Stepping up primary care
Since 2003, Greater Glasgow Primary Care NHS Trust (now Greater Glasgow and Clyde) has set up five primary care mental health teams (with four other teams operating outside the city boundaries). Teams, generally led by a clinical psychologist, have developed independently, although all following a stepped-care approach. There are two fundamental aspects to stepped-care: starting with the most efficient, least intensive and least restrictive interventions; and that the model is self-correcting, with the ability to step up the individual to more intensive forms of intervention if necessary.
Based on a model that I proposed (White, 2000a), STEPS is the primary care mental health trust providing services to South East Glasgow Community Health and Care Partnership. The service began in November 2004. The remit of STEPS is to provide care to adults(16 years+) with common mental health difficulties. Our goals are outlined in the box opposite. STEPS comprises four workers from a cognitive behavioural therapy (CBT) background – two clinical psychologists and two CBT therapists; three person-centred counsellors; two assistant psychologists; a (volunteer) ‘expert patient’; and a sessional exercise trainer.
Working in a highly deprived city, we felt it crucial to develop
services appropriate to the range of psychosocial problems familiar to
any experienced clinician. We believe in a ‘horses for courses’
approach and do not accept the primacy of individual therapy in primary
care mental health. Our role as ‘gatekeepers’ to the service differs
from more traditional services which, too often, take on the role of
‘bouncer’ whose main task is to limit access to services. ‘Gatekeepers’
should act more as ‘greeters’ welcoming as many people as possible into
the service. We strongly believe that we are more than simply
therapists. NHS managers have provided strong support
in this.
The STEPS Service brochure
Since summer 2008, all services are accessed via the brochure. This
offers a menu of self-selection services that users can access, usually
by making a phone call to a STEPS admin worker. This negates the need
to individually assess the very large number of people using the
service. The brochure is widely distributed across southeast Glasgow –
GP surgeries, CMHTs, social work departments, ante- and postnatal
services, libraries, community centres, housing associations, bowling
clubs, pubs, churches, cafes, etc., and is available on www.glasgowsteps.com.
The first edition contained the following service options: Stress
Control class; Advice Clinic; First Steps support group; advice (phone)
line; Steps out of Stress self-help booklet series; website, book
prescribing; and healthy reading. The Revision adds: exercise class
(‘Step into Shape’); Mood Matters; social anxiety group (Connect); the
three ‘Work out at the Gym’ well-being classes, MindGym, Body Gym and
LifeGym; the rolling workshop programme, call-back line, service
directory (www.glasgowhelp.com);
Steps Sounds and podcasts; two mental health awareness DVDs; monthly
service updates; partner services available in south east Glasgow; and
a page in Urdu describing targeted services for the South Asian
community.
People are encouraged to hold on to this brochure and sign up for
services at any time. In this way a self re-referral call to STEPS is
seen as a positive act to nip problems in the bud, rather than a sign
of failure.
The six STEPS
The STEPS service operates at six interactive levels, progressively broadening from the individual to population level.
Level 1: Individual therapy
STEPS offers CBT and person-centred counselling. We hope to publish
shortly on the performance of the clinic but it is clear that attrition
is a severe problem, and this is intimately linked to deprivation. We
know that those from the most deprived areas are least likely to
opt-in, attend first appointment or complete a course of treatment
compared to those in less deprived areas. Our data so far suggest a
completion rate for those in the most deprived areas (of individual
therapy) of around 22 per cent. We are looking at more radical options
and, as part of this development, have introduced the ‘call-back’
service. STEPS therapists will phone triage to the full range of
services following self-referral, rather than rely on GP referral.
Level 2: Groups
All groups meet in community settings and can be booked by making
one phone call to admin. Some allow you to simply walk in off the
street. Stress Control, tackling common mental health problems at the
negative affect level (Barlow et al., 2004), is a large didactic CBT
‘evening class’ (there is a daytime option) that routinely attracts
over 100 people to each course (White, 2000b). Mood Matters, focusing
more on depression, is a new class that mixes CBT and positive
psychology. First Steps is a longer-term support group, led by an
‘expert patient’ volunteer who has long experience of common mental
health problems.
We believe many service users (not just those attending First
Steps) can best be described as suffering from ‘common and enduring’
mental health problems, for whom an approach based on the Recovery
Movement (e.g. Copeland, 1997) may be more appropriate than a ‘cure’
model. We hope to develop a recovery model for common problems using
First Steps as the foundation. In addition, STEPS offers a postnatal
group, book clubs, a social confidence group, and a free exercise class
open to anyone who has used a STEPS service. We are also developing
BodyGym and MindGym well-being classes, along with LifeGym. This will
focus on wellness recovery action planning, and will hopefully be run
by peer-supporters.
Level 3: Single contacts
The Advice Clinic offers a one-off 30 minute afternoon or evening
appointment with a therapist. Up to 15 slots are available each week.
Most people can be given an appointment within the week of phoning
(often the same day). An evaluation of the original advice clinic
in Clydebank Health Centre reported positive findings (White,
1998). As with the original clinic, the Advice Clinic typically
attracts a clinical population (with well-above threshold CORE scores –
average OM scores of 2.1) who would, in areas where traditional
services operate, be unable to access any specialised help due to the
volume limitations of these services.
The phone version of the Advice Clinic has been successful in terms
of dealing with problems quickly and efficiently, but less successful
in terms of numbers using the service. If this service is to continue,
we must look at extending the hours it is active. It is likely that
most people would want to use this service in the early evening.
We are also developing a rolling programme of workshops/events. We
have run a ‘Just had a baby?’ event, and a ‘Fancy a fresh start?’ event
based on money/mental health help (with stalls/talks offered by
statutory and community mental health organisations, credit unions,
welfare rights, debt advice, employment and training organisations,
volunteering, community engagement, housing organisations, etc.). We
are developing a programme on common problems, such as assertiveness,
panic, sleep, self-esteem, work stress, etc.
Level 4: Non-face-to-face work
The ‘Steps out of Stress’ series currently contains 22 self-help
guides to common problems. As too many mental health booklets are
written well beyond average reading skills, all our booklets have a
Flesch Kincaid Reading Ease score equivalent to a reading age expected
of a nine-year-old. We plan audio CD versions (some in Urdu) to
overcome the literacy problems common in the area.
We have developed a website – www.glasgowsteps.com – with three main
interconnected sections centred around the ‘Stress Wheel’. There is an
information section; an assessment section with 10 interactive
questionnaires on, for example, anxiety, depression, panic, alcohol
use, anger and self-esteem; and a self-help section offering CBT
options for a range of common problems. Users will be able to download
all the ‘Steps out of Stress’ booklets, watch video clips of local
people talking about their mental health problems; watch the STEPS
DVDs; sign up for STEPS podcasts and, in partnership with the Spoken
Word Project at Glasgow Caledonian University, access an archive of BBC
radio programmes on mental health. Progressive relaxation can be
downloaded to an MP3 player. A series of conversations with spiritual
leaders discussing mental health will be available. A gallery on the
site will display the work of mental health art groups. Users will also
be able to access information about all STEPS services (e.g.
forthcoming dates for workshops and groups). There are video clips
showing some of the more popular interventions, e.g. Stress Control.
There will be an online booking facility for Stress Control, the Advice
Clinic and the call-back service.
In partnership with Glasgow Culture and Leisure Services, we have also
set up dedicated mental health sections (‘Healthy Reading’) in all 34
Glasgow libraries. We spent around £2000 in each library, filling it
with a range of mainly CBT self-help booklets, DVDs and
booklets/pamphlets. The two libraries in areas with high Pakistani
populations also have materials in Urdu. In addition, the libraries
have multiple copies of all our booklets and DVDs.
Level 5: Working with others
An important part of our service involves partnership working. For
example, we have given 1000 copies of ‘Coping with Trauma’ and ‘Coping
with Panic Attacks’ to the local Accident and Emergency department, and
30,000 ‘Getting the Best out of Your Anti-depressants’ booklets to all
Glasgow GPs and community pharmacists to give out to patients. This is
to allow individuals to make an informed decision about whether to take
the medication and, if so, how to use it properly.
We are also targeting those with physical health problems. In line
with the Scottish Government’s goals as outlined in Delivering for
Mental Health (Scottish Executive, 2006), we plan to offer mental
health screening to anyone with a coronary heart disease or diabetes,
with the further offer of the STEPS rapid access services to those who
may benefit. As well as interventions with postnatal problems, and
given the risk factors to the fetus posed by antenatal anxiety (Talge
et al., 2007), we plan to offer a ‘Get into Great Shape for Your Baby’
intervention for those in the first trimester.
Clearly there is little point putting all this in place and then
failing to share it with others and to help them do the same.
Consequently, we have developed a primary care mental health forum in
Glasgow to ensure that good practice across the city is publicised and
that all
in primary care are communicating and learning from each other. We hope to develop an online forum (www.mentalhealthforum.org)
for all primary care mental health workers across Glasgow and beyond to
ensure the same ends. We hope to open the online forum to service users
to ensure their voices are heard.
We are also developing a series of self-help booklets that can be used both as pure self-help and as materials to help train non-mental health workers in guided self-help. Acknowledging that all primary care staff deal with mental health, whether directly or indirectly, we aim to train groups such as podiatrists who have shown enthusiasm in learning basic skills – as one podiatrist told me ‘I’m down there [working on the feet of diabetic patients] while they are up there crying their eyes out and I don’t have a clue what to do.’
Finally, we are developing a training package in basic CBT
strategies and delivering it to other PCMHT staff, social workers,
voluntary organisation and community support workers. We are involved
in training the trainers for Scottish Mental Health First Aid. We have
trained, and been trained by, the (Gorbals) Working Neighbourhoods
Project who are tasked by the Department of Work and Pensions to help
those on incapacity benefit return to work.
Level 6: Population level
In addition to the widespread distribution of leaflets across the
Glasgow area, we have conducted a number of more innovative
interventions at the population level.
STEPS assistant psychologists regularly run stalls at community
fairs, carers’ events and schools. Stalls offer copies of STEPS
booklets and pamphlets, interactive questionnaires on a laptop, STEPS
brochures and sign-up forms for STEPS services such as Stress Control.
We hope to take this further by setting up a ‘one-stop shop’, hopefully
in a main street shop, to offer an assessment and intervention designed
for a range of social, physical and mental health conditions relevant
to a deprived area. We anticipate assessing blood pressure, BMI,
alcohol use, smoking, mental health, employment, debt, benefits and
housing issues.
DVDs play an important role in getting our message out, and we have developed two and made them widely available. ‘100 People’ looks at how common mental health problems are and suggests some straightforward ways to prevent/tackle them. Given the importance of early intervention in teenage years (e.g. Kessler et al., 1998), we have developed an interactive event for senior pupils in all southeast Glasgow secondary schools based around the themes in the DVD (which is also available on YouTube – search for ‘100 people stress’).
Our latest DVD, Everything you always wanted to know about stress (but were afraid to ask), made in partnership with Blindside Productions, features service users, therapists and GPs talking about common mental health problems. In order to make the DVD more watchable, we worked with local stand-up comedians and created a script centring on ‘Alex’, a young man suffering from mixed anxiety/depression who, in a series of comic encounters learns how to handle ‘stress’. We launched this DVD at a STEPS night of stand-up comedy on the theme of mental health as part of the Scottish Mental Health Arts Festival during Mental Health Week, October, 2007. The DVD is being given, free of charge, to all Glasgow NHS employees, all City Council workers and all members of the local Police Force (around 100,000 people), and is also available via the STEPS website.
Also linked to the website, users can sign on for STEPS (audio)
podcasts. These include information on CBT and PCT, sleep problems,
anxiety, depression, panic and many other common mental health
problems.
Sometimes we can coordinate these offerings into a series of
awareness-raising and intervention events. ‘Good Mood Week’ allows us
to use local media, organise community events, go into large local
businesses, schools, elderly lunch groups, etc. Working in partnership
with a wide range of statutory and community organisations, we would
hope to offer a range of interventions for those who wish to tackle a
mental health issue. This event is planned for mental health week in
2009.
As southeast Glasgow has the highest concentration of individuals
from a Pakistani background in Scotland, STEPS has, in the absence of
dedicated funding, developed a limited service to this population. We
wrote a series of daily mental health tips which were read out on Radio
Ramadhan during the Holy Month. We have delivered mental health advice
sessions on Awaz FM. We organise STEPS stalls at BME health and
community fairs. STEPS sponsored the annual prayer timetable with
information about our service alongside mental health tips. We plan to
train women from the Asian community to provide, e.g. guided self-help
to small groups of women who would not traditionally seek access to our
services. We hope to provide an Urdu voice-over on the DVDs and have
applied for funding for a dedicated Urdu section on the website. We
have delivered a session on mental health awareness for Glasgow Imams.
This has led to offers to work more closely with them with invitations
to deliver talks or set up stalls, for example after prayers at the
mosques. We hope to have our booklets and other materials readily
available at mosques and community centres.
So what have we learned?
We have found completion rates (of all those referred) of 41 per
cent for CBT and 18 per cent for counselling. When we looked closely at
these data, the overwhelming factor explaining these poor outcomes was
deprivation. It is clear that the individual therapy service – GP
referral, set weekly/fortnightly appointment times – is not a suitable
model for many people. Rather than blame them for not coming, we are
trying to offer more comprehensive service options. The STEPS service
brochure now offers reasonable choice and we are continuing to expand
the range of options. We are beginning to work closer with
organisations such as housing associations and benefits agencies who
are already in touch with the (to us) ‘hard to reach’ groups to offer
more relevant psychosocial services to better meet their needs. We will
continue to offer individual therapy but we anticipate being able to
offer help for those individuals who are unlikely to benefit from any
other approach, allowing them immediate access to the appropriate level
of care. This is perhaps better seen as matched- rather than
stepped-care.
Are we reaching the right people??Like most primary care services,
we do not see people who are ‘mild’. Mean CORE scores in individual
therapy, Stress Control and the Advice Clinic are in the
moderate/severe range; yet even with such significant problems, 85 per
cent of those attending the Advice Clinic have had no previous contact
with mental health services – another reason why we need to question
the highly restrictive individual therapy service models to allow us to
reach the huge number of people in our communities who are suffering.
Advertising is key in this goal. Some of our workshops and events
are underpopulated. We believe the content is good, and that the
problems are with advertising – how do you inform diverse communities
about services? We are considering seconding someone from an
advertising agency to teach us how to do this – an example of the need
to attract a range of diverse skills to complement those already in the
team.
Interconnectiveness, in service as well as personnel, strikes us as
key. Stepped care can only function well when its component parts are
working together. For example, an Advice Clinic could not function well
in isolation. Thus having self-help booklets, Stress Control, First
Steps, the website, the service directory, etc. helps to ensure that
options at the Advice Clinic are immediately available for the range of
needs seen there.
We also believe the concept of ‘risk’ has emerged as vital. While
risk assessment is an important consideration in mental health,
particularly with the severe and enduring population, we are concerned
that primary care services may restrict the help they can provide if
they overemphasise risk considerations in their decision making. It is
our belief that risk is not a major issue in primary care and that
clinicians who do not offer services to much larger numbers should
consider risk from the other side of the coin – what are the potential
risks to individuals in the future if they are prevented from accessing
primary care mental health services perhaps at an earlier stage in
their problems?
Challenging sacred cows
It is clear to us that CBT, probably more than any other approach,
has the flexibility to develop stepped-care – not the rather
stultifying CBT that emerges from the research centres but a more
robust, creative, relevant CBT that can make a large contribution to
primary care at the population level. We are now at the point of
knowing what is working and what is not and will publish data shortly.
We see STEPS are constantly developing. The coming year will see us
focus more on the ‘hard to reach’ groups – generally those from
deprived areas, particularly men, the over 65s and the under 25s.
Primary care is a specialist area requiring specialist knowledge
and training. You don’t get this on the cheap – if you want a
multilevel, multipurpose service, you need psychologists, but only
psychologists who are not precious, who are happy to work with others,
who are happy to challenge the dominant ideas and sacred cows;
clinicians who are happy to challenge the academics and who have a
truly holistic view of individuals – not just the way they think but
also they way they exist in a social world that often places unbearable
demands on them. In particular, we need better, possibly very
different, services for those living in deprivation. We are still not
clear what those services will look like, but we are convinced that we
are on the right road to discovering them.
Psychologists are worth the money as long as we exploit all our
skills, not just the therapeutic ones. The tendency in IAPT to go for
minimally trained, low-paid workers has merits but these workers
typically are trained to do one thing – guided self-help. We need
initiators, dynamically creating, developing and running innovative
services using all the skills at our disposal. Perhaps we have to stand
up and shout a bit more loudly about these skills – not putting down
our colleagues but emphasising the unique contribution psychology can
make to the rapidly developing mental health scene.
(Please note that some pictures may have been removed for copyright reasons)
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