Distress Brief Intervention pilot programme: evaluation

1 Executive Summary

1.1 Distress Brief Intervention Programme

Distress Brief Interventions (DBI) are ways to support people who are in distress. The aim and content of the Scottish Government DBI programme emerged through direct engagement with people who had experienced distress, with front-line service providers, and from a literature review. Within DBI, distress was defined as,

"An emotional pain for which the person sought, or was referred for, help and which does not require (further) emergency service response (NHS Scotland 2017)."

The DBI programme aims to provide a framework for improved inter-agency coordination, collaboration and cooperation across a wide range of care settings, interventions and community supports for people who present in distress.

The DBI programme has two Levels. Level 1 is provided by trained front-line staff from Police Scotland, the Scottish Ambulance Service, NHS Accident & Emergency (A&E) departments and Primary Care. Level 1 staff are trained to provide a compassionate response and offer individuals in distress the opportunity to be referred to a brief (around 14 days), compassionate, community-based problem-solving intervention, known as DBI Level 2. Following a referral from Level 1, Level 2 staff attempt to make contact with the individuals within 24 hours. They are empowered to deliver support beyond 14 days, in-line with the person-centred approach, based on individual need and where appropriate.

The Level 2 intervention is provided by specially trained third sector staff; it is not a clinical intervention. While some individuals receiving DBI may have mild to moderate mental health problems, DBI is not designed for those with more severe or enduring mental illness or complex psychosocial needs. As part of their problem-solving approach, Level 2 practitioners work with individuals to develop a personalised distress management action plan (D-MaP). When necessary, individuals are signposted or referred to statutory or non-statutory services at the end of DBI for follow-up support tailored to their needs.

The Scottish Government conducted the original DBI pilot programme from November 2016 to March 2021 in four pilot sites: Aberdeen, Inverness, Lanarkshire and Scottish Borders. The DBI programme has expanded in location and scope since it was first launched. The evaluation commenced during the original pilot of DBI when the service was targeted at those aged 18 and over and then incorporated a small number of under 18's following the extension of the pilot to those aged 16 and 17 in May 2019 in Lanarkshire and Scottish Borders and July 2019 in Aberdeen and Inverness (See footnote 3).

1.2 Evaluation aims

The overarching aims of this evaluation were:

• To determine the extent to which the DBI programme was implemented as intended, identify variation and any associated impacts.
• To determine the impacts of the DBI programme on services, practitioners and individuals.

1.3 Methods

To meet our evaluation aims, we used a mixed-method approach, undertaking various forms of data collection and analysis between 1^st January 2019 and 30^th April 2020. We gathered, analysed, and synthesised data that were collected as a routine part of the DBI programme and that were publicly available. We asked individuals who had received DBI to complete questionnaires at the start, end and three months after they had completed DBI and linked this to their routine DBI data. We also interviewed people who delivered DBI at Levels 1 and 2, key stakeholders who managed DBI and related services, and people who had received a DBI intervention. We used a research approach known as realist evaluation (Pawson & Tilley 1997). This enabled us to explore both the way that DBI was delivered and understood and the extent to which it worked as intended (Creswell et al. 2011). Our realist evaluation approach provided insight into what aspects of DBI worked, for whom, and under what circumstances. Throughout our evaluation, we fed back findings to the DBI programme to enable them to make informed decisions about improvements they could make.

1.4 Key Findings

1.4.1 Implementation of the DBI programme

Overall delivery of the DBI programme was successful. The pilot programme DBI was successfully adapted, where appropriate, to different local contexts while maintaining the core elements of the DBI programme. Referrals to DBI were mostly appropriate, with ongoing work throughout the pilot to find solutions to decrease less appropriate referrals, such as individuals with highly complex needs. As DBI referral numbers grew, this necessitated some services to change their staffing and other resources, such as premises. The aim of attempting to contact each referral from Level 1 within 24 hours was met in 100% of cases. Two-thirds (65%) of individuals were contacted within 24 hours, rising to 86% in the following days. Findings suggest that the time to contact was not associated with individuals' eventual outcomes.

As the DBI pilot programme progressed, more emphasis was placed on the importance of providing as much practical and emotional support as possible within the initial Level 2 contact, including use of the D-MaP. The guideline of up to 14 days of DBI Level 2 contact was met for 58% of individuals who took up more support than just one initial supportive call, with length and intensity of support (number of sessions) varying by pilot site. Although around a third (30%) of individuals participating in the evaluation thought the guideline of 14 days was not enough, the length and intensity of DBI Level 2 support were not found to be associated with individual outcomes. Generally, individuals engaged well with DBI Level 2 with some reporting using plans and strategies developed with their DBI practitioner (including the D-MaP) up to three months beyond the end of their Level 2 intervention. Individuals referred by Primary Care and mental health unscheduled care teams were more likely to take up any support from DBI Level 2 than those referred by A&E services, Police Scotland and the Scottish Ambulance Service. This may be due in part to individuals referred from emergency services having less clarity during the referral process and hence less understanding of what DBI was about.

1.4.2 Factors contributing to and impeding implementation success

While not originally envisaged as a core component of DBI, the role of DBI Central (coordinating services, facilitating effective and efficient inter-and intra-agency networking, enabling open communication, information sharing, and problem-solving) was an essential component of the DBI programme's success. The constructive leadership of the DBI programme manager who led DBI Central and championed the DBI programme was central to this.

Cross-sectoral delivery of DBI was enabled and enhanced by DBI Gatherings (where key staff from each pilot region and national partners came together); and by local implementation groups (where an 'open door' ethos enabled (a) joint acknowledgement of where implementation was less effective and (b) joint solution generation). Local DBI implementation groups allowed problem-solving at a local level and successfully enhanced inter-agency engagement.

Contextual factors that challenged DBI implementation included where people in existing local services doubted the added value of DBI and viewed it as a potential replacement for more specialist services that they considered to be of greater value. Also, some Level 1 practitioners felt that addressing individuals' mental health issues was outwith their role. A further challenge was where existing frontline operational systems could not be adapted to incorporate DBI referrals. In some areas, this considerably impeded the smooth running of the referral process.

Most practitioners found that Level 1 and Level 2 training prepared them well to effectively implement DBI. However, one in seven (15-16%) of the Level 2 practitioners felt their training had not adequately prepared them with the skills or confidence required for the job. Delivery of Level 1 training varied across pilot sites but face-to-face training was broadly the preferred mode of delivery. Some Level 1 practitioners (e.g. ambulance clinicians) found making time for training difficult.

Some of the clinically trained Level 1 practitioners felt their clinical training provided them with more advanced specialist skills than those provided by DBI, particularly when it came to identifying distress and responding compassionately. However, around half (45%) of practitioner evaluation participants reported that following DBI training they were more likely to treat someone fairly who was seeking help with their distress. This may consequently have reduced the chance of those in distress feeling stigmatised by those they approached for help.

1.4.3 Meeting individuals' needs

A key strength of DBI was its flexibility to be tailored to individuals who received DBI Level 2. This resulted in it being appropriate for the needs of a wide range of individuals in distress who presented with an array of different characteristics, life circumstances and problems. Relationship issues were the most frequently recorded contributory factor for both men and women, recorded in 48% of all referrals. Other common contributing factors included alcohol use (22%), life coping issues (21%) and money worries and unemployment (18% each). Alcohol use was recorded as a contributory factor in a higher proportion of men (29%) than women (16%). Substance misuse was also a contributory factor in a higher proportion of men (19%) than women (7%). Recorded alcohol and substance use were lowest among those referred to primary care in hours (10% and 5% respectively) and highest in A&E (35% and 23% respectively).

A large proportion of individuals who accessed DBI were signposted to, or a supported connection was made by the DBI Level 2 service (assisting by making initial contact with an appropriate post-DBI service, on behalf of the person to initiate contact) to other services [hereinafter referred to as 'supported connection']. Almost one in three people (29%) who had a successful contact at Level 2 were signposted to statutory services. Approximately three-quarters (73%) of people who had a successful contact at Level 2 were signposted to non-statutory services. Around one in ten (11%) were provided with a supported connection to statutory services and a quarter (25%) were provided with a supported connection to non-statutory services.

The DBI Level 1 response had direct, immediate benefits for the individual, with most reporting that their Level 1 provider had helped them cope with their immediate distress (mean rating = 7.8, where 0 = 'not at all' and 10 = 'completely') and the more they were able to do this, the less distressed individuals were when they began Level 2. Although most individuals felt they were treated with a high level of compassion by Level 1 practitioners, younger people, those with higher levels of distress, and those presenting to A&E were more likely to give a lower rating of compassion than others. This may, in part, be explained by the likelihood that some people attending A&E were likely to be in greater or more acute distress than individuals attending other settings. DBI is working well for most individuals, with nine out of ten showing a continued decrease in their distress over the period of the Level 2 intervention; however, for around one in ten individuals their distress level was higher at the end of the Level 2 intervention. One in ten evaluation participants revealed that they may have attempted suicide or continued with suicidal thoughts if DBI had not been offered to them.

Although the extent of change in distress within individuals was not associated with age, gender, area deprivation or the main presenting problem, differences were seen in how individuals rated Level 2 practitioners in terms of compassion. Individuals who rated the Level 2 providers more highly tended to achieve greater decreases in their distress. It is important to note that Level 2 practitioner compassion ratings were fairly high overall and most of the individuals who experienced worsening distress during Level 2 felt that they had been treated with a fairly high level of compassion. When controlling for distress levels at the start of Level 2, women were likely to have a slightly higher distress level at the end of Level 2 than men. This suggests that for some reason DBI Level 2 may be working less well for women than for men. It is not clear why, but the difference is significant and merits further consideration. Another finding that merits further investigation is that, when controlling for distress levels at the start of Level 2, younger adults, particularly those aged under 35, were likely to have lower distress by the end of Level 2 than older adults (by 2.5 - 3 points on the CORE-OM 5 distress scale). This may indicate that DBI Level 2 works better for younger adults at least in the short term. There was also evidence that when DBI practitioners helped individuals to improve their understanding of why they feel distressed, this had an important influence on reducing their distress level.

The impact of DBI on the wider service system seems to be largely positive. Level 1 and Level 2 practitioners, who took part in the evaluation agreed that DBI provides a more effective way for services to respond to people in distress and that DBI has improved integrated working across frontline services.

1.5 Conclusions

Overall, DBI has proved to be successful in offering support to those in distress. Most individuals received a compassionate and practical response that contributed to their ability to manage and reduce their distress in the short, and for some, in the longer term. This is particularly encouraging as the rationale for the development of DBI was a recognition that previous services did not meet the needs of many people, which could lead them to feel let down, vulnerable or at risk.

A key strength of DBI is its flexibility to be tailored to the individual, thus meeting the needs of a wide range of individuals in distress who present with an array of different characteristics, life circumstances and problems. However, while DBI met the needs of many, it worked less well for some.

While not originally envisaged as a core component of DBI, the role of DBI Central in coordinating services, facilitating effective and efficient inter-and intra-agency networking, enabling open communication, information sharing, and problem-solving was an essential component of the DBI programme's success.

When considering the future rollout of DBI services careful consideration should be given to choices about the organisation of resources and modes of service delivery. Future provision of DBI should consider the availability of community services in local areas and the risks of increased demand for services and the impact on their waiting lists as a result of DBI interventions.

1.6 Key Recommendations

Key recommendations based on our findings are set out below.

1.6.1 Roll-out

1. The national roll-out of DBI should continue, ensuring that core DBI elements (contact within 24 hours, guideline of 14-day intervention, use of D-MaP etc) are adhered to, along with the continuation of the central leadership, coordination and management function.

2. New DBI services should be aware that DBI may be perceived as a threat to, rather than complementary to, existing services. This may need to be overcome to ensure good engagement with and uptake of the programme amongst local delivery partners.

3. The evaluation findings should be used to inform the roll-out of the DBI programme and disseminated widely to share learning, encourage debate and further uptake of the DBI model.

1.6.2 DBI practitioner preparedness, training and development

4. Level 1 and 2 practitioners should not commence work on DBI until they have completed the standard DBI training.

5. DBI Level 2 training should note practitioners' previous experience and training and acknowledge practitioners' potential existing awareness and understanding of identifying distress and the importance of compassion.

6. Standard DBI training updates should be communicated to all trained practitioners, and local or service-specific buzz sessions should be encouraged.

7. It is recommended that Level 1 practitioners spend 1 hour of their paid work time to undertake regular DBI training (we suggest every 2 years); this should include interaction with Level 2 practitioners (where possible face-to-face).

1.6.3 DBI practice

8. To facilitate uptake and adoption of DBI, referrals to Level 2 should be incorporated within existing frontline services' processes.

9. Review the evaluation findings that the DBI Level 1 experience is not working as well for younger people and those attending A&E - and explore whether their experience can be improved.

10. Consider how DBI Level 2 is described and delivered as a brief intervention for those using the services and practitioners. Strategies such as leaving more expansive written information for the person being supported than is currently available, could be helpful in the most challenging circumstances (e.g. when individuals are highly distressed, disoriented or affected by drugs or alcohol).

11. DBI management and practitioners should continue to work to refine the appropriateness of referrals and review whether inappropriate referrals are highlighting service gaps or unmet needs.

12. DBI management and practitioners should look for opportunities to build on the finding of the importance of helping individuals to understand why they become distressed and to recognise when it starts, as this seems key to improved reduction in distress.

13. Consider whether DBI has a potential role in offering follow-up support or contact to individuals following a planned exit (i.e. because waiting for follow-up support can be a difficult time). A more tapered withdrawal may be beneficial for some and/or checking whether individuals feel able to initiate contact with follow-up services themselves.

14. Within the Level 2 services, decisions are needed on staffing composition to ensure a range of skills and experience that will meet the needs of a wide range of service users.

1.6.4 Research

15. Further research is recommended on the following: the level of uptake of follow-up services after DBI Level 2; the longer-term impact of DBI on individuals and the wider service system; whether and how DBI might help prevent suicide; and the factors associated with increased distress among some individuals at the end of Level 2.