The Matrix - Current Context

Home Overview of Psychological Services in Scotland Current Context

Current Context

Increasing Access, Policy Context and Workforce

The Scottish Government continues to state a commitment to increasing access to high quality, evidence based Psychological Therapies and Interventions across Scotland.

Increased Need

Mental Health and wellbeing is a significant public health challenge and evidence suggests existing difficulties were exacerbated by the COVID-19 pandemic and ongoing economic instability. The evidence shows that mental health and wellbeing difficulties are not evenly distributed throughout society but there are higher risks for those who live with poverty, other inequalities, or protected characteristics. Life experiences such as exposure to trauma and other adversity are also well-recognised risk factors as are the presence of existing complex and enduring physical and mental health difficulties. These factors, along with stigma, can be both risk factors but also barriers to accessing services and need to be carefully considered to ensure we get the most effective help to those that could most benefit from psychological therapies and interventions.

As the evidence for psychological therapies and interventions develops, this also, rightly, creates additional demand for services. The Matrix focuses on summarising this evidence, supporting services to understand what psychological interventions and therapies to deliver, and with guidance on how to implement them to best effect. However, as outlined in the ‘Introduction to the Matrix’, and underpinned by a whole system approach, opportunities not covered in the Matrix remit, such as peer support, counselling or meaningful activity, which are known to support recovery should be part of a range of accessible options that are available to people seeking help.

Over recent years there has also been a significant and sustained increase in people seeking diagnosis and support in relation to neurodivergence including autism. Improvement in mechanisms that ensure people are able to receive the right help in a way that works for them is also a priority outcome for Scottish Government. To achieve that goal, the Matrix supports psychological therapies and interventions being adaptable to individual needs, through the good practice guidance. These remain underpinned by the best evidence available and informed by expert guidance, in collaboration with people with lived experience.

National Strategies and Policy Context

The Matrix is part of a range of responses which will contribute to the ambition of the Scottish Government (2023) Mental Health and Wellbeing Strategy.

In particular

The importance of access to ‘timely, effective support, care and treatment that promote and support people’s mental health and wellbeing’ is an overarching summary outcome in the new Strategy. With a priority being the ambition to ‘improve mental health and wellbeing support in a wide range of setting with reduced waiting times and improved outcomes for people accessing all services, including Child and Adolescence Mental Health Services (CAMHS) and Psychological Therapies’, The Matrix remains a key resource to support this.
This strategy also prioritises prevention and early intervention as key elements of improving the overall mental health and wellbeing of the population. Where available, evidence on prevention and early intervention are included in the updated evidence summaries. In addition, the NES/SG Early Intervention Framework, offers an accessible summary of early intervention and prevention programmes for children and young people.

A lifespan approach reflecting stages in life underpins the SG (2023) Mental Health and Wellbeing Strategy. This reflects the importance of understanding the changes in people’s needs across their life. To support this The Matrix has been designed to summarise the available evidence base for psychological therapies and interventions across the lifespan.

The move towards integrated health and social care as outlined in the Public Bodies (Joint Working) (Scotland Act) (2014) has gathered pace over the intervening period and this landscape needs to be reflected in the Matrix. Therefore, this Matrix resource should be helpful to practitioners delivering psychological therapies and interventions in a wider range of contexts such as care homes, schools and 3^rd sector settings.

The Scottish Government (2023) National Specification for The Delivery of Psychological Therapies and Interventions in Scotland describes what the public should expect when accessing psychological therapies and interventions and is an essential benchmarking tool for quality that should be read alongside The Matrix. The outcomes in the national specification state what people should expect when accessing psychological services, and the expectations of teams and services that offer psychological practice. This is to enhance quality of service delivery, and to support access to psychological therapies in line with the Public Health Scotland 18 weeks referral to treatment standard.

Public Health Scotland have re-issued the Psychological Therapies and Interventions Waiting Times Standards definitions guidance document to improve accuracy of reporting against the Psychological Therapies waiting times standard. It applies to all psychological therapies and interventions delivered by the range of professionals as set out in the national PT Specification. It does not change the Waiting Times Standard which states that at least 90% of people start treatment within 18 weeks of referral for PT. The PT waiting times guidance states that it applies to all ages and should be measured by all staff trained at enhanced and specialist practice. To meet the standard, psychological therapies and interventions should be delivered in line with both The National Specification and The Matrix.

A Diverse, Skilled, Supported and Sustainable Workforce

The Matrix contributes to this by outlining what the psychological services workforce should be able to deliver to ensure best possible outcomes for those using services. The Matrix also describes the training, and supervision required to ensure psychological therapies and interventions are delivered in line with the best available evidence and outline the range of options that should or could be open to them as well as how it can be delivered, for instance, in person, online or via the telephone or using a technological platform such as an app.

For staff to deliver high quality care they need to have their wellbeing supported. This reflects the ambition of The National Workforce Strategy for Health and Social Care in Scotland to achieve the goal of ‘a sustainable, skilled workforce with attractive career choice where all are respected and valued for the work they do’.

The workforce has been under increasing pressure across the last decade in the face of austerity and pressures created by the COVID-19 pandemic. This is reflected in the growing evidence of deteriorating workforce wellbeing and ultimately this can be an influencing factor in recruitment and retention.

Staff wellbeing overall will be complex and reflect individual, organisational and relational elements, but should be a core concern. Planning to support this will require both proactive (preventative) and reactive (responding) strategies to be in place. Our workforce is our key resource, and we need them to be ‘present and well’. Additional information and support are available from The National Wellbeing Hub or from NES Wellbeing Sway.

In Scotland, there has been an expansion in the size of the workforce who can deliver psychological therapies and Child and Adolescent Mental Health Services (CAMHS). This has been supported by increased places for training in a number of existing training programmes including the Doctorate in Clinical Psychology and Masters in Psychological Therapy in Primary Care for adults and Masters in Applied Psychology for Children and Young People. Further innovation in the expansion of skill mix and different levels of knowledge and skills, through training programmes reflecting the range of needs in the population has included the recent development of Enhanced Psychological Practice Programme (EPP). In addition to the workforce in traditional core roles in psychological services there continues to be investment in training and supporting other workforce members to deliver evidence based psychological interventions as part of wider roles in an increasing number of contexts (e.g., school nurses delivering evidence-based anxiety management programmes).

These innovations are essential to continue to meet demand. Evidence supports the importance of delivering psychological therapies and interventions in line with the published evidence base and means that robust training, implementation and governance are required to lead to best outcomes for the populations via services that are delivered safely and effectively across all sectors.

Best Use of Data and Evidence in Policy and Practice

Effective services should be both good users and consumers of research and evaluation but also contributors to the evidence base. A thriving research culture which can improve routine practice and support innovation will produce best outcomes for people using services, where this is partnered with careful evaluation and local governance. High quality, accessible and informative workforce data is a key element for future planning for training and workforce development.

Technology enabled options

There is also an increase in remote and technology enabled care and treatment options. The move towards a blended approach in service delivery with an increased contribution from digital or online options alongside more traditional face to face delivery is something that was underway prior to March 2020 and has been accelerated by the COVID-19 pandemic. This evolution will be reflected in this guidance.

The Matrix review has considered the evidence for delivery of psychological services using technology enabled approaches such as screen to screen, or on the phone (which usually involve similar therapist interactions as traditional face to face treatment) or using digital services such as evidence-based apps or websites which can be accessed as self-help resources or guided/supported self-help. The findings are clear that screen to screen therapies are effective, accessible, and sometimes cost-effective ways of delivery, although careful consideration is needed in terms of choice and barriers to access such as digital literacy and costs of access. https://www.nes.scot.nhs.uk/media/ud0ijhyo/digital-delivery-guidance-report-final_09-04.pdf .

Websites/digital programmes and apps identified though robust evidence review can also make an important and effective contribution. Evidence highlights that outcomes for people using these digital approaches is improved through availability of a trained workforce member who can provide support, guidance or signposting. Where evidence is available on such programmes this has been incorporated into the Matrix evidence tables. It is anticipated that this will continue to grow in the future.

Values and National Principles

Safe and compassionate delivery of psychological therapies and interventions by staff who can build and nurture relationships with people accessing services are a critical element of successful outcomes and this will be directly guided by the National Specification for The Delivery of Psychological Therapies and Interventions In Scotland. Service should also be delivered by a workforce which is trained and supported to be aligned with the values and principles that are expected by the Scottish population and outlined by the Scottish Government (2023) Mental Health and Wellbeing Strategy 10 core principles.

Underpinned by Human Rights approach - this is about making sure that people’s rights are at the centre of practices and services.
Aligned with the United Nations Convention for the Rights of the Child (UNCRC), Getting it Right for Every Child (GIRFEC) provides Scotland with a consistent framework and shared language for promoting, supporting and safeguarding the wellbeing of all children and young people. Getting it Right for Everyone (GIRFE) is currently being developed nationally.
Person-centred care is about ensuring the people who use our services are at the centre of everything we do. The workforce across health and social care and wider partners should work together with people to tailor services to support what matters to them. Care should be personalised, sensitive to protected characteristics, culturally competent and adapted for neurodiversity. People should be supported to make choices, manage their own health and live the lives they choose, where possible.

Trauma Informed and Responsive services - the Scottish Government and Local Authorities (COSLA) have supported a joint commitment to trauma informed and responsive workforce nationally. This recognises specific barriers to accessing services that people who have experienced trauma often face, which can be overcome using trauma informed principles for service design and delivery. Trauma responsive services provide evidence-based approaches to reducing the impact of trauma on the lives of affected people. This is an important contributor to a range of priorities in Scotland including the ambition laid out in The Promise for babies, children and young people with care experience. Trauma informed and responsive services are all a key principle of the Scottish Government (2023) Mental Health and Wellbeing Strategy

Partnership with people with lived experience - enabling the norm of an active, valued role in the planning, design and evaluation of services is key.

People with lived and living experiences were involved in shaping the content and design of the Matrix guidance and we will have this as a critical element of the process going forward.

Whole system approach – effective working between and across services and sectors will be key to good outcomes. Whole systems approach requires collectively understanding the issue and the systems around this and creating a plan for action collaboratively with a wide set of stakeholders.
Driven by data and evidence- evidence based practice (EBP) - ensuring that the right intervention or therapy is offered at the right time and in the right way is essential and this is particularly the case in public services where effectiveness and safety are critical determinants of resource investment. However, evidence-based practice should also be delivered in collaboration with people who are accessing service based on an informed choice.

Evidence Based Practice requires 3 elements:

The skills and expertise of the practitioner through the application of appropriate clinical competences and in the context of careful governance and oversight from the system they work in. This means the availability of appropriately trained and supervised staff with access to additional expertise and organisational guidance where required for effective decision making.
Decisions informed by the best available research evidence as outlined in The Matrix and other evidence sources and guidance.
Alignment with the needs, values and priorities of the person receiving the service. This is shown in Figure 1 Evidence based practice for delivery of Psychological Therapies and Interventions below.

(based on) Sackett, DL et al British Medical Journal 1996; 312 (7023): 71-72

Lifespan informed

Services and practitioners must be able to deliver services and psychological therapies and interventions which are adapted to reflect different stages of life. For instance, delivery of effective psychological services should reflect the developmental needs of children and young people considering both the normal needs across the population but also the specific needs of the individual and their family. Services should also be responsive to context and specific requirements of those in adulthood and later life, where this is appropriate.

Outcomes focussed and Routine Outcome Monitoring (ROM)

The goal of effective and efficient services is better outcomes for people accessing psychological therapies and interventions in Scotland. An outcomes focussed approach is a key component of that. For psychological therapies and interventions, this should include Routine Outcome monitoring, using validated tools and supported by a digital system which can provide responsive feedback to clinicians or practitioners and people using services. This can support evidence-based decisions in a stepped or matched care system where critical decisions need to be made about ‘stepping up’ or ‘stepping down’, that is changing treatment to adjust to response and individual needs across time. ROM is also important as we increasingly understand and respond to any adverse response to psychological treatments.