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8.0 Grampian

8.1 Origin of project

There are three local authority regions in Grampian (Moray, Aberdeen City and Aberdeenshire) which means there are three local authority level mental health planning groups and a Common Issues Group which works on the links between local and Grampian wide strategies. This has resulted in a Grampian Mental Health and Well-being Strategy for 2004-2010 'A Brighter Future' which supports the Doing Well initiative. This configuration has also shaped the Doing Well project which works across three Community Health Partnerships ( CHPs) (one for each local authority) with separate projects in each and with both local and regional steering groups.

8.2 Core Functions

The aims of the project are:

• To develop a Primary Care service, providing rapid initial assessment and brief intervention for people presenting with mild to moderate depression and related problems, using CBT-based guided self help model
• To develop a local resource within GP Practices for Primary Care teams on mild to moderate mental health issues and to facilitate links with secondary care, voluntary sector and other agencies in a model of stepped care

8.3 Interventions Planned and Delivered

In Aberdeen City

Three Primary Care Mental Health Workers ( PCMHW) were appointed with each worker attached to four GP practices and spending approximately one day per week in each practice. The City PCMHW's are based together in a community remote from their respective clusters of GP Practices.

In Aberdeenshire

Four Primary Care Mental Health Workers have been appointed with the same remit as those in Aberdeen city. In Aberdeenshire the PCMHW's are based in or adjoining one of their respective of GP Practices.

In both CHPs, the PCMHWs are mainly qualified nursing staff appointed at G Grade. They have undergone the SPIRIT, START and Solution Focused Therapy training and offer basic assessment and brief interventions (maximum 3 hours total contact) using a range of guided self help materials and solution focused therapy. As necessary they will offer signposting/onward referral to other services.

A 0.5 wte Clinical Psychologist co-ordinates training and provides individual and group clinical supervision and facilitates peer support. PCMHWs are managed via the CHP.

Two psychology assistants were employed for the first year of the Project, first, to scope self help materials and produce a self help resources toolkit; secondly to research and produce a Grampian-wide local resources directory.

In Moray

Two psychological therapists ( PTs) MSc trained and supervised via Psychology are delivering services to GP practices, as well as a Counsellor for the region. The psychological therapists deliver highly structured CBT based treatments. During their first year whilst their training was ongoing, they worked on a part-time basis in primary care and it is intended that they will deliver full-time services across five Moray GP practices from January 2006. In addition, a toolkit for depression has been developed for their use which includes screening, assessment and monitoring tools, treatment protocols, referral guidelines, self help and educational materials.

From available data on the patient groups, there does not appear to be any differences in the client groups seen by the two service models ( PCMHWs and PTs). However, the length of time in contact with these two types of service differs significantly because of the type of approaches used (see Section 9.6 below).

8.4 Pathways

For both PCMHWs and PTs patients access the service via their GP although each GP practice has a slight variation on the administrative procedure in the pathway. The process generally reflects:

Patient sees GPGP uses screening/referral questionnaire and recommends PCMHW/ PTPatiient makes appointment at reception Practice staff allocate appointment PCMHW sees patient Follow-up at 4 months offered (if needed).

8.5 Capacity and structure

The structure of planning and management around the Doing Well initiative should have the potential for encouraging multi-agency approaches to depression, and indeed, particularly in Aberdeenshire, links to other initiatives have been reported to increase the range of responses for depression including those out with the healthcare sector. However, the sub-group structure has also meant that the Doing Well programme has become fragmented over the region as a whole with little integration of learning across the areas, particularly between Moray with the PTs and the other two sites with the PCMHWs.

Figure 4 Structure of the Grampian Doing Well project

8.6 Activity and outcomes for service users

So far 1211 individuals have been referred to the PCMHW service. Approximately one third completed the programme and one third decided to stop after one or two sessions. Some differences were also observed in the levels of deprivation among patients seen by the two different types of worker. Among those seen by the PCMHWs, 33% of patients were in deprivation categories 1 and 2 (most affluent) and 56% were in categories 3 and 4. Whereas for the PTs in Moray 98% of patients were in categories 3 and 4. This may reflect differences in the local populations. The average deprivation score for Moray based on the Scottish Indices of Multiple Deprivation ( SIMD) score at 2004 is 12.96, and although it is 15.29 in Aberdeen city and 15.62 in Aberdeenshire North, the Central and South Aberdeenshire areas are lower at 8.75 and 7.43 respectively.

Activity data for Grampian up to March 2006

The differences in waiting times may be a result of the PTs only being available part time throughout most of the period of evaluation, but will also be affected by the average number of sessions which their treatment delivery requires.

PHQ-9 scores for those seeing the PCMHWs showed a significant shift from the moderate/severe categories of depression towards the 'not depressed'/milder categories from baseline to discharge, and this was sustained in the limited sample who responded at follow-up.

Percentage of patients scoring in each of the categories of severity at baseline, discharge and follow-up for those seeing a PCMHW.

Similar findings were also seen in the data relating to those attending the psychological therapists. There were also significant improvements as measured by the EQ-5D (sustained in the limited sample at follow-up) within the domains of 'usual activities' (p<0.001) and 'anxiety/depression' (p<0.001) but not on the dimensions of 'mobility', 'self care' and 'pain/discomfort'.

8.7 System Impact

The interventions (being delivered by the PCMHWs) and the focus on networking with other agencies, has increased awareness of the choice regarding other options for support and more appropriate referral on to other agencies and services. The multi-agency involvement in the steering groups has encouraged Doing Well to link with other resources such as The Employment Officer (mental health) which may impact on the input needed by the PCMHW and MOMENTUM for early intervention in the work place. The use of assessment ( PHQ-9) encourages more appropriate referral on. The CMHTs no longer accept referrals for mild/moderate depression and recommend the GPs re-direct these to the PCMHWs. Such changes enable unmet needs to be addressed and for solutions to be found within the statutory and voluntary sectors.

The impact of the PCMHWs on other services has been estimated by GPs indicating what action they would have taken if the service was not available:

*Categories are not mutually exclusive

The PCMHW service is perceived to have had a substantial impact on GP workload. It was reported that 73% of the service's clients would otherwise have been seen more often by their GP.

8.8 Sustainability

The involvement of multi-agency steering and planning groups has not facilitated sustainability of the project. Future sustainability of the role of the PCMHW is dependent on their up-take by their respective Community Health Partnerships ( CHPs) and participating practices have lobbied their respective CHPs to continue the services. The source and structure to sustain supervision of the staff has been identified as problematic.

8.9 Key learning

• The multi-agency partnerships which have driven the Doing Well services in three distinct local authority areas has fragmented the potential impact and learning of Doing Well in Grampian. With no 'local champion' or strong lead influence with a clear vision for the project as a whole and to maximise learning across the different models being tested locally
• The level of integration of the PCMHWs into individual practice teams has an impact on their functioning. PCMHW roles need to be fully integrated within the practice team and to have access to the resources required to operate (office and storage space, IT, etc.) and substantial efforts may be required to facilitate this in some practices
• Adherence to the maximum number of sessions is crucial for maintaining capacity
• Professionally qualified nurses may not be required to deliver the type of self help interventions being offered
• The development of a network of self help workers is beneficial for peer support and sharing learning and experience

Challenges of the Grampian Model:

• Grampian should ensure that learning is taken from operating two different models of service provision, and use this learning to shape future planning in the region
• Further clarity is required on the profiles of those clients groups being seen by different models of service provision
• In light of this, work on the relative cost effectiveness of the different models of service provision may be beneficial

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