Distress Brief Intervention pilot programme: evaluation

2 Introduction

2.1 Establishment of the Distress Brief Intervention (DBI) Programme

Improving the response to people in distress was identified as a key priority in the Scottish Government's Mental Health Strategy 2017-27 (Scottish Government 2017), building on the Suicide Prevention Strategy for 2013-16 (Scottish Government 2013) and in response to calls from NHS practitioners and service users (Scottish Crisis and Acute Care Network, 2013).

Brief intervention as an approach to providing a timely and compassionate response to supporting people in distress has been gaining national and international interest. The Scottish Government sought the views of communities and partners and developed a proposed specification for a DBI. Simultaneously, a Scottish Government review of international research literature on brief interventions and similar pilot approaches in Scotland was conducted, concluding that there was some evidence that DBIs may have some impact on reducing the frequency of self-harm (Scottish Government 2015).

In 2016, the Scottish Government launched a Distress Brief Intervention programme, to test out a new approach to provide better support to people presenting in distress but who do not require further emergency service involvement. Within the DBI Programme, distress is defined as: "An emotional pain for which the person sought, or was referred for, help and which does not require (further) emergency service response" (Scottish Government 2017).

The University of Glasgow's Institute of Health & Wellbeing developed a DBI training programme and associated materials to support the implementation and delivery of the programme (see Chapter 5).

The pilot phase of DBI was planned to run from 2016 to 2021. The DBI programme began controlled implementation in the first of four pilot sites in June 2017. Delivery was incrementally extended to five delivery teams operating in four pilot sites: Aberdeen, Borders, Inverness and Lanarkshire (which has two teams). Full implementation was achieved by April 2018. 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 in May 2019 in Lanarkshire and Scottish Borders and July 2019 in Aberdeen and Inverness (See footnote 3). During the evaluation period, the DBI service was also expanded to other geographic areas (the associate programme) but these are not included in the evaluation.

2.1.1 Overview of DBI approach

The DBI pilot programme was a unique, time-limited approach to supporting those in distress who present to front-line services. The intervention is delivered at two levels.

DBI Level 1 is provided by front line staff (hereafter referred to as Level 1 practitioners) and involves a compassionate response to those who present in distress, signposting to other support available and offer of referral to a DBI Level 2 service. The main frontline services involved in the four pilot sites were:

• A&E departments
• Police Scotland
• Primary Care practices
• Scottish Ambulance Service

Individuals who were referred at Level 1 were then attempted to be contacted by Level 2 practitioners within 24 hours to offer their intervention. DBI Level 2 consisted of around 14 consecutive days of community-based, person-centred support with a problem-solving focus. Individuals who took up support from DBI Level 2 were offered assistance in identifying the source and triggers of their distress and identifying existing sources of support available to them. DBI Level 2 practitioners helped individuals to explore strategies to alleviate the issues causing them distress and supported them to develop a D-MaP, which individuals could use to help manage any future instances of distress. A key aspect of the DBI Level 2 intervention was to connect individuals with a wide variety of community and statutory services and support tools relevant to their needs. The DBI Level 2 practitioners signposted and/or supported individuals in distress to connect them with relevant follow-up support and assisted the individual in engaging with this support.

DBI Level 2 was provided by commissioned and trained third sector practitioners (hereafter referred to as DBI Level 2 practitioners) in four pilot sites:

• Richmond Fellowship and Lanarkshire Association for Mental Health (LAMH) in South Lanarkshire, and Lifelink in North Lanarkshire
• Penumbra in Aberdeen
• Support in Mind in Inverness
• Scottish Association for Mental Health (SAMH) in the Scottish Borders

2.1.2 DBI programme governance and oversight

The DBI programme was intended as a model of interagency joint working across frontline settings, third sector agencies and community-based support. DBI represents a national and regional collaboration between health and social care, Primary Care, emergency services (Police Scotland, Scottish Ambulance Service and A&E Departments) and the third sector, with the shared goal of providing a compassionate and effective response to people in distress.

Implementation and ongoing development of DBI was supported by a considerable infrastructure. The Scottish Government set up a national DBI Programme Board comprised of senior practitioners and/or leads from NHS Lanarkshire, Public Health Scotland, the third sector and front-line organisations delivering DBI, and the University of Glasgow. The DBI Programme Board provided oversight of the whole programme and met regularly to discuss the implementation of DBI.

A central management team called DBI Central was established within NHS Lanarkshire. DBI Central had a critical role in implementing the DBI programme. The team was responsible for sharing knowledge with other parts of Scotland and developing effective processes, tools and systems in support of the future implementation of the programme across Scotland. The DBI Central team was composed of a programme manager, programme administrator, clinical leads, a communications officer and two data analysts from Public Health Scotland. This team maintained close contact with local pilot site coordinators who oversaw the effective implementation of DBI in the respective pilot areas.

Local DBI Implementation Boards, each led by a DBI Level 2 pilot site coordinator, brought frontline services and relevant stakeholders together regularly to discuss how and where implementation could be supported and developed. The DBI coordinator in each area also acted as a liaison between both Level 1 and Level 2 services to monitor and promote the use of DBI.

2.1.3 Improvement science approach

An improvement science approach (Christie et al. 2017) was embedded throughout the DBI programme's implementation activities. This included opportunities for DBI practitioners, partners and other key stakeholders to come together to share learning and best practice. This included sharing emerging evaluation findings with DBI Central and practitioners to inform continuous improvement (see Section 3).

A national-level twice-yearly DBI Gathering brought together stakeholders and DBI Level 1 and Level 2 services. The Gathering provided a forum for sharing experience, consolidating local and national networks and allowing all those involved in DBI to share ownership of the ongoing improvement of the programme as a whole. The Gathering was not an intrinsic part of the DBI intervention, but it appears to have played an important role in achieving high cross-sectoral engagement and subsequent delivery of the programme. Therefore its impacts have been taken into consideration in this evaluation.

The DBI Central team also set up the DBI Level 2 provider forum. This provided an opportunity for Level 2 practitioners to come together for peer support, feedback and reflection and allowed discussion around issues and suggested improvements to the Level 2 service. DBI aims and intended outcomes.

The overarching aim of the DBI programme is to provide a compassionate and effective response to people in distress, within a framework of improved inter-agency coordination, collaboration and co-operation across a wide range of care settings, interventions and community supports.

The intended outcomes for the DBI programme, as set out in its published Theory of Change (NHS Scotland 2017), were developed by the Scottish Government and NHS Health Scotland, with input from the pilot sites and University of Glasgow (see Appendix A).

DBI Central, with the support of analysts from Public Health Scotland (formerly NHS Health Scotland), developed a centralised routine data collection and monitoring system to collect data on service use and outcomes. This data was collected by the DBI pilot sites and collated by the DBI Central Team. This enabled continual monitoring and adaptation of the DBI programme over the four-year pilot period.

2.2 Evaluation aims and approach

The overarching aims of the evaluation were to:

1. Determine the extent to which the Distress Brief Intervention programme was implemented as intended, identify variation and any associated impacts.

2. Determine the impacts of the DBI programme on services, practitioners and individuals.

The DBI evaluation design was guided by the DBI programme evaluability assessment (NHS Scotland 2017). While the evaluability assessment outlined a range of evaluation options, the evaluation procurement guidance for this document stated that a trail-based design, with a control group, was not desired. We, therefore, adopted a broadly realist evaluation methodology (Pawson and Tilley 1997). This approach focussed data collection on gaining insights into what worked, for whom, when and under what circumstances. This enabled aspects of the DBI programme that were working well, together with aspects that presented challenges, to be fed back to services on an ongoing basis, as well as informing the final report. A notable limitation of this design is the absence of a comparator – a relevant alternative to which DBI can be compared. While costs will be assessed and presented, with comparisons being made across the pilot areas, they cannot be brought directly together with outcomes observed.

The evaluation addressed the following overarching research questions:

1. Did frontline level 1 and level 2 practitioners feel empowered to provide a compassionate and constructive, effective response?

2. Who is the DBI programme effective for and why (this includes both individuals and practitioners)?

3. Who is the DBI programme less effective for and why?

4. What are the contextual factors that may impede or facilitate meeting the DBI aims and objectives?

5. What kinds of referrals were made for what needs and how appropriate were these referrals within and from DBI?

6. Did the DBI service meet its implementation targets (e.g. speed of response, appointments attended)?

7. What impact does DBI have on other service users and is this more efficient for services and appropriate for the individual's needs?

8. Did individuals benefit in the short (Level 1), or medium (Level 2) term? If so how and if not, why not?

An interim evaluation report (Duncan et al 2020) was published in January 2020. Recommendations from the interim evaluation included improving feedback loops between DBI Level 1 and Level 2 services on the appropriateness of referrals for individuals, further consideration of risk management of people who have been involved with the criminal justice system, review of 14 days as a time limit for support and enhanced and equitable provision of psychological and emotional supervision to DBI practitioners. The recommendations informed DBI's continuous improvement programme.

2.3 Structure of this report

This report sets out the summative findings of the DBI pilot programme evaluation. We present our findings following the DBI implementation and delivery pathway: from practitioner training and preparation; to delivery of DBI and the associated impact on individuals accessing the service; to referrals and signposting. Appendices that are lettered are available at the end of this report. Technical appendices are numbered and are available as a separate publication on the Scottish Government website.