To improve postgraduate psychiatry education and training in Northern Ireland.

Historically within Northern Ireland there has been a postgraduate Member of the Royal College of Psychiatrists (MRCPsych) teaching programme delivered to core trainees in preparation for MRCPsych examinations. There has been no official teaching programme for higher trainees. Northern Ireland Medical and Dental Training Agency (NIMDTA), in collaboration with the Royal College of Psychiatrists in Northern Ireland and all five Trusts developed the novel idea of introducing Postgraduate Education Fellows, to oversee and improve core training, and to develop a bespoke higher training programme.

The Postgraduate Education Fellows met to collate information from various sources in relation to issues within the current teaching programme and address these along with the development of new initiatives. The fellows further act as a point of contact for all trainees within their Trust to provide advice and support with education if needed.

One higher trainee was appointed to the role of Postgraduate Education Fellow in each Trust within the NIMDTA deanery for a term of 1 year.

The starting point was delivering the pre-established teaching timetable and gaining feedback from core trainees to identify areas for improvement. The next phase involved piloting traditional and contemporary methods of feedback. A further development was designing a mock paper A delivered under exam conditions. Two mock Clinical Assessment of Skills and Competencies (CASC) exams were organised under exam conditions, offering other trainees the opportunity to act as simulated patients and examiners.

The third aspect of this role involved creating a programme of higher trainee seminars. Baseline data were collated and identified key areas that higher trainees felt they needed further training and guidance in.

Using baseline data on the current teaching programme and from higher trainees as well as incorporating quality improvement methodology, we have been making small changes to each aspect of the teaching programme and evaluating the changes made. The feedback from trainees has been positive as evidenced by quantitative and qualitative feedback. 8 candidates sat our first mock CASC with a 100% pass rate in their MRCPsych CASC examination. There has been a positive response to the higher trainee seminar programme.

This programme has produced good outcomes to date and sets foundations for the future development of post graduate psychiatry education in Northern Ireland.

To understand the prevalence, patterns and correlates of substance use among transgender adults.

Minority stress theories suggest that the increasing rates of discrimination experienced by transgender people are precipitants of substance use. This is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which gender minority status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, EMBASE and Global Health databases. Primary quantitative studies, published in the English language, that reported the prevalence, patterns or correlates/risk factors of substance use by trans people were included, with no restriction on methodological design.

651 unique records were identified by the search and 40 studies were included in the synthesis. While there was some suggestion of excess risk of substance use among trans people, there was insufficient evidence to estimate prevalence or quantify the risk of substance use among transgender people, relative to a cisgender population. However, this review identified several gender minority related correlates of substance use which are of relevance to clinicians working with transgender patients, including transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

There are currently significant gaps in the trans substance use literature, relating to the disproportionate investigation of transgender women with multiple intersectional disadvantages, who are not representative of the wider trans community. However, there is sufficient evidence to recommend screening for substance use when individuals report high levels of gender minority stress and to consider the use of integrated trauma-informed psychosocial interventions when managing problematic substance use in the transgender adult.

To review the existent literature base regarding Black and Minority Ethnic (BAME) groups care pathway into and experience of care and treatment within secure services. This includes any differences (between BAME and majority ethnic groups) in rates of sentencing, sectioning, length of stay, received treatment and use of restrictive practice. Our overarching aim is to highlight the severe lack of research in this area and the corresponding need for increased research to both consolidate and progress the existing evidence base in order to inform and improve culturally competent service provision.

Research suggests that BAME groups have an increased risk of involuntary psychiatric care, longer-stays within services and higher rates of re-admission. Several explanations have been proposed for this observed disparity, however few of these proposed explanations have provided sufficient or consistent supporting evidence.

A review of both quantitative and qualitative research regarding BAME groups within secure services was conducted. Approximately twenty journal articles, literature reviews and meta-analysis published between 1988 and 2019 were included. The current study should be considered a snapshot and not reflective of the full extent of published literature on the subject. For inclusion, studies should have been conducted in either a forensic mental health setting or a prison and differentiate a minimum of two ethnic groups

Research suggest that BAME individuals continue to experience an increased risk of involuntary psychiatric care, longer stays within secure services and higher rates of re-admission. Whilst many explanations for this disparity have been proposed, few have provided adequate supporting evidence. The ongoing lack of research within this field has led to a limited evidence base from which to inform culturally competent practice. The research which has been conducted has tended to produce inconsistent findings, in part due to the reliance on small scale studies with limited generalisability. Research within this area has been further complicated by varying definitions of culture and ethnicity across studies, leading to some suggestion that the issue of ethnic inequalities and pathways to care, has been misconceptualised. This highlights a critical need for increased research efforts to:

Understand why BAME individuals are at increased risk of involuntary psychiatric care, and how this disproportionate risk can be addressed

Explore potential disparities in the care and treatment of BAME individuals within services and how this might impact upon higher rates of re-admission

Ascertain how best to improve culturally competent service provision.

To understand and learn from patients’ views and experiences. Ultimately, to improve quality, safety, and patients’ experiences and outcomes.

Service evaluation project of Mariposa House, London, the new women's forensic high support community step-down hostel after hospital admission. Run in partnership with Langley House (charitable) Trust. It is a co-produced, rare and innovative service- to our knowledge the only NHS women's service of its kind in England. In female and forensic community populations: transitions are the highest risk periods; the same treatment as men is unlikely to produce the same outcomes; and performance indicators and outcome measures are poorly understood.

Confidential patient questionnaire and self-reported Recovering Quality of Life (ReQoL) measure. Given to all patients in Mariposa House, before (in hospital) and 2-3 months after transfer to hostel. Themes included “my: care; voice (co-production); transition; & gender”. 12 questionnaires were received from 9 patients: 5 completed both pre- & post-; 3 (20%) were given but not received. Analysed by thematic content analysis. Additional focus group feedback session with patients and staff.

Overall, patients had very positive and similar views about both hostel and hospital(s), and similar views about both. Generally, patients feel treated with compassion, dignity and respect, and listened to and understood by staff members. They feel involved in and positive about their care.

There was a huge amount of involvement in co-producing the service and feeding back experiences, which has been very helpful. Co-production activities included: interviewing for staff and tenders; choosing hostel building; stakeholder meetings; and participating in meetings about training, policies and expectations. “I've been in hospital for so long moving was scary! But helping set up the project has given me confidence to move.”

There was strong agreement that transitions are difficult. Views on gender-specific needs being met were very positive, for both hostel and hospital. The main area for improvement was having better awareness of local neighbourhood and facilities- booklet now produced. Quality of life measures were at least maintained from hospital to hostel: 80% (n = 4) showed no reliable improvement/ deterioration, and 20% (n = 1) showed reliable improvement.

There are very positive and similar views about the hostel and hospital(s). Co-production and service user involvement has been very helpful. The new hostel has maintained patient satisfaction and quality of life measures compared to established inpatient services. These are positive findings, and crucially: in a less- secure, contained, established, and cheaper new community setting, involving complex and challenging transitions.

To describe and compare psychoactive substance misuse help-seeking among transgender (trans) and cisgender (cis) participants from a large multi-national cross-sectional survey.

Trans people experience stressors related to their minority status which have been associated with increased rates of psychoactive substance use and related harm. Despite this, there is a paucity of evidence relating to the treatment needs of trans people who use psychoactive substances, beyond a small body of literature describing a culture of transphobic hostility in general substance misuse services. This paper aims to describe and compare psychoactive substance misuse help-seeking among trans and cis participants from a large multi-national cross-sectional survey.

Over 180,000 participants, recruited from the world's largest annual survey of drug use - the Global Drug Survey (GDS) - during 2018 and 2019, reported use of a range of psychoactive substances in the preceding 12 months. Five gender groups (118,157 cis men, 64,319 cis women, 369 trans men, 353 trans women and 1,857 non-binary people) were compared, using Chi-square and z-tests with Bonferroni correction, on items relating to the desire to use less psychoactive substances and the need to seek help to achieve this. Respondents from GDS 2018 were also assessed for substance dependence. Binary logistic regression was used to compare gender groups on self-reported substance dependence to frame the help-seeking analyses.

Trans respondents (n = 1,710) to GDS 2018 were significantly more likely than cis respondents to report use of illicit substances (OR = 1.66-2.93) and dependence on cannabis (OR = 2.39), alcohol (OR = 3.28) and novel psychoactive substances (OR = 4.60). In the combined GDS 2018 and 2019 dataset, there were no significant differences between trans (n = 2,579) and cis (n = 182,476) participants on the desire to reduce substance use. However, among those who did report wanting to use less, non-binary people and trans women were most likely to want help to achieve this.

Trans respondents reported a greater need for help with reducing substance use than cis respondents. Given the deficit of specialist services for psychoactive substance users who are trans, there is a need for a more thorough understanding of the barriers and facilitators to their engagement in general substance misuse services. In the interim, substance misuse service providers require education about gender minority status to help meet the needs of trans clients.

To assess the feasibility and utility of introducing the following changes on to in-patient units:

Structural and cultural adaptation to create a sleep friendly ward environment

A “Protected Sleep Time” between midnight and 6am

Routine screening for sleep disorders, including obstructive sleep apnoea and restless leg syndrome

Insomnia and other sleep disturbances are cause, correlate and consequence of psychiatric disorders. Routine hourly night time observations, ward noise, bright lights at night time, sleep disorders, insufficient exercise, insufficient day light exposure, too much caffeine and inappropriate psychotropic use are all causes of disturbed sleep (Horne 2018).

Seven wards participated in a pilot (SleepWell). These consisted of one male and two female Acute Wards (General Adult), a High Dependency Unit, a Neurorehabilitation ward, an in-patient dementia service and one rehabilitation ward. These wards were supported via an existing trust management structure and the pilot was specifically supported by two trust managers (RW and RB) and by a clinical director (PK). The expectation was that each ward would identify a sleep champion from existing staff to facilitate the changes. A “product” was developed which identified core sleep management features but, in addition, wards were not confined to these. The existing policy that all inpatients should be checked each hour over night was suspended for the pilot wards and the patients had protected sleep time (PST) if the MDT agreed that it was clinically appropriate.

Quantitative and qualitative techniques were used to identify facilitators of change, impact on sleep and, outcome.

Protected sleep was viewed positively by all staff and approximately 50% of patients on the pilot wards were able to have PST at some point in their admission. Routine sleep disorder assessments were harder to implement and 33% of patients were screened. There were no deaths or significant events on patients due to PST. Hypnotic use on the pilot wards reduced. It is anticipated that PST where it is safe will be rolled out across all adult and old age wards in the trust.

With support, it has been feasible to change many aspects of sleep management across a breadth of inpatient units in a large NHS trust.

Concerns have emerged regarding infection transmission during flexible nasoendoscopy.

Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed.

A total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of ‘red flag’ symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13–21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4–11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0–1.3 per cent.

The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.