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7.0 Dumfries and Galloway

7.1 Origin of project

The Dumfries and Galloway Doing Well project developed as a way of filling the gap in an emerging tiered service of provision for people with mild to moderate depression. It also was an opportunity to develop a skills base for 'talking therapies', and to take forward an ideology of de-medicalising mental health services. These ideas were being put into practice in a short-term, small-scale project involving a small number of GP based primary care mental health workers ( PCMHW) offering guided self help. The Doing Well funding offered the opportunity to develop and consolidate this service across the area. It thus built on what was already in place. It was developed by a Director of Psychology, a CBT Therapist and a then director of Nursing, and these are still instrumental in running the project and ensuring its future sustainability.

7.2 Core function of project

The project aims to:

• Extend the provision of services to people with mild to moderate depression through guided self help
• De-medicalise services for this patient group

7.3 Interventions planned and delivered

Provision of guided self help for people with mild to moderate depression by non-professional primary care workers linked to specific GP practices. Services cover the entire Dumfries and Galloway helath board region. On referral, patients are offered an appointment for assessment. If suitable for the service, a limited number of structured self help sessions are offered.

7.4 Pathway

GPs can refer directly to the Doing Well workers, or to Psychology for allocation in the referral meeting (see Figure 4). 90% of Doing Well referrals come directly from GPs and only 10% through Psychology.

Figure 3 Structure and care pathway

7.5 Capacity and Structure

The Doing Well project has trained non-mental health professionals in guided self help and appointed them as Self Help Support workers. The posts are not intended to act as entry points for career progression but are envisaged as a new layer of capacity. The project also includes the part-time service of a CBT therapist/ Project Manager and the project sits within the Psychology Department. Supervision and line management of SHSWs is provided through the Psychology Department by the CBT therapist/project manager and the Director of Psychology respectively.

7.6 Activity and outcomes for service users

Dumfries and Galloway activity data (up to 31st March 2006)

Comparison of the HADS anxiety and depression scales from baseline to discharge and discharge to follow-up using the Wilcoxon signed rank tests (Non-parametric test for related samples) showed significant improvements for patients being seen by the SHSWs.

Client Satisfaction Questionnaire Outcomes showed a mean score of 29.01 at discharge (range 8-32, median=30). Mean WASAS scores were as follows:

Difference in mean Work and Social Adjustment Scale ( WASAS) scores by sex from baseline to discharge:

7.7 System Impact

The Doing Well project in Dumfries and Galloway had the advantage of several years previous experience of developing and implementing its initiative, albeit on a smaller scale. Therefore, the potential to impact on the wider system has probably been greater within this site. This has allowed time for General Practitioners to familiarise themselves with the service and to observe the impact of the service on their patients. The impact on GPs has been observed in the following questionnaire results:

Alternative interventions GPs would have chosen if the self help service was not available

The SHSW service would seem to have the potential to result in savings on GP time in dealing with mild to moderate depression.

7.8 Sustainability

Membership of the project steering group includes those with strategic responsibility for mental health locally. The group is chaired by the Director of Mental Health, who was also instrumental in the Doing Well bid. Over time the project has been able to generate considerable interest in and support for its work, aided by the clear, focused nature of the interventions offered and the positive outcomes demonstrated. Involvement of senior managers, in particular the Director of Psychology, as advocates for the service has been a strong advantage in developing a strategy for the service's continuation. From the outset, the project worked to secure future funding and this was secured from the Health Board in 2005. The project continues to link in with service developments around self care in other clinical areas.

7.9 Key learning points

• A focused intervention with clear management arrangements and sustainability strategies was a key factor in this project from the outset
• The project built on a previous local self help initiative offering non medical interventions and was able to expand this across the area
• Non-professional self help workers are a key resource in an area -wide service

Challenges of the Dumfries and Galloway model:

• The service is focused on one component; guided self help. The provision of this component is underpinned by a clear theory and robust evidence and is well managed. It is unclear however, what provision is planned for patients for whom this service is not appropriate.
• The service sits within psychology and management arrangements are clear and simple. Psychology has strengthened its position in terms of resource allocation for mental health. It remains to be seen whether this arrangement provides any opportunities for change in the wider mental health system.

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