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5.0 Argyll and Clyde

5.1 Origin of project

The impetus for the Argyll and Clyde Doing Well project was created from concern within the NHS about the relatively high rates of anti depressant prescribing locally, coupled with the recognition that such medication is not the preferred response for people with mild to moderate depression. The project was developed by secondary psychiatry, drawing on evidence based models of care from elsewhere.

The Doing Well project aimed to achieve 'complex system change' by focusing directly on primary care, adding in a tier of service that was previously absent and promoting integrated approaches to depression in primary and secondary care. The project was implemented in phases and gradually extended to reach the full target population of 80,000 people by the end of 2005. The project began working in three general practices that showed interest, through the involvement of the LHCC lead for mental health. This provided opportunity for the project to demonstrate its potential and engage the interest of other general practices. The design of the project was informed by patients' and primary care professionals' preferences in relation to access and location. Latterly, a public involvement programme of education and awareness raising was introduced.

5.2 Core functions

Doing Well in Argyll and Clyde has implemented a form of stepped collaborative care to integrate health systems in primary and secondary care. This aimed to:

• Provide enhanced capacity to support primary care in addressing depression, through the introduction of assessment tools and information systems and by making the specialist skills and knowledge of secondary care accessible in primary care settings
• Promote self help and minimise inappropriate medicalisation
• Promote the rational use of antidepressants

5.3 Interventions planned and delivered

Tier 1

The introduction of a public involvement and community development element into Doing Well in late 2005 added capacity to work with and through the community and voluntary sector and to utilise a wider range of routes, including local and national media and further education colleges to raise awareness of depression.

Tier 2

Doing Well has introduced an electronic referral and information system to improve the primary/secondary care interface. This gives GPs the facility to assess patients using a screening instrument ( PHQ) and then refer to the team.

An Assistant Psychologist provides guided self help. Four Primary Care Liaison Workers ( PCLWs), skilled and experienced in mental health, are attached to designated primary care practices. They offer short-term structured interventions (up to six sessions) including patient education on medication and psychological aspects of depression and strategies for coping. Workers can also provide advice and information to the primary health care team.

The project has implemented a prescribing formulary to minimise antidepressant use for people with PHQ scores <15 and to optimise antidepressant use for people with scores >15.

5.4 Pathways

Referrals are GP-initiated, using an electronic referral system that integrates with primary care, secondary care and NHS electronic referral systems. This makes for easy and rapid access and new referrals are seen on average within 11 days.

According to the project protocol, patients with a PHQ score of <15 are referred to the Self Help Support Worker ( SHSW) and those with a higher score to a Primary Care Liaison Worker or the Clinical Project Manager. In practice and over time, the complexity of cases allocated to the SHSW increased as demand grew and as the team gained confidence. Staff can refer patients on to a range of other services if required. Weekly team meetings allocate cases and review patient progress.

5.5 Capacity and Structure

The project comprises four PCLWs, one Assistant Psychologist ( SHSW), one Public Involvement Co-ordinator, a Clinical Project Manager. Support and clinical supervision are provided by from a Consultant Psychiatrist (Project Lead) and a Clinical Psychologist.

A key feature of Doing Well in Argyll and Clyde has been the high investment in staff training, development and supervision, with up to 1/5 of staff time allocated to CPD or related activities, and the commitment to developing and maintaining an effective team. Staff morale is high and commitment to the service model and core objectives strong. The Doing Well project has benefited from the vision and strong leadership provided by the Consultant Psychiatrist involved. The project sits within secondary service structures which were going through considerable upheaval with the merger of the parent NHS organisation into NHS Greater Glasgow. The project's establishment was supported by the local primary care LHCC lead for mental health and it has strong links into clinical psychology services. A Clinical Project Manager is responsible for day to day service management.

5.6 Activity and outcomes for service users

Argyll and Clyde activity data (up to 31st March 2006)

The referral process makes for ease and speed of access: first appointments are on average seen within 13 days. Clinical outcome data demonstrates improvements on discharge. The range and complexity of need identified has been greater than expected and, for these cases, skilled short-term interventions from the PCLW have been indicated rather than the guided self help option. High client satisfaction with the service is illustrated by DNA rates which are consistently lower that the average for mental health services locally and by client feedback.

Difference in mean PHQ scores from baseline to discharge by severity at onset:

Difference in mean Work and Social Adjustment Scale ( WASAS) scores by sex from baseline to discharge:

5.7 System impact

The project has harnessed principles of system change to offer a multi-dimensional response to manage all forms of depression and adjustment disorder. These include changing GP assessment and prescribing behaviour, providing referral options, and introducing IT innovation to facilitate the referral and management process. It works on a collaborative model, bringing secondary care expertise to assist in meeting the needs of general practice in responding to depression. The project has been able to embed changes in primary care assessment of depression by introducing new elements to general practice IT infrastructure.

Uniquely, this project set out to influence prescribing decisions in line with clinical guidelines and liaised with local prescribing advisors to this end. Compliance with the local prescribing formulary has doubled in the Doing Well area (from 45% to 87% as measured by local evaluation data), since the introduction of Doing Well. More detailed assessment of the impact of the prescribing formulary is presented in Section 12 of this report.

5.8 Sustainability

The project has been able to demonstrate effectiveness in providing an additional service component within the service system that eased access for people requiring help and extended capacity and capability within primary care. The careful attention to the development of care delivery systems that integrated primary and secondary care created capacity to manage high demand with good outcomes.

Because of local re-organisation of the NHS, the project has had to renew strategic connections and re-present the case for sustainability in these new structures. The project's ability to demonstrate its impact has been relatively strong in view of the commitment to collect and use extensive data on activity and outcomes from the outset, to guide practice and inform the development of the service offered.

5.9 Key learning

• Start small, demonstrate what you can do, engage interest and grow from there
• Investment of time in building on core IT infrastructure can reap considerable benefits in influencing practice in mainstream services
• Use audit and research - link local evidence and practice development
• Continuity of strategic relationships is important

Challenges of the Argyll and Clyde model:

• A coherent collaborative model of care was developed that achieved effective integration of primary and secondary care systems. Integrated IT systems lay at the heart of this. This remains a key challenge for many other areas
• A challenge will be to continue to extend links with the community and voluntary sector to avoid unnecessary medicalisation
• It remains to be seen how the introduction of the public education element adds value
• Guided self help, offered here as one of a number of options, was taken up less than in other places such as Dumfries and Galloway. Experience in Argyll and Clyde indicated that for some people, guided self help was not engaging or useful
• The project set a standard for investment in staff training and development that was higher than the norm for the NHS. It remains to be seen whether it is possible to sustain service quality and outcomes when the halo effects associated with innovation begin to pale

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