Scottish Government

4.0 Ayrshire and Arran

4.1 Origin of project

The Ayrshire and Arran Doing Well project grew out of several parallel developments, driven from different places within NHS Ayrshire and Arran, (Waiting list initiative, Choose Life), each of which pointed to the need to develop primary care mental health services. A key concern was to ensure appropriate access and treatment for mild to moderate depression, without fragmenting the service or adding pressure on waiting lists. The Doing Well programme offered such an opportunity. The project spent a year consulting, fact finding and process mapping to build a model that would streamline access and referrals and broaden the range of service options for people with mild to moderate depression. The service delivery components thus came on stream only in the second year of the three-year project.

4.2 Core functions

• To increase general capacity among NHS, voluntary organisation and social work staff in supporting people with mild to moderate depression
• To broaden the range of interventions for people with mild to moderate depression
• To rationalise the referral process and ensure appropriate interventions for different degrees of severity of depression.
• To pilot and evaluate new ways of working to inform future service redesign and development

4.3 Interventions planned and delivered

Tier 1

Training in early mental health support and crisis intervention to voluntary organisations and NHS staff and training of trainers

Guidelines and protocols

Lifestyle coaches who provide lifestyle advice and help with problem solving to patients with mild mental health problems

Bibliotherapy: direction to a range of self help materials

Book recommendation scheme

'Help yourself to better health' lifestyle information booklet

Tier 2

Primary Care Mental Health Workers ( PCMHWs) in GP pilot practices provide triage and short, structured treatment, based on guided self help, to patients with mild to moderate mental health problems

Tier 3

- An Assistant Psychologist offers 'lifestyle advice while you wait' to appropriate patients on psychology waiting lists

- Psychology one-stop assessment in 11 GP pilot practices

4.4 Pathways

The project involves a complex set of pathways within and between tiers, with several access points: voluntary services, primary care services and GPs, and psychology waiting lists (see Figure 2). Primary Care Mental Health Workers ( PCMHWs) take referrals from the pilot GP practices, or from the Community Mental Health Teams ( CMHT) Primary Care Worker. They triage referrals and refer down to tier 1 (Lifestyle coaches), or up to tier 3 ( CMHTs, psychology). Because triage is time consuming, this diminishes capacity for self help interventions with suitable patients. Lifestyle coaches receive referrals from the voluntary sector and from primary care. Patients who are not registered at pilot practices who need tier 2 interventions have to be referred back to their GPs for an appropriate referral in line with existing service delivery requirements. This process is cumbersome and time consuming. The Assistant Psychologist offers lifestyle advice while you wait to appropriate patients on psychology waiting lists. One-stop clinics replace the existing tier 3 service from psychology.

Figure 1 - Structure and pathways of Ayrshire and Arran Doing Well project

4.5 Capacity and structure

The project involves a three-pronged capacity building programme: 1) training in Scottish Mental Health First Aid ( SMHFA) for front-line NHS, social work and voluntary organisation staff, 2) training of two non mental health professionals to become lifestyle coaches providing lifestyle advice and problem solving approaches, 3) training of 18 PCMHW, PCMHN, OT, assistant psychologists in offering guided self help. The latter two components of this strategy provide access to new career pathways for the staff involved, who hope to use the opportunity for career progression. Project capacity also includes a project manager, a clinical psychologist assistant (lifestyle while you wait and training) and input from two consultant psychologists (one-stop assessments).

Organisationally the Doing Well project sits in-between the main players in primary care mental health (Adult Psychological Therapies Service, Primary Care and Community Mental Health Teams). The different Doing Well project components link into these as follows:

• Lifestyle coaches and the training programme are managed and supervised by the Doing Well project manager. Referrals for lifestyle coaching come from voluntary organisations, PCMHW, Primary care staff ( GPs and Health Visitors), CMHT, Adult Psychological therapies service
• The Primary Care Mental Health Workers are linked to GP practices and the Community Mental Health Teams, supervised by the latter, but managed by the Doing Well Team. Their referrals come mainly from the pilot GP practices. This split between supervision and line management arrangements can cause uncertainty
• The one-stop psychology assessment and lifestyle advice-while-you-wait services are managed from within Adult Psychological Therapies Service and take referrals from existing waiting lists, GPs, and PCMHW

The Doing Well Project Manager provides co-ordination and promotes coherence among the project components. This post is supported by an active Steering Group which includes a senior Mental Health Service Manager, the Patient Services Manager and the Director of Psychology.

4.6 Activity and outcomes for service users

The project has improved access to services for patients with mild to moderate depression and mental health issues by providing a variety of services across different service tiers.

Activity (up to March 2006. NB: Service started spring/summer 05)

* DNA - Did not attend

Mean waiting times:

Mean contact times

PHQ9 Scores

The non-attendance rate for the PCMHW is high and may, in part, be an indication of the ground work required to establish a new type of intervention. The lifestyle coaches and the PCMHW services demonstrated significant improvements in PHQ scores.

4.7 System impact

The project's position at the interstices between key services allows it both to act as a resource to all and as a boundary spanner: with opportunities for wider system and behaviour change across all tiers. In the general practices involved, the project simplified referral routes and directed patients with mild to moderate depression to appropriate tier 1 and 2 services without increasing pressure on tier 3 waiting lists. The training has increased capacity for health services, voluntary organisations and social services to respond to mental health issues. GPs, while slow to come on board at first, have begun to trust and take an interest in the service.

4.8 Sustainability

Because service delivery came on stream in the second year, data collection and dissemination to demonstrate impact have become key priorities in the project's latter phase. The project has developed extensive links with stakeholders in the local mental health service system at both Health Board and Community Health Partnership levels. Sustainability remains a key challenge. Because the project is not 'owned' by any one service, the strategy to promote sustainability has relied on demonstrating benefit and impact to key stakeholders and encouraging them to advocate for continuation funding, primarily within the emerging CHP structures. The project has been featured in a range of strategic planning groups, including Community Planning. Funding has been secured from the Ayrshire wide modernisation programme to fully fund the project until end March 2007. It is envisaged that this extension will allow the project to gather a more comprehensive data set that will fully evaluate the effectiveness of the project's initiatives.

The project will not continue as a whole package, but different components will be split off and reconfigured, for example, the Lifestyle coaches could be placed with local authority healthy living and fitness structures.

4.9 Key Learning Points

• Complex system redesign takes time and energy and considerable co-ordination to develop and maintain links at all levels and across the NHS, local authorities and voluntary organisations
• Project independence, combined with an active strategic group involving key stakeholders players can be an effective mechanism for change
• Activity and outcomes data help strengthen the case for change and for investment in new approaches to service delivery. However, it takes time to establish new interventions that can generate results

Challenges of the Ayrshire and Arran model:

• The project offers a range of services and different access routes into the service. This makes it possible for people with different needs to access appropriate help. However, PCMHWs in particular face the challenge of being drawn into a triage role for all primary care mental health problems, at the expense of providing direct interventions
• The project 'sits' between key departments and can therefore challenge boundaries, but it is complex to manage and co-ordinate. While Doing Well can be viewed as owned by everyone, it also runs the risk of falling off other service agendas
• The project is ambitious, wide reaching and well run, with a skilled and enthusiastic team. The challenge will be to maintain this focus and drive for the work in the longer term
• The project in its present form is unsustainable and different aspects of the project may be incorporated into different parts of the mental health service organisation, including the voluntary sector. Without central co-ordination, referral pathways in the future may become less clear