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14.0 Variations on the Doing Well theme
The analysis of the implementation of various service models identified a set of key themes relating to the introduction of self help interventions for people with mild to moderate depression and the system changes needed to sustain these interventions:
- The introduction of innovation
- The delivery of interventions
- Maximising capacity and capability
- Wider system change
14.1 Introducing innovation and promoting change
From the experience of the Doing Well projects, introducing effective innovation requires attention to the following.
- Leadership and vision are critical in creating and maintaining a sense of direction, and purpose and in representing and advocating for the approach with decision makers
- Having champions from a range of sectors and services to support the work and not relying only one 'hero innovator' helps create wider ownership and stability
- It pays to invest effort in planning, development and management of the new project and ensure there is sufficient protected capacity to work at system level to foster change. The time and effort required to achieve change in attitudes and behaviour in other services and practitioners should not be underestimated
- However, innovative developments can have a halo effect: the new service develops a distinctive approach and ethos, there is close attention to set-up, often relatively high investment in staff training and development and high morale. This poses challenges in considering how to translate the effects into a sustainable approach in mainstream service delivery
- Continuing effort is needed to promote and market the new service or approach, not only in the early stages of development
- Innovation challenges and yet needs the support of existing infrastructures such as IT and HR
- Ensuring reflective practice is essential, to review, learn and adapt. This requires robust, relevant data collection systems, a willingness to set goals and the means to measure progress and a desire to collect, share and use information
- There are strengths in projects which are developed by practitioners from the bottom up. However it is also critical to build connections into local planning structures and illustrate the contribution projects can make to key local priorities, to enhance prospects for continuation of the work
14.2 Delivery of interventions
Several factors proved to make a difference in delivering interventions that were acceptable and valuable:
- Timing: when help was offered and the readiness of both the service user and the referrer to make use of the opportunity
- Effective presentation and marketing to explain what was on offer to referrers and potential users
- The therapeutic relationship with the worker remains the essential element, backed up by self help materials
- Offering a wide range of options and modalities of interventions helps broaden access and engagement
- Time-limited focused interventions worked well for many people. This approach also acted as a stimulus for other mental health services to consider the rationale for their approaches
14.3 Maximising capacity and capability
It is possible to devise ways of delivering evidence-based psychological interventions, by creating a cadre of non-professional self help workers, establishing sufficient primary care mental health capacity and enhancing existing capability and confidence in other statutory and non statutory services. These strategies proved to have a number of implications:
- Using lay self help workers creates significant opportunity to match skills and experience to needs and to reach a larger number of people, faster
- Using non-qualified staff places high value on the interpersonal skills of carefully selected and closely supported workers
- This raises questions about career pathways for this 'new' type of worker,
- in terms of entry criteria, cores skills and competencies, progression and relationships to other types of roles in the NHS and in social care
- Introducing new roles requires a readiness to review existing roles and skills deployment
- There can be considerable demand for awareness raising and training from local service providers/stakeholders in the statutory and non statutory sector. However, it can be difficult to sustain the support required to ensure effectiveness
14.4 Wider system change
The experience of Doing Well in working to effect system change illustrated that:
- The locus of the project can influence outcomes, in terms of ownership, connectivity and leverage for change. It is important to have a strategy for communication and regular feedback across the system and to ensure connectivity at both operational and strategic planning level
- Fostering ownership and engagement is a prerequisite for the development of collaborative approaches with primary care and other stakeholders, who need to be convinced of the benefits of proposed changes
- System change is complex and takes time to plan initiate, implement and evaluate
- A single project innovation cannot in itself counterbalance systemic difficulties
- To achieve maximum impact across the system requires proactive investment of effort to build the case for change, gain support and establish processes to make it happen. It cannot be assumed that existing strategic structures and processes will necessarily bring this about
- Top-down approaches can help embed the changes desired, e.g. strategies and services plans that state guided self help is an accepted mode of treatment as part of a stepped care model
- Changes can take firmer root where there is synergy with other developments and priorities in mental health (for example on suicide prevention, tackling stigma, or promoting recovery) and health improvement for example, promoting healthy lifestyles
- The support of the local NHS board is a prerequisite to enable innovations to be mainstreamed
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