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.