abcdefghijkl - · PDF fileabcdefghijkl Health Department ... £420m in NHS costs ... Sturm R, Sherbourne CD, et al. Caring for Depression. Massachusetts: Harvard University Press,

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St Andrew’s House Regent Road Edinburgh EH1 3DG [email protected] Telephone: 0131-244 2444 Fax: 0131-244 2432 [email protected] Telephone: 0131-244 3749 Fax: 0131-244 2432 [email protected] Telephone: 0131-244 2816 Fax: 0131-244 2432 Http://www.scotland.gov.uk Your ref: Our ref: 48/2 21 May 2003

Doing Well by People with Depression

Programme Proposal

Dear , We are writing to Chief Executives of Boards and Primary Care Trusts about a programme to redesign services for people with depression. The Centre for Change and Innovation (CCI) and the Mental Health Division of the SEHD are proposing a programme shared with local health systems. We are seeking your views and invite declarations of interest in the programme. Depression is common, costly and treatable but in Scotland timely and local access to the full range of interventions and supports is not universal, even where there is good evidence of effectiveness. The issue is not just one of resources but also the way we manage, communicate and share information. The CCI has undertaken some initial spadework to test our own understanding of the issues and the range of ways in which they might be tackled. This has provided us with a start-point for detailed discussions with local health systems. Consultation with representatives of users, voluntary sector, local authorities and healthcare professionals

mailto: [email protected]



has achieved consensus on the way forward to tackle the issues1. A Programme Proposal2 has been developed which outlines a whole systems approach to develop capacity and make best use of resources by: • Building increased capacity for self-help in order to meet the needs of those with mild

depressive disorders and to provide support through the pathway of care. • Building increased capacity for psychological interventions in primary care thereby

offering the potential to reduce some of the current pressures on secondary services.

• Improving assessment of depressive symptoms and associated problems to ensure an agreed understanding of user need with users and carers together with the sequence of treatments and supports that would be effective, including all of a user’s needs and for people with particular needs.

• Improving access to a range of services and supports within local communities by the

creation and active management of networked pathways of care. We have been impressed by the need to adopt a whole systems approach to the problem and believe that all four elements need to be in place if the following benefits are to be achieved: • Improved wellbeing. • Improved access and waiting times. • More efficient use of resources. • Improved integration of services across existing boundaries. This is a demanding but vital agenda and we are therefore proposing a three year rolling programme, with indicative funding of £1.5m per annum from the CCI. The programme will work with local health systems to engage service users, clinical leaders and partners in the redesign and improved management of mental health services. The programme will be co-ordinated nationally, to provide support and share learning. The programme may start by working with three or more local systems, possibly at community level, in the first year and with other local health systems in subsequent years. The criteria which we feel are most likely to be relevant are laid out in the Programme Proposal and will be considered by the Programme Steering Group and the Scottish Health Change Panel in June.

1 Conference Report dated 24th Apr 03. 2 Doing Well by People with Depression. Programme Proposal. Version 6.0. Enclosed.

We would be grateful if you could provide us with your initial views and declarations of interest by 2nd June by replying to the Programme Manager, Martin Hopkins, at: Martin Hopkins Centre for Change and Innovation St Andrew’s House Regent Road EDINBURGH EH1 3DG 0131 2442816 0790 151 0081 (mobile) [email protected] If you have any queries at this stage or would like to discuss the programme further please do contact Martin Hopkins. We look forward to hearing from you. June Andrews David Bolger Head Head Centre for Change and Innovation Mental Health Division



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DOING WELL BY PEOPLE WITH DEPRESSION

CENTRE FOR CHANGE AND

INNOVATION

PROGRAMME PROPOSAL Version 6.0 19th May 2003

• Depression was the most common condition recorded at

GP consultations in Scotland in 2000. • Appropriate help can not only treat an episode of illness,

but may also help to deal with issues which have caused the individual to be vulnerable to its development, and, possibly, its recurrence.

• The way we manage organisational, communication and

information handling issues can have a significant effect in causing existing resources to be used in a sub-optimal way.


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DOING WELL BY PEOPLE WITH DEPRESSION CENTRE FOR CHANGE AND INNOVATION

CONTENTS Page

Executive Summary …………………………………………………………………… 3

Need……………………………………………………………………………………… 7 Benefits of Doing Well by People with Depression…………………….…………… 8 Context………………………………………………………………………………….. 9 Partnership for Care…………………………………………………………… 9 Mental Health: Moving the Agenda Forward………………………………… 10 Doing Well by People with Depression………………………………………. 11 Proposal for Doing Well by People with Depression……………………………….. 12 Introduction……………………………………………………………………… 12 Current Situation………………………………………………………………… 13 Priority Areas…………………………………………………………………… 15 A Collaborative Approach to Service Improvement………………………… 17 Learning and Self-Help………………………………………………… 17 Psychological Interventions……………………………………………. 18 Assessment of Depressive Symptoms and the Associated Problems19 Pathways through Services and Supports…………………………… 19 Criteria for Local Programmes………………………………………………… 20 Risks to be Managed…………………………………………………………. 21 Costs and Timescales………………………………………………………… 22 Costs……………………………………………………………………. 22

Timescales……………………………………………………………… 25


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PROGRAMME PROPOSAL EXECUTIVE SUMMARY Need The World Health Organisation has recently highlighted the heavy and increasing burden of disability, world-wide, that is caused by depressive disorders1. Depressive Disorders are: • Common. It is estimated that at any one time 5-10% of the population of the United

Kingdom experience depressive symptoms2 and that 60-70% of adults at some point in their lives will experience symptoms of depression or anxiety sufficient to influence their daily activities3. Depression was the most common condition recorded at GP consultations in Scotland in 20004.

• Costly. Depressive disorders are costly in terms of:

• Personal suffering through impact on wellbeing and quality of life5. • Reduced functional capacity with an impact on relationships, family,

community and economic activity. The costs of depression in the UK have been estimated to be £3 billion in the UK each year, £420m in NHS costs and the remainder due to lost productivity and the cost of benefits6.

• Increased requirement for healthcare. Use of general medical services by

people with depressive disorders is 50-100% higher than by those without depressive disorders 7.

And:

1 World Health Organisation. Annual Report 2001. 2 Singelton N, Bumpstead R, O’Brien, M, et al. Office of National Statistics: Psychiatric morbidity among adults living in private households, 2000. London: HMSO, 2001. 3 Mann A, in Jenkins R, Newton J, Young R, eds. The Prevention of Depresssion and Anxiety. London: HMSO. 1992. 4 Mental Health in Scotland: Information sources and selected insights. Mental Health Information Programme. ISD Scotland. http://www.show.scot.nhs.uk/isd/mental_health/sources_insights2002.pdf. Page 33. 5 Wells KB, Sturm R, Sherbourne CD, et al. Caring for Depression. Massachusetts: Harvard University Press, 1996. 6 Mind Factsheets on Mental Health Statistics: The financial aspects of Mental Health No 5. Quoted in NHS Highland Directorate of Information and Clinical Effectiveness. Issue 11. August 2002. 7 Wells KB, Sturm R, Sherbourne CD, et al. Caring for Depression. Massachusetts: Harvard University Press, 1996.

http://www.show.scot.nhs.uk/isd/mental_health/sources_insights2002.pdf


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Treatable. In the majority of cases Depressive Disorders are treatable:

• There is a solid evidence base to support the use of time-limited psychological interventions.

• There have been significant advances in the provision of effective

pharmacological approaches to treatment. • Psychological and pharmacological treatments can be used effectively either

singly or in combination • Nevertheless, many individuals with depressive disorders will have needs

arising from difficulties in their personal and/ or community circumstances which require a broad range of supports and services e.g. in relation to housing, childcare and/ or employment. A comprehensive and integrated assessment and management model is required to address these diverse needs.

But: • In Scotland there is probably no area where an individual with a depressive

condition has timely and local access to the full range of interventions and supports for which there is good evidence of effectiveness. This initiative sets out to address this.

Benefits of Doing Well by People with Depression An effective programme to Do Well by People with Depressive Disorders would: • Improve mental wellbeing for individuals whose needs otherwise may have lain

unacknowledged. • Improve access by individuals to interventions with an appropriate evidence base

and supports which they are assessed as needing. • Improve use of available skills and resources to the best advantage of people who

need a service. • Develop the capacity of local communities to better meet people’s broader needs. Context Mental Health services will be improved through the development of multi-disciplinary and multi-partner networks of care8. The Centre for Change and Innovation has been

8 Partnership for Care, Scotland’s Health White Paper. February 2003. Pages 33 and 38.


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set up to provide practical support and expertise to help NHSScotland improve the way in which care is provided for patients by supporting service improvement in national priority areas such as mental health. Current evidence shows that the rate of progress nationally to date to improve mental health services has been slow. There is a need for an approach which builds capacity, particularly in primary care and Community Health Partnerships, and manages existing capacity within and between all tiers more effectively and efficiently. Proposal A collaborative approach to service improvement is proposed to tackle the issues of capacity and make the best use of resources. The programme to improve services comprises four elements which are necessary to:

• Build increased capacity for self -help in order to meet the needs of those with mild depressive disorders and to provide support through the pathway of care.

• Build increased capacity for psychological interventions in primary care thereby

offering the potential to reduce some of the current pressures on secondary services.

• Improve assessment of depressive symptoms and associated problems to

ensure an agreed understanding of user need with users and carers together with the sequence of treatments and supports that would be effective, including all of a user’s needs and for people with particular needs.

• Improve access to a range of services and supports within local communities by

the creation and active management of pathways of care. A local programme would include components of each of the four elements, matched to local needs. This programme needs to be underpinned by a commissioning focus on the local provision of services and for psychological interventions in particular. We need to involve users, carers, clinicians and partners in the detailed design of effective systems and services to meet needs through sustainable improvement. This leads us to select an exploratory approach in a number of health systems, but one with sufficient national support to enable and ensure real change and improvement. Action Local health systems are invited to become engaged with Doing Well by People with Depression as part of their change and innovation plan.


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Indicative costs are provided to enable local health systems to consider the scale of resources required to deliver community health services and better integrate voluntary, social care, primary healthcare and specialist healthcare through a managed care network. A three year programme is proposed, supported by £1.5m of Centre for Change Innovation funding per annum and co-ordinated nationally, working with local health systems on a rolling programme to engage service users, clinical leaders and partners in the redesign and improved management of mental health services. Justification Local systems have often either struggled to improve their services or have had to bid for central funds which have resulted in short-term localised projects which may not have been mainstreamed in either local systems or shared nationally. Doing Well by People with Depression represents a different approach to previous mental health initiatives, providing support for local system change, underpinned by mechanisms to evaluate and to share effective solutions nationally. By addressing a widespread condition the programme affords the chance to fundamentally re-think the way in which mental health services, their partners and communities respond to the needs of local communities. Timetable The proposed timetable to start Doing Well by People with Depression is:

• Submission of Programme proposal to Steering Group 1st April

• Co-ordination across Scottish Executive Health Department April • Invite Declarations of Interest May • Mental Health National Event June • Agree 1st Year Project Areas June • Scottish Health Change Panel June • Definition of 1st Year Projects End-June • Start 1st Year Projects October

2003


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The programme is depicted as a diagram below: Issues

Areas for Action Programme Element

Better public information Self-Help Support for Voluntary Organisations

Learning and Self-Help

Availability of Mental Health Workers Capacity of Primary Care Health Team

Capacity

Range of Treatment Options

Psychological Interventions

Availability of Mental Health Workers Capacity of Primary Care Health Team

Assessment of Depressive Symptoms and Associated Problems

Clearer Routes through Services and Supports

Making Best Use of Resources

Com

missioning F

ocus

Range of Treatment Options

Pathways Through Services and Supports


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PROGRAMME PROPOSAL NEED The World Health Organisation has recently highlighted the heavy and increasing burden of disability, world-wide, that is caused by depressive disorders9. Depressive Disorders are: • Common. It is estimated that at any one time 5-10% of the population of the United

Kingdom experience depressive symptoms10 and that 60-70% of adults at some point in their lives will experience symptoms of depression or anxiety sufficient to influence their daily activities. Depression was the most common condition recorded at GP consultations in Scotland in 200011.

• Costly. Depressive disorders are costly in terms of:

• Personal suffering through impact on wellbeing and quality of life12. • Reduced functional capacity with an impact on relationships, family,

community and economic activity. The costs of depression in the UK have been estimated to be £3 billion in the UK each year, £420m in NHS costs and the remainder due to lost productivity and the cost of benefits13.

• Increased requirement for healthcare. Use of general medical services by

people with depressive disorders is 50-100% higher than by those without depressive disorders 14.

And Treatable. In the majority of cases Depressive Disorders are treatable:

• There is a solid evidence base to support the use of time-limited psychological interventions.

9 World Health Organisation. Annual Report 2001. 10 Singelton N, Bumpstead R, O’Brien, M, et al. Office of National Statistics: Psychiatric morbidity among adults living in private households, 2000. London: HMSO, 2001. 11 Mental Health in Scotland: Information sources and selected insights. Mental Health Information Programme. ISD Scotland. http://www.show.scot.nhs.uk/isd/mental_health/sources_insights2002.pdf. Page 33. 12 Wells KB, Sturm R, Sherbourne CD, et al. Caring for Depression. Massachusetts: Harvard University Press, 1996. 13 Mind Factsheets on Mental Health Statistics: The financial aspects of Mental Health No 5. Quoted in NHS Highland Directorate of Information and Clinical Effectiveness. Issue 11. August 2002. 14 Wells KB, Sturm R, Sherbourne CD, et al. Caring for Depression. Massachusetts: Harvard University Press, 1996.

http://www.show.scot.nhs.uk/isd/mental_health/sources_insights2002.pdf


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• There have been significant advances in the provision of effective

pharmacological approaches to treatment. • Nevertheless, many individuals with depressive disorders will have needs

arising from difficulties in their personal and/ or community circumstances which require a broad range of supports and services e.g. in relation to housing, childcare and/ or employment.

But:

• In Scotland there is probably no area where an individual with a depressive condition has timely and local access to the full range of interventions and supports for which there is good evidence of effectiveness. This initiative sets out to address this.

BENEFITS OF DOING WELL BY PEOPLE WITH DEPRESSION An effective programme to Do Well by People with Depressive Disorders would: • Improve mental wellbeing for individuals whose needs otherwise may have lain

unacknowledged. • Improve access by individuals to interventions with an appropriate evidence base

and supports which they are assessed as needing. • Improve use of available skills to the best advantage of people who need a service. • Develop the capacity of local communities to better meet people’s broader needs. The manner in which local projects contribute to these strategic benefits will be identified through consultation with users, clinicians and partners as an integral component of their development and evaluation.


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CONTEXT PARTNERSHIP FOR CARE Partnership for Care15, Scotland’s Health White Paper establishes plans to modernise services: ‘…teams…will work across communities and care settings so that patients can access services at a range of locations from a range of professional staff. This multi-disciplinary and multi -partner approach is particularly critical for the provision of local, integrated mental health services.16’ ‘Joint working is particularly important in improving menta l health services. Within this broad framework networks of mental health professionals can address the problems of patients or service users as they move from one service provider, or partner organisation to the next. Such care networks can improve the patient’s pathway of care and promote the better use of the shared resources….17’ ‘NHS Boards should work with Local Authorities to develop their Local Partnership Agreements to include targeted plans by early 2004 to: • reduce bureaucracy and duplication; • develop a network of modern, sustainable and integrated community services

focused on natural localities; • integrate community-based services and specialist healthcare services through

clinical and care network; and • develop organisations to support the necessary changes in service delivery18.’ Support for change and Innovation will be provided through the work of the Centre for Change and Innovation (CCI): ‘The CCI will provide practical support and expertise to help NHSScotland improve the way in which care is provided for patients. It will do this by: • supporting service improvement in national priority areas such as mental health,

cancer, coronary heart disease and stroke and chronic diseases such as diabetes……

15 http://www.show.scot.nhs.uk/sehd/publications/PartnershipforCareHWP.pdf 16 Ibid. Page 33. 17 Ibid. Page 38. 18 Ibid. Page 38.

http://www.show.scot.nhs.uk/sehd/publications/PartnershipforCareHWP.pdf


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• tackling national initiatives such as outpatient appointments, access to primary care and mental health services19.’

Mental Health services will be improved through the development of multi-disciplinary and multi-partner networks of care. The Centre for Change and Innovation has been set up to provide practical support and expertise to help NHSScotland improve the way in which care is provided for patients by supporting service improvement in national priority areas such as mental health. MENTAL HEALTH: MOVING THE AGENDA FORWARD Mental Health: Moving the Agenda Forward highlights the current challenge: ‘The published findings of the Mental Health and Well Being Support Group and Scottish Health Advisory Service20 from visits to NHS Board areas, the Annual Reports of the Mental Welfare Commission for Scotland and the Clinical Standards Board for Scotland (now part of NHS Quality Improvement Scotland) national report on implementation of the schizophrenia standards, provide a credible common base-line to judge the quality of existing service provision. Together, these show that the rate of progress nationally with the change and improvement agenda has been slow and patchy. This is despite the widely accepted objectives of the Framework for Mental Health Services in Scotland, amplified in Our National Health. These envisage services that make a difference by improving the speed, responsiveness and quality of care through: • early assessments and early delivery; • better and quicker decisions involving users of services and their carers; • more flexible responses to needs; • efficient use of resources and partnership working; and • better information.’ The paper re-states the aim: ‘The objective remains to develop comprehensive mental health services, care and support that: • are person centred; • support increased involvement of users of services and their carers; • provide better responses for people in the primary care setting with mental health

problems; • offer greater individual control and choice; • provide access to independent advocacy for all who need it;

19 Paragraph 63. 20 Now part of NHS Quality Improvement Scotland.


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• recognise and support the key contribution of local and national voluntary organisations;

• provide new ways of integrating services, between areas and between providers; • interact with the developing health improvement and public health agendas (for

example around action on stigma reduction and preventing suicide); and • are based on new, safer and fairer legislation.’ Doing Well by People with Depression is a programme to move the agenda forward for people with depressive disorders. DOING WELL BY PEOPLE WITH DEPRESSION For many people with depression their distress is invisible to others. This is because they may feel ashamed or they may lack the language to explain how they feel or fear being stigmatised if they confide in others. Chronic unrelieved depression leads to unrelenting misery. This is a tragedy because for many there are a number of interventions that can help. Appropriate help can not only treat an episode of illness, but may also help to deal with issues which have caused the individual to be vulnerable to its development, and, possibly, its recurrence. For many individuals the only service that they know of is that provided by their General Practitioner and the only available treatment they have heard of is medication. Generally people prefer non drug-based therapies, at least in the first instance and the increase in the rate of the prescription of oral antidepressant drugs in Scotland in the last 5 years has raised public and Parliamentary concern. There are a number of possible reasons for the difficulties that exist. These are not a matter of blame, but have much more to do with how our systems of care have evolved. Although there are skill shortages and some professionals are scarce in numbers, the work by the Glasgow Institute for Psychological Intervention (GIPSI) and The Scottish Development Centre for Mental Health Services, initiated by the Mental Health & Well Being Support Group21 suggests that the way we manage organisational, communication and information handling issues can have a significant effect in causing existing resources to be used in a sub-optimal way. Visits by the Mental Health and Well Being Support Group show that local areas are finding it difficult to focus effort on the provision of psychological interventions, and that as a result there is fragmentation of services, and resulting difficulties in access for those in need. Various reasons can be cited for the lack of progress noted by the MH&WBSG, including gaps across organisational interfaces, particularly between the voluntary sector, primary care, and both secondary mental health and physical health

21 http://www.show.scot.nhs.uk/mhwbsg/Documents/PsychInt%20Final%20report.pdf (4th Mar 03)

http://www.show.scot.nhs.uk/mhwbsg/Documents/PsychInt%20Final%20report.pdf


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care. There also seems to be a lack of capacity to manage mental health service change in some areas. Listening to users, clinical experts and partners has provided a clear view of where the problems are and what needs to be done to tackle the situation. A full record of this consultation is provided by the report on the conference Doing Well by People with Depression. The principle findings are: • The sheer scale of those presenting with depressive symptoms overwhelms the

service • Stigma prevents users from seeking help, resulting in concerns that there might be

significant unrecognised need • Current approaches to the assessment of depressive symptoms and associated

problems do not provide a good start to a pathway of care • There is a lack of capacity, particularly in primary care • From a user’s point of view there is a lack of psychological therapies available and

difficulties in accessing those that are available. This in turn leads to limited treatment options and over-reliance on medication

• Even when a diagnosis is reached the lack of knowledge about what evidence

based treatments may be available and treatment protocols to guide referral leads to uncoordinated and inconsistent service for users

• A similar lack of knowledge and co-ordination limits the use made of agencies other

than health in both the statutory and voluntary sectors • More specialised services are not always being used to help those with most need It is clear that we are not Doing Well by People with Depression. This proposal sets out to redress that situation.

PROPOSAL FOR DOING WELL BY PEOPLE WITH DEPRESSIVE DISORDERS

INTRODUCTION Consultation with stakeholders has identified two broad issues: lack of capacity and limitations in the management of services. There is a therefore a need for a twin-track approach which builds capacity, particularly in primary care, and makes best use of existing capacity within and between all tiers more effectively and efficiently.


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CURRENT SITUATION The context in which local healthcare and wider systems which help those with depressive disorders varies considerably across Scotland. There is no need nor wish to impose a uniform model in areas with different needs and organisational forms. Nevertheless to analyse need, services meeting all needs can be described in terms of a tiered model of service in which services are described as belonging to a particular tier22: • Tier 0 - community health and wellbeing in the neighbourhood or locality • Tier 1 – General Practice • Tier 2 – mental health worker in a locality e.g. a Local Health Care Co-operative/

Community Health Partnership • Tier 3 – network of specialists/ secondary care • Tier 4 – area wide or supra area service There are limitations to the tiered model: • It does not describe an actual system. • The component parts of each tier can vary significantly, shaped by local

circumstances and patterns of service and support. This emphasises the need for effective co-ordination.

• A user may be receiving help from services in more than one tier at any one time.

For example an individual can be receiving a care package which includes care provided by a community mental health team (Tier 3) while also being supported within the community by say a voluntary self-help group and the local housing department while receiving treatment from their GP (Tiers 0 and 1).

• As important as the description of each level is the relationship between each level.

This is commonly described in terms of ‘filters’. By ‘filter’ is meant an understanding on the part of a person making a referral from one side of the filter of what is acceptable and the sort of problem the service on the other side can help.

• Equally the recipient has to be clear about that and the circumstances on the other

side of the filter. None of this can be assumed; the relationship has to be continually renegotiated, on the basis of a protocol or agreement.

Nevertheless, equipped with an awareness of these limitations, the tiered model provides a useful perspective through which to analyse and depict current issues. The model is depicted below, annotated with principal flows and issues:

22 Framework for Mental Health Services in Scotland – Psychological Interventions. NHS HDL (2001) 75 dated 9th Oct 2001.


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Generic Tiered Mental Health System for Depressive Disorders - Tiers 0-4

Tier 2

Tier 1

Tier 3

Tier 0: •Stigma and Lack of Knowledge •Failure to Seek Help

Tier 2: •Very limited capacity •Lack of Referral Criteria and Protocols •Lengthy Outpatient Waiting Times can result •Potential duplication of Tier 3 work

Tier 1: •Lack of Skills and Expertise •Lack of Time •Lack of Knowledge of Evidence-Based Treatments •Lack of Referral Criteria and Protocols

Tier 3: •Limited Capacity •Lack of Awareness of Capacity Within Tier •Lack of Referral Criteria and Protocols •Inefficient Matching of Need to Capacity •Lengthy Outpatient Waiting Times

Tier 4: •Limited number of people •with necessary expertise. •Important training •function.

Overall Issues: •Lack of Awareness of other Capacity •Limited Psychological Intervention Options •Don't have Capacity to Match Need to Supply •Capacity Overwhelmed

•Difficulty Accessing Services and Unmet Need •Lack of communication and integration across care settings

Tier 0

Tier 4

(Note: Considerable Local Variation)

Arrows Depict User Flows Between Tiers

Tiers are defined on Page 13


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Although the system is recognisable as a tiered model, the individual tiers within the system function inefficiently, there are no criteria and protocols to provide clear pathways between the tiers and it is often unclear what factors determine movement between the tiers. While it is recognised that within the sys tem there is an overall lack of appropriate quality services it is also the case that need is poorly matched to the services and supports that are available. As a result of all these factors the system is overwhelmed and individual need is unrecognised, unmet or only partially met. PRIORITY AREAS Consultation has identified a number of particular areas which need to be tackled if the underlying issues of capacity and management of services are to be addressed: • Capacity:

• Build increased capacity for self-help in Tier 0 and Tier 1 in order to meet the needs of those with mild depressive disorders and to provide support through the pathway of care. Priorities are to:

• improve public information about depressive disorders; • provide facilities for early and accessible self help using a range of structured

self-help resources that aim to improve user/carer knowledge and also skills of self-management;

• consistent support for voluntary organisations in alliance with statutory

services to meet a full range of needs.

• Build increased capacity for psychological interventions in primary care at Tier 1 and Tier 2 thereby offering appropriate services as locally as possible in the community with appropriate referrals to Tiers 3 and 4. Priorities are to:

• increase the availability of evidence based treatments in a community or

practice setting; • improve the capacity of mental health workers to meet a range of care needs

in the primary care, voluntary and social care settings; • develop a range of treatment options through more co-ordinated use of

existing resources and the provision of appropriate training and supervision for all workers in statutory and voluntary sectors;

• Making best use of resources:


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• Improve assessment of depressive symptoms and associated problems to ensure an agreed understanding of all of a user’s/carer's needs and the sequence of treatments and supports that would be effective, including those for people with particular needs such as those arising from previous traumatic experiences. Priorities are to:

• increase the capacity of General Practice to recognise and assess

depressive symptoms and associated psychosocial problems in the knowledge that a range of further care options are both available and locally accessible;

• improve the organisation and co-ordination of care provided by different

workers in the voluntary sector, primary care or community health partnership settings;

• Improve access to a range of services and supports within local communities by

the creation and active management of pathways of care. Priorities are to:

• develop a range of service and support options through more co-ordinated use of existing resources and the provision of appropriate training and supervision for staff.

• develop more effective working at a local level with social care, other

community agencies and voluntary organisations. • provide signposts and clearer routes through services, matching capacity to

need with agreed criteria for referral, including specific criteria for more specialist assessment and care.

These approaches may be taken to represent the beginnings of an effective managed care network. However, to implement a managed network without building capacity would be to build pathways which for many users would be pathways to nowhere. This is a fundamental systems problem, a single change addressing only one issue is very unlikely to lead to an overall or sustainable improvement, for example: • Improved assessment of depressive symptoms and associated problems is likely to

recognise previously unmet and unrecognised need and – even with better management - services do not have the capacity to provide sufficient evidence based treatments to meet an increase in recognised need. There is therefore a requirement to build capacity to meet this need.

• Improved management of the pathway of care will continue to be inconsistent in its

effectiveness unless it is accompanied by improved assessment of depressive symptoms and associated problems to ensure that available treatments and other interventions are matched to patient need.


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• The availability of self-help and psychological interventions will not be matched to need unless improvements in assessment of depressive symptoms and associated problems provide appropriate referrals to these treatments. This in turn requires improved organisation to signpost and underwrite the routes to these treatments.

A COLLABORATIVE APPROACH TO SERVICE IMPROVEMENT Our consultation through informal discussion, questionnaires and the conference in February 2003 indicates the imperative of collaborating locally and nationally to achieve service improvements. The four elements which the programme would endorse and support are: • Learning and self-help to improve user/carer knowledge and also skills of self-

management

• Evidence-based Psychological interventions

• Assessment of depressive symptoms and the associated problems which people may have.

• Pathways through services and supports to meet peoples’ needs. We anticipate that a local programme would include components of each of the four elements, matched to local needs. This programme needs to be underpinned by a commissioning focus on the local provision of services and for psychological interventions in particular. We need to involve users, clinicians and partners in the detailed design of effective systems and capacity building initiatives – both in order to ensure the best possible solutions, but also to ensure sustainable improvement. This leads us to select an exploratory approach, but one with sufficient national support to enable and ensure real change and improvement. We envisage that there is a need for a national programme manager to co-ordinate activities and to work with local areas in implementing their plans, to link with national bodies and to support sustainable improvements. Learning and Self-Help Initiatives to progress the learning and self-help element of the programme need to provide effective approaches to: • Raise awareness to reduce stigma and improve understanding in local communities

and by employers (including links to local initiatives to promote positive mental health).


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• Provide information and key skills of self-management for those experiencing depressive symptoms and those close to them about what might be happening and what could help.

• Involve the voluntary sector collaboratively and consistently. • Provide structured self-help interventions which people can find and get to without

delay. Depending on local and personal circumstances this may involve written or electronic materials for which the individual may need some initial support or which may be on a self-directed, or supported by a practitioner on a one to one or group basis.

Psychological Interventions Initiatives to progress the psychological interventions element of the programme need to provide effective approaches to: • Develop awareness of the role of effective evidence-based psychological

interventions can play in the treatment of depressive disorders by the following groups:

• Commissioners • Service providers • Users

• Carers • Partner organisations

• Determine the scale and scope of psychological interventions in relation to local

need. • Determine the role of psychological interventions alongside medication and other

interventions. • Define the skills and competencies required to deliver evidence-based

psychological interventions. • Develop a local map of services available and routes through it.

• Define training required to provide psychological interventions and selecting the best option for the local service.


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• Provide necessary training and supervision to provide and maintain a quality service.

• Ensure quality assurance of ongoing training and assessment of outcomes by

embedding clinical audit into all components of the services. Assessment of Depressive Symptoms and the Associated Problems Initiatives to progress the assessment of depressive symptoms and associated problems which people may have need to provide effective approaches to: • Agree a common local approach to assessment, problem focused, jargon free

negotiated between all parties and acceptable across the range of health care practitioners and agencies as well as to service users and carers.

• Determine the nature of depressive problems and disorders which would be best

managed by different components of service available locally. • Decide the requisite level of detail of assessment for each tier and establish criteria

for referral. • Decide the necessary skills and competencies required for assessment for each

tier. • Ensure appropriate reflection on practice and supervision in a clinical or other

appropriate governance or accountability framework (We recognise that voluntary organisations will wish to make arrangements appropriate to their circumstances).

Pathways through Services and Supports Initiatives to progress the pathways through care element of the programme need to provide effective approaches to: • Agree core roles and contributions of all sectors and professional groups. • Broker relations between and expectations of statutory and voluntary providers. • Map a network of local services and supports. • Signpost available services and supports. • Guiding users through tiers, treatments and supports including making contact,

receiving help and moving on. • Have enough information to prioritise need and demand against capacity.


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• Manage expectations and prioritise need and demand against capacity. • Connect the availability of people with skills to where services are needed. • Ensure that self-help is available and accessible to improve access to effective

treatments. • Connect with services and supports outwith health. • Support the development of local care pathways. • Connect local care pathways through protocols. CRITERIA FOR LOCAL PROGRAMMES We need to progress in all four areas of the programme to improve services in any health system – or run the risk of encountering the systemic problems discussed above. This, combined with the exploratory nature of the strategy, leads us to adopt this approach in a limited number of local health systems. Clearly there will have to be explicit criteria by which it is decided which local health systems are directly involved in exploratory work. The digest of responses from the February conference indicates that the following are the most likely to be relevant: • Conditions:

• Local need as identified by users, community and services. • Existing local models. • Available clinical information systems.

• Commitment:

• Clinical commitment to bridge professional and organisational boundaries in primary and secondary care services.

• Managerial engagement. • Working with users and carers in a framework of public involvement. • Working in partnership with social care in Community Health Partnerships. • Working in partnership with the voluntary sector.


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• Process:

• Inclusion of local Doing Well by People with Depression project within each NHS Board Change and Innovation Plan.

• Identifying benefits to be derived from the initiatives. • Evaluating activities to provide an evidence base. • Mainstreaming the most successful solutions.

• Enabling other local health systems to learn from the experience.

RISKS TO BE MANAGED The following risks, which will require explicit management, have been identified at the outset of the programme: • Leadership:

• Involving appropriate stakeholders including users and public. • Engaging a clinical champion who will engage a range of professionals and

workers in supporting a local initiative. • Gaining sufficient organisational consensus for action. • Achieving local prioritisation for planning and commissioning. • Securing any funding necessary on either one-off or recurring basis.

• Approach:

• Maintaining a ‘whole systems approach’. • Mapping existing services. • Finding and developing sufficient capacity, including capacity at a local level to

implement potential improvements • Evaluating activities.

• Implementation:


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• Developing sufficiently robust plans in short time. • Managing the interfaces with local service configurations. • Integrating with other programmes and projects, both local and national. • ‘Mainstreaming’ improvements in both short and longer term. • Changing Culture. • Short term increase in pressure on system as expectations and demand rise

before improved system is in place. COSTS AND TIMESCALES Costs Indicative costs of possible ways to introduce this collaborative programme are shown below to enable local health systems to consider the scale of resources required. It is assumed, for the purposes of this section, that initiatives are based on implementing the programme in a Local Health Care Cooperative/ Community Health Partnership and these potential initiatives reflect some ideas of what might be done. Programme Element:

Priorities: Possible Initiatives Indicative Cost:

Learning and Self-Help

Better Public Information

• An important interface with national and local ‘Positive Mental Health’ initiatives.

Self-Help and Support for voluntary organisations

• Support Workers based in and employed by a voluntary organisation working to primary care, social care and/or educational premises in sufficient numbers to provide an available and accessible service. Providing training in the assessment and use of

£20k pa each


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self-help materials to key practitioners and voluntary sector workers in different tiers.

• Admin, materials and

support.

£5k pa each

Support for voluntary organisations

• Within the context of the local mental health plan fostering the development of support groups for individuals identified as having particular care needs in the context of a depressive disorder e.g. CSA survivor.

• A Development Worker • Development activity

£20k pa £5k pa

Psychological Interventions

Availability of Mental Health Workers

• Attached mental health worker in primary care premises linking with local partners to provide:

• Planning • Education • Support • Liaison • (Triage) • (Limited treatment)

£30k pa each including support and training*

Capacity of Primary Care Health Team

• Voluntary organisation/ independent sector provision of workers able to provide psychological interventions at an appropriate skill level.

£30k pa each including associated costs


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• Each counsellor/therapist/practitioner working with 4 practices of 40,000 population.

Range of

Treatment Options

• Provide to staff Interpersonal Psychological Counseling/ Therapy training

• Sufficient for 60 mental

health workers including supervision

£40k in Year 1 and a proportion therafter

Assessment of Depressive Symptoms and Associated Problems

Availability of Mental Health Workers

• Attached mental health worker in primary care premises linking with local partners.

• Assessment • Triage • (Limited treatment)

£35k pa each*

Capacity of Primary Care Health Team

• By agreeing approaches to the assessment of depressive symptoms and associated problems to allow local agencies to:

• Identify those suitable

for self help • Lisise with local

voluntary sector organisations regrading provision of supported self-help approaches

• Refer to social care • Fast track to

appropriate/ available specialist care

• Monitor progress jointly and act together

£30k pa in support of activity and organisational development


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accordingly • Funding may support a

range of activities such as information systems, support of data collection and individual activity.

Pathways through Services and Supports

Clearer Routes through Service

• Local co-ordinator or clinical champion:

• Mapping • Building key

relationships • Collaboratively agreeing

criteria and protocols • Laying foundations of

managed care network • Admin

£40k pa This may engage a senior professional (from any sector of service provision) part time and allow for some backfilling. £10k pa

* These functions may be undertaken by the same individual. National Programme Manager

• Co-ordinate activities. • Work with local areas to

support implementation of their plans.

• Link with national bodies. • Support sustainable

improvements.

£53k


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Proposal A three year programme is proposed, supported by £1.5m of Centre for Change Innovation funding per annum and co-ordinated nationally, working with local health systems on a rolling programme to engage service users, clinical leaders and partners in the redesign and improved management of mental health services. Justification Local systems have often either struggled to improve their services or have had to bid for central funds which have resulted in short-term localised projects which may not have been mainstreamed in either local systems or shared nationally. Doing Well by People with Depression represents a different approach to previous mental health initiatives, providing support for local system change, underpinned by mechanisms to evaluate and to share effective solutions nationally. By addressing a widespread condition the programme affords the chance to fundamentally re-think the way in which mental health services, their partners and communities respond to the needs of local communities. Timescales The proposed timetable to start Doing Well by People with Depression is:

• Submission of Programme proposal to Steering Group 1st April • Co-ordination across Scottish Executive Health Department April • Invite Declarations of Interest May • Mental Health National Event June • Agree 1st Year Project Areas June • Scottish Health Change Panel June • Definition of 1st Year Projects End-June • Start 1st Year Projects October