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9.0 Greater Glasgow

9.1 Origin of project

Greater Glasgow published its Primary Care strategy in 2001, which led to the development of Primary Care Mental Health Teams across the city. Alongside this, the Glasgow Institute for Psychosocial Interventions ( GIPSI) had produced written Overcoming Depression and Anxiety self help materials based on CBT approaches, and had been involved in a previous self help pilot in Drumchapel. The Doing Well initiative provided an opportunity to extend the work of the Primary Care Mental Health Teams ( PCMHTs) to include this self help focus. The work undertaken under this initiative was a joint collaboration between Depression Alliance Scotland ( DAS) and Greater Glasgow Health Board. The START team was formed to reflect the partnership. (Self Help Treatment Access Resource Team.)

9.2 Core Functions

The aims of the project are to:

• Train the PCMHTs in a self help Cognitive Behavioural Therapy approach to embed self help into their practice
• Integrate self help support workers into PCMHTs on a rolling basis throughout the city. The SHSWs work to build capacity within the teams and deliver self help approaches in a variety of formats for a time limited period before moving on to new teams
• Enable DAS to establish local self help support groups
• Provide multiple ways for people affected with depression to access self help
• Carry out a Randomised Controlled Trial examining two different ways of supporting the delivery of self help treatments (telephone and face to face)

9.3 Interventions planned and delivered

Tier 2:

Self Help Support Workers

Three self help support workers and one self help support nurse were recruited in 2004 to work as part of Primary Care Mental Health Teams in Strathkelvin, Maryhill, Drumchapel and Clydebank. The SHSWs were given 9-12 month attachments, with the intention that PCMHTs would decide whether to mainstream the role within their team after this period. Easterhouse has recently become the fifth site in Glasgow to host a SHSW.

Training

The START Project Lead has managed the roll out of training across Greater Glasgow. Staff within the four PCMHTs that hosted SHSWs have been trained in CBT self help approaches, and roll out across other areas of the city is progressing. Participants in DAS groups have also been offered this training. The clinical credentials of the Project Lead were viewed as a key factor in facilitating acceptance of these new approaches within primary care.

Randomised Control Trial

Recruitment to the trial, although slow, is ongoing.

Tier 1:

Self Help groups

Initial plans were for DAS to develop groups in the four pilot PCMHT areas. However, problems with recruiting facilitators and finding appropriate venues made this difficult, and at the time of the case study interviews, only Maryhill and Drumchapel were running groups. A Group Development Officer has since been employed.

Tier 0: Living Life to the Full

The START project was given extra resources by CCI to develop the Living Life to the Full website and college course (at Anniesland College), based on the Overcoming Depression and Overcoming Anxiety workbooks. Plans are now in place to extend the course into other colleges across the city.

9.4 Pathways

GPs refer people with mild to moderate mental health problems directly to the PCMHT. The teams have weekly allocation meetings where it is agreed where referrals should go. In three areas, all those with mild to moderate depression/anxiety are referred to the SHSW for assessment. If appropriate the SHSW will then take the patient on and offer 3 +1 sessions of guided self help. Patients with high scores on the PHQ and BDI- II scales are offered a full clinical assessment by a qualified mental health practitioner within the team. In the fourth area concerns about risk management have resulted in more senior members of the PCMHT assessing all patients with mild to moderate depression/anxiety before they are referred to the SHSW. This has resulted in longer waiting times for patients seen by the SHSW in this area. In all areas, if patients require further help and the end of the intervention they can be referred on to a range of statutory and voluntary services.

People can self refer to the DAS groups, college course and website.

9.5 Capacity and Structure

The START Project Lead is managed by the GIPSI Director and receives good strategic support from the Greater Glasgow Primary Care Project Manager. The START team employs four SHSWs, three of whom are Assistant Psychologists and one G Grade Nurse. Since the project began, two SHSWs have left the team to begin postgraduate courses, and been replaced. A Group Development Officer, Administrator and two G Grade Nurse Trainers have also recently been recruited.

9.6 Activity and Outcomes for Service Users

Greater Glasgow Activity Data (up to March 2006)

Patients in three out of four PCMHTs experience shorter waiting times than for other PCMH services. The total caseness on CORE domains for treatment completers at baseline was 82.1%; falling to 34.1% at discharge and increasing to 43.1% at 4 month follow up. Although there was a slight increase in those classed as a clinical case there was still a significant decrease in caseness compared to baseline. Results from baseline to discharge and from discharge to follow up were highly significant.

Caseness on CORE and CORE domains for treatment completers (3+ sessions) at each site

P<0.05 ** p<0.001

Patient choice has increased locally with the introduction of groups, college courses and website. Self reported knowledge about depression and anxiety has increased as a result of participation in the college course as detected via eight questions on a scale of 1-7.

Patients were asked to rate their current health state by selecting a rating on a 100-point visual analogue scale (EQ5D Temperature). Results for females were more significant than for males which may be attributed to a larger sample size.

EQ5D Visual Analogue ( VAS) scores at Baseline and 4 Month follow-up

P<0.05 ** p<0.001

9.7 System Impact

The START project has extended the range of services available within the four pilot PCMHT sites through the addition of dedicated SHSWs within these teams. Training in CBT approaches has been delivered to PCMH team members (primarily those with a nursing or clinical psychology background) and to other Doing Well sites across Scotland. DAS have been in a position to develop self help groups in Glasgow for the first time, although uptake has been variable. The development of the Living Life to the Full college course and website have opened up self help materials for those who might not consider themselves as having depression or choose not to visit their GP.

9.8 Sustainability

The START project has built in sustainability through the permanent project lead and administrative positions. The Project Lead will continue to roll out training across Glasgow, in the hope that CBT approaches will continue to be used by those trained. The SHSW roles are continuing at present, with a new SHSW based in Easterhouse. Following the pilot SHSW phase, Clydebank PCMHT has identified resources to continue the SWSW role within the team, although there has been no commitment to date from other teams to do likewise. START provides phased funding for colleges to run the Living Life to the Full course, with the intention that colleges take on the funding entirely after they have completed their third course.

9.9 Key Learning

• Strategic support from within Greater Glasgow Primary Care has been key to ensuring buy in from primary care and sustainability for the work
• The availability of locally developed evidence based self help materials has opened up opportunities to extend self help into new mediums (website and college course) and reach a wider population
• Guided self help has brought a greater social/community focus to pre-existing primary care mental health teams

Challenges of the Greater Glasgow model:

• START may have lessons to share about the optimum levels of skills/ experience/training required to assess people for a service aimed at those with mild to moderate mental health problems.
• It not as yet entirely clear where responsibility should lie for ensuring inappropriate referrals are kept to a minimum.
• It may prove difficult for START to ensure that training in CBT approaches is sustained in primary care mental health workers roles.
• It remains to be seen whether colleges will continue to run the Living Life to the Full Course after START funding is removed.
• More research is needed to ascertain whether groups are the most appropriate format for supporting those with mild to moderate depression.

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