Introduction
Method
Results
The Current Status of Implementation in the NHS
Implementation Barriers and Facilitators
Exemplars of Implementation in Practice
Area | Summary of development | Implementation barriers | Implementation facilitators |
---|---|---|---|
Exemplar 1 | Classes intermittently available in community mental health teams since 1999 | Lack of strategic direction and leadership | Proximity to a mindfulness-based training and research centre |
MBCT service depends on enthusiasm of particular clinicians and therefore ceases when they move post | |||
Health board reorganisation leading to strategic uncertainty | Grassroots enthusiasm from clinicians who want to offer MBCT classes to their clients and who are willing to give their personal time to ensure they happen | ||
Inclusion criteria broadened to include anxiety and depression-related disorders | Funding constraints which limit the provision of training | ||
About 24 classes delivered providing a service to 276 clients | Clinicians who are trained in MBCT were not given protected time to deliver classes | Staff willingness to self-fund their training | |
One pilot class delivered and researched in primary care setting in 2010—research underlined its effectiveness for patients and that referrers valued the provision of the service for their patients | Organisational preference for individual rather than group interventions | ||
Exemplar 2 | Started as a solo therapist offering MBCT classes (2003–2005) and then offered by two teachers as part of an MBCT research trial (2005–2007), which led to MBCT being commissioned as part of primary care mental health provision (2007–date) | No strategic plan that included MBCT nor careful consideration of depression care pathway | Over time (5–10 years) becoming known regionally for providing MBCT (with GPs and other services) |
Research context provided resource for training teachers and setting up services | |||
Excellent relationship with NHS primary care mental health commissioners | |||
Staying close to the MBCT treatment manual and ensuring referrals and patients were appropriate | |||
Routine reporting of acceptability and outcome data | |||
The university established a training programme in 2008 which has led to a larger pool of MBCT teachers who are now offering MBCT/MBSR in a range of settings across the region, including MBSR staff groups, mindfulness groups for carers and mindfulness groups for people with chronic physical health problems | MBCT teachers in the NHS unable to secure funding for training | Care over selecting committed, competent teachers | |
Care over selecting committed, competent teachers | |||
Supporting teachers in their learning | |||
Former MBCT participants have acted as advocates of the service with GPs, the local media and commissioners | |||
Ongoing reunions 4 times a year for all former MBCT participants is highly motivating both for participants and teachers | |||
Exemplar 3 | Part of trust wide strategy to increase access to psychological therapies | Limited resources—demand for the classes is greater than can be provided for by currently trained staff; lack of money for CDs, books and photocopying and printing | MBCT being in the NICE guidelines |
Strategic trust-wide approach with clear management structures | |||
Practical constraints (e.g. limited availability of teaching rooms) | Trust-wide strategy group consists of clinicians who are trained in MBCT and therefore understand the requirements of the teaching process | ||
Development of critical mass needed to deliver MBCT to patient groups integrated with provision of mindfulness training for staff for personal and professional development | Competing clinical and management demands of individuals who lead the strategic direction of the implementation process | Strategically influential staff have trained as MBCT teachers and act as champions to facilitate the implementation process | |
Since 2008, 12 client groups serving 105 patients and 8 staff groups serving 65 staff have been delivered | The challenge of scheduling the MBCT 8-week course within the constraints of other service demands and staff holidays | Provision of staff taster, professional development workshops and conferences on MBCT | |
Collaborating with Bangor and Oxford Universities to develop staff MBCT teaching expertise | Debates with psychiatry over the meaning of recurrent depression | Positive feedback from patients and staff who have taken the class | |
Target patient group is those vulnerable to recurrent depression | Increasing media interest in mindfulness | ||
MBCT special interest group for staff is in place | Outcome data being collected on patient classes | ||
Exemplar 4 | Government run body has developed a strategy for implementing evidenced-based psychological therapies across the region. MBCT is part of this because of its recommendation by NICE | Occasional lack of support from local management which is usually easily addressed because of the presence of a central strategy | Central strategic lead enabling a regional focus for development |
Systematic process of building capacity in MBCT teaching skills has been in development since 2005 | Recent budgetary constraints in the NHS have reduced time that trained MBCT teachers can dedicate to the teaching development | Trained MBCT/MBSR teachers had strategic influence within government and so championed the development of central initiatives | |
There are now NHS clinicians trained to deliver MBCT within most areas in region | Budgetary constraints for staff training process | Two implementation leads are paid centrally to take a strategic view of the process of training, supervision and implementation | |
Referral criteria for classes have been broadened to include anxiety and depression-related disorders | A regional forum of mindfulness leads from each locality is in place | ||
Work has taken place on specifying standards for both teachers and supervisors | Supervision courses for experienced mindfulness teachers are being delivered to ensure that good practice provision of supervision for teachers can be met | ||
Evaluations of all mindfulness activity (patient MBCT classes and staff teacher and supervisor training) are routinely collected |
Discussion
Guiding principles | How this relates to MBCT |
---|---|
Research needs to be translated | - Make local decisions about target populations/inclusion/exclusion criteria |
- Base decisions on definitive and emerging MBCT evidence for MBCT and on local service priorities | |
- Research needs to be accessible to services. Typically, this involves tailoring the research and consensus development at a local level | - Consider and map out how new MBCT service will sit alongside existing care pathways |
Ownership is critical | - Engage key stakeholders in service planning and commissioning |
- Ownership of the research or of the implementation process is likely to positively affect uptake | - Offer taster sessions/intern places for stakeholders to communicate MBCT's aims and intentions |
- System based, top-down approaches that “force” research use in organisation can negatively affect uptake | - Support grassroots interest through experiential opportunities to take mindfulness classes |
- Develop local networks for interested clinicians and stakeholders | |
Enthusiasts are key | - Identify one or more “champion(s)” with adequate knowledge and access to key networks |
- People who are enthusiastic about the issue/topic/practice can act as champions and promote new ideas | - Champions are needed both within the organisation and external to the organisation |
- Former participants in MBCT classes can be compelling advocates | |
Conduct an analysis of context | - Analyse local context to identify implementation barriers and facilitators |
- An analysis of the context of implementation prior to designing the strategy can facilitate a particularised approach through the targeting of local barriers and facilitators | - Set up an implementation steering group to systematically address local barriers and facilitators in the range of challenge areas and to develop and oversee the new service until it is fully embedded |
Ensure credibility | - Ensure that key evidence and national guidance on MBCT is clearly conveyed to staff by a credible champion |
- Research use is enhanced by credible evidence, credible champions/opinion leaders and a commitment to process | - Set up appropriate and realistic service evaluation |
- Ensure evaluation data are routinely collected and reported to key stakeholders | |
Provide leadership | - An overall MBCT service lead is required who can provide clear leadership |
- Strong and facilitative leaders at project and organisational level can lend strategic support and authority to the process | - Leadership is needed on a strategic and a clinical level |
- Strategic leaders within the organisation's management should ideally have experiential understanding of MBCT | |
- Clinical leaders need in-depth training in MBCT, so they can teach the course and support other staff in developing their skills through supervision and mentoring | |
- Leadership on good practice governance is needed using national guidance and contextualising it locally | |
Provide adequate support/resources | - Identify appropriate and adequately trained staff to run MBCT classes who at minimum meet the UK good practice recommendations (UK Network 2011) |
- Implementation needs adequate resources and support including financial, human (dedicated project leaders) and appropriate equipment | - Using epidemiological data, it is estimated that a population of 200,000 would need 2 full-time MBCT teachers to provide a service (Patten and Meadows 2009). If the service is being offered to a broader client group that is recommended by NICE, then more teachers will be required |
- Support and cultivate competent MBCT teachers | |
- Support and cultivate (though the classes and reunions) former MBCT participants | |
- Secure staff time to prepare and run classes | |
- Secure staff time for screening, assessment and orientation of participants | |
- Secure staff time for providing some individual participant support between sessions in person or via phone, text or email | |
- Put in place required training, supervision for ongoing development and adherence to good practice standards | |
- Ensure that a fit for purpose room is available | |
Ensure that an ongoing supply of meditation recordings and participant handouts is available | |
- Secure administrative support for setting up classes and preparing class handouts | |
- Ensure that equipment for sessions is available | |
Develop opportunities for integration | - Integrate MBCT implementation strategy with local and national strategies for increasing access to psychological therapies |
- Activities, changes and new practices need to be integrated into the organisation's systems and processes to enhance their sustainability. Initiatives that fit with strategic priorities are more likely to be given/allocated adequate resources and support | - Identify appropriate imperatives for MBCT, such as the NICE depression guidance, health economic data or local strategic initiatives |
- Establish a service pathway from referral through to discharge and communicate this effectively to all stakeholders | |
- Cultivate relationships with referrers | |
- Enhance service sustainability by promoting it and integrate it with other strategic priorities |