1 Executive Summary
Distress Brief Interventions (DBIs) are an innovative approach to reducing emotional pain in people who present in distress. They equip individuals with a range of skills and support to cope with emotional pain, both in the immediate term and for the future. In 2016, the Scottish Government established a DBI pilot programme which ran until March 2021 in four areas: Aberdeen, Inverness, Lanarkshire and Scottish Borders. In April 2020, the Scottish Government announced funding for an extension of the programme, to support people across the whole of Scotland who were distressed during the Coronavirus pandemic.
There are two levels in the DBI programme. Level 1 is provided by trained front-line staff, who provide a compassionate response and offer individuals in distress the opportunity to be referred to Level 2. Specially trained staff in third sector organisations, who offer a brief (around 14 days), compassionate, community-based problem-solving intervention, provide Level 2.
In the original pilot programme, Level 1 was provided by staff from Police Scotland, the Scottish Ambulance Service, NHS Accident and Emergency (A&E) departments and Primary Care. In the extended scheme, Level 1 was provided by NHS24 (a special Health Board in Scotland that runs a telephone advice and triage service). In the pilot, Level 2 was provided by the Richmond Fellowship Scotland (TRFS) and Lanarkshire Association for Mental Health (LAMH) in South Lanarkshire, and Lifelink in North Lanarkshire; Penumbra in Aberdeen; Support in Mind in Inverness; and Scottish Association for Mental Health (SAMH) in the Scottish Borders. In the extension, Level 2 was delivered by the same third sector organisations, but their geographical remits were extended and shared to cover the whole of Scotland. In the extended programme, the Level 2 sessions were provided by telephone or video call, rather than face-to-face.
This evaluation covers the period from May to December 2020 and focuses on the extended DBI programme. A separate evaluation of the original pilot has also been undertaken Distress Brief Intervention Pilot Programme evaluation: findings report - gov.scot (www.gov.scot). The aims of this evaluation are to investigate the implementation of the extended DBI programme, the experiences of those who delivered and received a DBI in the extended programme, and the impact that DBI had on levels of distress.
To meet the evaluation aims, we used a mixed-method approach. We analysed aggregate data collected by DBI practitioners as a routine part of the DBI programme. We asked individuals who had received DBI through the extended programme to take part in individual telephone interviews. We also interviewed people who delivered DBI at Levels 1 and 2.
1.2 Key Findings
1.2.1 Modes of Delivery
Nearly all (96%) Level 2 sessions were delivered via the telephone. Video conferencing was used for less than 1% of all sessions. Other modes of delivery (such as text messaging) were used in a maximum of 3% of sessions. There were mixed views on the preferred medium to deliver/receive the DBI support. Some individuals that used the Level 2 service indicated they would have liked using video conference, whereas others appreciated the anonymity and convenience a phone call provided.
Many Level 2 providers described the challenge of supporting an individual over the telephone rather than face-to-face. Practitioners mentioned the increased importance of being able to pick up nuances in voices and interpreting silence when no visual or physical cues were present.
Both face-to-face and telehealth modes of delivery were recognised as having different strengths and limitations. One aspect of telehealth that can be viewed as both an advantage and a disadvantage is the ability to support more people per day than with face-to-face services. However, practitioners also felt that while they could support more people they had to be careful to ensure they still had time for aspects of their role such as administration, getting support after difficult conversations and ensuring boundaries between work and home life.
1.2.2 Experiences of involving NHS24 as a DBI Level 1 provider
Overall, NHS24 staff found Level 1 training to be a positive experience and they praised the trainers for their enthusiasm and knowledge. NHS24 staff felt that the training was a good introduction to what DBI is and the role of Level 1 practitioners. However, some of the more experienced staff perceived the training as too basic and that there should be separate training for more experienced staff. Others felt that the training served as a useful refresher of their existing knowledge.
Not all staff received training prior to working as a Level 1 practitioner. However, the Level 1 participants interviewed in this evaluation did not perceive this as detrimental to the service, as many felt learning on the job and working through training scenario calls were the best ways to learn. In addition, the NHS24 Mental Health Hub was viewed as a supportive environment, with mental health practitioners available to provide advice and support when required.
In general, NHS24 interviewees felt that DBI aligned well with the existing processes and did not create substantial additional work. All NHS24 interviewees felt DBI was a positive addition to their existing Mental Health Hub service. They felt the service allowed practitioners to provide a follow-up that was timely and helpful in supporting individuals with their anxiety or distress. Feedback also highlighted how DBI provided a much-needed alternative to existing support from the Mental Health Hub, such as signposting individuals to other services. Feedback from Level 2 providers regarding NHS24 Level 1 referrals was extremely positive in terms of appropriateness of referrals and level of detail provided.
1.2.3 Implementation challenges of delivering the expanded DBI programme in the context of COVID-19
Most individuals (70%) were recorded as engaging with Level 2 and exiting with a planned discharge/closure. The second largest group of individuals (13%) engaged in an initial supportive phone call but then declined further support. Other individuals either had an unplanned discharge (8%), did not engage in Level 2 (6%), ceased Level 2 due to an escalating level of risk (1%), were classified by Level 2 practitioners as an inappropriate referral (1%), or were admitted to inpatient NHS care (1%).
COVID-19 restrictions meant that Level 2 services were delivered remotely rather than providing face-to-face support, as had been the case in the pilot DBI areas prior to the pandemic. The advantage of this change in modality was that the reach of the service could be extended to the whole of Scotland.
A key component of the DBI intervention is the development of a Distress Management Plan (D-MaP). This is a written action plan that contains agreed key actions that the individual will undertake to avoid future crises and episodes of acute distress. Most individuals engaging in Level 2 had developed a Distress Management Plan. Almost all individuals who engaged with DBI until an agreed discharge had a Distress Management Plan. Despite the challenges of not being able to complete the Distress Management Plan in a collaborative, face-to-face environment, the general view of practitioner interviewees was that they were able to adapt to the situation and still ensure the plan was an integral part of the support process.
1.2.4 Demographic characteristics of individuals who accessed DBI
A total of 1685 calls were referred to Level 2 during the evaluation period. Just over half of all calls came from areas of large urban density: a quarter (25%) of all calls to the NHS24 Level 1 service were from individuals within the NHS Greater Glasgow and Clyde Health Board area; a further 17% were from individuals living in NHS Lothian; and 12% from individuals in NHS Lanarkshire. The remaining 46% of calls were spread across the other 10 Health Boards or the Health Board area was not recorded. Penumbra and SAMH received by far the largest number of referrals (41% each), reflecting the multiple Health Boards that these two organisations provided DBI support for.
Demographics – age group and gender
The age distribution of people who received DBI is strongly skewed towards the younger age groups, with highest prevalence of both males (29%) and females (25%) in the 25-34 age category and lowest prevalence of males (1%) and females (1%) in the 75+ category. Although there is a slight variation between men and women across the age ranges (16-24: 52% female; 25-34: 45% female; 35-44: 44% female; 45-54: 54% female; 55-64: 55% female; 65-74: 52% female; 75+: 42% female), the overall split between men and women is equal (49% and 51% respectively).
Most individuals that interacted with the Level 1 service lived in the most socially deprived areas (as classified by the Scottish Index of Multiple Deprivation quintiles) - 61% in the two most deprived quintiles.
Referral to DBI Level 2
1685 people were referred to Level 2 during the evaluation period, and from these, 1570 cases were completed (referred and then case closed) within the evaluation period. All individuals referred to Level 2 were attempted to be contacted within 24 hours: 94% of which were contacted successfully with 6% unsuccessful contact attempts. Of those who were contacted, most (85%) were successfully contacted within 24 hours. Most individuals (78%) took up Level 2 support. Of individuals who did not engage in Level 2, 13% had one supportive phone call and then declined further support and 9% did not engage for other non-specified reasons. Of those receiving support at Level 2, 90% had a planned exit from Level 2 support whilst for 10%, exit from Level 2 support was unplanned.
The main presenting problems (reasons for referral) recorded in the DBI routine database of individuals who contacted Level 1 were: depression/low mood (68%), stress/anxiety (61%) and suicidal thoughts (48%). Relationship issues (32%), life coping issues (28%), money worries (26%), and employment issues (25%), were the most frequently recorded contributory factors.
Only 8% of individuals who used the service referred to COVID-19 as a contributory factor. However, many DBI practitioners felt that, while not directly mentioned, the pandemic and its associated restrictions had caused an indirect impact on the distress individuals experienced. Individuals and practitioners both noted the negative impact that COVID-19 had had on general local third sector service availability, which individuals would normally have accessed.
1.2.5 Experiences of people who accessed the DBI service
Individuals were asked to rate their experience of compassion from Level 1 practitioners (1 = not at all compassionate to 10 = completely compassionate). Out of the 1085 responses recorded, 87% of individuals rated the NHS24 Level 1 service as 8/10 or above (very compassionate-completely compassionate) for compassionate response. Only 1% of respondents rated the service as being not very/not at all compassionate (2/10 or below).
Individuals were asked to rate their levels of distress at three time points: at Level 1, and at the start and end of the Level 2 intervention. They used a scale called the Distress Thermometer, which has a simple 10-point score where 0 = no distress and 10 = extreme distress. Out of the 1076 responses recorded, 80% of individuals felt they were fairly to completely able (score of 6-10 on distress scale) to manage their current level of distress following their interaction with the NHS24 Level 1 practitioner. A further 6% of respondents felt they struggled (score 1-3 on distress scale) to manage their current level of distress, with 3% not managing at all (score of 0 on distress scale).
1.2.6 Overall impact of DBI intervention on participants' level of distress
Distress Thermometer scores changed slightly from the start of Level 2 interaction to Level 2 completion. Of cases where scores were recorded (n=991), 76% of individuals recorded that they were less distressed (their distress score had reduced by 1 scale point or more), while 8% felt they were more distressed (their distress score had increased by 1 scale point or more), and for others (16%) their distress levels were unchanged. The largest reduction in Distress Thermometer score was for those who engaged in Level 2 support and had a planned discharge/closure. At Level 1, the average distress score for this group was 8 and by the end of their Level 2 contact, this had reduced to an average score of 4. The average distress score increased from Level 1 to end of Level 2 interaction when the individual was classified by Level 2 practitioners as an inappropriate referral (average increase of 2).
1.2.7 Comparing findings between the main DBI pilot evaluation and the expanded DBI programme.
Alongside this evaluation, a larger and more comprehensive evaluation was undertaken of the main DBI pilot programme Distress Brief Intervention Pilot Programme evaluation: findings report - gov.scot (www.gov.scot). The main evaluation drew on a wider range of data sources, collected over a longer period, including independently gathered outcome data on the individuals receiving Level 2 intervention. Consequently, the findings of the larger evaluation are more in-depth. Notwithstanding these differences, it is possible to broadly compare the high-level findings across these two evaluations.
As far as can be ascertained, the changes to DBI service provision that were made at the start of the COVID-19 pandemic (Level 1 service provision by NHS24; and Level 2 mode of delivery (telephone versus face-to-face)) did not lead to different outcomes to the service than those in the main DBI evaluation. Level 1 practitioner and individual participants in both evaluations recognised the potential benefit of DBI in providing a practical and timely solution to many individuals in distress. As in the main DBI pilot evaluation, some of the more experienced Level 1 practitioner interviewees perceived the level of DBI training to be too basic.
The main presenting problems in both evaluations were the same: depression/low mood, stress/anxiety, and suicidal thoughts. As with the findings of the main DBI pilot evaluation, Level 1 practitioners in this extended evaluation felt that DBI empowered them to offer a compassionate and constructive response. Level 2 contact was attempted in 100% of cases and achieved within 24 hours for most individuals in both evaluations (in this extended evaluation, Level 2 providers successfully achieved contact with referred people within 24 hours in 85% of cases).
Though using different methods to measure service user outcomes, average distress scores for most people decreased between Level 1 and the end of Level 2 in both evaluations.
Both evaluations highlight that DBI appears less suited to some individuals presenting with long-term mental health issues and other complex needs. This finding emphasises the importance of refining the appropriateness of referrals and reviewing whether inappropriate referrals are highlighting further gaps in existing services in terms of meeting needs that DBI is not designed to meet.
Despite COVID-19 and associated restrictions, the extended DBI service adapted successfully and provided telehealth support to individuals presenting with mild-moderate distress. The provision of Level 1 by the NHS24 Mental Health Hub was successful. NHS24 appropriately integrated Level 1 into its existing provision and provided a compassionate response, making appropriate and adequately detailed referrals to Level 2. The success of this integration may have been facilitated by Level 1 practitioners having a higher baseline of people being referred to their service who met the criteria for DBI and additionally having experienced qualified mental health practitioners available where they had any questions.
Within the limitations of the data collected, it appears that the DBI service evaluated in this report has successfully supported many of those individuals who were referred in distress. Delivery of Level 2 as a telehealth intervention was feasible and felt by many to have advantages and disadvantages over face-to-face contact.
In general, the direction of improvement for individuals in the DBI extended evaluation mirrored that found in the more in-depth pilot evaluation. As in the main DBI pilot evaluation, DBI does not appear to work equally well for everyone. Feedback from Level 1 and 2 providers and individuals who received DBI suggest that DBI is less appropriate for the needs of those with severe and/or enduring mental health problems and/or other complex needs.
1.4 Key Recommendations
The evaluation findings have several implications for the ongoing roll-out and improvement of the DBI programme. Key recommendations based on the findings are set out below.
1.4.1 Roll out
1. Overall, Level 2 provider participants felt both face-to-face and virtual/telephone interaction with individuals receiving DBI had advantages and disadvantages. When it is possible, even when COVID related restrictions are no longer in place, providing both options to individuals receiving DBI may be advantageous and enable the preferences of both individuals and DBI service providers to be met.
2. NHS24 processes meant that each call they received could only result in a choice of referring an individual to DBI Level 2 or another signposted service. Enabling NHS24 Level 1 practitioners to refer individuals to DBI in addition to another signposted service would be helpful for practitioners and valuable for individuals receiving the service.
3. The evaluation findings should be incorporated in the roll-out programme and disseminated to share learning, encourage debate and promote further uptake of the DBI model.
1.4.2 DBI practitioner preparedness, training and development
4. Level 1 training with staff in the NHS24 Mental Health Hub should be explicitly and respectfully cognisant of practitioners' previous experience and training, acknowledging practitioners' potential existing awareness and understanding of identifying distress and the importance of compassion when individuals present to them in distress.
5. Level 1 practitioners in the NHS24 Mental Health Hub would value receiving a more detailed checklist as to what is and is not appropriate to refer to Level 2.
6. Level 1 practitioners in the NHS24 Mental Health Hub would value further information regarding the role of Level 2 providers.
7. Increased usage of anonymised case studies in Level 1 training in the NHS24 Mental Health Hub would help trainees' understanding of what was appropriate and the overall DBI journey individuals commonly take.
1.4.3 DBI practice
8. The NHS24 Mental Health Hub should consider how to maintain the capacity for Level 1 service provision and reduce the general challenge of waiting time for NHS24 calls to be answered.
1.4.4 Future Research
9. Further research is recommended about the longer-term impact of DBI on individuals and the wider service system, particularly when the DBI intervention is conducted via telephone and other digital media when compared with face-to-face interactions.
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