Redesigning Paediatric Emergency Care for Mental Health: A realist, mixed-methods evaluation of a new model of integrated care (Best For You)

Background Adolescent mental disorders, and related emergency care utilisation, worsened alarmingly during the pandemic and have remained high. Emergency departments experienced an increased demand, calling for improved facilities and workforce training. This is supported by national and local policy guidance to deliver integrated physical-mental care, integrated acute-preventive care, early assessment and triage, and workforce capacity and competency. Evaluating local initiatives must account for contextual, organisational, and procedural factors for design and delivery, to assess generalisability. Methods This study documented the implementation of an innovation (Best For You) in Northwest London to redesign paediatric emergency services – assessment, triage, treatment, facilities, and integrated care-planning. A formative, realist evaluation used the consolidated framework for implementation research (CFIR). The underlying programme theory was detailed, alongside the processes, facilitators and barriers of its planning and implementation. A mixed-methods synthesis of thirteen interviews with programme implementers and stakeholders, 49 observations of planning meetings, a population needs assessment using hospital episodes, plus quality improvement techniques (process mapping and programme theory), detailed the innovation, context, and implementation. Results Key innovation drivers were dissatisfaction with inappropriate facilities for managing behavioural risk in emergency care, a rise in service demand which was reflected in hospital statistics, and policy targets to improve care discrepancies for adolescent mental health emergencies. Key drivers formed a coherent vision between policy, providers, and patients to reduce emergency care use. Covid-19 caused implementation delays due to staff shortages and competing priorities. Unavailability of physical infrastructure for a new integrated care service and disagreements on financing staffing models caused further delays. However, high motivation, persistence and capability among the implementers and deliverers achieved implementation, which involved substantially adapting the initial innovation design. Conclusions Achieving improved mental health competency in acute care facilities and staffing required extensive planning, and availability of resources including physical space, clinical leadership and innovation, and capital costs and staffing. Real-time adaptations to the innovation contextualised implementation factors important for scalability. These findings are useful for policymakers, healthcare strategists, and clinical practice leaders, to identify innovations to meet local health policy targets.