Cross-sector user and provider perceptions on experiences of shared-care clozapine: a qualitative study

Objectives (1) To explore individual perceptions on experiences of people receiving and/or delivering a shared-care clozapine serviceand (2) to gain an understanding of effectiveness and acceptability of shared-care clozapine. Design Interpretative phenomenological analysis guided the delivery and analysis of a semistructured interview and focus group study designed to explore participant experience of shared-care clozapine. Ethical approval 13/EM/0286 was gained in July 2013 from East Midlands—Nottingham 1 REC. Participants Eight stakeholder groups from Adult and Forensic Mental Health involved in shared-care clozapine provision delivered in primary care were identified for recruitment from one mental health trust in England (six different groups of healthcare professionals (HCPs), clozapine service users (CSUs) and their carers). To be eligible for recruitment, all potential participants had to be either providing, receiving or the carer of a person receiving clozapine by shared care. Results 32 HCPs and 6 CSUs were recruited and 14 interviews and 6 participant homogenous focus groups were run. Four shared superordinate themes were identified: Clozapine Process, The Sharing of Care, The Provision of Care and Multi-professional Relationships. Differences between Adult and Forensic engagement in shared care were noted and both HCP and CSU relationships were mapped to the Wish conceptual framework of relationships to provide insight into how shared-care clozapine can provide a mechanism for provision of person-centred care, which was present in the Forensic HCP–CSU but not General Adult HCP–CSU relationship. Conclusions The Forensic HCP/CSU relationship demonstrated how cross-sector working through shared-care clozapine can provide a mechanism for provision of person-centred care by enabling a person-centred focus to care delivery which supported CSUs to live as independently as possible. Person-centred care demonstrably improves patient care outcomes and wider implementation of shared-care clozapine could provide greater integration of people with serious mental illness and reduce stigma within the community while improving patient outcomes.

It is hard to understand the logic of the superordinate themes, and what is described under the themes. It is also hard to see the meaning from the participants' narratives in the wording of the superordinate themes. For example: clozapine process: Includes importance of knowledge of the process, learning by experience is important, how HCP decide whether a CSU would be suitable for shared-care, how the shared care model facilitate the true potential of the patient. Shared of care: Includes shifted responsibility, the need to work in a new way, CSU experience independence and boosted self-esteem, change in relationship, CSU in the center of care, assumptions limited the HCP´s trust in CSU ability to take responsibility, stability and capability are used when to decide if a CSU would be suitable for shared-care… The provision of care: Includes different roles, attitudes and responsibility of each member of the MDT, different ways of finding time to understand shared-care, and CSUs roles in the shared-care. It also includes CSU and professionals thoughts about the clozapine-treatment compared to other treatments. My recommendation is to develop the result further and to use other sub-themes. All to make it easier to understand the meanings of the experiences and perspectives that has been narrated. Now you have to read the result many times and make your own analysis in order to understand. The text in the principle findings in the discussion could be a starting point for how to organize the result section. Result and discussion The second aim was to gain an understanding of the effectiveness and acceptability of the shared-care service. Little in the result or in the discussion describes acceptability and effectiveness. As the understanding of the effectiveness and acceptability of the model is one of the objectives of the study this needs to be developed further.

Discussion
In the abstract it is written: the Wish conceptual model of relationships provided further insight into the acceptability of care delivery. But in the discussion where the model is referred to, I find no comment about acceptability. This has to be developed further. In discussion: page 9 line 4, the Forensic HCP/CSU relationship appears to possess a more symmetric co-operative, intimate and social characteristics if mapped onto the Wish conceptual model of relationship. Please develop this further how the result show a more symmetric co-operative ….relationship between HCP and CSU! In discussion: page 9 The characterization of the Forensic HCP/CSU could be said to fulfil all of the conditions of the enabling principle of person-centered care…..Please develop this further what the principles are and what in the result that fulfill the conditions. The title of the paper is: Enabling person-centred care through sharedcare clozapine so this needs some more attention in the text.

REVIEWER
Inti Qurashi Hon senior lecturer consultant forensic psychiatrist Institute Brain and Mind University of Manchester REVIEW RETURNED 19-May-2017

GENERAL COMMENTS
The study aims i) to explore perceptions and experiences of people receiving and or delivering a shared care clozapine service and ii) gain an understanding of the effectiveness and acceptability of a shared care clozapine service.
The study appears compromised in its' aims by a) The selection of participants; of the 38 identified 32 were Healthcare professionals (I could find no breakdown by profession in terms of numbers or service in which they worked (general adult or forensic) which would have been informative. I am unsure why a receptionist was included as a participant b) Only 6 clozapine service users were identified of which 5 were forensic patients; given the authors principle findings regarding a general adult/forensic service difference this may be explained by the bias of participants. This needs to be reflected in the discussion and limitations. c)The principle findings section requires major revision to reflect the actual findings -an interesting point that appears to be overlooked is the observation that within general adult services patients on shared clozapine care plans cannot be discharged and it potentially prevents patient independence; this raises the spectre of unintentional consequences in terms of increasing caseload and work for general adult CPN's and whether shared care clozapine is deliverable within devolved commissioning budgets and not least shared care clozapine contributing to iatrogenic harm in terms of limiting independence and progression of patients. g) to a reader unfamiliar with the field/topic I found the paper difficult to read in terms of complex phraseology being used when simple sentences would have been clearer.

VERSION 1 -AUTHOR RESPONSE
The objective of this study was to explore individual perceptions on experiences of people receiving and/or delivering a shared-care clozapine service. Interpretative phenomenological analysis methodology was used to explore individual experiences of clozapine service users (CSU), general practitioners (GPs); community psychiatric nurses (CPNs), social workers (SWs), community and hospital pharmacy staff and responsible clinicians (RCs). Data was collected using semi-structured interviews and focus homogenous groups. This study highlights differences between Adult and Forensic healthcare professionals (HCPs) engagement in shared care clozapine.
Both Adult and Forensic HCP-CSU relationships were mapped to the Wish conceptual framework of relationships to provide insight into how shared care clozapine can provide a mechanism for provision of person-centred care. Person-centred care was present in the Forensic HCP-CSU but not General Adult HCP-CSU relationship. We propose that wider implementation of shared care clozapine could enable greater integration of people with serious mental illness into the community, reducing stigma, whilst improving patient outcomes associated with person-centred care.
This manuscript should be published in the BMJ Open as the implications for practice include: the need to reflect on the impact of service provision on CSUs ability to recover and rehabilitate; and how shared care clozapine could provide a mechanism for provision of person-centred care, leading to improvement in quality of care and potentially decreasing demand on limited health service resources.
We have responded to each of the reviewer comments as detailed in the Excel Spreadsheet embedded below and have taken the opportunity as suggested, to re-write the results section with greater clarity and focus.
This manuscript is over the suggested word count due to the need to publish quotes as evidence of data synthesis, which cannot be tabulated without disrupting the flow of the reader. This has been discussed with yourself by email (attached as a supplementary file) demonstrating agreement that the word count is acceptable.

GENERAL COMMENTS
The revisions have resulted in improvements from the previous submission, and I only have some concern about the aim/s. In the abstract there is one aim: To explore individual perceptions on experiences of people receiving and/or delivering a shared-care clozapine service.
In the background there are two aims: 1) To explore individual perceptions on experiences of people receiving and/or delivering a shared-care clozapine service. 2) To gain an understanding of effectiveness and acceptability of shared-care clozapine. Both aims should be included in the abstract.

REVIEWER
inti qurashi University of Manchester UK REVIEW RETURNED 21-Jul-2017

GENERAL COMMENTS
The substantial revisions have improved the quality of the paper making it more focussed and readable.

VERSION 2 -AUTHOR RESPONSE
Please find uploaded a revision of the manuscript which addresses the comments made by a reviewer to ensure that the abstract reflects both objectives stated in the background.