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13.0 Discussion
13.1 Overview
Through Doing Well by People with Depression, the Scottish Executive sought to introduce a programme of developments in local areas to build capacity at different levels within local service systems to respond to depression and to enhance access to sources of support by trying out 'new' approaches and changing existing ways of delivering interventions.
The drivers behind this programme were several.
- The recognition that depression and other common mental health problems are a major source of distress in Scotland (as in other western European countries) and can have a significant impact on individuals, families and communities
- A growing body of clinical research ( e.g.NICE, 2004) supported the use of time-limited focused psychological interventions rather than pharmacological treatments for people with mild to moderate depression and anxiety. In addition, research in the field of mental health promotion and the prevention of mental health problems is increasingly strong to support approaches that build skills, resilience and social resources
- Stepped care and collaborative care models have proven to be effective in other service contexts in providing an integrative framework of comprehensive responses where skill deployment is geared to needs
- Health policy in Scotland has placed increasing emphasis on self help and self management and on anticipatory and preventive care across a range of health problems and conditions
- As a corollary, there is now pressure on local health and social care systems to devise and deliver imaginative responses to needs in line with evidence of what can be effective
Taken together these factors indicate the relevance and potential significance of what can be learned from Doing Well, to inform future developments in addressing depression and other common mental health problems. This section reviews the key achievements of the programme and explores the features of local Doing Well developments that contributed to success. The concluding section draws out implications emerging from the evaluation that provide pointers for future policy, service and practice development beyond the Doing Well programme.
13.2 Doing Well: summary of progress and achievements
The range of information collected in the evaluation demonstrated the progress that had been achieved by the local projects in terms of outcomes for individuals receiving the service, impacts on components of the local service system and benefits at national level, as summarised below.
Table 1 Summary of benefits and limitations
| BENEFITS | LIMITATIONS |
|---|
| Individual | Clinical improvements Those who need it, get medication and support to take it Provision of tools for coping/problem solving for current and future use Advice and information on looking after your own mental health/related matters Support and signposting to other services and resources Increased choice, e.g. web, college courses, workbooks; group and 1:1 support Ready access to non-stigmatising help Ease of 'stepping up or down' through tiers as needs require it | Lack of understanding of notion of self help Self help materials suit some people but not all Requires readiness and ability to engage with guided self help approach |
|---|
| Community and voluntary sector | Raises awareness about depression Information on mental health and on resources widely distributed through variety of channels For some networks and groups, capability and confidence to provide support has increased Growing mutual awareness of roles and expertise in voluntary and statutory services | Difficulties in providing supervision and support in non statutory sector, to ensure effective use of skills Continuing need to build stronger links with primary care |
|---|
| Primary care | Widens options for referral and increases capacity to manage depression Can promote adherence to good practice re: - non-medical interventions
- antidepressants (when, what and how much to prescribe)
Offers regular feedback to and communication with referrer Assists in working towards targets set in Quality Outcomes Framework | Primary care referrers lack understanding of self help models Reluctance to refer outside the NHS Variable uptake of model by primary care practices Triage needs to be kept as simple as possible How to sustain necessary level of training and supervision beyond pilot stages? |
|---|
| Local service system | Opportunity to extend capacity by utilising non-professional staff to deliver interventions and match skills to needs Increases options to allow stepping up and down, which is important given the complexity of depression Extends service reach to meet identified needs Assessment, triage and pathways to other services are clearer Short term interventions can work with high volume and achieve good results Decrease in pressures on specialist services Stepped care and guided self help models have wider applicability, e.g. long-term health conditions | Need clarity about links into relevant primary care, mental health and health improvement planning structures and strategic priorities To be effective, the stepped care model requires to be supported by HR and IT systems Multi-level/multi-faceted approach is most effective, therefore needs support and commitment across system to ensure co-ordination and consistency |
|---|
| National | National Doing Well programme provided a supportive framework to foster innovative approaches to build local capacity. The national Development Network was extremely valuable in this regard in creating a regular forum for projects and professional groups to learn together Doing Well 'branding' helped raise and maintain a profile nationally and locally Demonstrated the applicability of nationally driven service redesign/improvement in mental health | How to maintain momentum as programme concludes The programme, network membership and service models tended to be clinical in orientation Low engagement from primary care, in the early stages in particular Challenges in agreeing and applying common data sets for monitoring and evaluation |
|---|
13.3 What makes for success?
The Doing Well programme served as a means to test out different models of delivery in different healthcare contexts. The Doing Well interventions across the seven sites cover a variety of levels within a general stepped care approach. Some projects have introduced an intervention within a single service tier and other sites have introduced multiple services covering more than one tier of service provision. Some Doing Well sites have introduced integrated and collaborative care models.
Whilst there were strong similarities in the overall objectives across all seven areas that participated in the national evaluation, there were also clear differences between them, for example in how each local project articulated target group needs, the characteristics of the whole service system, the location and position of the Doing Well project within the system, and the impacts the project expected to achieve in that context. This provides a rich opportunity to draw on the evaluation findings to consider the elements of a local approach which are more likely be effective in achieving the desired outcomes within a local service system.
Service model
The following features of the service model are important:
- Start from a clear understanding of the nature of 'the problem' for which Doing Well is a solution. This will determine the scale and scope of system change required. It will also indicate where attention needs to be directed and the types of collaborative relationships that need to be developed
- Some Doing Well projects had a sharp, narrow focus on establishing a discrete new self help service; others had more complex, longer-term goals to bring out service redesign, within a local health care system or across a whole health board system
- The former approach is likely to produce more rapid benefits in terms of enhanced capacity for service delivery and outcomes for service users in response to clearly defined sets of needs, but may not in itself engender wider system change
- The latter approach is more ambitious and requires engagement and commitment of those at strategic and operational levels to be able to implement the changes required
- For areas which are developing this type of intervention for the first time, it may be advisable to start small and demonstrate what can be achieved, before tackling wider system change
- Incorporate a range of functions: capacity building and training; defining care pathways; delivery of guided self help and other CBT-based interventions; advice, information and sign-posting; building collaborative capacity; promoting prescribing concordance; awareness raising and education
- Define pathways into, out of and between services, as well as steps up and down. This requires clarity about the range of relevant and appropriate services available and the gateways to access them
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