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London | Brussels | Los Angeles |New York | Washington, DC | Zurich
The Alchemy Project Evaluation Report
Cultural Utilities Enterprises
17 February 2016
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Matrix Knowledge formally joined the global consultancy group Optimity Advisors in September 2014. As its European arm, the newly combined business trades as Optimity Matrix to run the public policy arm of Optimity Advisors’ global operations. For more info go to: www.optimitymatrix.com. Optimity Matrix and Matrix Knowledge are trading names of TMKG Limited (registered in England and Wales under registration number 07722300) and its subsidiaries: Matrix Decisions Limited (registered in England and Wales under registration number 07610972); Matrix Insight Limited (registered in England and Wales under registration number 06000446); Matrix Evidence Limited (registered in England and Wales under registration number 07538753); Matrix Observations Limited (registered in England and Wales under registration number 05710927) and Matrix Knowledge Group International Inc. (registered in Maryland, USA under registration number D12395794). Disclaimer In keeping with its values of integrity and excellence, Optimity Matrix has taken reasonable professional care in the preparation of this document. Although Optimity Matrix has made reasonable efforts, it cannot guarantee absolute accuracy or completeness of information/data submitted, nor does it accept responsibility for recommendations that may have been omitted due to particular or exceptional conditions and circumstances. Confidentiality This document contains information that is proprietary to Optimity Matrix and may not be disclosed to third parties without prior agreement. Except where permitted under the provisions of confidentiality above, this document may not be reproduced, retained or stored beyond the period of validity, or transmitted in whole, or in part, without Optimity Matrix’s prior, written permission. © TMKG Ltd, 2016 Any enquiries about this project should be directed to
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Table of Contents
Plain English Summary ............................................................................................. 4
1. Introduction ...................................................................................................... 5 1.1. Background ......................................................................................................... 5
1.1.1. The purpose of this evaluation ........................................................................... 5 1.1.2. The background to the intervention evaluated .................................................. 5
1.2. Context of the intervention .................................................................................. 7 1.3. Intervention details and conceptual theory .......................................................... 8
2. Methodology .................................................................................................. 11 2.1. Evaluation logic model ....................................................................................... 11 2.2. Methods of data collection ................................................................................ 12
2.2.1. Quantitative methods ....................................................................................... 13 2.2.2. Qualitative methods .......................................................................................... 14
2.3. Methods of data analysis ................................................................................... 14 2.4. Limitations ........................................................................................................ 16
3. Results ............................................................................................................ 18 3.1. Quantitative data .............................................................................................. 18 3.2. Qualitative data ................................................................................................. 37 3.3. Economic analysis .............................................................................................. 39
3.3.1. Intervention cost ............................................................................................... 40 3.3.2. EQ-5D outcomes ............................................................................................... 41 3.3.3. Outcome star .................................................................................................... 44 3.3.4. Warwick-Edinburgh Mental Wellbeing Scale .................................................... 45 3.3.5. Interpretation .................................................................................................... 47
4. Discussion and conclusions ............................................................................. 48
5. Recommendations .......................................................................................... 50
6. Appendices ..................................................................................................... 51 6.1. Appendix 1: EQ5D .............................................................................................. 51 6.2. Appendix 2: Outcome star ................................................................................. 55 6.3. Appendix 3: Alchemy Project Evaluation ............................................................ 56 6.4. Appendix 4: The Warwick-Edinburgh Mental Well-being Scale ............................ 57
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Plain English Summary
Introduction
An intensive contemporary dance programme was used in an innovative pilot project in 2013 as an
intervention for young people with psychosis in South London. ‘SeaBreeze’ was conducted by Dance
United in conjunction with South London and the Maudsley’s (SLaM) Early Intervention (EI) service.
Positive feedback from the EI clinical teams and service users led to a further test of the intervention with
participants drawn from the same population, to assess whether any identified impact was consistent
with the pilot results. An independent evaluation of both service impact and value for money was
commissioned to help build the case for local commissioning.
The intervention consisted of an intensive four-week programme, preceded by taster sessions during
which participants learned to perform a contemporary dance piece, while engaging in trust-building and
team-building exercises. Two groups of participants were drawn from SlaM’s EI teams and were recruited
following a thorough process by EI team members, with support and guidance from the intervention
team.
Methods
An evaluation was conducted using standardised tools that measure changes in participants’ mental
wellbeing and quality of life, focus group meetings with the intervention team and interviews with the EI
teams. A simple and limited value for money analysis was also conducted to assess the costs of the
benefits derived from the programme.
Results
The findings of the evaluation are limited by the lack of data for assessments beyond the end of the
intervention. The data available shows that, for both groups, there were improvements in participants’
self-belief, confidence and trust in others over the course of the intervetion. The intervention also
improved the quality of life of the participants in the timeframe measured (four weeks). Optimity was
unable to evaluate how sustained the effects of the intervention were over longer periods of time due to
lack of data for assessments.
The value for money analysis showed that, based on the gains observed, the intervention is unlikely to be
cost-effective unless benefits are sustained for a considerable period of time.
Recommendations
There is a need for a longer-term study to assess whether the intervention effects are sustainable in the
medium to long term. Such a study should use a larger sample size and a control group to ensure that the
findings are sufficiently powered to evidence any intervention effects, and allow for the attribution of the
effects to the intervention.
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1. Introduction
1.1. Background
1.1.1. The purpose of this evaluation
In late 2013, an intervention, developed and tested by Dance United, was piloted in a mental health
setting for the first time. ‘SeaBreeze’ was designed to test the effectiveness of professional contemporary
dance training and performance on the mental wellbeing of young adults accessing treatment for
psychosis at an Early Intervention service. The methodology of the intervention was found to be
“…innovative, holistic and based on positive psychology rather than deficits, and one that fully
complements SLaM’s social inclusion and recovery policy.” The results, together with the positive
feedback from the EI clinical teams and service users, led to a need to further test the intervention with
participants drawn from the same population. The aims were to assess whether any identified impact was
consistent with the pilot results and build a strong case for local commission-ability through independent
evaluation of both service impact and value for money.
1.1.2. The background to the intervention evaluated
Psychosis is a mental health condition that causes people to perceive or interpret things differently from
those around them.1 The condition might also involve hallucinations or delusions. Typical treatment
involves a combination of antipsychotic medication, psychological therapies such as cognitive behavioural
therapy (CBT) and social support that might include education, training, employment or accommodation.
In the UK, the prevalence of psychotic disorders is 0.7% in the general population, and 0.2% in 16-24 year
olds.2 With limited evidence of the efficacy of antipsychotics in the latter population and a higher risk of
their side effects such as weight gain, metabolic effects and movement disorders, psychological
interventions, including family intervention, cognitive behavioural therapy (CBT) and arts therapies, have
been suggested as the preferred treatment approach for this group.3 Currently, Early Intervention in
Psychosis Services (EIS) provide those aged 14–35 years with a more intensive therapeutic service than is
obtainable with traditional community mental health services. These EI services are designed to intervene
1 Royal College of Psychiatry Mental Health Factsheet
http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/psychosis.aspx
2 Kirkbride JB, Errazuriz A, Croudace TJ, et al (2012). Incidence of schizophrenia and other psychoses in England, 1950–2009: A Systematic Review
and Meta-Analyses. PLoS One. 7(3):e31660
3 NICE (2013) CG 155: Psychosis and schizophrenia in children and young people: recognition and management
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early, and deliver support and evidence-based interventions in a more relaxed environment for the first
three years after onset of psychosis4.
The incidence rate of psychosis in young people is higher in South London, with 55.8% more new cases of
schizophrenia and other psychoses each year, compared to England as a whole (49.4 cases per 100,000
persons per year in South London compared to 31.7 cases per 100,000 persons per year in England).5
However, these figures for South London are likely to be underestimates with other studies finding higher
incidence rates for psychosis6, thus emphasising the need for care in the area.
The South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM), provides mental
health services in South London. It provides front-line EI for psychosis services via its various local teams
in Southwark (Southwark Team for Early Intervention in Psychosis - STEP), Lambeth (Lambeth Early Onset
- LEO) team, Lewisham (Lewisham Early Intervention Service – LEIS), and Croydon (Croydon Older Adults
Support Team – COAST). These services work with young adults in the first few years after the onset of
psychosis, when there is often the potential for a full recovery and return to health. The services focus on
the journeys of these young adults, offering treatment options for a maximum of three years before
discharging them to their GP. The treatments focus not only on the reduction of symptoms, but also on a
more holistic recovery with improved wellbeing, and return to education, training or employment.
In 2013, following the identification of problems faced by EI clients which included feeling isolated,
struggling with interpersonal relationships, issues with their body awareness and physical fitness which
have a negative impact on their overall levels of confidence, difficulty with maintaining energy and
optimism, and a tendency to over-focus on their condition and worry about the future7, a collaborative
programme was initiated. Senior personnel from the Institute of Psychiatry (IOP) at King’s College, London
and SLaM, having witnessed a performance by Dance United’s Academy participants, for whom
contemporary dance was used as an intervention, initiated a collaboration between Dance United, the
IoP, SLaM and two voluntary organisations (Bipolar UK and Rethink Mental Illness). This collaborative
programme pilot, SeaBreeze, used dance as an intervention for people with early psychosis. It was found
to be successful in its objectives of helping participants achieve greater satisfaction in interpersonal
relationships, improved embodied confidence and raised motivation, energy and optimism8. It also sought
to achieve some of its broader ambitions of reducing the stigma associated with accessing mental health
services and consequently reduce the co-morbidity of delayed diagnosis, highlighting the fact that modern
medications for psychosis do not impair movement functions, and drawing attention to recent radical
changes in the delivery of a care model from clinical management to holistic recovery.
4 Ibid.
5 Kirkbride JB, Errazuriz A, Croudace TJ, et al (2012). Incidence of schizophrenia and other psychoses in England, 1950–2009: A Systematic Review
and Meta-Analyses. PLoS One. 7(3):e31660
6 Campion (2013) Commissioning Support Factsheet: Prevalence, Causes and Treatment of People with Psychosis
7 Seabreeze: South London Mental Health Pilot Project Evaluation Report (2014)
8 Ibid.
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Using this pilot as a baseline, the project team sought to prove that the effect of the intervention was not
random. To evidence the replication of the intervention results, two cohorts were selected by SLaM EIS
teams in 2015, using clear criteria and process and put through the intervention. The 2015 intervention
programme was conducted by SLaM, Dance United and Cultural Utilities Enterprises (CUE), and funded
by the Guy’s and St Thomas Charity and the Maudsley Charity. This report presents the findings of an
independent evaluation of the 2015 intervention programme.
1.2. Context of the intervention
In England, mental health and emotional wellbeing is an integral part of both the Public Health and Adult
Social Care Outcomes Frameworks. It is associated with a range of outcomes and applied to all areas of
health and care. Given the high level of mental health need, improving mental health and wellbeing makes
a vital contribution to achieving these general measures. The cross-government mental health outcomes
strategy for people of all ages, ‘No health without mental health’9, supports the vision for improving
mental health through evidence-based practical recommendations, as well as providing the framework
for improving outcomes. With the transfer of public health into local government in England there are
opportunities for arts in health, as part of community empowerment strategies and outcomes-based
commissioning, to reduce health and wider inequalities and help improve the lives of local communities.
The case for future commissioning of arts in health initiatives is underscored by the fact that sustained
investment in the arts results in significant economic savings even in the short term occurring in a wide
range of public sectors including health and criminal justice10.
Recently, the work in arts and health has been aimed at tackling key targets of national and international
health policy such as physical health, emotional wellbeing, drug and alcohol misuse, healthier lifestyles to
reduce obesity and heart disease, supporting families, healthy ageing and engaging individuals and
communities. The arts, culture and heritage can contribute to health promotion, social capital
development and community engagement. Providers of services have been encouraged to include arts as
part of offerings in health and social care settings. At SLaM, an arts strategy exists with which the Trust
develops the use of art in mental health, wellbeing and recovery. Some of the aims of the strategy include
improving patient experience through engagement in the arts, reducing ‘revolving door care’ by sustaining
people’s wellbeing and recovery, encouraging a culture of innovation, and increasing the knowledge and
evidence base of the effect of the arts on health and mental wellbeing.
Although the use of arts in healthcare has been growing in the UK for a long time, it is only recently that
significant robust research has been carried out to provide evidence of the claimed benefits. A review of
medical literature, exploring the relationship of arts and humanities with healthcare and the influence
9 Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages
10 Department of Health (2011). Mental health promotion and mental illness prevention: the economic case. London.
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and effects of the arts on health, found clear, reliable evidence of clinical outcomes achieved through the
intervention of the arts including reduction in blood pressure, heart rate, length of hospital stay and
perception of pain11. It also showed the value of the arts in mental healthcare including improving clients’
communication skills, enabling them to express themselves, enhancing self-esteem, and bringing about
positive behavioural changes, as well as the differing impacts of different art forms on mental health
service users. A study carried out at Chelsea and Westminster Hospital also evaluated the effect of visual
and performing arts in healthcare and explored their effect on psychological, physiological and biological
outcomes of clinical significance12. It found that the integration of visual and performing arts into the
healthcare environment has a range of outcomes of clinical significance.
Recognition of the impact of such intervention on outcomes including mental wellbeing, social isolation
and physical health have informed their current use with these outcomes mandated by current local13 and
national policy14.
1.3. Intervention details and conceptual theory
EI services are aimed at early detection and treatment of symptoms of psychosis during the formative
years of the psychotic condition. Specialised multidisciplinary teams provide intensive case management
using a combination of low dose medication, cognitive behavioural therapy and integrated
psychotherapy.15 Clients are also offered the opportunity to participate in activities such as sports and
photography as well as support for their family and carers in partnership with a range of statutory and
non-statutory services. Results from evaluations show that EI services are cost effective in an evaluated
short term16 and gains achieved are lost when clients are moved to traditional community based mental
health teams17. However, the frequency of contact with the service tends to vary depending in individual
need, from weekly to monthly contact18, although the focused interactions at an early stage of the onset
of psychosis are considered a main feature of the success of such services19.
11 Staricoff (2004) Arts in health: a review of the medical literature.
12 Staricoff et. al. (2005). A Study of the Effects of Visual and Performing Arts in Health Care
13 South London and Maudsley NHS Foundation Trust (2014). Social Inclusion and Recovery (SIR) Strategy 2013–2018.
14 NHS England (2014). Our Ambition to reduce premature mortality. NHS, London.
15 Stafford et. al. (2013). Early interventions to prevent psychosis: systematic review and meta-analysis BMJ;346:f185
16 McCrone P, Craig TKJ, Power P, Garety PA (2010). Cost-effectiveness of an early intervention service for people with psychosis. Br J Psychiatry;
196: 377– 82
17 Gafoor R, Nitsch D, McCrone P, Craig TKJ, Garety PA, Power P, et al. (2010) Effect of early intervention on 5-year outcome in non-affective
psychosis. Br J Psychiatry; 196 : 372–6.
18 As reported by EI team members
19 Singh (2010). Early intervention in psychosis. The British Journal of Psychiatry, 196 (5) 343-345
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The Alchemy Project intervention emphasised focused interactions with clients and was designed
specifically for people who had never danced before. It was delivered in a highly structured, safe and
supportive environment. The main intervention, which was preceded by four, two-hour taster sessions,
consisted of a four-week, full-time dance-based programme starting at 10am and ending at 4pm each
day, and included the provision of healthy meals. Participants learned how to dance, and also engaged in
trust-building and team-building exercises. The intervention culminated in the performance of El Camino,
an original dance composition choreographed by Dance Directors Carly Annable-Coop and Ellen
Steinmuller in collaboration with Darren Ellis. Post intervention dance sessions were also provided for
participants. The Project was managed by Gwen van Spijk from Cultural Utilities and Enterprises with
expert advice provided by Dr Matthew Taylor of the IoP.
Participants were recruited by SLaM EI staff with support from members of The Alchemy Project delivery
team. The recruitment process followed meetings between The Alchemy Project delivery team and EI
teams who were provided with recruitment packs which contained detailed information about the
intervention, a typical participant profile and the criteria (including clinical considerations) for selecting
prospective participants. The EI teams oversaw the recruitment process, working closely with The
Alchemy Project delivery team to jointly meet with prospective participants and explain the intervention.
Each participant signed a referral and consent form and was encouraged to attend the taster sessions at
which they could interact with dancers and ask any questions. Regular communication was maintained
throughout the intervention period with updates from the intervention team to EI care coordinators
about the progress of their clients.
A ‘theory of change’, was created to articulate how the activities and their key qualities could bring about
a number of measurable, intermediate outcomes leading to three, long-term outcomes.
1. Satisfying interpersonal relationships
Improved communication skills
Increased level of trust in others
Increased capacity to work as part of a team
2. Positive Functioning: improved embodied confidence
Improved stillness and bodily control
Increased capacity for symbolic expression
3. Positive Affect: raised motivation, energy and optimism
Improved resilience
Increased optimism
The logic model for the ‘theory of change’, which illustrates the relationship between the intervention
and the anticipated outcomes, is presented below.
Figure 1: The Alchemy Project ‘Theory of Change’
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Two cohorts of young people participated in the project with the intervention provided in February and
June 2015. This report presents the results of an independent evaluation of the programme.
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2. Methodology
This section presents the general research strategy or design process that underpinned this evaluation.
It includes the methods that were utilised in the evaluation of The Alchemy Project as well as a
description of the logic model being tested.
2.1. Evaluation logic model
Logic models (or ‘theories of change’) explicitly set out the hypotheses about the impact of an
intervention. They are deductive models of reasoning and can be used both formatively (during an
intervention to inform learning iteratively) and summatively (after an intervention is complete to report
on impact). In this instance, the model was used summatively. A summary of types of evaluation
considered by Optimity Advisors is presented below (Fig. 2). This evaluation was aimed and answering the
last two questions and therefore falls into the outcome/impact evaluation category.
Figure 2: Types of evaluation
The premise of The Alchemy Project intervention was that the activities and rigour associated with it, and
the discipline and commitment it requires, will lead to a number of measurable, intermediate outcomes
such as improved team working, trust and communication skills. These would in turn lead to long-term
outcomes of improved self-efficacy and confidence, and a return to Education, Training and Employment
(ETE).
The research questions set out for the evaluation were as follows:
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Does the intervention improve Quality of Life (QoL) of participants? (Improved self-efficacy and
confidence)
Does the intervention improve participants’ interaction with the Early Intervention Service (EIS)?
(Improved interactions with the service)
Does the intervention enable progression of the participants to Education, Training and Employment
(ETE)? (Return to education, training and employment)
Is the intervention value for money? (Cost per benefit derived)
A logic model for the evaluation of these outcomes, and associated tools with which they would be
measured was designed. The model is presented below:
Figure 3: Evaluation logic model
2.2. Methods of data collection
The tools with which data was collected can be found in the Appendix. The methods with which the
evaluation was conducted are as follows:
Data was to be collected at various time points during the evaluation for each cohort, as follows:
Table 1: Data collection timetable
Time of collection Data collection tools
Baseline Participants - Outcome star, WEMWBS, EQ5D
EIS Staff - SES, Outcome star, interview
Four weeks Participants - Outcome star, WEMWBS, EQ5D
EIS Staff - Outcome star
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Time of collection Data collection tools
Three months Participants - Outcome star, WEMWBS, EQ5D
Six months Participants - Outcome star, WEMWBS, EQ5D
EIS Staff - SES, interview
2.2.1. Quantitative methods
Data was collected from programme participants, the intervention delivery team and members of EI
teams using standardised quantitative tools. The tools selected provided data relevant to the summative
outcome and impact evaluations. For the outcome evaluation, the Warwick-Edinburgh Mental Wellbeing
Scale (WEMWBS) and the Outcome star, which assessed positive affect, personal optimism, team working
and level of trust were used. These tools had been used in the pilot and provided comparable data. For
the impact evaluation, the EQ-5D-5L was used to assess changes in the self-efficacy and confidence of the
participants.
WEMWBS: A self-reported tool for measuring mental wellbeing, using a 14-item scale with five response
categories, summed to provide a single score ranging from 14-70. The items are all worded positively and
cover both feeling and functioning aspects of mental wellbeing. For this evaluation, the WEMWBS was
used to assess outcomes (participants’ positive functioning, positive affect and improved optimism from
satisfying interpersonal relationships) at baseline, end of intervention (four weeks) and at three and six
months post-intervention.
Outcome star: The Outcome star provides an easy to use and visual way of measuring progress in mental
health settings. It is completed on a scale of one to 10 in five domains and was used to assess participants’
team work, increased trust levels, improved communication skills, improved body control, and increased
resilience. It was completed by participants, and for each participant by EI staff and the project delivery
team at baseline and end of intervention.
Service Engagement Scale (SES): The Service Engagement Scale asks 14 questions to measure service user
engagement, reported from a service provider perspective. It is a practical, reliable, and valid measure of
engagement with services that can be completed quickly. It assessed participant interaction with the EI
team and was completed by EI staff at baseline and six months.
EQ-5D-5L: The EQ-5D is a standardised user reported instrument for use as a measure of health outcomes.
It assessed improved self-efficacy and confidence as a measure of Quality of Life (QoL). It was completed
at baseline, end of intervention (four weeks), and at three and six months post-intervention.
Data collection templates: Bespoke data collection templates were prepared for the collection of project
related inputs (number, time spent and costs of staff/mentors), process (quantitative data on
recruitment) and outputs (participation, adherence and completion rates) data. This was completed
throughout by the intervention delivery team.
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Value for money: An economic analysis was conducted. .
2.2.2. Qualitative methods
Qualitative data was collected from the project intervention team via focus group sessions conducted at
baseline and end of intervention for each cohort to assess the adequacy of participant referral and
recruitment and adherence to intervention. In addition, face-to-face interviews were conducted with EI
staff at baseline and six months to assess participant recruitment, participant engagement with EI staff,
and participants’ return to ETE.
2.3. Methods of data analysis
The analysis of the collected qualitative and quantitative data, as well as the value for money analysis,
consisted of the following:
Quantitative data analysis: Three instruments were used for the collection of quantitative data – the
Outcome star, the WEMWBS and the EQ-5D-5L. Data from the Outcome stars completed by participants,
EI and The Alchemy Project intervention staff were analysed using simple descriptive statistics and
presented pictorially. Data from the WEMWBS was analysed by individual and by cohort using simple
descriptive statistics and by paired sample and correlation statistics. The data was also analysed to show
the degrees of change for participants moving from a score band (described as low, medium or high) to
another score band. Data collected using the EQ-5D-5L was analysed using the standard EuroQol analysis
template, and presented descriptively as well as converted to quality adjusted life years (QALYs), a
standard measure for quality of life.
Qualitative data analysis: Data collected from the qualitative enquiries were summarised into a
framework to allow comparisons both within and between data sources, enabling Optimity to gain an in-
depth understanding of the key issues. Once the data had been organised and reduced into the
framework, analysis was conducted to establish the main emerging themes. The preliminary themes for
data analysis and the framework for the analysis of the data are presented below:
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Figure 4: Qualitative analysis framework
Value for money analysis: In considering the approach to be taken, the research team sought to compare
the benefits of the intervention (derived from the EQ5D, Outcome stars and WEMWBS) to the cost of the
intervention for each cohort, to provide an understanding of value for money.
Ideally, this would take the form of a cost-benefit analysis, where benefits and costs are both expressed
in monetary units, enabling the calculation of a ratio of benefit to cost (e.g. £3 value created per £1 spent).
This is possible, even with outcomes such as mental wellbeing, as monetisation is just an attempt to
measure outcomes in common units, rather than calculating money saved. (For example, a three point
improvement in total OS score could be valued at £8,000 and a 10 point improvement in WEMWBS score
over a year could be valued at £10,000, but this simply reflects that the OS improvement is valued at 80%
of the WEMWBS improvement).
Regrettably, there is no available research on the monetary values of the OS or the WEMWBS to draw on.
Instead, for these measures, the improvement in scores is simply compared to the cost, to provide
information to support a subjective decision on value for money. The EQ-5D, however, is well established
as a metric from which quality-adjusted life year (QALY) gains can be drawn.20 QALYs are used by NICE,
among other bodies, as a way of appraising the cost-effectiveness of health interventions (known as cost-
utility analysis). One QALY equals one year of perfect health, and NICE has an informal ‘threshold’ of
between £20,000 and £30,000 per QALY, below which an intervention is more likely to be considered
cost-effective. 21 By presenting this cost-utility analysis alongside the outcomes of the OS and the
WEMWBS, the research team sought to draw an initial picture of outcomes versus cost for The Alchemy
20 https://www.nice.org.uk/article/pmg9/chapter/the-reference-case
21 This threshold is based on analysis around value for money and affordability for the NHS, and is intended for use as a guide to what is cost-
effective, rather than an explicit rule. It has also been subject to some contention in the literature, with some advocating for a lower and
others for a higher threshold. See, for example, https://www.nice.org.uk/news/blog/carrying-nice-over-the-threshold
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Project. However, there are a number of limitations of this analysis. As such these results should be
considered a preliminary exploration of cost-effectiveness, with recommendations for future data
collection included.
2.4. Limitations
The aim of this project, and its evaluation is to provide further evidence of the effectiveness and value of
the intervention for the population served by EI services provided by SLaM. However, the achievement of
this aim was limited by a number of factors. These limitations included:
Bias in selection of participants
Although efforts were made to standardise the recruitment process by providing a recruitment package
and Alchemy Project staff supporting EI staff it is likely that there was some bias in the process. This is due
to the subjective application of the guidance, with staff recruiting mainly those they ‘felt’ would either
benefit from the programme, or who were available at the time. It is likely that other EI service clients
that were not selected might have derived benefit from the programme.
Sample size
The sample size is important to determine the impact of the intervention on a typical group of users. One
of the difficulties with a small sample – 22 across both cohorts in this case – is that the overall results are
very sensitive to changes in one or two people’s scores. As an example, take participant AP0112 in cohort
one. Their measured utility gain was 0.433, while the sum of the whole group’s utility gains was 0.428.
This means that without AP0112 in the group there would have been a slight utility loss overall. With a
larger sample size there would be a clearer picture of whether AP0112 is legitimately representative of a
subset of the population (if others had similar results), or an outlier whose results should not inform
overall conclusions as much as they do in a small sample. Additionally, a larger sample size may pick up
on a potential subset of the population, not represented by the participants in this study, who may
respond differently to the 22 considered here.
Lack of a control group
In the assessment of the evidence of the effectiveness of an intervention, it is difficult to determine
whether any observed outcome is directly attributable to the intervention, or a chance occurrence. The
use of a comparable control group allows for the attribution of outcomes to an intervention. The lack of
an intervention group for The Alchemy Project limits the attribution of the observed effects to the
intervention, especially for a population receiving that intervention, as well as standard care.
A control group was not used for this evaluation due to difficulties with identifying and recruiting one
from a comparable service. In addition, the lack of access to data from SLaM precluded the use of a
standard care dataset to use as the comparator.
Self-reported tools
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There is potential for either exaggeration or underreporting of outcomes by the participants using self-
reported tools. However, this potential limitation was minimised by the use of standardised tools that
have been tested and validated for use in this population group.
Issues with data collection
The main limitation of this evaluation was the difficulty with collecting data when due. Planned data
collection was to have occurred at baseline, four weeks, three months and six months for each cohort.
However, data was only collected essentially as planned at baseline, and at four weeks with some delay.
Three and six month data for cohorts one and two were not collected despite efforts to ensure its
collection.
Issues with the data collection were primarily due to the difficulty experienced in getting relevant EI staff
to collect and send data from their clients. The busy and dynamic nature of their workloads was cited as
the reason for the failure to engage with data gathering. However, this limitation had a detrimental impact
on the ability to evidence some of the programme outcomes as medium term data such as return to ETE
was not available.
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3. Results
3.1. Quantitative data
Participants’ recruitment and dropout
For cohort one, 15 participants were recruited for the intervention, of whom 12 completed the four-week
programme, with a completion rate of 80%. For cohort two, 18 participants were recruited for the
intervention, of whom 11 completed, with a completion rate of 61%. These compare to the pilot
‘SeaBreeze’ programme for which 18 participants were recruited, of whom 16 completed the four-week
programme,22 with a completion rate of 89%.
Recruitment rates for all three groups were similar for cohort two and the pilot group, with cohort one
having the fewest number of recruits. The time frame available for recruitment of this cohort was the
shortest of the three cohorts because it was a busy reporting period for the EI service and staff could not
be made available for selection and recruitment.
Table 2: Recruitment and completion rates
Detail Pilot Cohort one Cohort two
No. recruited
18 15 18
No. completed intervention
16 12 11
% completed
89% 80% 61%
Reasons for attrition 2 drop outs One completed the taster session and only one day in week one and decided not to continue with the project One only attended a taster session and did not return. One attended taster session only and was not allowed to return to do the project at this time – clinical decision
Four only attended a taster session and did not return. One had to travel on a family holiday. One was ill and had to drop out. One started a job and had to leave the project.
Warwick-Edinburgh Mental Wellbeing Scale Scores
22 Dance United (2014). SeaBreeze: South London Mental Health Pilot. www.dance-united.com
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Individual scores
Individual WEMWBS scores for cohort one ranged from 26 to 56 with an average of 47.1 at baseline, and
41 to 67 with an average score of 55 at the end of the intervention. For cohort two, the scores ranged
from 38 to 64 with an average of 51.3 at baseline, and 45 to 69 with an average score of 55 at the end of
the intervention. These were comparable with scores from the pilot ‘SeaBreeze’ project for which scores
at baseline ranged from 31 to 67 with an average of 46.7 at baseline, and 37 to 70 with an average score
of 53.4 at the end of the intervention.
Figure 5: Cohort 1 individual WEMWBS scores
Table 3: Cohort 1 individual WEMWBS descriptive statistics
N Min Max Mean Std. Deviation 95% CF
Baseline 13 26 56 47.1 9.2 5.0
Week four 12 41 67 55.0 7.0 3.9
Valid N 12
Table 4: Cohort 2 individual WEMWBS descriptive statistics
N Min Max Mean Std. Deviation
95% CF
Baseline 14 38 64 51.3 7.4 3.9
Valid List ?
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INDIVIDUAL WELLBEING SCORES ( WEMWBS) AP0101
AP0102
AP0103
AP0104
AP0105
AP0106
AP0107
AP0109
AP0110
AP0111
AP0112
AP0113
AP0108
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Week four 11 45 69 55.0 7.6 4.5
Valid N 11
Figure 6: Cohort 2 individual WEMWBS scores
Figure 7: Pilot individual WEMWBS scores
Valid List ?
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35
40
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50
55
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65
70
75
B A S E L I NE W E E K 4
INDIVIDUAL WELLBEING SCORES ( WEMWBS) AP0201
AP0202
AP0203
AP0204
AP0205
AP0206
AP0207
AP0208
AP0209
AP0210
AP0211
AP0212
AP0213
AP0214
AP0215
AP0216
AP0217
AP0218
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Table 5: Pilot individual WEMWBS descriptive statistics
N Min Max Mean Std. Deviation
95% CF
Baseline 16 31 67 46.7 10.4 5.1
Week four 14 37 70 53.4 9.1 4.8
Valid N 14
Participants were grouped by their scores. A score of low wellbeing where the total score is less than 42,
moderate in the range of 42-58 and high for scores greater than 58. Cohort two participants showed
marked progression across groups compared to cohort one and the pilot groups, as none of the
participants were in the ‘low’ wellbeing group at four weeks as well as an increase in the proportion with
‘high’ wellbeing scores.
Valid List ?
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B A S E L I NE W E E K 4
INDIVIDUAL WELLBEING SCORES ( WEMWBS) P001
P002
P003
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P007
P008
P009
P010
P011
P012
P013
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P014
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Figure 8: Cohort 1 - proportion of participants by wellbeing group
Figure 9: Cohort 2 - proportion of participants by wellbeing group
15%8%
85%
58%
33%
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60%
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90%
100%
Baseline Week4
Proportion of participants in each group before and after intervention
% Low wellbeing % Moderate wellbeing % High wellbeing
14%
64%
73%
21%27%
0%
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30%
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90%
100%
Baseline Week4
Proportion of participants in each group before and after intervention
% Low wellbeing % Moderate wellbeing % High wellbeing
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Figure 10: Pilot group - proportion of participants by wellbeing group
Individual degrees of change
When participants were analysed with respect to their positions relative to the midpoint of the scale
(score 42) at baseline and at four weeks, in cohort one, two participants were below this point at baseline,
but only one was at four weeks. For cohort two, two participants were below the midpoint at baseline,
but none was below the line at four weeks. The pilot group was similar to cohort one, as three participants
were below the midpoint of the scale at baseline, but only one participant was below that point at four
weeks.
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Figure 11: Cohort 1 - Individual degrees of change
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We
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Baseline
Degrees of Change for Participants on WEMWBS
Mid-Point Line
Mid
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Figure 12: Cohort 2 - Individual degrees of change
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Figure 13: Pilot group - Individual degrees of change
Group scores
Group average wellbeing scores increased across all groups from 47.1 to 55 for cohort one and 51.5 to 55
for cohort two. These scores compare favourably with the average results of the pilot, which increased
from 46.7 to 53.4. Group average incremental score for cohort two was slightly lower than for cohort one
and the pilot, but their baseline average group score was higher, and might suggest that the participants
had better wellbeing at baseline and consequently only improved marginally, relative to participants in
cohort one and the pilot.
Data from the paired sample and correlation statistics, also show that the effects elicited for all groups
were broadly comparable.
30
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25 30 35 40 45 50 55 60 65
We
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Baseline
Degrees of Change for Participants on WEMWBS
Mid-Point Line
Mid
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ine
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Figure 14: Cohort 1 – group wellbeing scores
Figure 15: Cohort 2 – group wellbeing scores
Figure 16: Pilot group - group wellbeing scores
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B A S E L I NE W E E K 4
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Figure 17: WEMWBS paired sample and correlation statistics
Outcome star Average Outcome star scores improved for all three groups from baseline. The data shows that ’Level of
trust’ was the domain showing the most consistent improvement across all the groups.
For the pilot group, ‘communication skills’ was the domain with the most marked improvement at four
weeks, while for cohorts one and two, it was ‘level of trust’.
Pilot
Descriptives N Min Max Mean Std. Deviation 95% CF
Baseline 16 31 67 46.7 10.4 5.1
Week4 14 37 70 53.4 9.1 4.8
Valid N (l istwise) 14
Paired Samples Statistics Mean N Std. Deviation Std. Error Mean
Baseline 43.9 14 7.5 2.0
Week4 53.4 14 9.1 2.4
Paired Samples Comparisons Mean N Std. Deviation Std. Error Mean t df Sig (2-tailed)
Baseline_Week4 -9.5 14 6.1 1.6 -5.8 13 0.000
Correlation Pearson Correlation Sig. (2-tailed) N
Baseline_Week4 0.743 0.002 14.0
Cohort1
Descriptives N Min Max Mean Std. Deviation 95% CF
Baseline 13 26 56 47.1 9.2 5.0
Week4 12 41 67 55.0 7.0 3.9
Valid N (l istwise) 12
Paired Samples Statistics Mean N Std. Deviation Std. Error Mean
Baseline 46.5 12 9.4 2.7
Week4 55.0 12 7.0 2.0
Paired Samples Comparisons Mean N Std. Deviation Std. Error Mean t df Sig (2-tailed)
Baseline_Week4 -8.5 12 11.3 3.3 -2.6 11 0.025
Correlation Pearson Correlation Sig. (2-tailed) N
Baseline_Week4 0.0653 0.0246 12.0
Cohort2
Descriptives N Min Max Mean Std. Deviation 95% CF
Baseline 14 38 64 51.3 7.4 3.9
Week4 11 45 69 55.0 7.6 4.5
Valid N (l istwise) 11
Paired Samples Statistics Mean N Std. Deviation Std. Error Mean
Baseline 50.2 11 7.2 2.2
Week4 55.0 11 7.6 2.3
Paired Samples Comparisons Mean N Std. Deviation Std. Error Mean t df Sig (2-tailed)
Baseline_Week4 4.8 11 6.5 2.0 2.5 10 0.033
Correlation Pearson Correlation Sig. (2-tailed) N
Baseline_Week4 0.618 0.033 7.0
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Figure 18: Cohort 1 – average self-reported outcome star scores
Completed By
Outcomes Baseline Week4
Communication Skills 6.8 7.5
Resilience 6.8 7.1
Concentration and Focus 6.1 8.0
Level of trust in others 5.4 8.0
Working with others as part of a team7.2 9.2
Participants
0
1
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5
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Figure 19: Cohort 1 – average project team reported outcome star scores
Completed By
Outcomes Baseline Week4
Communication Skills 4.4 6.9
Resilience 4.9 8.2
Concentration and Focus 4.8 8.0
Level of trust in others 3.8 7.6
Working with others as part of a team4.5 8.0
Intervention Team
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Figure 20: Cohort 1 – EI team reported outcome star scores
For cohort one scores, the participants on average, rated themselves higher on the domains assessed, when compared with the average scores given to them for the same domains by both the EI and Alchemy Project intervention teams. This is consistent with participants rating themselves high on self-assessments. This difference was more obvious for the baselines than for the four-week scores. The EI team also rated the participants higher than the project team for the same domains.
The project team and the participants scored the assessment for the four week Concentration and Focus domain the
same (eight) while the EI team scored those 6.5. It is unclear the reason for such differences in the scoring.
Outcomes Baseline Week4
Communication Skills 5.5 6.4
Resilience 5.5 6.5
Concentration and Focus 4.7 6.5
Level of trust in others 6.3 6.7
Working with others as part of a team4.8 6.6
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Figure 21: Cohort 2 – average self-reported outcome star scores
Figure 22: Cohort 2 – average project team reported outcome star scores
Completed By
Outcomes Baseline Week4
Communication Skills 6.9 8.5
Resilience 7.6 8.9
Concentration and Focus 7.6 8.3
Level of trust in others 5.6 7.5
Working with others as part of a team8.1 9.2
Participants
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Completed By
Outcomes Baseline Week4
Communication Skills 4.5 8.0
Resilience 4.9 9.1
Concentration and Focus 4.4 8.4
Level of trust in others 4.4 8.1
Working with others as part of a team4.9 8.4
Intervention Team
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Figure 23: Cohort 2 – EI team reported outcome star scores
Figure 24: Cohort 2 – Jide Ashimi reported
Completed By
Outcomes Baseline Week4
Communication Skills 5.1 7.6
Resilience 5.2 7.4
Concentration and Focus 5.9 7.5
Level of trust in others 6.1 8.0
Working with others as part of a team6.6 8.2
EIS Team
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
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Baseline
Week4
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For cohort two scores, participants on average similarly rated themselves higher on the domains assessed, when compared with the average scores given to them for the same domains by both the EI and Alchemy Project intervention teams. This difference was more obvious for the baselines than for the four-week scores. The EI team also rated the participants higher than the project team did for the same domains, with the scores by Jide Ashimi (an EI staff embedded with the project) comparable with those given by the intervention team.
Figure 25: Pilot - average self-reported outcome star scores
Completed By
Outcomes Baseline Week4
Communication Skills 4.8 9.0
Resilience 4.8 9.4
Concentration and Focus 4.6 9.1
Level of trust in others 4.6 9.0
Working with others as part of a team4.9 9.5
Jilde Ashmi
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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EQ5D scores
There were improvements in mean quality of life scores reported for both cohorts. However, although
both cohorts had similar baseline mean scores, cohort one showed greater mean improvement in quality
of life scores than cohort two. This difference appears to be consistent with the finding from the Outcome
stars and WEMWBS scores for which cohort one had lower baseline scores than cohort two, and showed
a more obvious improvement at four weeks.
For cohort one, baseline EQ-5D scores ranged from 0.567 to one, and at week four the range was 0.837
to one. The greatest improvement in scores was 0.43, the lowest was a decline of 0.163. Of the 12
participants who provided week four EQ-5D scores (out of 13), three suffered a decline in utility, five
remained the same and three saw an improvement. The total improvement in utility scores was 0.4280,
or 0.036 per person. However, as the EQ5D is self-reported, it is unclear what effect any exaggerated
scoring might have had on the results.
Figure 26: Cohort 1 EQ5D scores
Completed By
Outcomes Baseline Week4
Communication Skills 2.0 6.0
Resilience 3.0 6.0
Concentration and Focus 3.0 7.0
Level of trust in others 5.0 8.0
Working with others as part of a team5.0 8.0
Participants
0
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CommunicationSkills
Resilience
Concentrationand Focus
Level of trust inothers
Working withothers as part of
a team
Baseline
Week4
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Figure 27: Cohort 2 EQ5D scores
Service Engagement Scale
The SES was not used for the evaluation of the pilot. However, only baseline data was collected for both
cohorts one and two, due to the difficulty in collecting the data from EI staff, one of the key limitations of
the study. Consequently, the data is not presented.
3.2. Qualitative data
Qualitative data was collected from EI staff via face-to-face and telephone interviews, and from members
of The Alchemy Project team through focus group meetings. The qualitative enquiries sought to
determine their perceptions of the intervention, its impact on the participants, and challenges they faced
during the intervention and its evaluation. The key themes that emerged are presented below.
Interviews with EI staff
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Face-to-face baseline interviews were conducted with seven EI staff responsible for cohort one
participants, while five interviews were conducted for cohort two. A total of eight interviews were
conducted post intervention, although three of the interviewed staff had clients in both cohorts. Using
the analytic framework described above, data from the interviewees was analysed thematically. Some of
the themes that emerged are as follows:
The relevance of the project for the participants
All the interviewed staff noted that the intervention was well received by their clients. A repeating theme
was that all their clients had improved social skills, greater confidence, and had started taking interest in
things other than their health status. Most stated that their clients had been socially isolated prior to the
intervention, but had since become more involved in activities around them.
One had been pessimistic about his client’s ability to participate in the programme, but was pleasantly
surprised to find that the client fully participated, and “…was attending sessions on time!”
One interviewee, however, noted that both clients she had on the programme had relapsed and been
admitted into acute care. She stated, though, that it was unlikely to be linked to their participation in the
programme.
All the interviewed staff noted that the full time nature of the intervention provided structure to their
clients, increased their levels of physical activity, with some reporting weight loss during the period.
The longer term impact of the project on the participants
Most of the interviewees noted that it was unclear what the longer-term effects of the intervention might
be. This was primarily due to the fact that they felt that the participants essentially went from being
occupied with activities five days a week for a month, to having a once weekly dance session, and this did
not provide adequate continuity for participants.
While some suggested that a post-intervention activity, more frequent than the once a week session in
place might help, others suggested that the difficulty and cost of such an on-going effort might make it
unlikely.
Difficulties experienced
The main difficulty experienced by the interviewees, was the requirement to help collect data from
participants in the midst of a busy schedule with multiple competing priorities. Some suggested that
although they valued the impact of the intervention on their clients, the burden of data collection
requirement might be better placed elsewhere.
Focus groups with The Alchemy Project team
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Focus group meetings were held with members of The Alchemy Project team, at baseline and end of the
intervention for each cohort. Using the analytic framework described above, data from the meetings was
analysed thematically. Some of the themes that emerged are as follows:
Participant attributes
At baseline and end of intervention, the project team was asked to describe each cohort with attributes
pertinent to a dance company, and rate them on a scale of one to 10, with one the least rating and 10 the
best. For cohort one, the pertinent features were trust, social interaction, wellbeing, sense of self and
confidence. The ratings improved from two to nine for trust, four to 10 for social interaction, three to nine
for wellbeing, two to 10 for sense of self, and one to 10 for confidence. For cohort two, the features were
support for others, trust, confidence, willingness to learn, self-belief and mastering movement. The
ratings improved from seven to 10 for support for others, four to nine for trust, three to nine for
confidence, six to 10 for willingness to learn, two to 10 for self-belief and two to eight for mastering
movement.
Difficulties experienced
The team reported that the main difficulty they experienced was the short turnaround time for the
recruitment of participants and commencement of the intervention for cohort one. This was suggested
to be the cause of the low recruitment number for that cohort. This difficulty was, however, not
experienced with cohort two.
Things to improve on
For cohort one, the team considered that some of the things that could be improved upon included the
information provided for the EI staff about the intervention and the evaluation in order to better educate
them and foster increased acceptance. These elements were implemented for cohort two and the team
felt it helped improve the recruitment of participants.
3.3. Economic analysis
Three main outcome measures were collected from participants at the beginning and the end of the
intervention (after four weeks), for both cohorts. These comprised EQ-5D scores, Outcome star (OS)
scores, and Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) scores. All are compared to the cost
of the intervention for each cohort to provide an understanding of value for money.
Ideally, this would take the form of a cost-benefit analysis, where benefits and costs are both expressed
in monetary units, enabling the calculation of a ratio of benefit to cost (e.g. £3 value created per £1 spent).
This is possible, even with outcomes such as mental wellbeing, as monetisation is just an attempt to
measure outcomes in common units, rather than calculating money saved. (For example, a three point
improvement in total OS score could be valued at £8,000 and a 10 point improvement in WEMWBS score
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over a year could be valued at £10,000, but this just reflects that the OS improvement is valued at 80% of
the WEMWBS improvement).
Unfortunately, there is no available research on the monetary values of the OS or the WEMWBS to draw
on. Instead, for these measures, the improvement in scores is simply compared to the cost, to provide
information to support a subjective decision on value for money. The EQ-5D, however, is well established
as a tool from which quality-adjusted life year (QALY) gains can be drawn.23 QALYs are used by NICE,
among other bodies, as a way of appraising the cost-effectiveness of health interventions (known as cost-
utility analysis). One QALY equals one year of perfect health, and NICE has an informal ‘threshold’ of
between £20,000 and £30,000 per QALY, below which an intervention is more likely to be considered
cost-effective.24
By presenting this cost-utility analysis alongside the outcomes of the OS and the WEMWBS an initial
picture of outcomes versus cost for the Alchemy Project can be seen. However, there are a number of
limitations of this analysis, including a small sample size, lack of a control group, short follow-up as well
as additional potential benefits not covered by these tools (such as productivity benefits and reduced
health service utilisation). As such these results should be considered a preliminary exploration of cost-
effectiveness, with recommendations for future data collection included.
3.3.1. Intervention cost
In order to provide an assessment of value for money, the cost of the intervention must be calculated.
These figures were provided by Alchemy, and the column referring to ‘actual’ costs was used for
calculations. Planning, set up and development costs were £11,807 for cohort one and £13,715 for cohort
two. (This difference results from the need to train a new member of staff for cohort two.25) The £43,000
project management and running costs were divided in two, representing £21,500 per intervention. This
gave a total cost for cohort one of £85,463; and for cohort two of £87,661. Documentation and evaluation
costs, as well as the cost of an ongoing dance group, were not considered part of the intervention cost.
Per person costs were also calculated. For this the total cost was divided by the number of people who
completed the programme and reported results (11 in cohort one26 and 11 in cohort two), rather than
23 https://www.nice.org.uk/article/pmg9/chapter/the-reference-case
24 This threshold is based on analysis around value for money and affordability for the NHS, and is intended for use as a guide to what is cost-
effective, rather than an explicit rule. It has also been subject to some contention in the literature, with some advocating for a lower and
others for a higher threshold. See, for example, https://www.nice.org.uk/news/blog/carrying-nice-over-the-threshold
25 While this means that future rollout of the intervention could be slightly cheaper if trained staff were already available, there is likely to be
some need to train staff in future, and so this cost has been included in the analysis.
26 Twelve participants reported results in cohort one, but one – participant AP0110, was excluded due to their self-reported baseline results
being significantly anomalous. This is discussed further in the EQ-5D section
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the number starting at baseline (13 and 18 respectively). Cost per person was therefore £7,531 for cohort
one and £7,731 for cohort two.
Table 6: Intervention cost
Intervention cost Raw data For analysis
Cohort one Cohort two Total Cohort one Cohort two
Planning set up and development £11,807 £13,715 £11,807 £13,715
Delivery £49,531 £49,821 £49,531 £49,821
Ongoing dance group N/a
Project mgmt. & running costs £43,000 £21,500 £21,500
Documentation & evaluation N/a
Total £82,838 £85,036
Number completing programme 11 11
Cost per person £7,531 £7,731
3.3.2. EQ-5D outcomes
EQ-5D values were converted into utility scores using a conversion table obtained from EuroQol, who
developed the questionnaire.27 Utility scores are the quality of life aspect of QALYs, and they range from
zero (death) to one (full health). A utility score of one sustained for one year equals one QALY.
For cohort one, results were obtained for the 12 participants (out of 13). However, one of these results
(for participant AP0110) showed a baseline score of 0.097, i.e. very close to death, and a week four score
of 0.837, i.e. not far from perfect health. This was assumed to be inaccurate self-reporting and was
removed from calculations. As such, baseline EQ-5D scores ranged from 0.567 to one, and at week four
the range was 0.837 to one. The greatest improvement in scores was 0.43, the lowest was a decline of
0.163. Of the 12 participants who provided week four EQ-5D scores (out of 13), three suffered a decline
in utility, five remained the same and three saw an improvement. The total improvement in utility scores
was 0.4280, or 0.036 per person. However, that aside, from one other participant, AP0112, who saw a
0.433 utility improvement, there would have been a slight decline in utility scores. As such, the small
sample size and lack of a control group for this intervention make it difficult to make firm conclusions
based on these values.
Table 7: Utility gains for cohort 1
Participant ID Baseline Week four
State EQ-5D-5L index value State EQ-5D-5L index value Utility Gain
AP0101 11112 0.879 11121 0.837 -0.042
27 http://www.euroqol.org/about-eq-5d/valuation-of-eq-5d/eq-5d-5l-value-sets.html
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AP0102 11113 0.848 11113 0.848 0.000
AP0103 11111 1 11111 1 0.000
AP0104 11112 0.879 11111 1 0.121
AP0105 11111 1 11111 1 0.000
AP0106 11111 1 11111 1 0.000
AP0107 11212 0.837 11121 0.837 0.000
AP0108 11222 0.736 99999 #N/A
AP0109 11111 1 11121 0.837 -0.163
AP0110** 33444 0.097 11121 0.837 0.740**
AP0111 11112 0.879 11111 1 0.121
AP0112 23322 0.567 11111 1 0.433
AP0113 11112 0.879 11121 0.837 -0.042
Total 0.4280
Average 0.036
** Removed from calculations
For the 11 participants in cohort two who reported results, a more uniform slight utility increase was
observed, although the small sample size and lack of a control group prevent this from being interpreted
with a great deal of confidence. Baseline utility ranged from 0.606 to one, and at week four from 0.635 to
one. The total improvement was slightly larger for cohort two, at 0.6690, with an average of 0.06 per
person.
Table 8: Utility gains for cohort 2
Participant ID Baseline Week four
State EQ-5D-5L index value State EQ-5D-5L index value Utility Gain
AP0201 11111 1 11111 1 0.000
AP0202 12223 0.634 11121 0.837 0.203
AP0203 11123 0.75 11111 1 0.250
AP0204 11112 0.879 11114 0.635 -0.244
AP0205 11214 0.606 11233 0.696 0.090
AP0206 11222 0.736 11122 0.768 0.032
AP0207 11113 0.848 11111 1 0.152
AP0208 11111 1 99999 #N/A
AP0209 99999 #N/A 99999 #N/A
AP0210 11211 0.906 11211 0.906 0.000
AP0211 11123 0.75 31131 0.727 -0.023
AP0212 99999 #N/A 99999 #N/A
AP0213 12222 0.649 12121 0.737 0.088
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Participant ID Baseline Week four
State EQ-5D-5L index value State EQ-5D-5L index value Utility Gain
AP0214 11112 0.879 99999 #N/A
AP0215 99999 #N/A 99999 #N/A
AP0216 99999 #N/A 99999 #N/A
AP0217 11112 0.879 11111 1 0.121
AP0218 11111 1 99999 #N/A
Total 0.6690
Average 0.061
In order to convert these scores into QALY gains how long this improvement was sustained for needs to
be known. Unfortunately, this is not possible given that the post-intervention data is only from one time
period (four weeks). As such, a range of scenarios is presented, and calculated costs and cost per QALY
for each: one month, three months, six months, one year, two years, five years and 10 years. These are
shown below:
Table 9: QALY gains and cost per QALY
Cohort one Cohort two
Total utility gain 0.428 0.669
Benefit sustained
for
Undiscount
ed QALY
gain
Discounte
d QALY
gain
ICER Undiscounted QALY
gain
Discounte
d QALY
gain
ICER
1 month 0.04 0.04 £2,322,56
1
0.06 0.06 £1,525,31
5
3 months 0.11 0.11 £774,187 0.17 0.17 £508,438
6 months 0.21 0.21 £387,093 0.33 0.33 £254,219
1 year 0.43 0.43 £193,547 0.67 0.67 £127,110
2 years 0.86 0.85 £97,494 1.34 1.33 £63,555
5 years 2.14 2.08 £39,870 3.35 3.25 £25,422
10 years 4.28 4.01 £20,677 6.69 6.26 £12,711
The ‘undiscounted QALY gain’ column multiplies the total utility gain by the time period (in years) to
calculate the QALY gain from each intervention. For instance, if it is assumed that the intervention benefit
is sustained for one month, the 0.428 utility gain in cohort one represents 0.04 QALYs gained. However,
if the intervention benefit were sustained for 10 years, this would represent 4.28 QALY amongst the
cohort.
The discounted QALY gains column introduces a concept called discounting, which is regularly used in
economic analysis. It represents the concept that a benefit in the future is not equal to the same benefit
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now, by ‘discounting’ future benefits by a given amount each year.28 Following NICE guidance29, a discount
rate of 1.5% has been used. This means that for cohort one, were the benefit to be sustained for 10 years,
the discounted QALY gain is 4.01 QALYs, slightly less than the undiscounted 4.28.
The third column for each cohort calculated the ICER, or Incremental Cost-Effectiveness Ratio. This
represents the marginal intervention cost divided by discounted QALY gain, i.e. cost per QALY. The NICE
threshold policy for health interventions generally takes a cost per QALY of £20-30,000 or below to mean
an intervention is cost-effective. As the table above shows, this would only occur if the benefit was
sustained for several years. The years of benefit required at each threshold value were calculated for each
cohort and presented below:
Table 10: Years of benefit required for NICE cost-effectiveness thresholds
Threshold value Benefit required in years
Cohort one Cohort two
Using undiscounted
QALY gains
Using discounted
QALY gains
Using undiscounted
QALY gains
Using discounted
QALY gains
£20,000 9.7 10.4 6.2 6.6
£30,000 6.5 6.7 4.1 4.3
The table shows that, using discounted QALY gains as is the recommended approach, cohort one benefit
would have to be sustained for 10.4 years to achieve a £20,000 ICER, or 6.7 years for a £30,000 ICER.
Cohort two, with a slightly higher utility gain, would require 6.6 years of benefit using the £20,000
threshold, or 4.3 at the £30,000 threshold. Overall, the suggestion here is that the benefit would have to
be sustained for several years following a one-off intervention to be cost-effective in terms of utility gain,
which is unlikely to be the case.
However, given the focus of the OS tool on non-health outcomes, and the focus of the WEMWBS on
mental health outcomes that reaches beyond the one EQ-5D mental health question, there may be some
benefits captured by those tools that is not covered in the EQ-5D, and this is discussed below.
3.3.3. Outcome star
The Outcome star measures five areas of benefit on a one to 10 scale: communication skills, resilience,
concentration and focus, level of trust in others, and working with others as part of a team. It was
completed by participants, the intervention team, the EIS team, and, for cohort two participants and Jide
Ashimi. Results were averaged across all of these assessors to provide the average scores below.30
28 Costs should also be discounted if occurring beyond the first year of the intervention (which is not the case for this intervention)
29 https://www.nice.org.uk/article/pmg4/chapter/1%20introduction
30 As per the EQ-5D scores, participant AP0110 was removed from results
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Table 11: Outcome star results
Category Cohort one Cohort two
Before After Improvement Before After Improvement
Communication Skills 5.6 6.9 1.2 5.3 8.3 3.0
Resilience 5.8 7.1 1.3 5.6 8.7 3.1
Concentration and Focus 5.5 7.5 2.0 5.6 8.3 2.7
Level of trust in others 5.4 7.6 2.1 5.2 8.2 3.0
Working with others as part of a
team 5.5 7.9 2.4 6.1 8.8 2.7
Total improvement 9.1 14.4
As the results show, an improvement occurred across each of the five categories for both cohorts. This
was more significant in cohort two, who saw most improvements in the range of two to three out of 10,
while cohort one saw improvements of around one to two points out of 10.
In the absence of any monetary valuation available for these results, or a similar cost-effectiveness
methodology to that used for EQ-5D results, the cost per improvement in OS score can only be presented.
The cost per person achieving a one point increase has been calculated. Results are shown below.
Table 12: Cost per improvement in OS score
Category Cohort one Cohort two
Improvement
Cost /
Improvement Improvement
Cost /
Improvement
Communication Skills 1.2 £6,106 3.0 £2,611
Resilience 1.3 £5,648 3.1 £2,504
Concentration and Focus 2.0 £3,693 2.7 £2,889
Level of trust in others 2.1 £3,574 3.0 £2,598
Working with others as part
of a team 2.4 £3,167 2.7 £2,858
Total 9.1 £828 14.4 £537
The table shows that, overall, it cost £828 for every point increase in OS score per person in cohort one,
and £537 in cohort two.
3.3.4. Warwick-Edinburgh Mental Wellbeing Scale
The Warwick-Edinburgh Mental Wellbeing scale measures a number of aspects of mental wellbeing, and
aggregates these into one score, ranging from 14 (the lowest value) to 70. Although the EQ-5D also
contains a question on mental health (in terms of depression and anxiety), the WEMWBS is a mental
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health specific tool covering areas beyond that captured in the EQ-5D, suggesting that at least some
WEMWBS benefits are additional to EQ-5D improvements.
For this economic analysis, the cost per improvement in three areas was measured: the mean score, the
number of people achieving meaningful positive change, and the number moving from one category of
wellbeing (low, medium, high) to another. (Note that the number moving category counts those moving
up a category as +1 and moving down a category as -1.) These results are provided in the table below31:
Table 13: WEMWBS Results
Cohort one Cohort two B
efo
re
Aft
er
Imp
rove
men
t
Co
st/
imp
rove
men
t
Bef
ore
Aft
er
Imp
rove
men
t
Co
st/
imp
rove
men
t
Mean score 48.3 54.4 6 £1,255 50.2 55.0 4.8 £1,595
No. people with meaningful positive change 7 £11,834 7 £12,148
No. moving up a category (net) 3 £27,613 3 £28,345
There was a general improvement in both cohorts – six points for cohort one and 4.8 for cohort two.
Interestingly, the mean score after the intervention was the same for both cohorts, so the difference
represents the higher baseline values in cohort two. Using cost per person figures as for OS scores, the
cost per one point improvement per person was £1,255 for cohort one, and £1,595 for cohort two.
In addition, results were provided showing the number of people who achieved a ‘meaningful positive
change’ (defined as an increase greater than two points) was seven for both cohorts. Using the total
intervention cost, this represents £11,834 per person achieving meaningful positive change for cohort
one, and £12,148 for cohort two.
Finally, results were categorised into ’low‘, ’moderate‘ and ’high‘ wellbeing, using the same scale as the
pilot programme.32 Based on this, the numbers of people who moved from one category to another were
calculated. Cohort one saw one participant move from low to moderate wellbeing, three move from
moderate to high wellbeing, and one move down from moderate to low wellbeing. This was considered
for the analysis as a net gain of three people moving up a category. Similarly for cohort two, two people
moved from low to moderate, two from moderate to high, and one from high to moderate, also giving a
net gain of three. The cost for both cohorts per person moving up a category was, therefore, just under
£30,000.
31 As per EQ-5D & OS, participant AP0110 was removed from the cohort one results
32 Low wellbeing is a score <42, high wellbeing is a score >58, and moderate wellbeing is a score between the two
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3.3.5. Interpretation
As indicated in the introduction to this section, caution should be exercised when interpreting this analysis
for a number of reasons. There were three key limitations – small sample size, lack of a control group and
a short follow-up. The small sample size (11 in each cohort) means that results are very sensitive to the
scores of individual participants which, when combined with the self-reported nature of the outcomes,
means it is difficult to judge how accurate outcomes results are. Similarly, the lack of a control group
means results cannot be compared against what would have happened without the intervention – some
participants who declined in mental health outcomes may have declined more without the intervention,
and vice versa. Finally, the short follow-up prevents understanding of how benefits are sustained over
time, which is crucial for making assessments of the value of a programme – if participants quickly return
to the same state they were in at baseline the benefits are limited.
What the results do show is that, based on the utility gain observed, the intervention is unlikely to be cost-
effective unless benefits are sustained for a considerable period of time. While the OS and WEMWBS
provide potentially complementary benefits, it is difficult to adjudicate the value of this in isolation,
especially given the limitations mentioned above. However, other potential benefits, which could add to
the intervention’s cost-effectiveness, were not measured: these include productivity benefits through
improved employment and training outcomes as well as health service utilisation (which could provide a
direct cost saving to the NHS).
In summary, the analysis would suggest that further follow-up, the rollout of the intervention to a larger
group and the addition of a well-matched control group is likely to greatly improve insight into the value
for money of The Alchemy Project.
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4. Discussion and conclusions
The evaluation sought to assess whether the outcomes elicited in the pilot can be reproduced in
comparable cohorts, and to extend the evidence base by considering medium term outcomes. The
questions posed were:
Does the intervention improve Quality of Life (QoL) of participants? (measured by improved self-
efficacy and confidence)
The results showed that for both cohorts, there were improvements in self-efficacy and confidence
over the duration of the intervention. For cohort one, QALY scores ranged from 0.567 to one at
baseline, and at week four the range was 0.837 to one. The greatest improvement in scores for a
participant was 0.43, the lowest was a decline of 0.163. The total improvement in utility scores for
cohort one was 0.4280, or 0.036 per person. For cohort two, QALY scores ranged from 0.606 to one,
and at week four from 0.635 to one. The total improvement was slightly larger for cohort two, at
0.6690, and the average was 0.06 per person. These indicate good effect of the intervention on
participants in the short term. QoL, as a study that assessed the appropriateness of using the EQ–5D
to measure improvements in mental health (participants with psychosis), 33 showed a post-
intervention mean change of 0.029 to 0.117. Thus it can be stated that the intervention improved the
quality of life of the participants in the timeframe measured (four weeks of the intervention). Data is
not available to demonstrate if this improvement is sustained over time.
Does the intervention improve participants’ interaction with the Early Intervention Service?
(measured by improved interactions with the service)
The evaluation sought to assess whether there was any change in interactions with the EI service but
the data collected was insufficient. This was essentially due to the lack of post intervention data.
Consequently, this question cannot be answered by this evaluation.
Does the intervention enable progression of the participants to Education, Training and
Employment (ETE)? (measured by return to education, training and employment)
One of the anticipated programme impacts was a return of participants to education, training or
employment. This was to be evidenced by either a return to ETE at six months, or at the least
interactions with the service’s social interaction team. However, due to the lack of data, this
evaluation cannot answer this question.
Is the intervention value for money? (measured by cost per benefit derived)
A value for money analysis, as proposed in the original methodology, was not conducted because of
the limitations mentioned above. Based on the utility gain observed, however, the intervention is
33 Barton et al (2009). Measuring the benefits of treatment for psychosis: validity and responsiveness of the EQ–5D. The British Journal of
Psychiatry
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unlikely to be cost-effective unless benefits are sustained for a considerable period of time. Other
potential benefits, which could add to the intervention’s cost-effectiveness, were also not measured:
these included productivity benefits through improved employment and training outcomes as well
as possible lower health service utilisation (which could provide a direct cost saving to the NHS).
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5. Recommendations
This evaluation sought to assess whether the intervention improves the mental wellbeing and quality of
life of participants as evidenced by the pilot as well as its value for money.
Despite the limitations the results indicate that the programme results are positive in the short term and
replicated across the pilot and both cohorts. However, in order to further strengthen the evidence base
for using this intervention in the EI population, the following recommendations can be made:
There is a need for a longer-term study to assess whether the intervention effects are sustainable in
the medium to long term. This will also provide further evidence to support the value for money of
the intervention, especially from a wider societal perspective.
The use of a larger sample size and a control group in any further research will ensure that findings
will be sufficiently powered to evidence any intervention effects, and allow for the attribution of the
effects to the intervention.
As the literature and anecdotal evidence suggests that there are wider health benefits to this
intervention, further research should include an assessment of these wider health benefits such as
physical activity.
This evaluation noted the limited nature of the tools available for assessing some of the ‘softer’
effects of the intervention. Any further research should consider other tools, including qualitative
tools that might better assess such outcomes.
Considering the possible selection bias encountered in this study, any further evaluation of such an
intervention should include an assessment of the selection process, in order to determine whether
likely participants that might benefit from it are not excluded due to such bias.
A key limitation of this evaluation was the difficulty in accessing data. It is likely that the embedding
of an evaluation and tools used to collect data into routine EI work and data collection, will greatly
reduce the difficulties experienced with the current evaluation.
There is a need to ensure some continuity or gradual reduction of the pace of activities participants
experience over the course of the intervention. This softer landing has been suggested by EI staff as
a necessity to allow for a fostering of the cadence of the activities experienced during the
intervention.
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6. Appendices
6.1. Appendix 1: EQ5D
Health Questionnaire
English version for the UK
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Under each heading, please tick the ONE box that best describes your health
TODAY.
MOBILITY I have no problems in walking about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about
SELF-CARE I have no problems washing or dressing myself
I have slight problems washing or dressing myself
I have moderate problems washing or dressing myself
I have severe problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework,
family or leisure activities) I have no problems doing my usual activities
I have slight problems doing my usual activities
I have moderate problems doing my usual activities
I have severe problems doing my usual activities
I am unable to do my usual activities
PAIN / DISCOMFORT I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
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I have extreme pain or discomfort
ANXIETY / DEPRESSION I am not anxious or depressed
I am slightly anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed
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The worst health
you can imagine
We would like to know how good or bad your health is TODAY.
This scale is numbered from 0 to 100.
100 means the best health you can imagine.
0 means the worst health you can imagine.
Mark an X on the scale to indicate how your health is TODAY.
Now, please write the number you marked on the scale in the box
below.
The best health you
can imagine
YOUR HEALTH TODAY =
10
0
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95
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6.2. Appendix 2: Outcome star
OUTCOME STAR:
SCORE: 1-10 (1 being low and 10 being high) on the following
statements – Please Circle:
My communication skills: such as speaking with confidence and listening to others 1 2 3 4 5 6 7 8 9 10
My resilience: my capacity to overcome obstacles in order to achieve something 1 2 3 4 5 6 7 8 9 10
My capacity to maintain concentration and focus on what I am doing 1 2 3 4 5 6 7 8 9 10 My level of trust in others 1 2 3 4 5 6 7 8 9 10
Baseline assessment Participant: AP02 Completed by:
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My capacity to work as a team 1 2 3 4 5 6 7 8 9 10
6.3. Appendix 3: Alchemy Project Evaluation
Service Engagement Scale (Tait et al. (2002)
Note: Items are rated 0 (not at all or rarely), 1 (sometimes), 2 (often), 3 (most of the time).
*Reverse scored (i.e. 0 = most of the time, 3 = not at all or rarely). Please circle relevant response.
Availability
1. The client seems to make it difficult to arrange appointments
2. When a visit is arranged, the client is available*
3. The client seems to avoid making appointments
Collaboration
4. If you offer advice, does the client usually resist it?
5. The client takes an active part in the setting of goals or treatment plans*
6. The client actively participates in managing his/her illness*
Help seeking
7. The client seeks help when assistance is needed*
8. The client finds it difficult to ask for help
9. The client seeks help to prevent a crisis*
10. The client does not actively seek help
Treatment adherence
11. The client agrees to take prescribed medication*
12. The client is clear about what medications he/she is taking and why*
13. The client refuses to co-operate with treatment
14. The client has difficulty in adhering to the prescribed medication
Baseline assessment Participant: AP02 Completed by:
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6.4. Appendix 4: The Warwick-Edinburgh Mental Well-being Scale
Below are some statements about feelings and thoughts.
Please tick the box that best describes
your experience of each over the last
two weeks STATEMENTS
None of the time Rarely Some of the
time
Often All of the
time
I’ve been feeling optimistic about the
future
1 2 3 4 5
I’ve been feeling useful 1 2 3 4 5
I’ve been feeling relaxed 1 2 3 4 5
I’ve been feeling interested in other
people
1 2 3 4 5
I’ve had energy to spare 1 2 3 4 5
I’ve been dealing with problems well 1 2 3 4 5
I’ve been thinking clearly 1 2 3 4 5
I’ve been feeling good about myself 1 2 3 4 5
I’ve been feeling close to other people 1 2 3 4 5
I’ve been feeling confident 1 2 3 4 5
I’ve been able to make up my own mind
about things
1 2 3 4 5
I’ve been feeling loved 1 2 3 4 5
I’ve been interested in new things 1 2 3 4 5
I’ve been feeling cheerful 1 2 3 4 5
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