Key Change Area 2: Rethinking how we Respond to Common Mental Health Problems
Common mental health problems such as depression and anxiety can be both severe and enduring, but the response they will generally require is different from that for illnesses such as schizophrenia. However, in many ways the systems for providing care and treatment can look very similar. We need to examine and challenge that model.
The themes above and commitments set out throughout this Strategy promise a system where therapies are more readily available, but also where there is a wider range of responses, including social prescribing, self help and peer to peer work. People already have access to more information themselves and are increasingly able to self refer to services or to seek support for themselves. These approaches build capability and make choices, and that degree of control and mastery is itself health producing.
This marks a move away from the model where, uniformly, the doctor diagnoses and treats illness, to a wider range of responses which includes that approach, but also includes approaches where people will be identifying problems for themselves and seeking help or taking action, and where families and friends are more likely to say something or offer support. Information and support will be more widely available, whether from health care professionals or from the web.
This is not a utopian vision and these new ways of working will not be for everyone, whether because of personal choice or for reasons linked to illness. Services as we know them will continue to be necessary as part of a mental health system.
This is a change which will accelerate over the next period of time and services and approaches need to adapt quickly.
Faster Access to Psychological Therapies
The Scottish Government is already committed to delivering faster access to psychological therapies for those with mental illness or disorder. We have already seen improvements in service performance across Scotland since the HEAT target was set. Patients and clinicians have long identified access to therapies as a key service improvement that would better meet their needs and expectations in getting access to world class clinical care, both for those with severe and enduring mental illness and for those with more common illnesses such as depression and alcohol addiction.
Delivering faster access is a significant and complex challenge. The objective is that by 2014 the standard for referral to the commencement of treatment will be 18 weeks, irrespective of age, illness or therapy. No other country in the world has set such a wide ranging and comprehensive target within a publicly funded healthcare system.
The programme to take forward this work is delivered locally, but supported nationally. To deliver the target we have had to undertake the following work:
- we are developing national and local information systems and data to record performance and progress against the target; this has required us to specify and define the target and what should be recorded, as well as creating the capability to record data to a high standard over time;
- we have offered guidance through the Matrix58 on what treatments are effective for which illnesses and conditions; the HEAT target covers all types of evidence-based therapy for all types of mental illness or disorder, as well as allowing for work where the evidence base is underdeveloped or not available at this time;
- the Matrix also stresses that services must provide adequate psychological therapies supervision for staff delivering psychological interventions, to ensure patient safety and the delivery of evidence-based care; the evidence also shows that supervision improves the quality of outcomes and the efficiency of service delivery;
- with NHS Education Scotland, we are working to assess and develop workforce capacity; this is not just about psychology staff, but ensuring that a range of staff including psychologists, nurses, allied health professionals and doctors are equipped to deliver therapies, at a range of levels, as part of their clinical practice;
- we are working to ensure that systems are designed to make the most effective use of current resources by removing duplication, unwarranted variation and waste;
- we are building processes into the work to gather information on clinical outcomes; while it is important that we are able to offer faster access to services, it is equally important that what we offer produces clinical benefit.
While data systems are still developing and we are continuing to resolve issues with recording and reporting systems, good progress is being made across NHS Boards in Scotland which gives us confidence that the target will be achieved on time. More information on the target and the work to support its implementation is on the NHS ISD website59.
Local service redesign informed by evidence is central to delivery of the target. For example, mental health services historically have tended to have high rates of people not attending appointments. One service reduced its Did Not Attend rate from 21% to 7.5% by making changes which gave patients more choice over appointment times. Another service reduced the amount of time spent in allocation meetings by 312 hours, giving an extra 312 hours to see patients just by changing its processes for allocating patients to staff. Work being taken forward by NHS 24 to deliver therapies and guided self-help by telephone is increasingly being accessed by people who self refer to the service. In each case these improvements contribute to the objective that people in distress get to see the right person as quickly as possible.
Commitment 13: We will continue our work to deliver faster access to psychological therapies. By December 2014 the standard for referral to the commencement of treatment will be a maximum of 18 weeks, irrespective of age, illness or therapy.
Equality of Access to Services
Some people can experience more difficulty than others in accessing mental health services to meet their needs. This can be because some groups are less likely to try to access services, for example due to stigma, or because there are gaps or lack of capacity in some services.
We need to understand who is accessing services to identify where there might be unmet need or where additional preventative action could be taken. Consistent recording of data about ethnic background and other information, for example, gender, sexuality and disability provides us with information about whether services are delivered in a way that meets people's specific needs.
Commitment 14: We will work with NHS Boards and partners to improve monitoring information about who is accessing services, such as ethnicity, is consistently available to inform decisions about service design and to remove barriers to services.
Social Prescribing and Self Help
The work on access to psychological therapies is just one part of creating the well functioning mental health system. In parallel with this, NHS Boards and their partners offer access to information and advice, self-help approaches, some of which may be online or through NHS 24, bibliotherapy, counselling and other accessible low-intensity treatments, including exercise, to meet the needs of people experiencing psychological distress.
The evidence base for a wider range of approaches to tackle common mental health problems like depression is already established. Many people would prefer to 'do something' to improve their mental health than to receive a treatment. We also know that the recovery of people with more severe mental illnesses also benefits from access to services that support physical activity and social integration. The poor life expectancy of those with mental illness is as much or more driven by poor physical health and health behaviours as it is by their mental illness.
A standardised assessment tool and a pathway for brief advice and brief intervention have been developed for use by primary care teams, to assess and improve levels of physical activity in the community. Though we know activity has physical and mental health benefits, currently only 39% of the adult population in Scotland achieve the minimum guidelines of 30 minutes five times per week of physical activity. NICE describe Brief Intervention for Physical Activity as highly cost effective, at £20-£440 per quality adjusted life year (QALY)60. These tools and pathways are being integrated into existing Keep Well pathways. eLearning modules on Health Behaviour Change including "Raising the Issue of Physical Activity" have been developed and can be used by any health professional.
We do not think the challenge here is primarily about the range of local services and facilities. The challenge is more about connecting people to such opportunities and addressing the reasons why they might not access them. Our focus is on things that people and communities can do for themselves which are particularly valuable given the additional benefits that people derive from taking control of their own health and wellbeing. However, people may not access services for the following reasons: they may not know about them; they may not think they are for them; or they may be uncomfortable or nervous about going for the first time.
Primary care and particularly General Practitioners have a key role to play in this work. Often they are the best placed to signpost a person successfully to such a service. They have a good understanding already of their patients and what might work for them. Toolkits and reviews have been produced previously to show the benefits and give guidance on social prescribing approaches. We will ensure that this information is easily available. One example is Developing Social Prescribing and Community Referrals for Mental Health in Scotland61. Similarly the Links Project Report62, based on work in Glasgow and Fife, showed how General Practices can make better use of community resources to help and support the people they are working with. It was notable that in many cases, up to 50% in Glasgow, the resources being referred to were for addiction or mental health. In some cases it is necessary for practitioners to connect people to local community and voluntary sector services to assist people to access activities for the first time and to develop confidence and skills to do so on an ongoing basis.
Commitment 15: We will work with partners, including the Royal College of General Practitioners and Long Term Conditions Alliance Scotland, to increase local knowledge of social prescribing opportunities, including through new technologies which support resources such as the ALISS system which connects existing sources of support and makes local information easy to find63. We will also raise awareness, through local health improvement networks, of the benefits of such approaches.
One of the 22 commitments delivered under Towards a Mentally Flourishing Scotland was the development and publication of Steps for Stress64. Steps for Stress is a short booklet which provides an easy guide to understanding common mental health problems and providing advice on things that people can do for themselves or services such as debt advice that they can access to gain support.
Steps to deal with stress
The booklet is supported by a website that has additional content and links65 and a relaxation CD is also available. Since 2009 more than 420,000 copies of the booklet and almost 970,000 CDs have been handed out. We have recently agreed to allow the Northern Ireland Assembly to produce their own local version of the resource.
We intend to take this approach forward in a number of ways to make best use of the existing resources and materials. One component of this will be to provide and share learning for local health improvement and voluntary sector staff in how they can use the materials in their locality and how they can work with people who are using the materials. A second element will be to link the resource more directly to the ALISS project so that people can easily identify local opportunities to access help and support.
Commitment 16: NHS Health Scotland will work with the NHS, local authorities and the voluntary sector to ensure staff are confident to use Steps for Stress as an early intervention approach to address common mental health problems.
Mental Health and Alcohol
There are strong links between depression and drinking above recommended guidelines. The SIGN Guideline - 'The management of harmful drinking and alcohol dependence in primary care'66 - explains how hazardous drinking and alcohol dependence present in many ways, one of which may be through depression.
Alcohol Brief Interventions (ABIs) are part of the Scottish Government's wider strategic approach to tackling alcohol67. In 2008, an NHS health improvement HEAT target was introduced, based on the SIGN Guideline, requiring NHS Boards to deliver ABIs within the following 3 priority settings - primary care, A&E and antenatal. To date, over 272,000 ABIs have been delivered. Many of these interventions have been delivered in primary care settings. We believe there is value in clearly aligning the work in place to diagnose and respond to depression with the delivery of brief interventions to reduce people's alcohol consumption.
For 2012-13 ABI delivery has become a HEAT standard. NHS Boards and Alcohol and Drug Partnerships (ADPs) will sustain and embed ABIs in the 3 priority settings. In addition, they will continue to develop delivery of ABIs in wider settings, which may include specific mental health settings.
NHS NES is supporting the development of a standardised training and certification programme in Motivational Interviewing which will be of relevance across all tiers of service in relation to alcohol misuse and wider health behavioural change issues. Training is also being delivered in core behavioural and cognitive behavioural therapy skills for relapse prevention and recovery management.
Commitment 17: We will work with NHS Boards and partners to more effectively link the work on alcohol and depression and other common mental health problems to improve identification and treatment, with a particular focus on primary care.
Mental Health and Debt
In 2010/2011 Citizens Advice Scotland (CAS) received over 90,000 new debt enquiries and over 15,800 new debt cases. There is evidence of a link between debt and mental health problems, and research shows that suicide risk is raised for virtually all mental health problems and substance abuse. Bureaux advisers reported that some clients experiencing debt were also indicating signs of stress and anxiety. CAS identified a need for further training on mental health awareness and suicide awareness for advisers, and training for supervisors to enable better support of client advisers following a distressing contact.
Earlier this year, the Scottish Government funded Samaritans to undertake joint work with Citizens Advice Bureau Scotland to produce two e-learning modules to develop the service which clients with mental health problems receive from Citizens Advice Bureaux (CAB). The first module covers suicide risk awareness, recognising signs of suicidal intent and providing first level response and support to clients and is aimed at paid staff and bureaux volunteer advisers across Scotland. The second module is for use by CAB line managers and supervisors to support advisers after they have handled a distressing contact.
The relation between trauma and mental illness is complex. Across the lifespan trauma is a relatively common phenomenon and many people have experience of single life-threatening events, or longer-term traumatic circumstances, without suffering significant psychological harm. However, some do suffer harm and that harm, while rooted in the psychological trauma, may manifest in a variety of mental health problems including depression, addiction or physical symptoms. There are clear linkages to the work on distress set out later, as well as to the work to improve access to psychological therapies.
While there is a growing recognition of the significance of trauma, clinicians and others may be reluctant to engage with it because of the concern of causing further harm, or of not being able to offer an appropriate response which meets the needs of the person. We need to address that deficit and improve the general service response to trauma.
The Rivers Centre in NHS Lothian has been commissioned to investigate the issue of staff awareness of trauma-related mental health disorders in primary care. The work will begin with engagement with a number of GP practices in NHS Lothian with different experience and circumstances. A consultation process will follow with the Royal College of General Practitioners and with representatives of NHS Education for Scotland.
The objective of this work is to develop an approach designed to raise the awareness of primary care practitioners of post traumatic disorders, facilitate best practice management of post traumatic disorders and improve identification of available local resources and services for onward referral. This approach will be piloted in the same GP practices as are involved in the first stage study. The pilot data will be analysed, modifications to the training package will be made in consultation with the Royal College and with NES, and, if appropriate, a wider roll-out plan will be designed.
NHS NES will continue to develop and deliver a range of training courses to support staff working across the tiers of the stepped care system, including psychoeducation for complex trauma, trauma-focussed cognitive behavioural therapy and Working with Dissociation in Survivors of Trauma.
The Scottish Government is also supporting the UK Psychological Trauma Society to develop and support a national learning network for trauma practitioners and services working in Scotland.
Commitment 18: We will develop an approach to support the better identification and response to trauma in primary care settings and support the creation of a national learning network.
Over recent years there has been a greater recognition of a group of disorders, illnesses and behaviours which present particular challenges to services and to families. Particular examples are eating disorders and self harm. The common characteristics are that they are behaviours that involve risk to the individual and which others find frightening or upsetting; they are associated with self-stigmatisation and guilt leading to avoidance and disengagement; generally individuals are regarded as having capacity, and so there is an element of voluntariness which produces confusion about interventions; they present in primary care and A&E and other non-specialist settings; and they tend to begin early in life, but can be fatal or have a continuing impact.
The current model of service delivery is treatment approaches that tend to focus on the behaviours, not the underlying cause (except in some cases where trauma or personality disorder is identified), alongside treatment of co-occurring illness issues, notably depression, anxiety and addictions. In some cases these treatment approaches are effective and successful, but often that is not the case and the behaviours are chronic. There is a preference in primary care to refer to secondary care for 'specialist' mental health treatment, but also often a recognition by primary care practitioners that this is unsatisfactory. Families and carers are able to act as advocates, but often feel disempowered to help.
People within this group may have frequent contact with crisis and healthcare services and a subset have regular attendances at A&E. Some will also have regular contact with the police or with social work services, but the challenges they present are very similar. At times they may seek or request help, but they are likely to disengage or to fail to take up appointments. There is no single treatment or intervention which is appropriate and referrals to specialist mental health or addiction services are often unsuccessful. There is an interaction with the work on Adult Support and Protection which may also offer new opportunities for different ways of approaching the challenge and co-ordinating the statutory sector response.
The Scottish Government has been undertaking recent work with NHS Tayside and partners, including families, focusing on this group following on from a group of suicides in 2010. Developing ideas from that work include moving the focus from the behaviours to focus more on the underlying distress. The thinking is that doing so would offer a more human, caring response that acknowledges what is going on with the person and which is less likely to produce a stigmatizing and excluding response, with the effect that more people will come forward for treatment or engage with services. It could also give family members and others a better basis for offering care and support and enable us to mobilise a wider range of treatment and community supports. Initial discussions with service users and others suggest that further work to develop the approach would be welcomed.
Commitment 19: We will take forward work, initially in NHS Tayside, but involving the Royal College of General Practitioners as well as social work, the police and others, to develop an approach to test in practice which focuses on improving the response to distress. This will include developing a shared understanding of the challenge and appropriate local responses that engage and support those experiencing distress, as well as support for practitioners. We will develop a methodology for assessing the benefits of such an approach and for improving it over time.
Mental Health of Older People
There has been a significant focus on the mental health of older people through the work on dementia. The next stage of work on dementia will be consulted on later this year and there is a commitment to produce an updated strategy in 2013. However, more older people experience illnesses such as depression and anxiety than experience dementia and there is a need to better respond to their needs. More than any other group, older people are less likely to have illness diagnosed and less likely to receive treatment, though prescribing data since 2000 would suggest that this is improving and the mental health needs of older people are increasingly recognised.
In 2010, as part of the work on better access to psychological therapies, the Scottish Government established a working group to focus on the mental health needs of older people. That working group reported in December 2011 and made recommendations for service development based on seven key principles68:
Seven Principles of Good Psychological Care for Older People
1. A psychologically and age-aware workforce for all services.
2. Specialist older people's psychological services are based on need not age.
3. Access for older people to general non-age related services where appropriate.
4. A matched care approach is used that meets the needs of older people.
5. Sufficient numbers of highly trained staff are available to undertake low and high intensive therapy, plus training, research and service development.
6. Trained staff will have reserved and protected time to undertake such work.
7. There will be ongoing clinical support, clinical supervision and reflective practice opportunities.
The report identified the need to make improvement across the system, from highly specialist therapeutic approaches to better community and self help approaches that support and maintain people's wellbeing in later life. This is consistent with the recommendations that were produced by the reference group for Mentally Healthy Later Life69, flowing from the commitments in Towards a Mentally Flourishing Scotland to explore what is needed to support wellbeing in later life. The indications are that in a number of local authority areas preventative approaches have been prioritised under service redesign initiatives being taken forward under the Change Fund70. As with the adult population, we know that addressing common mental health problems such as anxiety and depression alongside co-occurring long-term conditions improves clinical outcomes and reduces the likelihood of admission to hospital or institutional care.
Commitment 20: We will take forward the recommendations of the psychological therapies for older people report with NHS Boards and their statutory and voluntary sector partners and in the context of the integration agenda. Access to psychological therapies by older people will be tracked as part of the monitoring of the general psychological therapies access target, which applies to older people in the same way that it applies to the adult population.
In addition, the Scottish Government is currently consulting on the integration of adult health and social care, with a particular focus in the first instance on improvements in services and support for older people71.
Commitment 21: We will identify particular challenges and opportunities linked to the mental health of older people and will develop outcome measures related to older people's mental health as part of the work to take forward the integration process.
Mental Health of those with Physical Illness
In "Improving the Quality of Health Care for Mental and Substance-Use Conditions", the Institute of Medicine identified as its first overarching recommendation that: "health care for general, mental and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body."72 In "Long-term conditions and mental health: the cost of co-morbidities", the Kings Fund found that people with long-term conditions who also had co-morbid mental health problems such as depression and anxiety had increased health care costs and poorer clinical and other outcomes73. Recent research in Scotland supports these conclusions and argues for new approaches to care and treatment to enable clinicians to offer better support to those with co-morbidities, particularly in deprived areas74.
This academic and clinical research evidence is in accord with what patients often tell us, that they feel that their treatment is fragmented. There is an ongoing need to address co-morbidities with a particular focus on identifying and responding effectively to depression. The indications are that clinicians in primary care in Scotland have been very effective in closing the treatment gap for patients with depression, but further work is needed in all settings to tackle this challenge.
The Living Better Project - a learning collaboration between a number of partners including the Royal College of General Practitioners in Scotland - identified key lessons for staff working with people with long term conditions who also had common mental health problems75. It developed training interventions both for professionals and for patients and addressed issues to do with stigma by promoting activity in a way that plays down the connection to mental illness and focused on positive wellbeing and people's potential strengths as individuals and as a group. Similarly, work with the Thistle Foundation in Craigmillar in Edinburgh gave us insight into how local community services can engage with General Practitioners. GPs became more confident about referring to services if they got feedback from those services about how patients benefitted. As part of that programme the Thistle Foundation provided GPs with data on improvements on depression scores over time. Seeing benefits in clinical terms encouraged GPs to make greater use of the service and also kept it at the front of their mind.
NHS NES will continue to support work to produce learning resources for staff working with patients with physical health problems, particularly long-term conditions, which will help them to understand the link between physical and emotional issues and deliver more holistic and effective care.
Commitment 22: We will work with the Royal College of GPs and other partners to increase the number of people with long term conditions with a co-morbidity of depression or anxiety who are receiving appropriate care and treatment for their mental illness.