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Executive Summary
Background
Depression
Depression is now recognised as a major public health problem, to which primary care based provision has a significant contribution to make. However, at present a large proportion of people with depression remain with their condition unrecognised and do not receive appropriate treatment or support. Research evidence favours the use of time-limited psychological interventions to address mild to moderate mental health problems in primary care, as well as mechanisms to link people to non medical sources of support. In addition, there is a growing body of evidence in support of guided self help approaches for common mental health problems. In general pharmacological treatments for people suffering from mild to moderate depression are not indicated. Evidence from organisational models of care has demonstrated that stepped care and collaborative care models are effective in delivering integrated care, in ways which best meet the needs of individuals. These approaches are also superior in terms of the utilisation of expensive and scarce resources.
The Doing Well by People with Depression Programme
Through Doing Well by People with Depression, the Scottish Executive introduced a programme to build capacity at different levels within local service systems to respond to depression and to enhance access to sources of support. The programme presented an opportunity to try out 'new' approaches and to change existing ways of delivering interventions. Doing Well was a three-year initiative, managed by the Centre for Change and Innovation, and aimed to: build capacity for self help to meet the needs of those with mild to moderate depressive disorders and provide support through the pathway of care; build capacity for psychological interventions in primary care to reduce pressures on secondary services; improve assessment of symptoms and associated problems to ensure an agreed understanding of user need and the most effective sequences of treatments and/or support; and improve access to a range of community-based services and support.
Seven local areas received project funding in the first phase of Doing Well and these were the focus of a qualitative evaluation led by the University of Edinburgh and the Scottish Development Centre for Mental Health.
The evaluation
The evaluation identified key achievements of the programme, explored the features of local Doing Well projects developments that contributed to success and drew out pointers for future policy, service and practice development beyond the Doing Well programme.
Findings
Benefits and limitations
The Doing Well programme tested out different models of delivery in different healthcare contexts. Overall, the programme demonstrated that stepped care and collaborative care are appropriate and potentially effective models for the management of depression in Scotland. Guided self help proved to be a useful first-line intervention for many of those with mild to moderate depression.
The benefits and limitations of Doing Well programme are summarised below.
Level | Benefits | Limitations |
|---|
Individual | Positive feedback from service users who found the interventions beneficial and acceptable Clinical improvements were achieved Those who needed it, got 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 suited some people, but not all Required readiness and ability to engage with guided self help approach |
Community and voluntary sector | Raised local 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 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 | Widened options for referral and increased capacity to manage depression Promoted adherence to good practice re: - non-medical interventions
- antidepressants (when, what and how much to prescribe)
Offered regular feedback to and communication with referrer Assisted in working towards targets set in Quality Outcomes Framework | Primary care referrers lacked 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 Sustaining the 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 Increased options to allow stepping up and down, which is important given the complexity of depression Extended service reach to meet identified needs Assessment, triage and pathways to other services were clearer Short-term interventions proved effective in dealing with high demand Decreased pressures on specialist services Stepped care and guided self help models had 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 valuable as a regular forum for learning Doing Well 'branding' helped raise and maintain a profile nationally and locally Demonstrated the applicability of nationally driven service redesign/improvement in mental health | Maintaining momentum as the 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 |
Key learning: service models
Whilst there were strong similarities in the overall objectives across all seven sites, there were also clear differences between them, highlighting those elements of a local approach which are more likely be effective in achieving the desired outcomes within a local service system, as outlined below.
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 about 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.
It is important to start from a clear understanding of the nature of 'the problem' for which a solution is sought. 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.
Effectiveness is likely to be enhanced by incorporating 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.
Key learning: innovation
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 project management 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
- Innovative developments can have a halo effect. The new service enjoys a distinctive approach and ethos, considerable effort devoted to set-up, often relatively high investment in staff training and development and consequent high staff morale. This poses challenges in translating these effects into a sustainable approach in mainstream service delivery
Key learning: delivery of interventions
Several factors proved to make a difference in delivering interventions that were acceptable and valuable:
- Persistent marketing and promotion is essential to explain the notion of guided self help to referrers and potential service 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
Key learning: maximising capacity and capability
It is possible to devise ways to deliver evidence based psychological interventions, by creating 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 have a number of implications:
- Using lay self help workers provides opportunity to match skills and experience to needs and to reach a larger number of people, faster. This strategy places high value on the interpersonal skills of carefully selected and closely supported workers. It raises questions about career pathways for this 'new' type of worker, in terms of entry criteria, core skills and competencies, progression and relationships to other types of roles in the NHS and in social care
- 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 and supervision required across sectors to ensure effectiveness
Key learning: 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
- 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 and assess progress. It cannot be assumed that existing strategic structures and processes will necessarily bring this about. Changes can take firmer root where there is synergy with other developments and priorities in mental health and health improvement
- 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. The support of the local NHS board is a prerequisite to enable innovations to be mainstreamed
Pointers for development and recommendations: national level
Pointers for development | Recommendations |
|---|
Stepped care and collaborative care are appropriate models for the management of depression in Scotland. Guided self help has proved to be a useful first-line intervention for those of those with mild to moderate depression. | The implementation of stepped and collaborative care models in primary care should be promoted to address depression and common mental health problems The Doing Well work should inform the planned development of Integrated Care Pathways for Depression |
There is a need to promote understanding of a range of psychological and psychosocial interventions in primary care, including guided self help, to enhance their acceptability and relevance to referrers and potential users. This includes identifying those groups for whom guided self help is neither engaging nor effective | The Health Department and other national bodies should support the implementation of the interventions piloted in Doing Well by actively promoting the changes in attitudes and behaviour required for the effective use of guided self help (for example by sponsoring awareness raising and training in self help models). Further research and development is required to identify how best guided self help can be adapted for a wider range of groups and acceptable alternatives where guided self help is not indicated |
Community Health Partnerships ( CHPs) are likely to need support to maintain the appropriate level and quality of staff training and supervision for the delivery of psychological interventions, including guided self help | CHPs would benefit from national guidance and support to create and maintain capacity for psychological interventions Steps should be taken to ensure that training for health care professional incorporates sufficient attention to psychological therapies |
| As part of a national initiative that fosters locally driven service innovation within a common framework of aims, there is considerable added value to be derived from offering local participants a range of tools and supports to facilitate change processes | Implementation of future national redesign and service development initiatives should include support with project management, as well as the provision of opportunities for networking and learning The Doing Well Development Network should develop wider links with other relevant initiatives on primary mental health care, to continue to bring together experience from practice and evidence from research in a range of fields relevant to the management of depression and common mental health problems |
Service redesign methodologies can have application and utility in mental health and the experience of Doing Well can be built on in future work on system redesign and service improvement | The lessons from Doing Well should inform the development and implementation of the Delivery Plan for Mental Health in relation to primary mental health care |
| To learn from innovation requires meaningful data and the selection of outcome measures that can identify the systemic impact of interventions | It is essential to incorporate consistent data collection systems, including appropriate outcomes measures, into national initiatives from the earliest possible stages |
| There is a need to ensure complementarity and synergy among nationally initiated developments, e.g. tackling stigma, raising awareness, preventing suicide | The learning from Doing Well should be linked to other national priorities for mental health improvement, including Choose Life |
Depression is a complex problem, which requires a range of responses and interventions, both from the health sector and from its community and voluntary sector partners. Stepped collaborative care provides a useful and viable model on which to build. Resources such as guided self help have a valuable role in the repertoire of responses and services required to treat and support people with depression, but are not the only solution | CHPs should review the range of options and pathways in place and identify unmet needs and areas for improvement. This should include identifying how to strengthen current capacity and capability in health and social care and in the community and voluntary sectors and where necessary realign roles The development of pathways for people with depression should include attention to the rationalisation of prescribing practices |
| Innovation can be a means to further strategic goals by bringing about changes in how service system works. It is an opportunity to test out ways of working that can be absorbed into mainstream activities (rather than to create projects which then require long term funding | CHPs should invest in systems to generate data that can inform primary mental health care planning and development To enhance the sustainability of interventions for depression, CHPs should look for connections with other agendas and strategies, e.g. health improvement and the management of long-term conditions |
| Getting and keeping the engagement of key stakeholders requires sustained effort and is vital for system change. Achieving change in the attitudes and behaviour of practitioners and the public is not simple and has to be tackled at different levels over the long term. It is not only a matter of offering training or distributing information about the value of guided self help | CHPs should work with local stakeholders to agree goals for change and to design appropriate local solutions, recognising that these may include interventions at individual and community level and may involve a range of service providers, not only the NHS |
| Research can help with understanding the problems to be addressed, the features of effective interventions and models for delivery | In planning and developing services and resources for common mental health problems including depression, CHPs should draw on a range of bodies of research evidence on: clinical interventions, models of service delivery and mental health promotion and prevention |
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