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Abstract
Background Allied health professionals (AHPs) in inpatient mental health, learning disability and autism services work in cultures dominated by other professions who often poorly understand their roles. Furthermore, identified learning from safety incidents often lacks focus on AHPs and research is needed to understand how AHPs contribute to safe care in these services.
Methods A rapid literature review was conducted on material published from February 2014 to February 2024, reporting safety incidents within adult inpatient mental health, learning disability and autism services in England, with identifiable learning for AHPs. 115 reports/publications were included, predominantly consisting of independent investigations by NHS England, prevent future deaths reports and Care Quality Commission reports.
Findings Misunderstanding of AHP roles, from senior leadership to frontline staff, led to AHPs being disempowered and excluded from conversations/decisions, and patients not getting sufficient access to AHPs, contributing to safety incidents. A central thread ‘organisational culture’ ran through five subthemes: (1) (lack of) effective multidisciplinary team (MDT) working, evidenced by poor communication, siloed working, marginalisation of AHPs and a lack of psychological safety; (2) (lack of) AHP involvement in patient care including care and discharge planning, and risk assessment/management. Some MDTs had no AHPs, some recommendations by AHPs were not actioned and referrals to AHPs were not always made when indicated; (3) training needs were identified for AHPs and other professions; (4) staffing issues included understaffing of AHPs and (5) senior management and leadership were found to not value/understand AHP roles, and instil a blame culture. A need for cohesive, well-led and nurturing MDTs was emphasised.
Conclusion Understanding and recognition of AHP roles is lacking at all levels of healthcare organisations. AHPs can be marginalised in MDTs, presenting risks to patients and missed opportunities for quality improvement. Raising awareness of the essential roles of AHPs is critical for improving quality and safety in inpatient mental health, learning disability and autism services.
- mental health
- patient safety
- health services research
Data availability statement
Data are available on reasonable request. The search strategy and full list of materials reviewed are provided in the article. Full data extraction tables are available on request from the first author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Research has indicated that while allied health professionals (AHPs) have many important roles in inpatient mental health, learning disability and autism services, their roles are often poorly understood by other professionals.
Similarly, while the importance of applying lessons from patient safety incidents to prevent recurrence is widely understood, the role of AHPs in identifying risks and promoting safe, high-quality care is often overlooked in the findings from these incidents.
WHAT THIS STUDY ADDS
This is the first review to systematically analyse safety incidents in inpatient mental health, learning disability and autism services, with a focus on learning for the AHP workforce.
AHPs make a unique and important contribution to multidisciplinary teams (MDTs), but we found that understanding and recognition of AHP roles is lacking at all levels of healthcare organisations.
We found that AHPs can be marginalised through poor communication in MDTs, which presents risks to patients, and missed opportunities for quality improvement.
Raising awareness of the essential roles of AHPs is critical to improving quality and safety in these services.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The review findings highlight the need to raise awareness and understanding of the roles and value of AHPs within MDTs in inpatient mental health, learning disability and autism services, at all staff levels.
This will be facilitated by having more AHPs in senior leadership positions.
Additionally, guidance is needed on how many and what variety of AHPs are needed to provide high-quality and safe care based on client population and size of service.
Future reviews should use search terms related to the aspects of care delivered by AHPs, given their poor visibility in quality and safety reports.
Greater visibility of AHPs is also warranted in future quality and safety reporting.
This review methodology should be expanded to include psychological professions and older people’s mental health services, and future research should explore the lived experiences of AHPs working in these services and their suggestions for increasing wider understanding of their roles.
Background
Allied health professionals (AHPs) are the third largest clinical workforce in the UK National Health Service (NHS) and are professionally autonomous practitioners educated to at least degree level. NHS England define AHPs as 14 registerable professional titles: arts therapists (art/music/drama), chiropodists/podiatrists, dietitians, occupational therapists, operating department practitioners, orthoptists, osteopaths, paramedics, physiotherapists, prosthetists/orthotists, radiographers and speech and language therapists.1 AHPs are involved in assessing, treating, diagnosing and discharging patients, and adopt a holistic approach to patient care. AHPs have long worked in mental health, learning disability and autism services, providing personalised, solution-focused, goal-centred care to improve patient outcomes and parity between mental and physical health.2 Evidence of the importance of AHPs and their specific roles in these services is wide ranging.3
Occupational therapists, for example, support mental health service users to overcome barriers to positive engagement between themselves, their values, interests and their social and physical environment, through recovery-focused goal setting.4 They support individuals to develop identity and competence through meaningful occupation. The role of occupational therapists in addressing physical health inequalities of people with serious mental illness, due in part to lifestyle factors,5 has been highlighted due to their skills in delivering health-promoting interventions by taking a solution-focused behaviour change approach.6 The role of dietitians in supporting the physical health of individuals with mental health conditions, learning disabilities and autism is becoming increasingly recognised.7 Dietitians identify nutritional needs/concerns (eg, malnutrition), and have specific skills for planning, monitoring and evaluating dietary interventions while considering co-existing health conditions, medication side effects and behavioural challenges.7 Dietitians have an important role in supporting individuals with eating disorders during refeeding and weight restoration,8 9 as well as addressing obesity levels in mental health inpatient services by promoting healthy eating and weight management.10 Additionally, speech and language therapists support the communication skills of individuals with mental health conditions, learning disabilities and autism, who frequently experience language and communication difficulties.11 However, these individuals need sufficient communication skills to effectively engage in talking therapies. Speech and language therapists play an important role in the management of dysphagia (swallowing difficulties), which is more common in adults with learning disabilities6 and mental health conditions such as schizophrenia.12 Speech and language therapy input reduces choking and other negative health consequences associated with aspiration.2
While AHPs represent a significant portion of clinical workforces internationally, their numbers are proportionately smaller in mental health, learning disability and autism services. AHPs often work in isolated roles within a culture dominated by other professional groups. International research indicates that AHP roles are poorly understood by other professions within these services7 13 14 and are perceived as low in the hierarchy of professions in multidisciplinary teams (MDTs).15 16 However, little published research focuses on AHPs working in these services compared with other professions. Further research is needed to better understand how AHPs can contribute to high-quality, safe care, ensuring that workforce is appropriately commissioned, trained and deployed to optimise their impact.
Within the NHS, it is important to apply lessons learnt from patient safety incidents—unintended or unexpected events that lead to harm for patients receiving healthcare17—to prevent recurrence. The Patient Safety Incident Response Framework sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving safety,18 replacing the previous Serious Incident Framework.19 To date, quality and safety reviews in England, including their recommendations and findings, do not always reflect the multiprofessional nature of clinical teams and often lack focus on AHPs. However, these reviews frequently underline the critical importance of multiprofessional clinical teams and therapeutic climate. In considering the strategic focus for AHPs in mental health, learning disability and autism services, it is valuable to capture and understand the learnings from quality and safety reviews, but this has not yet been achieved. Recent high-profile cases of quality failures in UK hospitals—such as the cluster of mental health inpatient deaths in Essex, which is currently under inquiry—and international incidents, like recent safety issues in psychiatric hospitals in New Jersey, USA, underscore the need to learn from situations when things go wrong.
To address this knowledge gap, Anglia Ruskin University was commissioned to conduct a rapid literature review with the following objectives:
To capture and understand the lessons learnt from safety incidents that have occurred within adult (aged 18–65 years) mental health, learning disability and autism services in England over the last 10 years.
To identify the learning, implications and recommendations for the AHP workforce.
Methods
Rapid literature reviews
A rapid literature review is a form of knowledge synthesis in which the steps of a systematic review are streamlined to produce evidence within a shorter timeframe.20 21 Rapid reviews are an efficient method of providing policymakers and health system stakeholders with actionable evidence to strengthen health policy and systems.21 Inherent components are a clear research question, search protocol, simplified process of study selection and data extraction.22 Early and continuing stakeholder engagement, careful streamlining of decisions for each step and transparency of methodological decisions are essential to their success.20 21
Stakeholder engagement
It is recommended that NHS Trusts appoint a chief AHP who provides strategic collective leadership for the 14 allied health professions within their Trust.23 Many UK AHP leaders (including chief/deputy chief AHPs) participated in the review process. A project delivery board consisting of seven AHP leaders from across England contributed to the final search strategy and provided feedback on both the draft and final iterations of the review. A clinical advisory group (including representatives from dietetics, occupational therapy, speech and language therapy and mental health nursing), provided feedback on the draft findings and co-produced the recommendations. All NHS AHP leaders in England were invited to an online forum, where the preliminary findings were presented. This was attended by 47 AHP leaders, whose engaged conversations and suggestions were incorporated into the discussion. An Experts by Experience advisory group comprising adults with experience in child and adolescent mental health, psychiatric intensive care unit (PICU) and high-secure and medium-secure services, provided feedback on the draft findings.
Inclusion criteria
The inclusion criteria were material published over the last 10 years (from February 2014 to February 2024) that reports on safety incidents within adult inpatient mental health, learning disability and autism services in England, with identifiable lessons for AHPs. This included material published by reputable organisations who publicly report on quality and safety in health services in England or published within peer-reviewed academic journals. This excluded quality and safety data/materials from service providers that were not publicly available. Material on incidents that occurred within community mental health services, where the service user was previously under the care of inpatient services and where there was potential learning for AHPs in inpatient care—such as in relation to discharge planning—was also included.
Search strategy
The search strategy was developed in collaboration with the project delivery board. Procedures were pilot tested by the lead author before conducting study selection and data abstraction. Due to the nature of the review, most of the relevant material was unlikely to be found in academic databases. Consequently, the search strategy was broad and primarily focused on capturing grey literature.
Authors 1 (CW) and 3 (LP) conducted searches from February to March 2024 using keywords related to safety, inpatient mental health, learning disability or autism setting, AHPs and location (online supplemental file 1). The project delivery board recommended including only those AHPs who most commonly work with inpatient mental health, learning disability and autism service users in England as search terms (art/music/drama therapists, dietitians, occupational therapists, paramedics, physiotherapists, podiatrists and speech and language therapists). The term ‘MDTs’ was also included, as materials may reference MDTs (which include AHPs) without specifying individual professions.
Supplemental material
Relevant academic databases were searched (CINAHL, MEDLINE, PsychINFO, Cochrane Library) using safety and setting keywords in abstracts, and location and AHP keywords in ‘all text’. On advice from the project delivery board regarding the most relevant sources, searches were carried out on the following websites: the Care Quality Commission (CQC), NHS England, Getting It Right First Time, Royal College of Psychiatrists, UK Government, Office for National Statistics and the Health and Care Professions Council. Additionally, Google News and the Health Services Journal were searched for media reports signposting to reports/investigations published by reputable organisations. NHS England independent investigation reports were reviewed (https://www.england.nhs.uk/publications/reviews-and-reports/invest-reports/), by searching within each report for setting and AHP keywords using the ‘find’ tool. CQC reports for mental health, learning disability and autism inpatient services where safety was currently rated ‘inadequate’, and for such services which had been prosecuted by the CQC (https://www.cqc.org.uk/about-us/how-we-do-our-job/prosecutions), were searched for the AHP keywords. Mental health-related reports to prevent future deaths (PFDs) were also searched for AHP keywords (https://www.judiciary.uk/pfd-types/mental-health-related-deaths/).
Data extraction and analysis
Author 1 led the searches of NHS England independent investigations, CQC and PFD reports, as well as the relevant websites. Decisions to include materials were discussed and mutually agreed on with author 3. Author 3 led the searches of academic databases and media reports, with inclusion decisions also mutually agreed on with author 1. Once materials meeting the inclusion criteria had been identified and agreed on, authors 1 and 3 extracted information relevant to AHPs using a predesigned data extraction table. They excluded references to AHPs when relevant learning could not be identified, such as instances where AHPs were mentioned only as having been interviewed during the review process or having seen a patient without further detail provided. Authors 1 and 3 independently reviewed the extracted data to identify common themes using an inductive thematic synthesis approach, which is the preferred method for rapid qualitative reviews.20 They then met to discuss, refine and agree on the identified themes. Themes were presented to and reviewed by the remaining authors, advisory groups, project delivery board and AHP leads who attended the online forum. Following feedback, the themes were refined into the five themes presented below.
Findings
51 NHS England independent investigations, 34 PFD reports and 26 CQC reports met the inclusion criteria. Despite 1229 hits from academic database searches, only one publication met the inclusion criteria after screening.24 Three reports were identified through the website searches: a Getting It Right First Time Programme National Specialty report on adult mental health crisis and acute care,25 the CQC State of Care 2022/23 report26 and a Department of Health and Social Care report on mental health inpatient settings.27 This resulted in the inclusion of a total of 115 reports/publications (see figure 1 and table 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. AHP, allied health professional; CQC, Care Quality Commission; NHS, National Health Service; PFD, prevent future death.
Materials reviewed
An overarching theme ‘organisational culture’—defined as the shared ways of thinking, feeling and behaving within an organisation139—was identified. There was evidence of a misunderstanding of AHP roles, ranging from senior leadership to frontline MDT staff. This misunderstanding led to AHPs being silenced, disempowered and even excluded from key conversations and decisions, leading to insufficient access for patients to AHPs, which in turn contributed to safety incidents. This was a central thread running through five subthemes: (1) (lack of) effective MDT working, (2) (lack of) AHP involvement in patient care, (3) training needs, (4) staffing levels and (5) senior management and leadership.
(Lack of) effective MDT working
The reviewed material contained many references to poor communication within MDTs. Some reports cited an overall lack of integration of AHPs into the wider team,38 while others referred to specific examples such as AHPs not being informed about important aspects of a patient’s history, presentation or care needs.32 A lack of effective communication between consultants and the wider MDT was reported.43 118 In some cases, consultants made care decisions without seeking input from, or listening to advice from, the MDT.29 52 118 138 A lack of effective close working relationships between nursing staff and wider MDT members was also reported.63 116 MDT meetings were reported as too infrequent,73 121 135 136 and did not happen when patient risk had escalated.60 102 The care coordinator role, which can be filled by an occupational therapist, was viewed as pivotal to the quality of information provided to the MDT, with some poor examples identified.42 86 110
AHPs were often not able to access all relevant patient information,39 44 111 as different professions entered notes in different places that were not accessible or updatable by all MDT members.38 64 91 101 102 111 129 The reviewed documents contained multiple references to poor record-keeping of MDT meetings, care plans, safety plans, risk assessments, patient activities and instances of seclusion/restraint.38 52 88 91 97 115 127 129 133 137 One report stated:
The files we reviewed were not fit for purpose and potentially unsafe…They do not provide a well-structured, easily accessible and effectively recorded set of clinical notes that inform the care and treatment of a patient. There is no …single multi-disciplinary care plan… (Hussain and Nash, p. 18).38
Several sources cited problems with the culture on inpatient wards, and identified changes needed to facilitate effective MDT working. A need for an inclusive, open, inquisitive and nurturing culture was emphasised, where multidisciplinary staff can challenge and support one another.24 64 67 68 75 76 There were descriptions of a lack of united and collaborative multiprofessional working, with siloed practices among different professions,68 78 80 116 118 which was associated with poorer outcomes.116 It was noted that MDT staff were not always included in internal investigations,65 which led to feelings of marginalisation and frustration,65 as well as a failure to disseminate learning from investigations and incident reviews to MDT staff.25 A culture of reflective practice was identified as absent from, yet needed within, MDTs.28 38 67 It was noted that different disciplines bring varied skillsets and emphases. While it is the organisation’s responsibility to ensure that appropriate skills are available within a team, it is also the responsibility of individual professionals to ensure their skills are effectively employed in patient care.28 A need for psychological safety was recognised, allowing professionals within MDTs to feel comfortable speaking up both within their teams and to senior leaders.24 76 Staff needed to be empowered to speak up in meetings and to make decisions.68 In one report (Ibbs, p. 46),42 an occupational therapist serving as a care coordinator for a patient who died by suicide after discharge described having ‘deferred to the view of the PICU staff’ during an MDT meeting where the decision to discharge was made.
One CQC report noted that the introduction of occupational therapists to MDTs on mental health wards within one NHS Trust ‘had a positive impact on the culture’ of the wards, and their contributions were ‘greatly valued by (wider) staff’ (CQC, p. 26).123
(Lack of) AHP involvement in patient care
In some cases, a lack of AHP input in MDT meetings was reported. Sometimes, there were no AHPs in the MDT at all58 119 121 123 124 126 128 135; other times, AHPs were part of an MDT but were not present at MDT meetings31 88 or did not speak up despite their attendance.128 There were cases where recommendations made by occupational therapists and physiotherapists were not acted on by care coordinators or other MDT members.60 128
It was repeatedly reported that occupational therapists, dietitians, physiotherapists, speech and language therapists, and arts therapists were not involved in a patient’s case at all, despite a clear need for their input.34 36 37 46 47 56 58 65 68 77 84 90 93 94 123 131 132 Three reports40 43 57 mentioned that patients with psychosis or schizophrenia were not offered arts therapies despite a National Institute for Health and Care Excellence recommendation being in place at the time.140 Sometimes referrals to AHPs were not followed through,77 or a referral was never made despite a clear indication, for example, for patients experiencing dysphagia, weight gain or malnourishment.34 47 65 84 90 131 This may be due to limited resources and/or a lack of visibility of AHP referral pathways.131 Some report authors postulated that the lack of AHP involvement led to delays in patients being discharged.35 119
There were numerous reports of a lack of AHP (or whole MDT) involvement in discharge planning,36 61 66 transfer planning61 70 (between locations and services), decision-making,89 risk assessment/management,45 63 78 100 135 care plans38 51 63 78 110 and crisis plans.45
Training needs
Numerous documents cited the need for staff training to address some of the issues identified. Sometimes AHPs were mentioned in relation to identified training needs, but always alongside other professions.
The most frequently mentioned training need was related to caring for autistic inpatient service users on general (ie, not specialist autism) mental health or learning disability wards.25 34 79 80 83 128 Some documents outlined cases of MDTs not tailoring or adjusting care to account for the needs of autistic service users. The absence of, and the need for, training on assessing the emotional well-being of autistic individuals—considering sensory and environmental needs, as well as tailoring risk assessments—was highlighted. One report83 mentioned the importance of speech and language and occupational therapists facilitating autism training for the wider MDT. It is worth noting that many documents were published prior to the introduction of the Oliver McGowan Mandatory Training on Learning Disability and Autism for UK health and social care staff. However, in some reports investigators cited that compliance with mandatory training (including autism training) was lower than desired.99 128
The second most frequently identified training need related to risk management,39 48 53 91 100 followed by supporting and monitoring physical health, both generally131 and specifically related to epilepsy,78 diabetes98 and resuscitation.110
Other needs identified repeatedly include training on the Mental Health and Mental Capacity Acts,36 85 109 working with high-risk service users24 99 119 and restrictive practice.119 127 Although the need for training on effective care planning was not explicitly mentioned, documents referenced poor care planning by occupational therapists,72 and multiple sources cited that care plans did not reflect patients’ needs and were not personalised, holistic or recovery-oriented.28 127 131
Staffing
Numerous sources cited understaffing within the settings.24–26 35 58 65 76 99 104 113 116 122 128 129 134 135 138 Six documents highlighted an insufficient skills mix within MDTs, indicating that there were not enough staff with the right experience to deal with the complexity of patients’ need.68 124 125 135 138 In some cases, this was due to vacancies in occupational therapy and speech and language therapy posts,68 113 114 128 129 132 137 138 which was believed to negatively impact quality of care and number of incidents.24 99 135 Within the sources reviewed, staff reported being too busy and stretched,65 68 ‘firefighting’ and experiencing low morale.135 The need for more staff, and AHPs specifically, was frequently highlighted. One report recommended ‘a review of the staffing levels and benchmarking these against other services’ (Psychological Approaches CIC, p. 35).65
It was frequently reported in CQC reports that there was a lack of meaningful activities and occupational therapy input, especially at weekends.114 123 125 130–132 134 135 Many service users reported being bored due to a lack of weekend activities, resulting in more incidents.134 While some reports implied that providing activities and alleviating boredom was a role for all MDT staff, others implied that meaningful activities were solely an occupational therapist’s responsibility. One report stated that ‘patients did not always engage in meaningful activity…and reported…feeling bored as there were not enough activities available’ immediately followed by reference to ‘a new occupational therapist had recently joined the service and had started work to review individual patient activity’ (CQC, p. 21).129 Another report131 stated that “occupational therapists worked Monday-to-Friday, and we were told that ward activities were not the responsibility of the occupational therapy department” (p. 22–23), implying that the inspectors had assumed this was solely an occupational therapy role. In a further report, a ward was inspected where there was no occupational therapist employed, and a lack of meaningful activities was cited, alongside an observation that ‘an extra member of staff was available to work an “OT (occupational therapy) shift” to cover activities’ (CQC, p. 21).114 Indeed, in a recently published NHS England independent review,76 occupational therapists reported that managers viewed their role as solely to occupy patients, demonstrating a narrow understanding of their role.
Senior management and leadership
Within several of the reports reviewed, senior management and leaders were described as not listening to the AHP voice,76 135 not valuing or understanding AHP roles,65 76 instilling a blame culture,24 not taking staff concerns seriously,135 not acknowledging the challenges faced by staff,24 not supporting staff (including AHPs)24 and not providing development or improvement structures for AHPs.126 The need for healthcare provider organisations to develop stable, cohesive, well-led and nurturing MDTs was emphasised.67 76 135 Reports asserted that senior leaders needed to ensure MDTs had an appropriate skill mix, that included AHPs, and that staff from various professions and levels of seniority attended and participated in team meetings.68 There was also an identified need to develop a culture of learning from safety incidents and continuous quality improvement, rather than one of blame.112 The importance of leadership teams engaging in reflective practice was also emphasised.38
Discussion
The need for a cultural shift in how AHPs are viewed, understood and included in mental health, learning disability and autism services has been identified. Formulating the recommendations requires a systems approach that extends beyond the AHP workforce itself.
While AHPs constitute significant proportions of clinical workforces internationally, they often work in isolated roles within inpatient mental health, learning disability and autism services, and operate in a culture dominated by other professional groups. This review found evidence of non-AHP MDT members and senior leaders/managers not understanding and valuing AHP roles, and as a result, failing to refer to/include AHPs in patient care or allocate resources to AHPs appropriately. There were several examples of AHPs being marginalised within MDTs. Leaders set the tone for how staff interact with each other, which in turn determines the culture an organisation has, and evidence shows that a positive workplace culture impacts staff performance and patient outcomes.141 142 Kline143 asserts the importance of understanding how leaders can ensure staff are valued and supported, and that the workplace values the difference and uniqueness that staff bring, with equitable access to resources. A workplace which is ‘psychologically safe’, where staff feel confident in speaking up without fear of being unfairly judged, is also vital.143 More AHPs in senior leadership positions could facilitate advocacy and championing of specialty interdisciplinary practices within leadership teams. Further examples of clinical leadership are needed but the opportunities for influence and transformation are becoming evident.144 While there has been an increase in chief AHP roles within UK health services, the proportion of service providers with senior AHP leadership remains small, and the need for AHP leadership is generally not well understood.145 As of 2023, only 14% of NHS Trusts had an AHP on their executive board.146 There is a dearth of research on allied health leadership internationally,147 148 although a 2015 mapping exercise revealed only 3.4% of top management positions within Australian public sector health services were AHPs.149 In response, the State of Queensland’s 2019–2029 strategy for the allied health workforce prioritises a drive for more allied health leaders and executive positions.150
The review findings provide a case for a review of AHP staffing levels in inpatient mental health, learning disability and autism services, for the purposes of delivering safe and high-quality care. There are recognised shortages in the health and care workforce, high rates of attrition and ill-defined career pathways.151 There is a long-standing policy imperative to improve interprofessional leadership in teams that results in better quality and effectiveness.152 However, guidance is needed on what professions should be represented within a core MDT, what a highly effective MDT looks like and how many and what variety of AHPs are needed to provide high-quality, safe care based on client population/needs and service size. While appropriate staffing levels have been considered for nurses (https://www.england.nhs.uk/nursingmidwifery/safer-staffing-nursing-and-midwifery/safer-nursing-care-tool/) and doctors (https://www.rcplondon.ac.uk/file/10367/download) in the UK, this has been missing for AHPs. This review highlights that there is much variation in the inclusion of AHPs within MDTs, and more AHPs are needed within mental health, learning disability and autism services. While this fits within a wider context of long-standing staffing shortages,76 our review indicates that AHPs have been disproportionately excluded from staffing considerations (as recently found by Colesby153). The expressed concern in the reviewed material regarding the lack of AHPs working in inpatient services on weekends and attending MDT meetings can only be addressed by increasing AHP resources, as there are currently insufficient AHPs to cover extended working hours. More appropriate resourcing is only likely to happen if commissioners and senior leaders better understand the value of AHPs and allocate resources accordingly.
While 115 documents were reviewed, they often lacked depth regarding learning for AHPs. References to AHPs were minimal compared with other professions, with many materials mentioning AHPs in just a single line. Furthermore, a large majority of NHS England, PFD, CQC and academic publications did not mention AHPs or MDTs at all, leading to their exclusion. We welcome the approach of a recent NHS England independent review76 that provided explicit reference to, and learning opportunities for, AHPs. It is also worth noting that some AHPs were more visible in the reviewed documents than others, with occupational therapists being referenced most frequently.
This review represents the first time that learning from safety incidents for AHPs in inpatient mental health, learning disability, and autism services has been curated. While the review has identified important learning, it also highlights the need to improve the evidence base regarding the value of AHPs in improving quality and safety of inpatient services. There were also some quality and safety incidents that were not identified as frequently as might be expected. The ‘too hot to handle’ report154 highlights the negative experiences of black and minority ethnic NHS staff (including AHPs), therefore, we know that issues related to racism and discrimination are prevalent and need addressing. However, there were only two references to patients’ ethnicity not being considered in assessment and care planning54 71 and three references76 114 116 to staff experiencing discrimination based on race and ethnicity. This may be due to racism not being traditionally seen as a quality and safety issue and/or a hesitancy for staff and patients to voice such concerns. The few incidents mentioned in the reviewed documents were not specifically related to AHPs; therefore, further learning is needed to promote an antiracist and antidiscriminatory AHP workforce, in line with the AHP strategy for England.1
As direct references to AHPs are scarce in quality and safety reports, future reviews may benefit from broadening the search strategy to include keywords related to aspects of care that AHPs deliver, for example, “weight management”, “diet”, “malnutrition”, “refeeding”, “goal setting”, “meaningful occupation”, “dysphagia”, “aspiration”. Inclusion of keywords related to environment to explore how this can facilitate AHP care, or not, would also be valuable for example, “sensory integration environments”, “rehabilitation spaces”, “gym”. Achieving greater visibility of AHPs in future quality and safety reports is also warranted.
Expanding the review methodology to include psychological professions would be valuable, as some of the reviewed material identified similar challenges for these professions as those faced by AHPs, indicating that they can also feel marginalised within MDTs.155 Indeed, in Australia and Canada, psychological professions are classed as AHPs. Furthermore, expansion to older people’s services is warranted, given the advocacy for the role of AHPs in improving the health of older adults as highlighted in the Chief Medical Officer’s 2023 Annual Report.156
Some limitations of the review should be acknowledged. This review looked at extreme forms of harm. Future work is warranted that explores the learning for the AHP workforce from a broader spectrum of quality and safety incidents. The findings would also benefit from being further illuminated by primary research exploring the lived experiences of AHPs working in inpatient services, and their ideas for enacting the review recommendations in practice, such as increasing wider understanding of their roles.
Recommendations for future research
Future reviews should use search terms related to aspects of care that AHPs deliver, due to poor visibility of AHPs in quality and safety reports.
The review scope should be expanded to psychological professions, older people’s mental health services and potentially wider health settings.
Future research should explore the lived experiences of AHPs in these services and their suggestions for increasing wider understanding of their roles and potential contribution to improving care quality and safety.
Recommendations for practice
Raise awareness and understanding of AHP roles and value within MDTs, at all levels of management to highlight the risks associated with poor team practices. This can be facilitated by having more AHPs in senior leadership positions that enables recognition of different role contributions.
Provide evidence-based guidance on how many and what groups of AHPs are needed to provide high-quality and safe care based on client population and service size.
Require quality and safety reports to include explicit consideration of AHPs’ roles and contribution.
Conclusion
This review represents the first analysis of quality and safety incidents in inpatient mental health, learning disability and autism services, focusing on learning for the AHP workforce. AHPs make a unique and important contribution to MDTs by facilitating rehabilitation services and enabling patients to manage discharge and improve their functional mental health, including activities of daily living. The review highlights that understanding and recognition of AHP roles are lacking at all levels of healthcare organisations. AHPs can be marginalised within the MDT, which presents risks to patients, and results in missed opportunities for quality improvement. This marginalisation can also lead to AHPs missing opportunities to share risk-related knowledge and insights. Raising awareness of the essential roles of AHPs in inpatient mental health, learning disability and autism services is critical for improving quality and safety in these settings.
Supplemental material
Data availability statement
Data are available on reasonable request. The search strategy and full list of materials reviewed are provided in the article. Full data extraction tables are available on request from the first author.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
X @CeriWilson4, @LouiseProthero3, @DrGillianJanes
Contributors CW (first author, corresponding author) is responsible for the overall content as the guarantor. All authors meet the four criteria for authorship: (1) substantial contributions to the conception or design of the work (CW, RW), acquisition of data (CW, LP), analysis of data (CW, LP), interpretation of data (CW, LP, RW, GJ, FN, SF-D); (2) drafting the work or critically revising it for important intellectual content (all authors); (3) final approval of the version to be published (all authors) and (4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved (all authors). In addition to the authors, there were the following non-author contributors: the Project Delivery Board critically reviewed the search strategy and inclusion criteria, and draft findings. The Clinical Advisory Group critically reviewed the first draft of the findings and co-produced the recommendations for practice. The Experts By Experience Advisory Group critically reviewed the first draft of the findings and advised on language used. Forty-seven allied health professional (AHP) leaders attended an online forum and provided critical feedback on the findings and recommendations. Several chief AHPs provided feedback on the draft and final versions of the paper. A full list of non-author contributors is available on request.
Funding This study was funded by NHS England via the National Workforce Skills Development Unit hosted by the Tavistock and Portman NHS Foundation Trust.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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