International Review of Psychiatry, October 2009; 21(5): 465–471

Enhancing Pathways Into Care (EPIC): Community development workingwith the Pakistani community to improve patient pathways within a crisisresolution and home treatment service

RASHNA HACKETT1, JO NICHOLSON2, SIMON MULLINS1, TONY FARRINGTON1,

SHARON WARD1, GARETH PRITCHARD1, ELIZABETH MILLER1, &

NAYLA MAHMOOD1

1Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK and 2Sheffield Teaching Hospital NHS Foundation

Trust, Sheffield, UK

AbstractBlack and Minority Ethnic (BME) communities receive different pathways into mental health care with BME service usersoften presenting in crisis. This is associated with both an over representation of such groups in psychiatric wards and peopleavoiding mainstream services altogether. The Sheffield Crisis Resolution Home Treatment (CRHT) created the EnhancingPathways Into Care (EPIC) project, which initially focused on engagement with the Pakistani community (the largest BMEgroup in Sheffield). The project aimed to empower the Pakistani community to seek mental health support earlier withintheir own community, build up trust in mainstream services and enhance the clinical pathways within services to providemore culturally appropriate care. CRHT joined with the local Pakistani Muslim Centre (PMC) to work in partnership. ThePMC had existing links with the Pakistani community and provided a range of social, respite and occupational opportunities.The partnership created an innovative new role: the Pakistani link worker. The EPIC partnership strengthened the PMC’sinfluence and raised awareness of mental health issues in the community. Through integration of the link worker within theeveryday practice of clinicians, pathways of care showed evidence of positive change including more referrals to the PMCfrom psychiatric services. The EPIC project piloted a model of partnership working that is effective and transferable.

Introduction

The city of Sheffield has developed from its largely

industrial roots to cover an extensive economic base.

The city enjoyed world-wide recognition during

the nineteenth century for its production of steel.

International competition resulted in the decline

of the local industry in the 1970s–1980s. The

population of Sheffield is estimated at 513,234

people. The ethnic composition of Sheffield’s pop-

ulation is 91.2% white, 5.1% Asian, 1.8% black and

1.6% mixed. Sheffield also has large Polish, Somali,

Slovak, Yemeni and Albanian populations.

According to the 2001 Census (Sheffield City

council, 2001), Pakistanis form the largest black

and minority ethnic (BME) group in Sheffield with a

population of 15,844 people (3.1%). Sheffield has for

three decades had twice the national representation

of Pakistanis (White & Scott, 2006).

Evidence suggests that the majority of the black

and minority ethnic population live in the major

cities and particularly inner cities. Pakistanis and

Bangladeshis are most likely to live in the most

deprived wards (Dorsett, 1998). The related social

disadvantage has implications for health and illness.

In terms of health in Sheffield, the Pakistani,

Bangladeshi and mixed ethnic groups have a high

incidence of long-term limiting illness and for the

Pakistani population this is despite having very

low numbers of older people. According to a 2006

report by the Sheffield Director of Public Health,

increased diversity of the population of Sheffield has

resulted in services struggling to respond adequately.

The position in mental health services mirrors this

finding.

Sheffield enhancing pathways into care

The available national evidence suggests that by

the time many BME communities access secondary

mental health services it is usually in crisis. This in

turn creates a profound impact on their families, and

individuals can experience great difficulty in reinte-

grating back into their communities with any sense of

dignity. The poor early detection of mental health

Correspondence: Rashna Hackett, Email: rashna.hackett@yhip.org.uk; Simon Mullins, Email: simon.mullins@shsc.nhs.uk; J. Nicholson. E-mail: J.nicholson@

sth.nhs.uk

ISSN 0954–0261 print/ISSN 1369–1627 online � 2009 Institute of Psychiatry

DOI: 10.1080/09540260903163366

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problems in primary care compounds the problem of

pathways of care for BME communities seeking

mental health services. Further, data gathered from

the audit department of Sheffield Health and Social

Care NHS foundation trust (SHSC) suggests that

BME representation within the acute psychiatric

wards is disproportionately high.

It is within this context that our project is set; the

CRHT Service has been in a unique position to

contribute to the improvements in pathways of care

for our Pakistani population. The Sheffield CRHT

leadership took on the challenge of improving health

inequalities and created the EPIC project. The

project mission was to empower the Pakistani

community to seek mental health support earlier

within their own community and build up trust to

use the mainstream services. CRHT joined with a

community organisation called the PMC to work in

partnership. The PMC is located in the heart of the

Pakistani community in Sheffield and provides a

range of social, respite and occupational opportu-

nities. The partnership created an innovative new

role, the Pakistani link worker, influenced by the

Department of Health (2006) guide to ‘Community

Development Workers’. This role was to build

bridges with the Pakistani community and integrate

with the everyday practice of the acute care staff to

influence their pathways of acute care. The EPIC

partnership achieved much broader influences and

these only emerged as the relationships flourished.

The evidence of change (both quantitative and

qualitative) is presented below.

Crisis resolution and home treatment

(CRHT)

One of the Government’s key targets for mental

health services was the establishment of 335 crisis

resolution and home treatment teams by Dec 2004.

These teams act as the gatekeepers to acute psychi-

atric services and aim to provide home treatment

for people in crisis, as far as possible, as well as

supporting early discharge for those admitted into

inpatient beds (Department of Health, 2001). In

addition, the Sheffield CRHT was seeking to make

the service more responsive and accountable to the

local population and prioritise social inclusion with

scope to involve voluntary and non-statutory agen-

cies in a coordinated system of mental health care.

The team was also keen to ensure equitable

care pathways were sought, i.e. varied routes to the

recovery process.

Translating policy into practice

The EPIC project design was influenced by govern-

ment policy. The Delivering Race Equality (DRE)

action plan (Department of Health, 2005) was

launched after an enquiry into the death of an

African Caribbean man in a forensic unit. Systemic

review of the evidence base for working with BME

communities led to a three building block framework

for services to seek local solutions to the problem of

inequalities in care.

Delivering Race Equality

1. Better Information more intelligently used

2. Community engagement

3. More appropriate and responsive service

Utilising this framework enabled the project team

to have a robust strategy for developing a cohesive

approach to project management, including identifi-

cation of areas for capacity building but also resource

constraints.

Engaging the Pakistani community in a process that

would yield partnership work was the first step to this

project. The CRHT leadership team sought to utilise

the community development model to enhance

services for Pakistani communities. The strength of

the community development approach recognises the

belief that people know best about their own needs

and requirements, and that they have knowledge,

abilities and experiences which should be utilised.

However, the responsibility for policy development

and practice cannot be the individual responsibility of

the Pakistani communities; it requires a multi-agency

approach with effective partnership arrangements.

This involves building on the strength and creativity of

the community in a manner which does not exploit or

oppress them.

A partnership was created by the CRHT with

a local non-statutory provider called the Pakistani

Muslim Centre (PMC).

Strategic and clinical intervention

The EPIC project has two strands of delivery;

strategic and clinical. The strategic intervention

focused upon the DRE building blocks and within

this framework sought to address:

. Better information more intelligently used – utilise

audit department within SHSC, reciprocal skills

transfer between PMC and SHSC for data collec-

tion, management and interpretation, planning

and provision of reciprocal training initiatives

. Community engagement – introducing forums and

consultations that involved executive board mem-

bers/directors from SHSC and PMC as well as

project team members, full representation of PMC

to national EPIC forums, PMC facilitating SHSC

and the project team to meet the ‘community’

through formal and informal events, commitment

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to social inclusion agenda expressly stated and

articulated in project aims

. More appropriate and responsive services – the

conceptualisation of an improved/enhanced care

pathway for Pakistani people was achieved through

the two foundations of better information and

community engagement.

Overall, the strategic delivery aimed to build

capacity across both organisations and communities.

The clinical strand aimed to better understand and

improve the pathway and experience of Pakistani

patients in receipt of Home Treatment and/or

admitted to the Acute Psychiatric Inpatient Services.

Strategic outcomes

A major outcome was developing a well described

model of community involvement, participation and

collaboration that could be transparently utilised as

a basis for other DRE-related initiatives. However,

the model is not restricted to issues of diversity

in terms of race and culture but is applicable to

development work with any community organisation

that aims to improve health outcomes.

Another major outcome was the recruitment of

a dedicated community development worker, whose

job specification was to improve patient pathways

for Pakistani service users. This post was funded

by SHSC, specifically following on from the early

involvement of SHSC executive board members and

the SHSC equalities lead. Significantly, this post,

whilst funded through the statutory board, handed

management and ownership to the host community

of the PMC. This continued as a mutually beneficial

and reciprocal arrangement with clinical supervision,

mentoring and guidance provided through CRHT

and inpatient staff.

Other outcomes, that should not be underplayed,

included attendance by PMC members to national

EPIC events and hosting of a national EPIC event

within PMC and with open attendance by commu-

nity members. This significantly reflects the degree

of partnership and the genuine embracing of

collaborative working. The attendance and involve-

ment of community at the national EPIC event

within PMC meant a transparent and explicit

statement from SHSC acknowledging problems

for community access, and demonstration of a pre-

paredness to seek mutually acceptable and flexible

approaches to improve relationships.

Clinical outcomes

In terms of the clinical strand, the EPIC project

built upon service strengths within the Sheffield

CRHT. From service inception, the Sheffield

Crisis Resolution and Home Treatment service had

a comprehensive audit strategy that had a core

purpose of facilitating examination of issues of

diversity and equity. There was also a small, but

significant, number of staff who expressed an interest

and wish to improve the ‘reception’ and experience

of people from black and minority ethnic groups.

The EPIC project utilised these internal resources,

successfully developing, expanding but also focusing

the clinical interests and strategic repertoire of the

existing staff. A core project team internal to the

CRHT service was therefore built, whose members

could ‘champion’ the project within the service and

whose composition reflected the multi-disciplinary

ethos of CRHT.

Audit design

The focus of the EPIC audit was to provide data

about patterns of access and standards of care within

CRHT across a two-year period (presenting data

from 2005 and comparing this to 2006). These two-

year periods could be roughly conceptualised as

representing periods prior to EPIC (year period

2005) and active project development (year period

2006). Whilst there had been problems and delays

in achieving full implementation in 2006, this

year period still represented an impactful stage of

preparation where engagement of stakeholders,

refinement and development of project purpose

were all actively occurring both within and outside

CRHT.

The pathway of focus for this audit is diagram-

matically represented in Figure 1.

Measures

The Sheffield CRHT has a clinical database that

included information on patterns of access, clinical

Pakistani patient referred to CRHT in crisis

Home treatment Early discharge

PMC link worker/

CRHT

Inpatient ward

Social/respite and

occupational needs

PMC link worker/CRHT

Social/respite and

occupational needs

PMC link worker

Pakistani Muslim Centre

Figure 1. Sheffield EPIC – Clinical intervention pathways.

Enhancing Pathways Into Care 467

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pathways within CRHT, clinical outcomes, inpatient

activity and demographic data. The existing database

enabled the working team to easily examine patterns

of access and changes across the two time-periods,

although some data components were not available

across both year periods.

Specific to the EPIC project, a ‘Standards of Care

Checklist’ was developed that enabled retrospective

interrogation of case notes and could be used to

compare received care standards across different

ethnic groups. The checklist provided a detailed

examination of the core administrative and clinical

care components delivered to patients and families.

The checklist was completed based upon the

written notes and, therefore, was as much an audit

of documentation standards as of quality of care

provided.

The Pakistani link worker also provided a quali-

tative account of their project work and processes.

Results

Demographics

As CRHT is effectively a community service, but

one that provides a crisis response and an alterna-

tive to hospital admission, it was important to

understand whether CRHT had differential rates of

access as compared with inpatient services and to

the population statistics for the Sheffield area. The

results are summarised in Figure 2 which shows the

local situation mirrored the national picture of

disproportionate use of inpatient care for BME

groups (Healthcare Commission, 2005). In 2005,

the proportion of BME groups on psychiatric wards

in Sheffield was double what you would expect if it

simply reflected the general population in the

community (21.5% cf. 10.9%). However, the fact

that Pakistanis only represented 3.9% of the total

Sheffield inpatient population in 2005 (cf. 3.1% of

the general Sheffield population in 2001) indicates

that over representation on inpatient wards is more

of an issue for other BME groups. It is heartening

to find at face value that the CRHT had a very

similar percentage distribution to the acute inpatient

services for BME groups, as access to community-

based services can be a problem for BME groups.

The CRHT and inpatient data was interrogated

in more detail, which showed there was a marginal,

increase in referral rate of British Asian/Asian

Pakistanis to the CRHT service between 2005 and

2006. There were no significant changes in propor-

tional distribution of inpatient admission rate

between 2005 and 2006 across the ethnic

groups reported. It is probably to be expected that

the EPIC project would not significantly impact on

some pathways of care within a year. However,

Table 1 shows the changes that occurred reflecting,

on face value an overall positive trend towards

pathways that EPIC aimed to enhance. For example,

proportionately more Pakistanis were referred to the

CRHT (31 more Pakistani patients in total) which

may indicate greater confidence in use of the service.

Despite these ‘green shoots of recovery’, statistically

significant changes in pathways such as avoiding

Table 1. Comparing clinical pathways for Pakistanis before EPIC

(2005) and during the first year of the project (2006). Pathways

relate to those represented in Figure 1.

2005 2006

Pakistanis referred to CRHT

in crisis

80(2.6%) 111(3.2%)

Pakistanis receiving Home

Treatment

19(3.8%) 17 (3.4%)

Pakistanis admitted to hospital 33(4%) 32(3.8%)

Referred to PMC from Home

Treatment

1 7

Referred to PMC from

Inpatient ward

0 9

Numbers in brackets are the proportion that Pakistanis representof the whole clinical population.

89.1 84.878.5 83.0

10.9 15.221.5 17.0

3.1 2.7 3.9 2.9 3.60

102030405060708090

100

2001 Census SheffieldPsychiatricInpatient

Admissions2005–2006

CAHT TotalEpisodes

2005–2006

CAHT HomeTreatment

2005–2006

All black and minority ethnicWhite British British asian/Asian Pakistani

Health carecommission 2005

SnapshotPsychiatric

Inpatient survey

83.0

17.0

Figure 2. Summary demographic data for Sheffield, Sheffield CRHT and inpatient services by BME group.

468 R. Hackett et al.

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admission to hospital and improved access to Home

Treatment could not be shown.

Standards of Care Checklist

The Standards of Care Checklist was used to compare

different groups for the 2005 period. Three sample

groups from the home treatment population were

identified for comparison of checklist standards;

White UK, British Asian/Asian Pakistani, Black/

Black British Caribbean. This enabled comparison

of potential differences of White UK compared to

BMEs, but also Pakistani service users as compared

to other BME groups. For the White UK group

a random sample of patient identification numbers

was drawn from the database. For the two BME

groups the sample represents every case-note file that

could be found for the CRHT BME service user

population. For both BME groups some files were

not accessible at the time of the audit. For the 2006

period the checklist was used to interrogate notes

for Pakistani home treatment patients only, enabling

comparison in standards between the two year-

periods.

The analysis of the Standards of Care Checklist

revealed huge discrepancies in the standard of

note keeping from individual case to individual

case – but no discernable trends by group were

observed and the amount of variability case by case

meant the audit tool served best to illustrate

problems in quality of note keeping across the

board rather than the tool having utility for the task

in hand – i.e. to discern potential differences in qual-

ity in processes and procedures of care for specific

groups.

As the project was subject to a developmental

process of refinement (i.e. increasing clarity regard-

ing the focus and specificity of intervention) that was

not mirrored by changes in the audit tools, the audit

tool was found to have limited utility for the

emerging purpose of the EPIC project.

Patient pathway

The pathway data from CRHT and inpatient services

shows that whilst there are minimal fluctuations in

access rates to both services, the early discharge flow,

and the flow to the PMC improved (see Table 1) is

significantly improved. Whilst the numbers are small,

the dramatic difference to quality of life and function

that can be afforded by community support and

access cannot be underestimated. Reduction in

isolation, increase in opportunity and access can all

make a critical difference to the individual pathway to

recovery. Further, there were marked improvements

in 2006 in access for CRHT Pakistani service users

to statutory day services and alternative non-

statutory services (usually when refusing attendance

at the PMC, in contrast to clinical practice prior to

the EPIC project, Pakistani patients were offered a

mainstream alternative). Therefore, the EPIC project

had served to highlight and put the social and

occupational and needs of this vulnerable group

high onto the agenda of staff working within the

CRHT service, facilitating referral onwards to com-

munity-based support services.

Qualitative report from link worker

The PMC link worker provides regular contact

to both the CRHT and the acute psychiatric inpa-

tient wards. In both settings the worker, where

appropriate and practically achievable, would attend

multidisciplinary team meetings. This enabled recip-

rocal learning:

. The link worker learnt about the roles of staff and

the structures, processes and methods of clinical

decision making

. A developing relationship enabled increased

understanding and trust over time, a mutual

exploration of role, value and contribution

. The link worker provided information and acts as

a resource for staff to explore issues of culture,

increasing capacity through knowledge sharing to

make inpatient staff more aware and sensitive of

cultural needs, to apply this learning to enhance

the care of new patients who may enter the wards

at later times

. It assisted in the identification of unmet need

with patients, carers and other family members,

advocating and signposting to both mainstream

and culturally appropriate support services

. It provided a link to the PMC as a culturally

appropriate community resource

. It provided knowledge of the capacity of inpatient

wards as compared to CRHT

The link worker identified the particular concerns

of families and carers and their fears about treatment

on inpatient wards, in particular where the patient is

a female member of the family. The link worker

observed that members of the family would often stay

with the patient 24 hours a day, despite reassurances

about safety. She commented that ‘the cultural

aspect is so strong that girls are not left by themselves

in any case, mothers will stay with them despite

hassle and inconvenience to them by doing this’. In

these cases the link worker would advocate for early

discharge to home treatment.

Enhancing Pathways Into Care 469

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Impact for inpatient services

A further measure of outcome for EPIC was impact

on inpatient admission and length of stay for the

Pakistani group. There were minimal fluctuations

in numbers and proportional percentages admitted

for 2002–2006 (see Figure 3). The average lengths of

stay by ethnic groups across 2002-2006 are presented

in Figure 4. From Figure 4 we can see a larger degree

of variability and an overall longer length of stay for

the Pakistani group as compared to the other ethnic

groups. All groups, however, show an overall trend

(smoothing variability) for reduction in length of stay

across the five-year period. It should also be noted

that as these lengths of stay include admissions to

substance misuse beds, academic and learning dis-

ability beds which limits interpretation.

Discussion

The DRE agenda is a passionate vision that is a

response to highly specific examples of discrimination

and disadvantage. Scoping a project that uses such a

vision as a framework will then obviously encounter

difficulties of ‘evidence’. This project, whilst having

strategic aims, was fundamentally targeted to improve

clinical pathways. The outcomes described here are

based on a necessarily small number of patients.

Hence, changes and improvements reported need

to be interpreted in terms of clinical and social

significance rather than statistical power.

The passion of the DRE agenda was upheld by the

active project participants and was conducted with

limited resources, and most often on the basis of

goodwill alone. However, it is important to state that

the position of the core team members was to

fundamentally ‘own’ the principles of DRE rather

than waiting as passive recipients for policy, training

and practice change to be imposed from ‘above’.

This underpinned the successes of the project.

20062005200420032002

Admission year

40

30

20

10

0

Nu

mb

er o

f P

akis

tan

i pat

ien

ts a

dm

itte

d b

y ye

ar a

nd

per

cen

tag

eo

f to

tal i

np

atie

nt

po

pu

lati

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323335

31

26

2.7%

3.2%

3.9%4%

3.7%

Figure 3. Numbers and proportional percentages of admissions to the acute inpatient setting for Pakistani patients across a five-year period.

20062005200420032002Admission year

60

50

40

30

Mea

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th o

f st

ay

Other BEMs

British Asian/AsianPakistani

White BritishEPIC Reporting

Figure 4. Average length of stay by ethnic group.

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This does not imply that the process was an easy or

a smooth one. Negotiation for consensus of personal

and professional meaning in relation to project aims,

objectives and procedures often delayed progress

and interrupted process. The issue of resourcing

was also a highly significant factor to delay, arrest

and interruption of the work in hand. The issue of

resourcing remains as the community development

post initiated was not funded through recurring

funds and hence there are issues of continuity.

The project team also hold broad professional

interests and have to some extent dispersed to

follow other (often related but separate) strands of

diverse work.

Lord Darzi (Darzi, 2008) has published a review

that sets out a vision to provide mental health

services for all. ‘Partnership Working’ and improving

pathways are key elements for achieving positive

change. This project was necessarily limited because

of focus on crisis and acute working; similar work is

urgently needed for early detection and improved

early access to primary care assessments and inter-

vention. This has implications for primary care trust

planning and development, with need for specific

focus on BME mental health needs and particularly

at a time of transformation in terms of world-class

commissioning and integration of health and social

care.

Declaration of interest: The authors report no

conflict of interest.

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