Summary of the impact

Recent NHS policy has prioritised improving access to cost-effective psychological interventions for people with mental health problems. Research by Lucock at the Centre for Health and Social Care Research (CHSCR) has contributed to meeting this challenge by developing and evaluating self-help interventions which can be provided by a range of NHS staff without professional psychotherapy or mental health training. This work has resulted in the creation of the Self-Help Access in Routine Primary Care (SHARP) initiative, a programme that gives practitioners materials and training which enable them to deliver brief self-help interventions supported by a dedicated website and a range of leaflets that recognise service users' need for easy-to-understand material. Feedback from practitioners on the website and training has been positive. There is evidence of positive impacts of the training on practitioners' confidence in their ability to deal with anxiety and depression, and in greater use of Cognitive Behaviour Therapy (CBT) approaches with patients. Evidence from testimony demonstrates impact on practice. Research also provides evidence of benefit to patients in terms of reduction of anxiety and depression and goal attainment. The research has also influenced national guidance on best practice.

Underpinning research

The case study fits into the Institute for Research in Citizenship and Applied Human Sciences research area of mental health and well-being (see REF5). It exemplifies impact derived from informing the development of complex interventions aimed at tackling difficult social, welfare and health problems (see REF3a).

Improving access to psychological therapies has been an NHS priority for a number of years. It is underpinned by the national and international health policy imperative of significantly reducing the consumption of psychoactive drugs by mental health service-users through a major but affordable expansion in the provision of psychological therapies. The National Institute for Health and Clinical Excellence (NICE) has recommended the use of self-help approaches as a low-intensity stage in a stepped-care service model. This service model includes provision of self-help information and interventions as an early step in a person's treatment pathway. Our research involves a programme of related studies into the development of effective and accessible self-help interventions, identifying which practitioners can and should support the interventions and how they can be delivered most cost-effectively. This research programme was developed in response to NICE's endorsement of self-help interventions based on cognitive behaviour therapy (CBT) for anxiety and depression, and NHS policy guidance to increase the capacity of primary care services to support people with mental health problems.

Studies led by Lucock since 2002 have made a major contribution to the implementation of self- help interventions for people with mental health problems. Underpinning this research is a major paradigm shift towards viewing mental health issues from a psychosocial rather than a medical perspective. The research addresses the implications for practice of this shift by investigating ways in which psychosocial interventions can be provided on a larger scale, partly to increase choice for the service-user but also as an alternative to drug and other medical treatments which are more appropriate for those with more serious mental health problems. The research has provided evidence for the feasibility of NHS practitioners in different roles to deliver effective interventions designed to support mental health service-users to help themselves more effectively and to manage their difficulties. The research has investigated self-help strategies used by people with mental health problems in their everyday lives and service-user views about what makes interventions designed to support self-help effective. This has led directly to practice developments which include interventions supporting self-help that can be accessed via routine NHS services, provided by a broad range of health professionals, and self-help materials available to the wider public.

Given the time-demands, and therefore economic cost, of delivering psychosocial support for effective self-help, research demonstrating its benefits can only generate beneficial impact if a large and affordable workforce with the appropriate capabilities can be trained. A 2003 study used case studies to evaluate the role of graduate primary care mental health workers (GMHWs), a then new addition to the NHS workforce, in providing CBT based guided self-help interventions for anxiety and depression^a. It was concluded that GMHWs can be trained to provide such interventions effectively. A pilot evaluation of guided self-help provided by primary care nurse practitioners was carried out in 2004-5^b. The findings showed that primary care nurses could provide brief and effective self-help interventions. It was recommended that primary care nurses should have access to self-help materials in the course of their routine work so that they could offer them to service-users as and when needed. This was a key study underpinning the SHARP initiative described later. Two pragmatic clinical trials were carried out in routine NHS services to evaluate the effectiveness of relatively inexpensive health care practitioners supporting service- users' self-help activities. One, in 2004-5, was a controlled clinical trial of a brief self-help intervention for patients with anxiety problems waiting for psychological therapy and provided by an assistant psychologist^c. The intervention was based on a CBT anxiety self-help programme developed by the research team. The second trial, in 2008-9, was a pragmatic randomised controlled trial of brief, three-session CBT based guided self-help intervention provided by graduate primary care mental health workers within a primary care mental health service^d. Both studies demonstrated that practitioners with less experience and training than psychotherapists or clinical psychologists can provide effective low-intensity guided self-help interventions in routine NHS services.

Other studies have sought the views of service-users. A study in 2004 used a consultation event to capture service users' views of the self-help strategies they use on a day to day basis that help them to manage their problems^e. A key finding concerned the importance of incorporating and building on self-help strategies which service-users found effective into self-help support. A further study in 2005 investigated service-users' views about self-help materials and their effectiveness in different service settings, including self-help groups^f. Drawing on semi-structured interviews and qualitative template analysis, the research focused on the effectiveness of a self-help programme for anxiety that was developed by the research team. Although the service-users were positive about the programme, they expressed a clear view that the material was too complex and insufficiently accessible for individuals to benefit from without a lot of guidance, particularly if they were depressed. The research recommended that self-help materials should be less complex, and that professionals should be trained to support service-users in making use of them. In 2007-9 Lucock also worked on NIHR Service Delivery and Organisation (SDO) funded research into the barriers and facilitators of effective self-care support in mental health services. This mixed-methods study, led by Dr Steve Gillard from St George's, University of London, illustrated how effective self- care support should be tailored by practitioners flexibly and over time, depending on the changing needs of people with mental health problems^g.

References to the research

^g Gillard, S., Edwards, C., Lucock, M.P., Minogue, V., et al: Understanding the Barriers and Facilitators of Effective Implementation of Self-Care in Mental Health Trusts, National Institute for Health Services Research (NIHR) Service Delivery and Organisation Research Programme, 2007-2009 - £302,662.

Details of the impact

More than 16 million people in the UK are thought to suffer from mental health problems. In 2010 the estimated cost to individuals, employers and the government has been estimated as more than £100 billion per annum. With only around 10 per cent of sufferers able to access psychological treatments, the development of effective self-help approaches represents an important means of supporting service users, offering them greater choice, control and shared decision-making. Lucock's research has underpinned increased support for the wider NHS workforce in providing brief, accessible guided self-help interventions. The two clinical trials mentioned above demonstrated the benefit to patients of this approach. The controlled clinical trial^c showed a positive effect on patients' anxiety for a very brief, low-cost intervention (£14 per person) and this included evidence of significant goal attainment. The pragmatic randomised controlled trial^d provided evidence of improvements in levels of depression following a brief 3 session intervention. The underpinning research led to the creation of SHARP, the Self-Help Access in Routine Primary Care project^1,2,3,4. Initially developed as a pilot initiative in Wakefield, Yorkshire, with the support of the West Yorkshire Workforce Development Confederation and Wakefield Primary Care Trust, SHARP was designed to supply primary care practitioners with the materials and training needed to provide brief, low-intensity, effective self-help interventions for sufferers of mild to moderate anxiety and/or depression. Between 2008 and 2010, 44 NHS practitioners in the Wakefield area received training in delivering guided self-help under the SHARP programme. The initiative received positive feedback from practitioners, with an evaluation of the pilot training programme reporting significant increases in confidence in their ability to deal with anxiety and depression and to use CBT in their practice⁵. For example, two nurse practitioners and a GP from a Yorkshire GP practice attended the SHARP training and used the approach in their mental health clinics. They reported that the introduction of mental health clinics based on the SHARP approach contributed to a reduction in the prescription for anti-depressants. The General Practitioner stated that "We have been running the mental health clinic for at least 4 years now. One of the big differences is the reduction in the number of patients suffering from stress related problems / anxiety / depression in routine GP clinics. We have also noticed a marked reduction in antidepressant prescribing"⁶. As a result of the pilot and expansion in the Wakefield District, the SHARP initiative was included in the specification for the roll out and development of IAPT services in Wakefield and adopted as one of the step 2 interventions in the stepped care service model⁷.

In 2009, with backing from Yorkshire and the Humber NHS, the scheme was extended across the Yorkshire and Humber region, where a further 50 NHS practitioners took part in a two-year `train the trainers' programme^2,3,4. This phase, completed in September 2011, was resourced in response to the positive feedback received from the pilot⁵, described above, and allowed the widespread training of SHARP practitioners in a number of localities. A project report produced in November 2011 showed that the SHARP approach had been taught to a wide range of regional practitioners including: 24 clinicians in midwifery and health visiting teams in Wakefield; Improving Access to Psychological Therapies teams in Barnsley, Bradford, Grimsby, Halifax, Sheffield and Wakefield; GPs in Sheffield; health visitors and health trainers in Kirklees; and a drugs support team in Leeds³. In keeping with the findings and recommendations of Lucock's studies, the training programme encouraged practitioners to understand and support service-users' own self-help strategies and to integrate facilitation of self-help into their routine work. The training programme confirmed our research finding that effective self-help support could be provided by a range of health professionals after only brief training (between one and two days).

The SHARP website¹ was launched in 2009, and from 2011 has allowed access to more than 40 self-help leaflets, most in both `full' and more readable `lite' formats. These leaflets offer information on self-help for anxiety, depression and stress. They cover both understanding and managing problems. In keeping with the underpinning research findings, these leaflets were designed, with input from a health literacy advisor, to be brief and readable. An audit using Google analytics in July 2013 showed that the website is being accessed over 600 times by up to 400 separate users each week with 95% accessed during weekdays. Access was worldwide, not just from the UK. UK users were located across the country, including the London region, Manchester and Glasgow, indicating widespread usage beyond the original area of dissemination. Local NHS practitioners can register on the website to access training resources, with 226 registering during the training period.

Feedback from services provides evidence of the value of SHARP in a number of ways. These include educating patients about their symptoms of anxiety and depression and preparing them for a referral to the IAPT service; supporting a shared dialogue between the GPs and the IAPT workers about who is likely to benefit from talking treatments for anxiety and depression; the benefits to patients of using the leaflets to normalise and explain their problems. An IAPT service manager stated that "The GPs now use SHARP leaflets to educate the patients about their reported symptoms, and introduce the idea that the patient can help themselves. The leaflets help the GPs to assess if the patient is willing or able to consider learning more about their problem. This helps them to prepare patients they think could benefit from IAPT"⁸ .

Lucock's research has also contributed to NHS guidance. His contribution to the Good Practice Guide on the Contribution of Applied Psychologists to Improving Access to Psychological Therapies ⁹included a description of the guided self-help intervention provided by the GMHWs described earlier^d. He also contributed to the Good Practice Guidance on the Use of Self-help Materials within IAPT Services¹⁰, which was written in response to feedback from services and those attending IAPT training courses who expressing a need for expert guidance on the use of self-help materials, given the wide range of different materials available. This guidance is therefore widely used to support the training and practice of those working within IAPT services in the UK.

Sources to corroborate the impact

¹ SHARP website

² Lucock, M., Lawson, M. and Khan, W. (2011) SHARP Training Manual, University of Huddersfield and South West Yorkshire Partnership NHS Trust.

³ Lucock, M., Lawson, M. and Khan, W. (2011) SHARP Project Report (for Yorkshire and the Humber NHS, November 2011).

⁴ Lucock, M. and Lawson, M. Self-Help Access in Routine Primary Care (SHARP). Yorkshire and the Humber NHS, 2009-2011 - £69,900.

⁵ Lucock M. and Lawson M. (2011) Self-Help Access in Routine Primary Care — the SHARP Project. Paper presented at the British Association of Behavioural and Cognitive Psychotherapy (BABCP) annual conference. University of Sussex, Guilford, July 2011.

⁶ Factual statement 1

⁷ Factual statement 2

⁸ Factual statement 3

⁹ Lucock M. (2007) Guided Self-Help for Common Mental Health Problems in a Primary Care Mental Health Team, in Good Practice Guide on the Contribution of Applied Psychologists to Improving Access to Psychological Therapies, pages 23-24. London: National Institute for Mental Health in England and British Psychological Society.

¹⁰ Baguley, C., Farrand, P., Turpin, G., White, J., Williams, C., Hope, R., Leibowitz, J.,Lovell, K., Lucock, M., O'Neill, C., Paxton, R., Pilling, S., and Richards, D. (2010) Good Practice Guidance on the Use of Self-Help Materials Within IAPT Services. London: IAPT, NHS.