Welcome to the FORUM: A new outcome measure for forensic mental health services.

Forensic mental health services provide care and treatment for people with a mental illness who are considered to pose a risk to the public. In England alone there are more than 6,000 forensic beds, costing the NHS over a billion pounds a year. It is vital that we can measure the outcomes of these services to make sure they are delivering the right care to patients, while also keeping the public safe.

What constitutes an ‘outcome’ is a complex question. Traditionally, research in this area has focused narrowly on ‘serious adverse events,’ like death, reoffending, or rehospitalisation. While clearly important, these events are thankfully rare and so are less useful for tracking individual patients’ progress.

More broadly, an outcome can be any change or result, such as improved mental health, better life skills and independence, or quality of life, which happens as a result of a patient receiving care. The goal is to measure these outcomes over time to see if patients are benefiting from treatment.

However, outcome measurement in forensic mental health has been limited, with tools focused heavily on public risk and patient symptoms. This is a problem, as it means such tools have neglected outcomes like quality of life and social functioning that are particularly meaningful for patients. In fact, patients have often been excluded from measuring their own outcomes, with few tools designed with, or rated by, patients themselves.

With this in mind, our project aims to broaden the outcomes measured by integrating assessments of the full range of important areas, including quality of life and overall functioning, from the perspective of patients, as well as clinicians.

We set up a Patient and Public Advisory Group which included people with lived experience of admission to forensic services. This group worked with the research team every step of the way to co-design the project. We started from first principles, by taking a step back to ask the fundamental question: What are the important outcomes in forensic mental health services?

We conducted interviews and focus groups with patients, carers, clinicians, and policymakers to find out more. We looked carefully at what people told us were important outcomes for them, with a process called ‘thematic analysis’ -- a method used to identify, analyse, and report patterns or "themes" within interview and focus groups, helping to organise, describe an interpret the data in rich detail.

We then used an approach known as the Delphi technique to prioritise these outcomes. This involved two expert panels, one of patients and carers, the other of professionals, reviewing the outcomes, and asking them to rate how important they thought each outcome was. We did this twice; the second time panel members were shown their own response from the first round and the aggregate scores from both panels.

The Delphi process helped to create a consensus about the most important outcome areas from the perspective of the two panels, and we used this to develop our new measure.

We also learnt from the expert panels that patients and carers prioritised different outcomes to professionals. We wanted the measure to be quick and easy to use, while covering all the key areas, so we designed two separate questionnaires, one for patients and one for clinicians, which would combine to form the final measure. While some questions were similar between the two questionnaires, others were unique. For example, the patient questionnaire has questions about identify and quality of life, such as ‘I have felt good about myself and ‘My life has felt meaningful.’

To ensure that the questionnaires made sense to the people who would use them we rigorously road tested them, making changes as needed. Once we had versions that we were happy with we studied how they worked in practice, in a real-world forensic mental health setting, to see if the measure was still valid and reliable. For example, how did the new measure compare to existing measures and would two clinicians give the same patient similar scores.

We are now working on a project to understand how the new measure can best be used in day-to-day clinical practice outside of a research and development context.

We have called the new measure the FORensic oUtcome Measure, or FORUM for short. This acronym reflects the intention that patients and clinicians come together to discuss their views on outcomes using the FORUM and can then jointly develop a plan to address any needs identified through the process.

We are keen to find out how the FORUM works in other forensic mental health services. We are looking to collaborate with others anywhere in the world who think that the FORUM might help them. For more information, please visit the website www.forensicoutcomemeasure.com or contact the team by emailing Dr Howard Ryland on howard.ryland@psych.ox.ac.uk.