%
10%
0%
NB: ‘Facial distress’ = distress or anxiety about facial appearance, and ‘Daily functioning’ =
negative impact of facial injury on day to day functioning
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Level of psychological intervention received
by pateints
26%
63%
28%
1%
1%
9%
Screening only, n = 59
Brief intervention in clinic, n = 398
In-depth intervention in clinic and onward referral, n = 165
Complex case requiring extensive liaison outside clinic, establishing pathway of care, n = 5
Specialist psychotherapy with psychologist outside clinic, n = 8
There was a correlation between the degree of psychopathology and the amount of
psychological intervention received by patients, i.e., those with more presenting difficulties
required greater contact with the service. In addition, of those patients followed-up at three
months, 25% of those who had received only brief intervention had not returned to work
whereas of those who had needed more in depth intervention, 36% had still not returned to
work.
Secondary data:
Psychological difficulty at follow-up in this sub-group of patients, indicated that overall there
was a reduction in morbidity from 79% to 58%. The largest improvements were in distress
about facial appearance and improvements in daily functioning. This might be expected,
given that recovery and healing of the acute facial injury would be most rapid in the
immediate weeks post injury. Depression and PTSD symptoms had also dropped, however
drug use and anxiety had increased. This indicated that psychological need in this patient
group was on-going at least over the medium-term.
The data below was collected from 8% of patients followed-up by phone, and the medical
team.
Of those patients who received any psychological intervention 78% said that the psychology
service either slightly or significantly improved their experience of attending the maxillofacial
trauma clinic.
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Core qualitative themes from patient feedback were as follows:
Positive feedback:
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Having someone to talk to about the psychological impact of their injury; being
proactively approached within clinic, receiving empathy, validation, support, hope and
having problems normalised was valued
Patients felt the psychology service was highly relevant to their presenting needs
Patients had an improved understanding of psychological difficulties, found tools for
managing psychological distress helpful
“[The psychologist] helped
address my drinking, helped
me offload and feel validated”
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Patients believed
significantly worse
input
that their recovery would have been
without psychological
“[It] helped me to think more
rationally, I was too
distressed to do that on my
own”
Areas for improvement:
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Patients wanted greater access to the psychologist; more private clinic space for
consultations, earlier contact (for patients whose injuries pre-dated the start of the
service and were seen at follow-up consultations)
Core qualitative themes from medical team were as follows:
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Rapid, flexible, integrated psychological care was beneficial to patients
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Addressing psychological issues facilitated medical recovery
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Families reported that they had also found psychological support very beneficial
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Their awareness of the psychological impact of facial injury had increased and they
would value more training in this area
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“Formerly I would
make an urgent
referral to the GP to
help the patient
access local
services – which
never happened or
happened slowly”
“It is good to know the
patient is being taken
care of as a whole.
Psychological
problems can be dealt
with efficiently which
means they’ll recover
[physically] sooner”
“Patients find it
helpful. They ask
where the
psychologist is” “I
now have more
awareness of the
domino effect of
trauma on a
patient’s life”
“[Having the
psychologist in
clinic means] I can
ask them for their
opinion and it frees
me up to see
another patient in a
busy clinic”
The impact of the psychology service was uniformly agreed among all stakeholders (medical
team, patients and psychologists) to be high. The introduction of comprehensive, expert,
patient-centred screening and psychological assessment into the clinic was a fundamental
change in service delivery team.
The reach of the psychology service was substantial. Unintended consequences of the
intervention were the provision of the following services by the clinical psychologist:
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Complex packages of care and liaison with secondary care mental health services
with a minority group of patients, e.g., where there was substantial risk to self or
others, multiple diagnoses ore pre-existing mental health problems
Brief neuropsychological assessment and referral to neurological services
Family and systemic work, e.g., with parents, partners, friends or children of patients,
who had been directly or indirectly affected by the facial injury, e.g., were traumatised
by witnessing the patient be injured or who had become carers for them
Two case studies illustrate the type and level of complex care required by a significant
minority of patients (see Appendices).
Part 3: Cost impact
Key cost measures were the employment of clinical psychology staff that was calculated
based on NHS Agenda for Change salary scales (see Addendum – Project Finance),
standard administrational costs and the cost of initial dissemination.
Two issues with respect to project costs were:
i)
Use of unpaid ‘Honorary’ psychology assistants (psychology undergraduates or
graduates) as additional staff who worked in the following areas; scoring
screening tools in clinic when exceptionally busy, production of clinical materials,
carrying out follow-up calls for evaluation purposes and analysis of evaluation
data.
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ii)
Increased Clinical Psychology (8b) time to 0.2wte at times of staff turnover when
recruitment tasks increased. This cost was absorbed by the Institute of
Psychotrauma.
Implementation costs such as staff training and change management activity were
accommodated within the supervision time offered by the 8b Clinical Psychologist and within
RA hours.
Evaluating the economic impact of the innovation was not a primary aim of the project. This
was challenging to measure in an early intervention service whose aim was prevention and
rapid identification of treatment needs and where no comparison group was available to
compare medium or long-term outcomes between those who had received psychological
input and those who had not.
Qualitative feedback from the medical team and patients consistently reported that the
psychology service had positively benefited medical and psychological recovery, and that
they anticipated this would have been slower or even severely disrupted in the absence of
psychological input.
There is substantial research evidence that indicates those with long-term physical health
conditions also have mental health problems, which was corroborated by our clinical
experience. A significant minority of oral and maxillofacial trauma patients come within this
category, e.g., those with brain injury, chronic pain, on-going need for reconstructive surgery
(sometimes up to years), disability due to sight loss or other functional loss and permanent
disfigurement. A recent report by the King’s Fund Centre for Mental Health (2012) concluded
the following, all of which are pertinent to the oral and maxillofacial trauma clinic patient
cohort and our innovation:
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By interacting with and exacerbating physical illness, co-morbid mental health
problems raise total healthcare costs by at least 45% for each patient with a longterm condition and co-morbid mental health problem(s), after controlling for severity
of physical illness
There is evidence that the relationship between having multiple long-term conditions
and experiencing psychological distress is exacerbated by socioeconomic
deprivation
A significant part of the explanation for poorer clinical outcomes is that co-morbid
mental health problems can reduce a person’s ability to actively manage their
physical health conditions
Detection of co-morbid mental health problems in those with long-term health
conditions is not done to a consistently high standard, and often goes undetected
Innovative forms of collaborative care (as modelled within this Shine project)
demonstrate that providing support for co-morbid mental health needs can reduce
physical health costs in acute hospitals and integrated treatment for mental and
physical health has better outcomes than overlaying mental health interventions on
top of medical treatment
Clinical commissioning groups should prioritise integrating mental and physical
health care more closely as a key part of their strategies to improve quality and
productivity in health care
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Part 4: Learning from your project
The key aims of this project were met which was to successfully introduce collaborative
psychological care within an oral and maxillofacial trauma outpatient service in a busy
London secondary care hospital.
The enablers that helped us to achieve this were:
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
Pre-existing relationships between Institute of Psychotrauma and oral and
maxillofacial department (through prior two-year research project) meant mutual
respect, confidence and trust between teams was high. This facilitated rapid
implementation of service and each team had clear, shared expectations for
service model
Highly competent clinical psychology staff that included clinical psychologists with
service development and entrepreneurial skills, the ability to liaise and lead the
MDT to implement service changes, high level communication skills, the capacity
to function independently and autonomously within non-mental health setting, the
ability to creatively respond to and find solutions to barriers to the service and
devise research and disseminate the pilot project at a high level
Commitment, enthusiasm, openness and buy-in from lead oral and maxillofacial
surgeons and medical team
Culture of collaborative and consultative working within the oral and maxillofacial
team
Inclusion of research staff within team to facilitate evaluation
Active engagement from patient representatives that informed service iterations
and leant service development ecological credibility
MDT buy-in was enhanced over time through responsiveness to clinical need;
clinical psychologist ‘going the extra mile’ for particularly complex patients, e.g.,
occasional in-patient assessments, regular board meetings and rapid
communications around these and research expertise of psychology team to
support publication output
Organisational culture of both services was innovation driven and proactive so
‘match’ of teams was highly congruent
The key project aims were achieved. However, there were some aspects of organisational
culture that acted as a barrier to service implementation at times. As clinical psychology staff
were employed by a local mental health Trust but working in a hospital run by an acute
Trust, communication and co-ordination was somewhat compromised by IT systems that
were not inter-operable, and access to useful patient data was not routinely facilitated for the
clinical psychologist. This meant some replication of communication, e.g., medics had to
receive paper copies of letters or reports about patients written by the clinical psychologist.
Similarly the clinical psychologist had a relative lack of influence within the acute NHS Trust
that was also financially vulnerable and with high turnover of senior staff, including at Board
level. This meant that targets for internal dissemination were difficult to identify and gaining
leverage for on-going commissioning was difficult within the acute Trust.
Securing protected, confidential and accessible clinic space was also problematic, and both
patients and medics recognised this limitation. Future service development would be
dependent on this being provided.
Staff changes were a significant challenge. Both the Band 8a clinical psychologist and RA
left the project part-way through the year due to maternity leave although the project lead
(who had also run the prior research project) remained in post. This leant the project
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continuity and the project lead oversaw recruitment of new staff, induction and integration in
to team. This resulted in an agreed break in the full psychology service for one month (with
urgent referrals from oral and maxillofacial surgeons only accepted I this time period), and
an extension to the project end-point by one month.
It is felt that our original ambitions were realistic given available resources and timescales
Specific learnings included:
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Need for highly qualified staff due to multiple skill set needed to establish service,
work autonomously and manage volume and complexity of work
Relationships between services and among Board members were primary to
success. The lack of felt hierarchy among those delivering a collaborative service
leant the innovation energy as ideas and changes were valued and welcomed from
all.
Part 5: Plans for sustainability and spread
A business plan has been drafted to submit to commissioners within Barts Health and to
NHS England, in order to sustain the innovation beyond the funding period. There is support
for this from the Business Development Units at Barts Health NHS Trust and East London
NHS Foundation Trust.
Plans to spread the innovation beyond the original site include the following;
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A number of patients have been interviewed and video or audio recorded, such that
their case studies can be included in research papers and further dissemination /
spread. There is an agreement to write up two papers for submission to the British
Journal of Maxillofacial Surgery. These will include i) a write-up of the psychology
service innovation and ii) a series of case studies highlighting the range and
complexity of psychological need in patients presenting to oral and maxillofacial
trauma services beyond that identified in the original research project.
Attendance and presentation of innovation at an international BAOMS conference in
2016
To designate the psychology service within Barts Health NHS Trust as a UK centre of
excellence for collaborative mental health care in oral and maxillofacial trauma clinics
To run an open / training day for other oral and maxillofacial trauma specialists about
the psychology service
To develop webinar training materials about how to replicate the psychology service
provision at other sites
Opportunities for media coverage (TV, newspaper, online news) via the
communications department of East London NHS Foundation Trust and media
contacts at Sky have started.
With respect to other resources, the team are applying for dissemination and spread monies
from the Health Foundation, for which there are funds of up to £30k for this purpose.
Dissemination already completed:
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An oral presentation about the Shine innovation was delivered at the British Association of
Oral and Maxillofacial (BAOMS) annual conference in July 2015 (See Appendices). A video
of the presentation being delivered at the conference can be accessed
here: http://we.tl/swqS4TeDdg. Three associated research papers were taken as poster
presentations (See Appendices for primary research paper). A medical audience received
these very positively, and numerous queries were made about how to develop similar
provision in other oral and maxillofacial trauma clinics. The lead clinical psychologist has
since liaised with one other service in Glasgow who are looking to develop similar provision.
Communication is also on going with the trauma special interest group within BAOMS for the
presentation (including video of this) to he shared with all members at a national level.
The service was featured in a London Evening Standard article, ‘Fix your bike face: how the
Royal London Hospital are repairing our broken cyclists’ 25 January 2015, which specifically
mentioned the importance of the psychological provision patients received (See
Appendices).
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