Shared learning database

central North West London NHS Foundation Trust- Camden Provider Services
Published date:
January 2012

This submission relates to the implementation of depression screening for adults with Chronic Health Problems through the application of rapid cycle audit, supported by the local development of a depression pathway within a Community Rehabilitation Team.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of the project was to support clinicians in screening older adults with chronic physical health problems for depression through the implementation of NICE guidance. -To embed depression / low mood screening questions into our holistic initial assessment form. -To develop a clear pathway of care for people who triggered the need for intervention on the basis of the screening questions. -To build clinician confidence in screening for depression in older adults in a non-mental health trained workforce through training and education. - To deliver a quarterly report on the percentage of patients screened for depression.

Reasons for implementing your project

The incidence of depression in persons with chronic health conditions is 2-3 times for prevalent than in a healthy population (Egede 2007). In managing depression alongside chronic health problems, including sub-optimal depression, quality of life can be improved (NICE 2009). The remit of the Community Rehabilitation Team is to provide a short term community based rehabilitation intervention to adults with physical health problems. The basis of this intervention centres on the completion of an initial holistic assessment. The team is a large multi-disciplinary team comprising Occupational Therapists, Physiotherapists, Speech and Language Therapists, Rehabilitation Nursing, Dietetic support and Psychologists. Due to the presence of Psychologists within the team it is appropriate that clients with low mood are identified and assessed. Following publication of the NICE clinical guideline (CG91) 'Depression in Adults with a Chronic Physical Health Problem', 3 supplementary questions were added to the holistic assessment form: 1. Do you have a history of Mental Health Problems? 2. Over the past 2 weeks have you often been bothered by having little interest or pleasure in doing things? 3. Over the past 2 weeks have you often been bothered by feeling down, depressed or hopeless? Initial audit figures from August 2010 demonstrated poor compliance with completion of the 3 questions. From a sample of 95 clients, only 21 clients had been fully screened for low mood. In total, only 25% of clients had been fully or partially screened for low mood. Ref: Egede, L. E. (2007), 'Major depression in individuals with chronic medical disorders. Prevalence, and correlates and associates of health resource utilisation, lost productivity and functional disability', General Hospital Psychiatry, 29, 409-16

How did you implement the project

The improvements in screening for depression / low mood can largely be attributed to the team commitment to an ongoing audit process, coupled with ongoing training and development opportunities within the Community Rehabilitation Team provided by the team Psychologist. During a team meeting, the initial audit results were fed back to the team by the Psychologist and a re-audit was agreed. A core part of this session was a presentation on the NICE clinical guideline and the newly developed local depression pathway for the Community Rehabilitation Team. This session was followed up by email by the team psychologist. In order to avoid any potential barriers to implementation and improvement, the supplementary screening was kept to the 3 questions listed above. This was to avoid any sense of onerous assessment by non-mental health professionals. Information was made readily available on induction to new starters and all staff received a copy of the pathway in A5 size, to fit neatly into their work diaries. Rapid audits comprising of 20 sets of new client notes were then initiated on a quarterly basis with results fed back to the team and reported upwards to the senior management team. The rapid cycle approach to audit ensured that staff remained mindful of the requirement to complete the 3 questions on the holistic assessment form. No costs were incurred as part of this project.

Key findings

Following 2 cycles of audit, completion rates for the questions on the holistic initial assessment form are currently 88%. This is based upon a sample of 20 new client notes per quarterly audit. Following each audit cycle, the team is kept informed of the completion rates and are reminded to consult the pathway to ensure those clients who require further investigation and support are provided with the necessary care. This permits the team to manage appropriate cases rather than having to refer back to the clients General Practitioner, resulting in a more co-ordinated and cohesive client experience. As the percentage of clients screened for depression has been adopted as a clinical outcome measure against which the service is to be assessed, the rapid cycle audit will continue to monitor compliance with NICE CG91.

Key learning points

The major driver in delivering this improvement was the leadership and engagement of our Psychologist, Dr. Esther Hansen. In implementing an improvement such as this, it is important that staff do not feel overwhelmed or burdened with the perception of additional work. In containing the screening to 3 questions, and in providing a clear and simple pathway to guide staff in analysing the response, staff have not reported significant difficulty in delivering this improvement. It is anticipated that staff will continue to be engaged in delivering a holistic assessment and given the continual evolution of clinical guidance, the rapid cycle approach has proven to be a useful method of embedding changes to practice

Contact details

Helen Love
Clinical Specialist & Lead Physiotherapist
central North West London NHS Foundation Trust- Camden Provider Services

Primary care
Is the example industry-sponsored in any way?