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6.0 Borders
6.1 Origin of project
The Self Help service in the Borders was originally conceived at Local Health Care Cooperative ( LHCC) level to prevent patients with mild and moderate mental health problems from needing higher level services. The Doing Well initiative was an opportunity to seek monies to support and augment existing plans. At that time, the Self Help service was taken on by the local Head of Psychological Services. The level of local financial investment in the Borders Self Help service exceeds the amount of national Doing Well project funding received. Funding from the National Programme to Improve Mental Health and Wellbeing was used to establish a successful database of local services relevant to people with mental health concerns.
6.2 Core functions
- To provide a service for people suffering from mild and moderate depression, which prevents the need for a higher-level service
- To provide people suffering from mild and moderate depression with strategies, knowledge, understanding, and appreciation of psychological processes
- To address previously unmet needs of people with mild to moderate stress, anxiety and depression and to link them with local services
- To provide comprehensive information about other services and support in the local area
6.3 Interventions planned and delivered
The Self Help service in the Borders exclusively targets patients with Tier 1 mental health problems. The intervention consists of guided self help, the Toolkit, and a variety of multi-media self help materials.
Self help
Two self help coaches (or advice workers) based in two medical centres provide guided self help. The service provision is limited to the catchment area of these Health Centres. Guided self help support is offered to people suffering from mild and moderate depression but includes anxiety management and psychosocial interventions. The self help coaches also function as a hub to refer to other services that form part of the Toolkit.
Toolkit
The Toolkit is a sign-posting database containing information about local health, social care, and voluntary services. It provides information to patients, carers, and professionals and facilitates networking between participating local services.
Self help materials
Professionals involved in the service produced dedicated self help materials including booklets, and relaxation CDs. These well-received and sought-after materials are disseminated to patients and a wide variety of associated statutory and voluntary organisations.
6.4 Pathway
Initially, only GPs in the Doing Well practices were able to refer patients to the Doing Well Self Help service. However, to increase potential referral rates and as referrals were deemed appropriate and everything was seen to work well, health visitors and nurses are now also able to refer patients.
Patients are given an appointment at reception on the referral day and are offered up to three sessions with a self help coach. In the course of these sessions the patients are assessed and the coach judges whether and how to make use of the self help materials and the Toolkit. If deemed appropriate the self help coaches accompany a patient to their first appointment with another service. Information about the service is disseminated to patients, carers, and organisations by all services that form part of the Toolkit.
6.5 Capacity and Structure
The Borders Self Help service is based within the psychology department. It employs two specifically trained, non-professional self help coaches. The coaches attend fortnightly team meetings where they discuss the service as a whole. The coaches also have supervision on these days, with a clinical psychologist. The self help coaches are based at two medical centres in two different parts of the Borders. The clinicians at one of the Medical Centres preferred the coach to be referred to as an Advice Worker.
Figure 1
Context of the Borders Self Help Service
Self help coaches do not need to have a background in any of the health professions but are chosen on the basis of their life experience, personality and social skills. They receive 3.5 hours of supervision and training on a weekly basis (out of a total of 18.5 hours). The Doing Well project also includes a supervisor for the Coaches and a clinical psychology assistant. The project is managed by the Head of Adult Psychological services.
In summary, the self help coaches are part of the psychology team, the national network and the primary care practice teams, and are linked to other professionals and volunteers dealing with people with mild mental health problems. A Management Group for the self help service was planned but did not meet.
6.6 Activity and outcomes for service users
Borders Activity Data (up to end March 2006)
| Number of referrals = 225 | |
| DNA rate = 13% | Hawick = 15; Selkirk = 12.83 |
| Average number of referrals per month | |
| Mean waiting time (days) = 10 | |
Making use of the self help service significantly improved patients' mental health and wellbeing as measured by a range of assessment tools ( WASAS, HADS, EQ-5D). The HADS scores are reported below as an example:
Combined HAD anxiety and depression scores at baseline and discharge by sex.
| Males | Females | Total |
|---|
Baseline assessment | 20.23 | 23.93 | 22.52 |
|---|
Mean | (N=57) | (N=92) | (N=149) |
|---|
Discharge assessment | 13.84 | 16.59 | 15.69 |
|---|
Mean | (N=19) | (N=39) | (N=58) |
|---|
Significance* | p<.01 | p<.001 | p<.001 |
|---|
(N=) | (N=19) | (N=36) | (N=55) |
|---|
*Full report results:
- males (t=4.053, df=18, two-tailed p=.001) The 95% confidence interval for this difference is 3.220 to 10.149 and so the difference is statistically significant at the p<.01 level.
- females (t=5.196, df=35, two-tailed p=.000) The 95% confidence interval for this difference is 3.943 to 9.001 and so the difference is statistically significant at the p<.001 level.
- total (t=6.640, df=54, two-tailed p=.000) The 95% confidence interval for this difference is 4.569 to 8.522 and so the difference is statistically significant at the p<.001 level.
Half of the patients referred to the service received some form of signposting (80 out of 158: 50.6%) and self help materials were given to 138 out of 158 patients seen (87.3%) with a relaxation booklet being most widely utilised.
6.7 System impact
Over the course of the first months the Self Help service received only a small number of referrals. This was explained by a lack of awareness of and confidence in the service among GPs, despite early efforts to promote the service. As a result posters and leaflets about the Self Help service were produced and disseminated in the practices.
The Borders Self Help service appears to be working in relative isolation from other mental health services in that there are few active, operational or strategic forums in which to discuss the project's progress and plan for its future. This is despite the fact that on the ground the project has been able to develop good horizontal links with a wide range of community services and resources through the development of the Toolkit.
Health service managers do not agree about whether/where the service fits in the local health care structure. The service has the potential to either be rolled out throughout the Borders or to be integrated with other local projects ( i.e. Men's Health Project, Women's health project, Lifestyle Advisor, Wellbeing Service). Funding was recently made available to merge the Toolkit with similar signposting tools created by two of these other projects.
So far, the self help service does not appear to feature in the Health Board's strategic plans for mental health and health service managers and clinicians considered this a missed opportunity to promote the approach and consider its wider application.
6.8 Sustainability
Permanent funding is available for two self help coaches, clerical support and clinical supervision. Referral, patient uptake, and the forging of closer links with other services, in particular GPs remain critical issues for sustainability. In the future the number and range of referring professions will need to be increased and self-referrals from patients will be considered. If referral rates continue to increase the service has the potential to be rolled out across the Borders either as it stands or in conjunction with other services. Further options for the Self Help service include becoming a part of a Health Board wide tiered and integrated pathway for depression. This envisions the service being used both as a treatment alternative and as an adjunct to other treatments. The Toolkit has been a particular successful element of this initiative but requires resources to maintain.
6.9 Key learning
- A database of local services including descriptions and contact details provides an asset for all participating services and for patients
- Offering free training events to the voluntary sector was well received and adds value to the Self Help service
- A new approach such as the Self Help service requires time to mature so that it can settle into its optimum position within the service system
- Using non-professional self help coaches appears to be a cost-effective approach that does not compromise patient satisfaction and measured clinical outcomes
Challenges of the Borders model:
- Links with related services and with local strategic priorities could still be strengthened.
- It is unclear who will be involved in the decision whether to roll the service out across the Borders and in which ways.
- GPs need to be encouraged to have a more active role in strategic decision-making in relation to the service. Doing Well also needs to consider how best to encourage GPs to refer patients to the service on a routine basis.
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