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10.0 Lanarkshire

10.1 Origins of the project

The Lanarkshire Doing Well project builds on the 2004 Review of Psychological Therapies which indicated that individuals in Lanarkshire required access to a variety of service options. A local Needs Assessment service map undertaken in Lanarkshire highlighted that although individual's health needs were often met, there were high levels of unmet social need. The project also builds on the work of local Focused Intervention Teams ( FIT) that are comprised of mental health nursing staff who work with those with mild to moderate problems.

10.2 Core Functions

The project works to:

• Extend the range of services provided by Motherwell and Bellshill FITs to include a guided self help component aimed at those with mild to moderate depression/anxiety
• Increase communication and support within primary care and develop links and support to non-statutory services through the recruitment of a liaison nurse
• Extend the use of evidence based CBT approaches across Lanarkshire through a recognised training programme

Initial plans to extend all components across the whole of Lanarkshire were deemed overly ambitious by CCI, and as a consequence the project was redesigned, with the guided self help component only available in Motherwell and Bellshill.

10.3 Interventions planned and delivered

Tier 2: Guided Self Help in Motherwell and Bellshill

Four team members have been providing guided self help since December 2004 to individuals referred from GPs via resource allocation meetings. The service is provided at a mental health day hospital in Motherwell.

Across the Tiers and Pan Lanarkshire: Linking agencies

Face-to-face connections were made initially with all fourteen GP practices in Motherwell/Bellshill, but this has proved a large number with whom to sustain meaningful relationships. Contact with GPs now focuses on the distribution of quarterly reviews about the project to all GPs and practice managers in the area. Talks and presentations have been given to a wide range of statutory and voluntary organisations. A database of local organisations has also been produced. At the instigation of the liaison nurse, voluntary organisations are now invited to monthly nurse/ OT meetings to share information, referrals, etc. Doing Well has also supported the Princess Royal Trust for Carers develop a support group for carers with depression/anxiety.

Across the Tiers and Pan Lanarkshire: Training

Because of difficulties receiving adequate training for trainers, the training component came on stream later in the life of the project. Since its introduction there has been widespread interest, and rolling out training has become the key focus of the work in Lanarkshire.

10.4 Pathways

GPs refer patients with mental health problems to weekly multi-agency resource allocation meetings (including Doing Well, CPNs, Social Work, Occupational Therapy, FIT, and Psychology). They can refer directly to the Doing Well self help option, or make general referrals to the team. Those with mild to moderate depression/ anxiety are in turn referred on to Doing Well. Patients are sent an appointment letter and at the first session they will be assessed to see whether the referral is appropriate or not. Where appropriate, they will then be offered four-eight sessions of guided self help. At the end of the intervention patients can be referred on to voluntary or statutory agencies if required. The team have been able to manage the caseload without developing waiting lists.

10.5 Capacity and Structure

The Lanarkshire Project employs four staff: a Project Lead, a Liaison Nurse, an Occupational Therapist and a Self Help Worker (Assistant Psychologist). The service is based in local day hospital in Motherwell, which is geographically accessible, but for some potentially stigmatising. The quality of office facilities has been problematic for the team.

Figure 5 Lanarkshire Referral Pathway

Technically all team members are supervised by the team leader. In addition, the Assistant Psychologist is supervised by psychology, and the OT and liaison nurse also receive peer supervision.

The service is independent and sits between the key departments in primary care mental health. It is linked to the Focussed Intervention Team, which is line managed by the Clinical Development Manager, Associate Director of Nursing. The links to the Steering Group are not formalised.

10.6 System Impact

Doing Well has slotted into the pre-existing resource allocation meeting system, thereby extending the range of treatment options available via traditional GP referral routes. However, there were initial doubts from some GPs about self help, and referral rates continue to vary from practice to practice (53% of referrals come from three practices). Interest in the project from other parts of Lanarkshire is growing and a guided self help pilot is now operating in Airdrie, based on the Doing Well model.

Through regular meetings, voluntary organisations are now linking better with statutory agencies and have been encouraged to develop new services ( e.g. carers group). The availability of training in CBT approaches has increased capacity in local health and social care staff. There has been high demand for this training, but as it only came on board towards the end of the pilot, its potential has not yet been fully realised. Ongoing supervision is currently provided by the Liaison Nurse to those who have received the training within statutory services. Lack of appropriate supervision has acted as a barrier to training for some within the voluntary sector.

10.7 Activity and Outcomes for Service Users

Patients experience shorter waiting times for the Doing Well service compared to other services available via the resource allocation meeting. Patients HAD scores decreased following intervention, although there have been low follow-up rates to fully verify this.

Lanarkshire Activity Data (up to 10th April 2006)

Combined HAD anxiety and depression scores (baseline and post-intervention)

10.8 Sustainability

In Lanarkshire training is viewed as the key method of creating sustainability for the work. It is hoped that through training existing health and social care staff, such as Health Visitors and Practice Nurses, in a range of CBT approaches that their availability for people with depression/anxiety will increase. The Princess Royal Trust for Carers is committed to continuing their depression and anxiety group for carers. It is planned that meetings introduced to improve communication between voluntary and statutory agencies will continue after the life of the project.

10.9 Key Learning

• The Doing Well project has acted as a catalyst for improving local interagency working
• An earlier introduction of the training component of the project could have increased the training's impact and built a higher profile for the work with statutory agencies
• Interest in CBT based self help approaches has been widespread and goes beyond those agencies traditionally supporting people with mild to moderate mental health problems to include voluntary agencies that support carers and those with longer term mental health problems

Challenges of the Lanarkshire model:

• It is uncertain whether those trained by the project will continue to use their training in their work
• The voluntary sector may currently be disadvantaged in terms of benefiting from training in CBT approaches because of the lack of appropriate supervision systems
• A decision is pending on future funding and sustainability of doing well services
• Team members have different backgrounds and varying levels of experience, but address similar patient needs. Lanarkshire may have learning to share as to who is best placed to provide self help intervention
• All GP practices within Motherwell/Bellshill were initially invited to be involved in the project, with varying degrees of success. In future a more targeted approach based on supportive GPs practices may be more effective

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