What does ‘safe care’ mean in the context of community-based mental health services? A qualitative exploration of the perspectives of service users, carers, and healthcare providers in England

Abstract

Background

Having traditionally received limited attention in empirical research and safety improvement agendas, issues of patient safety in mental healthcare increasingly feature in healthcare quality improvement discourses. Dominant approaches to safety stem from narrow clinical risk management perspectives, yet existing evidence points to the limitations of this characterisation. Although mental healthcare is increasingly delivered in community-based settings, narratives of safety pertain primarily to hospital-based mental healthcare. Therefore, through exploratory qualitative interviews and one focus group, we aimed to examine how service users, carers, and healthcare providers conceptualise ‘patient safety’ in community-based mental healthcare.

Methods

Semi-structured interviews and a single focus group were conducted with users of UK community-based mental healthcare provision for adults (n = 13), their carers (n = 12), and providers (n = 18), who were diverse in characteristics and experiences. Study data were analysed in accordance with a reflexive approach to thematic analysis.

Findings

Four key themes were developed, reflecting contrasting conceptualisations of safety in this care context, where participant thinking evolved throughout discussions. ‘Systemic inertia: threats to safety’ characterises the entrenched, systemic challenges which rendered participants powerless to advocate for or deliver safe care. ‘Managing the risks service users present’ equates ‘safe care’ to the mitigation of risks service users may pose to themselves or others when unwell, or risks from those around them. ‘More than responding to risks: everyone plays a role in creating safety’ recognises providers’ agency in causing or proactively preventing patient harm. Finally, ‘The goals of ‘safety’: our destination is not yet in sight’ positions safety as a work in progress, calling for ambitious safety agendas, giving primacy to goals which meaningfully improve service users’ lives.

Conclusions

Our findings have implications for the understanding and improvement of patient safety in community-based mental healthcare settings, where improvement objectives should transcend beyond management of risks and preventing deterioration to address patient and carer-centred concerns, including practices that make people feel unsafe.

Background

Improving healthcare safety and reducing avoidable harm are global imperatives [1]. Until recently, safety optimisation efforts have centred primarily on physical healthcare settings, including acute care hospitals [2,3,4]. Nevertheless, emerging research has begun to illuminate the nature and causation of safety problems within mental healthcare [5,6,7,8,9,10,11]. These works advance insights into inpatient safety, or that of various mental health settings more broadly. Safety challenges specific to community-based mental health services, where most mental healthcare is delivered, warrant focused scientific enquiry.

Although the field lacks coherent definitions and models of patient safety in mental healthcare, recognised safety concerns in mental healthcare include generic incidents, such as medication errors [12], and specialty-specific issues, such as self-harm or use of restrictive interventions [13,14,15]. Care in community-based mental health services may present distinct safety considerations. Lengthy waiting times; infrequent care encounters; and insufficient involvement of family carers in risk assessment, constitute particular concerns [5, 7, 16, 17].

Historically, ‘patient safety’ has been appraised through a narrow clinical risk management lens [18]. This is pertinent in mental healthcare, where management of risks to self and others are key aspects of clinical practice [19, 20]. That iatrogenic risks appear less widely considered, perhaps marks a distinction between mental healthcare and other health specialties [20, 21]. Nevertheless, existing research demonstrates that service users can play a valuable role in safety improvement [22], and may conceptualise safety differently to healthcare providers [23,24,25]. Alongside providers, it is vital that service users and carers are involved both in defining ‘safety’ and in shaping meaningful improvement agendas [26]. Accordingly, the present study aimed to examine service user, carer, and healthcare providers’ subjective experiences and conceptualisations of ‘patient safety’ in community-based mental healthcare. Specifically, we sought to understand what ‘safe’ and, conversely, ‘unsafe care’ meant to these participant groups.

Methods

Design

An exploratory design was adopted, involving semi-structured qualitative interviews and a single focus group with service users, carers, and healthcare providers. Participants took part in their choice of an individual interview or a focus group with others from the same respondent group. Compared to individual interviews, focus groups may yield additional layers of insight as a product of interaction between participants. Nonetheless, it is plausible that deeper understanding of individual participants’ subjective experiences may be achieved through individual interviews [27]. We expected that participants may describe distressing personal or professional experiences on the topic of patient safety problems in community-based mental health services. Therefore, presenting participants with the choice of an individual interview or a group discussion constituted an important ethical decision, allowing participants to take part in a format in which they felt most comfortable and able to speak with candour. Study methods were approved by a Welsh National Health Service (NHS) research ethics committee (IRAS ID: 279409) and prospectively registered (identifier: NCT04866693). Research reporting corresponds to the Standards for Reporting Qualitative Research [28].

Patient and public involvement

Through group workshops and individual consultations, seven service users and carers with lived experience of mental health services provided guidance on participant selection considerations, interview questioning, topic guide piloting, and refinement of participant-facing materials. A healthcare provider topic guide was also piloted and modified according to feedback from two clinicians. Based upon contributor feedback, we focused on both specialist and non-specialist mental healthcare provision, as general practitioner (GP) support represented the only care available for many people with mental health problems.

Participants and setting

Eligible participants had current or past year experience of contact with or employment within community-based mental health services for working-age adults within England, including primary care (e.g. GP support with psychotropic medication management) or specialist mental healthcare provision (e.g. community mental health team; CMHT input). Participants were required to be 18 years old or over and able to speak sufficient English to provide informed consent and to take part in an interview, owing to lack of resource for translation costs. Informed by comparable existing literature, where people from minority ethnic groups; male participants; and those with experience of severe mental illness (e.g. schizophrenia, bipolar disorder), have typically been underrepresented [5,6,7, 29], targeted efforts were made to ensure that a diversity of voices were heard. Accordingly, we selected participants purposively according to gender, ethnicity, age, mental health diagnosis (if applicable), and service(s) experienced. All individuals who were screened for eligibility were informed of the possibility that they may not be recruited to the study, where we had already heard from multiple participants sharing similar characteristics. We notified those we were unable to recruit within two months of screening and ascertained their interest in being contacted should future involvement opportunities arise.

The decision to stop sampling was guided by ‘information power’ principles, an indicator of internal validity based on the notion that the greater the ‘information power’ a sample provides, fewer participants are needed for adequate analysis [30]. Adequacy of our sample was appraised according to multiple interrelated facets of ‘information power’, such as the breadth of our study aims, sample diversity, and data quality. The achieved sample was diverse in terms of participant characteristics and perspectives.

Data collection

Recruitment and data collection were conducted by one researcher (PA) over a nine-month period (May 2021—February 2022). Advertisement flyers were distributed within a local English NHS mental health trust. An open recruitment call saw flyers shared online, through newsletters, and via pre-established service user and carer engagement groups. Participants contacted the research team directly to express interest in participating in their choice of an individual interview or focus group discussion.

Consenting participants primarily took part virtually via videoconferencing software, although two interviewees opted to participate in person. Except for one focus group comprising seven healthcare providers, all other participants expressed a preference to take part in individual interviews (n = 36), lasting between 26 and 89 (M = 47) minutes. Separate topic guides for service users, carers, and providers were developed for this study and used flexibly to guide discussions (Supplementary Materials 1, 2, 3). Participants were first asked contextual questions, and then to define patient safety in their own language, reflecting approaches used in prior research [7, 23]. Service users and carers were offered a £15.00 voucher for their contributions; and all participants were thanked and provided information about available sources of support, should they wish to seek support after taking part. Audio-recordings from interviews and the single focus group were transcribed verbatim and anonymised.

Methodological perspectives and reflexivity

Underpinned by critical realism, the ontological notion that reality exists, but that it is independent of human observation and cannot be accessed directly [31, 32], participants’ narratives were examined as representations of reality shaped by subjective experiences. To generate knowledge on the topic under investigation, it follows that participants’ subjective representations of phenomena must be interpreted [33]. Within reflexive thematic analysis, the analytical approach adopted, researcher subjectivity is acknowledged as the primary tool for generating findings [34]. Analysis was undertaken primarily by one researcher (PA, White British female), with multiple coding on several transcripts conducted by a second researcher (BB, White British female). We recognise that our own experiences, along with the social, economic, and political context contemporaneous to this study will have shaped our analysis. The lead author (PA) is currently an outsider to all groups at the centre of this research, though has prior experience of working in unqualified positions within various inpatient mental health services, including settings which at times felt unsafe for service users and staff alike. The second author (BB), a qualified mental health nurse, has lived experience of using services and of working within community-based mental healthcare settings. These experiences undoubtedly shaped our interpretations of meaning within the present study. Likewise, we were conscious of additional barriers to delivering safe care that providers faced during the COVID-19 pandemic.

Analysis

To examine patterns of meaning across the qualitative dataset, reflexive thematic analysis was conducted by the first author (PA) using methods outlined by Braun and Clarke [34, 35]. Braun and Clarke’s approach to reflexive thematic analysis has been widely used within the psychological sciences and across a range of research disciplines; it emphasises the active and iterative role of the researcher in generating meaning through analysis [34, 35]. The analysis was inductive and data-driven, comprising six phases (Table 1; phases 3–5 were performed recursively rather than linearly). First, audio-recordings, deidentified transcripts, and researcher notes were iteratively reviewed to gain familiarity with the dataset. Using NVivo software, transcripts were then systematically coded at semantic and latent levels, capturing both explicit and conceptual meanings (Supplementary Material 4). Multiple coding was conducted on three transcripts by a second researcher (BB) to explore alternative data interpretations, which were then discussed between both coders (PA, BB). Codes were further refined throughout the analysis and initial themes were generated through grouping of codes representing similar concepts or shared meanings. Theme fidelity was appraised against coded data extracts, resulting in reorganisation. Analytical progress was discussed regularly amongst all authors, and four themes were retained, defined, and labelled.

Table 1 Phases of reflexive thematic analysis (Braun & Clarke, 2021)

Findings

Participant characteristics

Of 97 expressions of interest received, 43 participants were recruited, comprised of 13 service users, 12 carers, and 18 healthcare providers. Participant characteristics are presented in Table 2. A further fifty-four people who expressed interest in taking part were not recruited for the following reasons: omission to provide information required for eligibility screening (n = 27); not meeting study eligibility criteria, e.g. experience of services involved mental healthcare provision for children and adolescents (n = 13); unable to schedule interview (n = 2). According to our purposive recruitment strategy, an additional 12 people were not recruited where they shared characteristics with multiple other participants who had already taken part (e.g. female gender, White ethnicity).

Table 2 Participant characteristics

Overview of findings

Four interpretative themes and several subthemes were developed, representing contrasting conceptualisations of patient safety in community-based mental health services (Table 3). Our thematic structure elucidates the ways in which notions of safety problems, their origins, and approaches to resolution were positioned within participant narratives. Each theme depicts a contrasting discourse as to whether safety risks are: (1) driven by systemic challenges; (2) by service users; (3) by responsible care teams; or (4) surmountable with an ambitious safety agenda, centred on outcomes of importance to service users and carers. These ideas are not mutually exclusive: participants typically espoused views aligning with several themes as their conceptualisations of ‘safe care’ evolved throughout discussions.

Table 3 Overview of themes developed through reflexive thematic analysis

Theme 1: systemic inertia: threats to safety

The first theme sets out the position that complex, systemic issues make community-based mental healthcare less safe. Accordingly, ‘unsafe care’ is presented as the product of these ingrained challenges. Healthcare providers appeared to situate systems-level challenges as beyond their own locus of control, at times apportioning responsibility to other care teams. However, whilst recognising entrenched safety threats within ‘the system’, service users and carers did not view individual providers and care teams as entirely blameless or external to their causation. All participant groups nevertheless faced the same experiential outcome: a shared sense of powerlessness.

Timely access was central to conceptualisations of safe care:

It’s not about panic buttons and CCTV. How about making mental healthcare available to people when they need it?’ (Carer, CMHT, individual interview)

Negotiating service access, from GP consultations through to crisis care, was likened to ‘moving mountains’ (Carer, Crisis team, individual interview). Access appeared contingent upon the advocacy of carers, who acquired expertise in the language of service navigation:

You have to say the words that get people moving: ‘risk’, ‘harm’, ‘complaint’, ‘crisis’…words you have to know to get something done. (Carer, Crisis team, individual interview)

Delayed, mismanaged, and inappropriately rejected referrals to specialist community-based mental health services constituted a particular obstacle to safe care, seemingly contributing to deterioration, hopelessness, and self-harm. For apparent mood disorders, GPs were obliged to evidence trialling several unsuccessful prior treatments for referral acceptance. For one individual, accurate diagnosis (bipolar disorder) and appropriate treatment were delayed, owing to late entry into specialist services:

It took years of fiddling with medications [in primary care] before I got to see a psychiatrist and in that time this life that I’d been trying to hold onto imploded. (Service user, CMHT, individual interview)

Once the case for referral was established, lengthy waits for assessment and initial outpatient consultations introduced further risks. These waiting periods were a collective concern. However, providers were thought not to appreciate the gravity of such delays:

Time is the enemy here…I don’t think they understand how each setback and every single delay, it just makes it more likely that my partner’s going to die. (Carer, CMHT, individual interview)

Access challenges were not resolved upon entering specialist mental health services. Waits spanning months to several years for autism assessments, or specialist psychological therapies, further obstructed safety. Moral injury—distress or internal conflict triggered by situations which contravene a provider’s personal or professional principles—was apparent where service users needed urgent input, yet providers perceived limited capacity to alleviate delays:

It feels like you are condemning someone to deteriorate because you’re putting them on such a long waiting list and contributing to their hopelessness…I think it does raise people’s risk of self-harm, of deterioration. Puts people in harm’s way really. (Clinical psychologist, Crisis team, individual interview)

Moreover, participant narratives suggested that care intensity was inadequate for maintaining safety and preventing harm. Staffing time limits, alongside closures of voluntary sector resources and day centres, meant that providers struggled to offer suitable support. Consequently, patient safety and public safety incidents were foreseeable:

I just don’t feel like we’re meeting his needs…a bit more input and attention might have avoided these situations blowing up. (Nurse, CMHT, focus group)

Service users and carers often communicated notions of ‘patient safety’ through the lens of feeling safe or unsafe within interactions with providers, or the community-based mental healthcare system as a whole. System-driven shortfalls in care provision seemed to threaten service users’ psychological sense of safety. This was particularly pertinent in conversations about crisis care:

I worry it will become so out of control because I didn’t get help soon enough…they won’t do anything and won’t notice, and I’ll just be gone in my mind (Service user, CMHT, individual interview)

Imbalances between demands for care and service offer were especially apparent in emergency situations. Crisis care, including out-of-hours provision, was characterised as inaccessible or insufficient to avert immediate safety risks. Challenges in reaching the crisis team via telephone, or refusals to conduct home visits, meant service users and carers felt unsafe. Even where daily care was provided, participants regarded crisis team care as an ineffective alternative to hospitalisation:

If they’re only there for one hour of one day…they can’t physically prevent you from killing yourself. (Carer, Crisis team, individual interview)

‘Falling through the gaps’ could be regarded as a further system-driven safety threat. ‘Gaps’ ranged from concrete and tangible, including a lack of services to meet service users’ needs, through to the relational, reflecting communication divides between care teams. ‘Gaps’ also manifested conceptually, characterising subjective experiences of powerlessness in the face of service exclusion.

Communication breakdowns were intimately linked to patient safety, emerging in verbal handovers; through documentation errors; or stemming from the design of formal information-sharing channels (e.g. lack of shared electronic patient records). For those under multiple services, communication challenges operated at organisational interfaces between primary care, specialist mental health services, and social care, contributing to care delays, omitted medications, and mistrust of services. To improve safety, there were calls to strengthen interprofessional relationships between services:

It is dialogue between primary and secondary [specialist] mental health services that should improve because we hardly have interactions with them apart from referrals. We don’t get to know them. (GP, Primary care, individual interview)

‘Falling through the gaps’ also arose from service organisation and patient flow. Gaps in commissioned care pathways resulted in service exclusion, including for individuals whose problems appeared too complex for primary care input, yet not severe enough to warrant specialist care. Poor cooperation between services was a product of workload pressures, manifesting in excessive gatekeeping, with some patients receiving no care at all:

Tying care together is much more challenging, because everyone is pressurised, every service tends to ringfence what they’re prepared to provide…The number of service users who are unable to access any care at all, it’s really difficult. (Nurse, CMHT, individual interview)

Impacts of service divisions were evident. It seemed that providers avoided delivering interventions requiring between-service multidisciplinary collaboration, including physical healthcare provision for people with severe mental illness. There was a tendency for siloed working, meaning that service users’ care was not cohesive:

90% of the people in my clinic will be on dreadful polypharmacy…the burden of side effects is horrendous, the interactions are dreadful, and the problem is, nobody will take responsibility and technically it’s not my job either. (Pharmacist, Specialist medication clinic, individual interview)

Care transitions were viewed as equally fraught; premature or poorly coordinated discharges jeopardised service user progress. Nevertheless, responding to pressure from service managers, providers recognised their own role in discharging patients before they were ready:

Loved ones start calling and say, ‘What are you people doing?…I don’t want to discharge, I am wanting to continue. (Nurse, CMHT, individual interview)

Service users’ sociodemographic and clinical characteristics appeared interrelated to their service navigation experiences. Care quality corresponded to social class; those regarded as articulate or well-presented reportedly received better standards of care. Care journeys for Black service users were characterised more-so by police involvement and restrictive practices, relative to White patients:

There are also the different pathways to care, how our ethnic communities perceive our systems, the fear of the psychiatric system…If you’re a Black family, you’re far more likely to have longer duration of untreated psychosis for your loved one…then you’re far more likely to call the police. (Clinical psychologist, CMHT, focus group)

Ethnicity-based preconceptions also appeared to shape the care offered to Asian patients:

Asian women, I don’t think we’re perceived as a danger to society…And of course, to get treatment, you have to be a danger to yourself or someone else. (Carer, Crisis team, individual interview)

Similarly, personality disorder diagnoses underpinned stigmatisation and service exclusion, with recurrent risks unaddressed:

They’ve said they’ll never take me back with the same presentation, which is self-harm. I’m not going to morph into someone with psychosis, so whatever risk I present, they’re not going to respond. (Service user, Primary care, individual interview)

Additional system-drivers of harm included chronic workforce underinvestment. Staffing shortages seemingly arose from long-term disinvestment from community teams, causing unmanageable workloads, which damaged recruitment and retention efforts. Whilst inpatient services are limited by bed availability, community-based providers experienced uncapped caseloads, exceeding safe limits:

These wonderful people trying to do their best with limited resources…when I have been let down, it’s not them…it’s the institution letting me down. (Service user, CMHT, individual interview)

Workforce underinvestment explained inadequacies in staff training and skills mix. Knowledge about psychotropic medications amongst care teams was thought inadequate. Risk assessment and management expertise were also considered lacking. Experience and seniority levels within community teams were understood to have declined over time, with inexperienced staff increasingly delivering care in high-risk situations.

Participant accounts suggested that policies and procedures resulted in further safety vulnerabilities. Administrative tasks aimed at monitoring safety, including incident reporting, equipment audits, and extensive paperwork, were thought to detract from time to deliver safe care:

Our performance is measured upon our completion of forms, rather than the risks that we’ve managed over the month… (Occupational therapist, CMHT, focus group)

Moreover, workarounds to staff safety protocols were necessary, including disregarding lone working protocols to ensure that service users were actually seen. Compromising one’s own safety appeared unavoidable in the face of unmanageable caseloads.

Another perceived mismatch between healthcare policy and achieving safety related to the UK Mental Health Act. Beyond challenges in securing police attendance at assessments and hospital bed availability, there were tensions between upholding human rights whilst preventing patient harm. Providers must wait for those declining treatment to become unwell enough to warrant detention and hospitalisation. Within this period, harmful outcomes included patient arrests, or involvement in an assault, possibly preventable with earlier hospitalisation. Legislation reforms worried carers, who feared increased thresholds for involuntary treatment:

Being sectioned, it’s not the most fun experience, but it does mean you get treated. But they’re bringing in the new White Paper. It’s going to be even harder to get her sectioned, so she might be facing a lifetime of illness. (Carer, Crisis team, individual interview)

Participant accounts suggest that efforts to deliver ‘safe care’ within community-based mental health services were rendered untenable owing to seemingly insurmountable systems-level issues. Local and distal challenges including insufficient resources, staffing shortfalls, and poorly joined-up services, constrained service users’ prospects of accessing timely, appropriate, safe care. Patient safety appeared to be compromised actively, through necessitating violations of unworkable policies, but also in more subtle ways, through communication disconnects; inequities in service access for specific patient groups; and erosion of workforce morale and resilience.

Theme 2: managing the risks service users present

Aside from systems-generated safety risks, ‘patient safety’ in community-based mental healthcare was equated to the management of risks originating from service users. Indeed, a second theme ‘Managing the risks service users present’, characterises a seemingly dominant perception that ‘safe care’ provision in this context is that which mitigates the risks of harm service users may pose to themselves or others when unwell. Risk of harm to self was a recurrent topic, including self-neglect, self-harm, and suicide. Although infrequent, risks to others of rare acts of violence were also raised. It appears that staff had limited tools for community prevention of violence, yet these incidents were contextualised in terms of care that is ‘unsafe’:

Unsafe mental healthcare could come from different means. Either the client is not engaging, or the risk associated with clients…did anyone call that the client is shouting along the road or tried to attack somebody? (Nurse, CMHT, individual interview)

Risks to service users from those around them were also described, including physical, sexual, and financial abuse. Family members who discouraged medication adherence presented further threats to safety. Oversight of such risks was considered a key function of safe mental healthcare:

In the thick of it in the community, you are in this incredibly vulnerable spot and that’s why we have things like care coordinators, so that they can keep an eye on you. (Service user, CMHT, individual interview)

Whilst ‘patient safety’ was framed predominantly as the inverse of ‘risk’, staff sometimes drew subtle distinctions between the two. Whether suicide constituted a safety incident was debated, in scenarios where providers deemed it beyond service prevention. Nuances were evident in sense-making about patient safety in this care context:

When you mention ‘patient safety’ within mental healthcare, my mind thinks about what is their risk of harm to themselves or others? Whereas ‘safe mental healthcare’ is where we are looking at providing appropriate or effective mental healthcare for their needs. It’s got two connotations in how it can be measured. (GP, Primary care, individual interview)

Likewise, ‘holding’ risk dominated conversations about community safety. Carers’ accounts suggested that they were insufficiently supported to maintain patient safety at home, holding risks such as self-neglect, or active suicidal intent. Although often excluded from formal safety planning, it appears that carers were positioned as part of the service user’s care team, relied upon to fill gaps within the care system and to navigate risk:

No one gave me any training, ’If she refuses her meds, if she doesn’t want to eat, this is the best way to approach it’…I didn’t have a clue. (Carer, CMHT, individual interview)

Beyond carers, providers were similarly apprehensive about assuming responsibility for risks. Community staff perceived greater individual accountability for risk relative to inpatient care teams. The burdens of clinical decision-making in high-risk situations were evident:

You hold those risks of patients going into crisis, harming themselves, harming other people…you hold that risk almost on your own…it’s only your clinical judgement keeping that person safe. (Nurse, CMHT, focus group)

Throughout participant accounts, it appeared that service users were positioned as inherently ‘unsafe’. It can be contended that risks were deemed to arise from service users, rather than the processes of healthcare itself. Key tensions can be discerned within this discourse: the extent to which risks could feasibly be averted within the structures of community care was unclear. Nevertheless, participant narratives suggest that the prevention of such harms by services should be considered a fundamental tenet of ‘safe care’.

Theme 3: more than responding to risks: everyone plays a role in creating safety

Beyond safety problems stemming from the system itself, or risks presented by users within it, a third theme recognises providers’ agency in contributing to safety. Within this theme, the creation of ‘safety’ can be regarded as a dynamic process, where it is acknowledged that ‘everyone’ (individual providers, care teams, and wider services) has the potential to cause or mitigate harm, but also to proactively influence the delivery of safe care.

It’s easy to say, ‘I didn’t cause someone harm’, but there needs to be more reflection on ‘Well what more could you have done to prevent that? (Carer, Crisis team, individual interview)

That contact with services could inadvertently cause harm appeared an accepted truth. Overt harm precursors included errors (e.g. incorrect medication), and protocol breaches, such as a failure to follow-up patients newly prescribed with antidepressants:

A regular number of people are taking their own lives, who have been recently prescribed an antidepressant and they’ve not had follow-up monitoring as per NICE guidance…those deaths are completely avoidable. (Pharmacist, Specialist medication clinic, individual interview)

Iatrogenic consequences of psychotropic medication, including weight gain-induced complications, sleep disturbances, and elevated blood pressure, were prominent concerns. In several cases, medications caused new physical health conditions (e.g. quetiapine-induced diabetes). There was a sense that prescriber opinions were privileged over service users’ lived experience:

Each time I see the psychiatrist, he will prescribe more drugs, he fails to listen to you first…about your side effects, about internal experiences that are horrible…he brings your medication, injects it into you, then he goes. (Service user, Community outreach and rehabilitation service, individual interview)

Failure to respond to patient deterioration, including reactive responses to accumulating safety risks, were described recurrently. Service users and carers were seemingly powerless to ensure their concerns were addressed:

He [psychiatrist] didn’t seem to appreciate the severity of my dad’s symptoms…it is so challenging to advocate for yourself because there’s such a power imbalance (Carer, Crisis team, individual interview)

Subtle manifestations of harm appeared widespread, including providers’ failures to meet commitments. This included appointment non-attendance or cancellation, or simply ceasing contact with service users without explanation. The latter occurred during long-term staff sickness absence, where there were no safeguards to ensure caseload reassignment. Equally, experiences of psychological harm were common. The potential for each care encounter to have therapeutic value was recognised by all participant groups and thought vital to maintaining safety:

What you want is staff who have good, positive relationships with patients. That is what keeps people safe. (Social worker, CMHT, individual interview)

Negative patient-provider interactions led to patients losing trust in services, non-disclosure of care-relevant information, or service avoidance. Service withdrawal following a harmful encounter occurred for varying reasons, including fears of involuntary treatment:

I don’t want her to be sectioned again, I don’t want them to decide she’s better off in the unit because she prefers to be at home, it’s safer for her… (Carer, CMHT, individual interview)

Also within this theme was the position that safer care can be achieved through proactive approaches to care delivery, emphasising harm prevention through planning, team working, and collaboration with service users and carers:

That time for safety, you just don’t find it. If you think about the time that you spend doing incident reports or, reading complaints…so yeah, I would have those safety mechanisms early on. (Psychiatrist, CMHT, individual interview)

Aspirations to mitigate harm were evident. One preventative strategy involved allocating more time resource at the outset (e.g. investing time into clinical formulation, learning from prior treatment history), rather than in response to something going wrong. Other examples of frontloading care included proactive medication monitoring, averting safety problems before they arose. In the case of lithium treatment, toxicity was prevented through reviewing longitudinal lithium level trends, instead of individual results in isolation. Service users were also educated on toxicity signs, encouraging timely support-seeking.

Communication systems appeared vital to planning for safety. Electronic patient record systems were paramount to effective information sharing, despite challenges in navigating large volumes of information recorded in different locations. The importance of documenting safety information so that it is meaningful to all providers, was explored:

When I’m documenting risks, that person might turn up to A&E [Accident and Emergency department], might be an inpatient, or might go to the home treatment team…I need to do it in a way that conveys easily that information, so you get a narrative of the patient, rather than a shopping list. (Psychiatrist, CMHT, individual interview)

Related to communication were the merits of team working for strengthening safety. ‘Zoning meetings’, where service users are classified according to risk and care needs, helped to prioritise interventions at team-level, supporting staff in caring for service users presenting with complex needs. Likewise, safety huddles were used proactively within primary care practices.

Service user’ and carer’ narratives suggested a similar endorsement of a proactive safety outlook. Harmful outcomes of deterioration, such as involuntary hospitalisation, breakdown of family relationships, or loss of dignity, were deemed avoidable with timely service intervention. Indeed, safety planning was thought most effective when designed whilst an individual was relatively well, rather than in crisis. It appeared that active involvement of service users and carers in crisis mitigation restored confidence and indicated mutual respect:

I have to give credit to the new psychiatrist my brother has been seeing…he decided to take the risk and he asked me, ‘Do you think it’s better just to be sent straight away to the hospital, or maybe just give him a chance?’…I said, ‘Okay, I’ll be home with him, let’s not lose what we actually achieved over these months. (Carer, CMHT, individual interview)

The above outlined theme, representing a third conceptual component of ‘safe care’, presents clear points of distinction from the preceding themes. Indeed, beyond apparent latent risks to safety which providers inherit from the systems they are required to operate within, or risks which surround service users, the agentic role of providers in ensuring that care is safe is clearly acknowledged. These findings highlight the propensity of providers, teams, and services to impact patient safety, both positively and negatively.

Theme 4: the goals of ‘safety’: our destination is not yet in sight

Marking a fourth element of participant characterisations of ‘patient safety’ in community-based mental health services, a final theme sets out a position that the pursuit of ‘safe care’ is a work in progress. Indeed, according to participant narratives, this theme depicts the breadth of change required to reach a point of safety: ‘our destination is not yet in sight’. Beyond managing risks and preventing deterioration, this theme presents the ideological stance that ‘safe’ mental healthcare provision is that which strives towards goals which meaningfully improve service users’ lives.

I don’t for one minute think that those people are causing him direct harm. But by indirect behaviour they are causing him harm…that harm is he’s not progressing, he’s not developing. (Carer, Dual diagnosis supported accommodation services, individual interview)

It appeared that safety was compromised by a preoccupation with managing incident outcomes, rather than addressing their causation. Basic wound care or liver function assessment sometimes constituted the only follow-up interventions provided after self-harm or suicide attempts, at the expense of compassionately exploring underlying distress. Services were seemingly oriented towards managing risks, lacking focus on promoting service user resilience and long-term care goals. Instead, respondent accounts are indicative that patient stabilisation was regarded as the treatment endpoint:

No one said ‘What do you want to achieve? How can we help you? (Carer, Crisis team, individual interview)

Beyond calls to re-examine the objectives of ‘safety’ in community mental healthcare, safety improvement priorities were widely explored. Enhancing care access could be regarded as a unanimous goal. Faster, streamlined routes into specialist services were deemed vital for promoting recovery. Accordingly, ineffective triage processes, crisis care, and out-of-hours care, were regarded as vital system-wide foci for safety improvement.

Further safety improvement priorities concerned care transitions and joint working between services. A higher intensity of support was considered essential for safer transitions across the inpatient-to-community interface, and from specialist community services into primary care. Proactive service follow-up was considered a vehicle for safer transitions, allowing timely monitoring for relapse signs:

Even if it’s like in a month or two…If you have that follow-up…you will be able to pick things up before it gets bad. (Service user, Specialist psychological therapy service, individual interview)

Where multiple teams were involved in a person’s care, participant accounts suggest that strengthening provider-collaboration was a safety priority. Relationships between staff in primary care and specialist services were strained by perceived reluctance on part of the other service to accept referrals or discharges. The need for improved cooperation was voiced:

We really do need to bring primary and secondary [specialist] care services closer together, to be working more with each other rather than this ‘us and them’ scenario. (Specialist pharmacist, Primary care, individual interview)

Improved joint working was also raised in relation to people at risk of service exclusion. These individuals often had multiple complex needs (e.g. severe mental illness and co-morbid substance use problems). There were calls for practical, cooperative, patient-centred approaches to planning care:

People might fall in theory into two or three services or none…It might be a negotiation, ‘Okay, this time I take this person, next time you take the case. (Psychiatrist, CMHT, individual interview)

Service user and carer support resembled a further safety improvement priority. It was proposed that service users could better maintain their own safety with individualised, co-produced, up-to-date safety plans, incorporating advanced planning for relapses. Carers similarly needed guidance for keeping service users safe (e.g. in lethal means restriction for suicidal individuals), but discerned a lack of provider willingness to offer such support:

Someone should come up with a plan to make sure carers have proper training…They need certain skills and they’re not given skills, and no-one wants to listen to them or encourage them. (Carer, CMHT, individual interview)

Medication safety represented a final safety priority. It was apparent that education on antidepressant use and prescription marked a key concern for respondents. Prescribers identified medication counselling needs on the risks of premature discontinuation of antidepressants upon perceiving no therapeutic benefit. Similarly, carers considered antidepressants to be prescribed too readily, without educating people about potential negative side-effects (e.g. suicidal thoughts) upon initial treatment:

They hand out antidepressants, whenever they feel like it. Without any recourse to ‘Is this person going to be susceptible to problems with these drugs? (Carer, Assessment and treatment team, individual interview)

Medication non-adherence could be regarded as an important early indicator of risks to safety. Given the narrow therapeutic range of many psychotropic medications, where dosage and timeliness are essential, the absence of mechanisms to detect when medications were not ordered or collected concerned participants. Where GP practices had in-house pharmacies, alerting systems were proposed to mitigate risks of delayed or omitted medications.

Moreover, medication interaction burden was another area warranting closer attention. Improved prescriber awareness of the potential for harm was considered an important prerequisite to reducing risk. Accordingly, a participant discussed developing a bespoke form within the electronic health record system, prompting clinicians to reflect on risks introduced by their prescribing, inviting consideration of alternative treatment approaches:

Once you’ve listed your drugs, then you have to list the potential interactions, and a suggestion of how you might want to manage that (Pharmacist, Specialist medication clinic, individual interview)

Although service users, carers, and providers alike indicated support for patient-centred care planning and delivery, there were seemingly differences between participant groups in views on how this is achieved in practice. It can be contended that patient safety is compromised owing to an apparent lack of ambition on part of providers to strive towards meaningful, recovery-oriented goals, which support service users to approach their own vision of ‘getting better’. Beyond the treatment of clinical symptoms alone, recovery approaches to mental illness are concerned with “the processes by which people experiencing mental illness can develop a purposeful and meaningful life” [36]. Recovery can be considered a deeply individual journey, characterised by connectedness; hope and optimism about the future; a positive sense of identity; meaning in life; and empowerment [37]. Indeed, service user’ and carer’ accounts implied that ‘safe care’ could not be realised where the objectives of community-based mental healthcare were limited to achieving stabilisation and preventing deterioration alone. Tangible avenues for improving patient safety within this care context are evident within participant narratives.

Discussion

This study articulates the multifaceted ways in which service users, carers, and providers conceptualise ‘safe care’ and, conversely, ‘unsafe care’ in community-based mental health services in England. Upon incorporating wider stakeholder perspectives, our findings suggest that the remit of patient safety and objectives for its improvement expand beyond mere efforts to manage risks. Indeed, aligned with mental health services research conducted primarily within inpatient contexts [9, 38], or mixed settings [7], service users often framed safety subjectively in terms of feeling safe. Although the management of risks to self, to others, and from others, when unwell is recognised as a core component of patient safety (Theme 2), we posit that this dominant perspective alone is incomplete. Threats to ‘safe care’ were apparent first and foremost at mental healthcare systems-level (Theme 1). Whether care is ‘safe’ is also contingent upon the actions, or inaction, of providers (Theme 3). Moreover, we hold that ambitious safety agendas, giving primacy to goals which meaningfully improve service users’ lives, are required for the achievement of ‘safe care’ (Theme 4).

Consistent with findings from non-psychiatric hospital-based settings [23], participants were unaccustomed to considering the meaning and connotations of ‘patient safety’ in the present service context. Surprisingly, this was true of all participant groups, including providers, perhaps reflecting the dominance of inpatient settings in current discourses and initiatives aimed at improving safety in mental healthcare [39]. Well-evidenced iatrogenic harms within these settings (e.g. physical restraint, seclusion) [10], are possibly particularly salient to service users, carers, and staff alike. Nevertheless, from a point of uncertainty, participants refined their conceptualisations of safety throughout the interviews.

Theme one findings illustrated that systemic conditions result in care which departs from safe practice. Mirroring conclusions of the annual NHS community mental health survey [40], service access was a prominent concern, where care delays risked potentially severe consequences for deteriorating patients. Apparent inequities in care access, corresponding to sociodemographic and clinical characteristics, contributed to a sense of ‘falling through the gaps’. That participants deliberated on disparities in care for service users from Black backgrounds was perhaps unsurprising, given evidenced inequities in experiences of mental health services. Indeed, delayed access to specialist services and higher rates of compulsory treatment, are salient examples of adverse experiences faced by Black communities [41,42,43,44]. In contrast, intersections between ethnicity and access for Asian women, as voiced by participants, are less well-documented amongst the literature and warrant exploration in further research. Issues in recruiting and retaining staff further undermined patient safety, culminating in a less experienced and insufficiently supervised workforce, as described in existing research [45]. Finally, key healthcare policies, including the UK Mental Health Act, presented challenges for providers in the balance between upholding human rights and preventing harm to patients.

A second position characterised ‘safe care’ as the management of risks originating from service users. Prior research indicates that risk and safety are treated as equivalent concepts by mental health services staff [19, 46]. Risks of harm from others in the community (e.g. physical, sexual, financial abuse) indicate setting-specific safety challenges within mental healthcare. Moreover, although carers felt left to hold risks, they were seldom involved in proactive safety planning; essential for improving safety in community-based care [16, 47].

Provider agency in harm causation or mitigation was recognised in a third theme. Overt unsafe practices (e.g. protocol breaches) were less widespread than other less measurable harms (e.g. psychological harm). Finally, a fourth theme set out visions for the future of patient safety within community-based mental healthcare, contending that supporting service users to live fulfilling lives must be considered within the remit of ‘safe’ care, consistent with research capturing nursing perspectives [17]. This finding provides backing to calls for patient-directed safety targets [47], and resonates with recovery principles [37]. Indeed, in the context of the ongoing transformation of community-based mental healthcare in England in efforts to deliver integrated place-based care [48], patient safety considerations within voluntary sector and social care services will become increasingly important, warranting attention in future research.

Strengths and limitations

We detail novel insights into how ‘safety’ is conceptualised by those who use or deliver care within community-based mental health services, illuminating plausible safety improvement foci. Key strengths lie in our study sample, diverse in participant characteristics including ethnicity, diagnosis, and service experience, where sampling was guided by information power principles [30]. Moreover, we hold that the reflexive approach to data analysis adopted, positioned in relation to our own experiences, constitutes an additional strength of this work. However, although our findings are not limited to a single region or NHS trust, almost two-thirds of participants were London-based. Accordingly, we may not have adequately captured geographical disparities in safety experiences, including the concerns of rural communities. Overall, we noted a preference amongst participants to take part in an individual interview. As such, whilst our findings present a rich picture of individuals’ subjective experiences, it is possible that further insights yielded from interaction between participants may have been gained had we have been able to conduct focus groups with service users and carers. Although we believe that service user and carer involvement in shaping the research methods and focus resembles a strength of this study, we recognise that a more extensive approach to patient and public involvement throughout the research cycle may have improved this work [49]. In future research examining the safety of mental healthcare, training of lived experience co-researchers in qualitative interviewing, analysis, and interpretation may introduce valuable new perspectives on this topic. Such methods were beyond the limits of available resource for the present study, which formed part of a PhD project. Taking the findings of this study as a starting point, we believe that equitable co-production partnerships with service users and carers will be particularly important in any follow-on research aiming to develop interventions to improve patient safety in this context [50].

Implications

This study supplements recently emerging literature exploring the specifics of patient safety in community-based mental health services [16, 17], expanding upon existing research by integrating service user, carer, and provider perspectives. Our findings offer a reimagining of ‘safe care’ in this service context, transcending narrow safety definitions and risk management agendas, which have dominated patient safety discourse [25, 26]. Safety improvement priorities, as identified by participants, warrant examination in future research, to move the field towards effective safety interventions.

There was striking overlap between the safety shortfalls participants recounted and recommendations from a suicide reduction toolkit for primary care and specialist mental health services providers [51]. For example, timely post-discharge follow-up; 24-hour crisis care access; and carer involvement, constituted key recommendations. Beyond associations with lower suicide rates [52, 53], full implementation of these recommendations may plausibly help to drive wider improvements in service safety.

In illustrating safety problems alongside examples of system resilience where safe care is successfully delivered, our findings correspond to both Safety-I and Safety-II paradigms [54]. Participants identified opportunities for optimising practice to improve service resilience, yet service pressures and efforts to manage the consequences of things going wrong (Safety-I), impacted provider capacity to engage in proactive planning for safety (Safety-II). Taken together, this underlines the importance of continued efforts to improve staffing and skills development, which will afford healthcare providers the time and expertise to deliver safer care.

Conclusions

The present research provides nuanced insights into the ways in which service users, carers, and healthcare providers conceptualise ‘patient safety’ within community-based mental healthcare, where extant research has primarily explored safety within inpatient mental healthcare settings only. Our findings indicate that participants conceived of ‘safe care’ in multiple contrasting, yet not mutually exclusive, ways. Dominant risk management narratives, which focus on those risks emanating from service users themselves when unwell, characterised one aspect of patient safety only. Indeed, systemic conditions were thought to culminate in mental healthcare provision which diverges from safe, effective clinical practice. Beyond these entrenched, systems-level challenges, participants nevertheless recognised the propensity of healthcare providers to cause or circumvent harm. Finally, this research highlights a vital need to pursue goals which are meaningful to service users in the shaping of safety improvement agendas within mental healthcare, indicating a range of potential foci for future interventional research.