Co-creating our own change model: the Sheffield model
University and College Counselling, March 2023

It is not surprising that the experience of delivering services during the pandemic led many services to reflect on their practice and delivery models. The teams delivering the services I led (LK), Student Access to Mental Health Service (SAMHS) and the University Counselling Service (UCS), agreed that it was timely for us to review our service vision and models. I believe this is a positive response to incredibly challenging times and I am grateful to our staff and senior management for the support they offered to help us take the process forward.

This article describes our journey and gives more detail about the feedback we received through a significant consultation process. It also introduces an outline of a refreshed vision for The University of Sheffield (TUoS) student mental health, counselling and psychological provision, and the actions we have taken to redesign our services.

We service a student population of 30,000 and have a combined clinical team of 10.5 FTEs, two Clinical Service Managers and one Head of Service.

Why change and what were the drivers for change?

Early in this development, we identified the following as key drivers for change:
– The increasing pressure on students, including the impact of the pandemic and the cost-of-living crisis, requiring new strategies for meeting the increased demand.
– The longer-term impact of the pandemic on patterns of demand and delivery models, including increased demand for digital delivery channels, increasing complexity of issues and pressures on NHS services.
– The institution had introduced a faculty-based Wellbeing Service (from March 2020, as a response to demand on our counselling and mental health services outstripping supply) and we wanted to understand how this had impacted on our clinical health services.

Preparing for change – was there a need?

– During March 2022, we engaged The Tavistock Consultancy to run ‘Managing and leading a change process’. This involved all our staff (clinical and non-clinical) in a two-day engagement, focusing on whether change was necessary and how to prepare for managing change going forward. There was a three-week gap between the first and the second day, offering staff the opportunity to reflect and integrate what had been covered on the first day.
– The sessions covered drivers and restraints for change, looking at the history of the services and how change had impacted on the service and staff in the past; considering what we had learnt from our past mistakes; failures and successes; stakeholder mapping; looking at where our strengths and weaknesses were; how and in what ways we could improve our stakeholder engagement/capital and, finally, dreaming up new services and looking at more realistic services/delivery.
– This was followed by a series of staff meetings, to give all our staff time to reflect on the two-day engagement.

The key outcomes from this process can be summarised as:

– The feedback from the consultants was that we had teams who were able and ready to change. Our team members are lively, energetic, passionate and care about their work and about students.
– There was an overall agreement that we were a service under constant pressure and that this pressure came from the level of demand from students and other stakeholders.
– Gatekeeping had become a necessary way of working, due to persistent increases in demand. This was not a satisfying way of working and was frustrating for us. Staff wanted to move instead towards more open and welcoming services that were able to accommodate and better meet the needs of the population we serve. Gatekeeping is a way of systems coping with overwhelming demand on the system.
– There was concern and confusion over our service name and branding. Were we SAMHS and UCS? Which logo did we use and when? Were we an integrated service or did we need to separate out and be two different services with two different entry points?

Importantly, there was a high degree of agreement across team members about the challenges ahead and a vision for the future. Critically, both the consultants and the management team were convinced that there was a strong willingness to cope with the challenges for change. 

Moving our focus outwards – listening to our key stakeholders

During the period March to July 2022, we sought out and listened to the views of our stakeholders:

Views of university staff stakeholders

We sought the views of a wide range of staff in other university-based services. This included sending a questionnaire to staff in other support services and across faculties.

Summary from staff stakeholder feedback

It was clear from this consultation that, overall, what we offered was greatly needed and appreciated. There was some agreement between respondents about the need to improve how we communicated, including changing the style and frequency of our communications. Some respondents commented on where we were positioned in the organisation, who we worked with in other support services, and how we interacted with our colleagues at faculty level. As in any consultation about mental health provision, waiting times are generally raised as an issue, irrespective of the length of wait. The following is a breakdown of our average wait times for the last five years.

Summary from service user – student feedback

Overall, it was gratifying to learn how positive students were about their experiences of the service. However, it was clear from the feedback that there were a number of opportunities for us to redesign our service and to take account of the priorities students were highlighting. While speed of access was important, continuity of care was consistently rated as more important. Confidentiality was rated as highly important. This is critical if students are to have trust and confidence in our service. This contrasts to some extent with the feedback from our external staff stakeholders, where there was a desire to share more
information about our service users.

When asked: how can we improve our service?

The most popular idea was shorter wait times and faster support, followed by longer-term counselling, more specific and tailored therapy, and being clearer about our service offer.

When asked what we should offer that we don’t currently offer, the most popular idea was ‘longer-term counselling’. This caused us to reflect on whether we were seeing a shift in the narrative from concern about wait times to an appreciation for longer-term interventions.

Anecdotally, what we know is that students find it difficult, having waited to see a clinician, to then receive a limited number of sessions. It is clear from this feedback that our students wanted some continuity and longer-term involvement with our service.

Furthermore, some students who waited for a triage were then told they needed a different service, for example, Welfare or Disability services, which meant our current system potentially delayed their access to the most appropriate service.

Summary of feedback from our stakeholders external to TUoS

We talked informally to key external stakeholders, including NHS staff and third-sector mental health services.

We were pleased with the level of positive comments about our services and the overall view that significant change was not required from an external perspective.

Of note was how welcomed our Mental Health Guidance and Liaison desk was as an important single point of contact and for guidance and information sharing. It offers internal and external staff and concerned others a single point of contact with the Student Mental Health Team to discuss concerns in relation to a student’s mental health and wellbeing.

UCS and SAMHS

Average waiting time for an initial appointment or triage

2021/22: 20.2 days (up to and including 29 July 2022)
2020/21: 17.1 days
2019/20: 12.4 days
2018/19: 6.2 days
2017/8: 5.3 days

The other notable point was that we should continue to have absolute clarity about the role of NHS mental health services, and the importance of clear and timely referrals when students require that level of support. As a civic university, we take our responsibility to our local community very seriously. Local NHS mental health and psychological therapies services are already over-stretched. If we compare the social determinants of student health to that of our local population, it offers a clear rationale as to why other sections of the population are rightly prioritised over and above our students. We accept this means that when referring into the NHS, we need to be mindful of this and exhibit some degree of patience.

Visioning a way forward – key themes and action points taken

Communication, identity, branding and service definition

In the main, this issue was highlighted by both staff within our service, and staff more widely across our institution, as well as our colleagues within the NHS and third sector. There was a need for the service to have a clearly defined service remit, which considers how it fits and operates with other internal and external service provisions. Communication about the service and its remit needed to be clearly and consistently communicated to staff. The primary focus had been on ensuring that students know about the service and that it is accessible. However, we now needed to work on ensuring internal and external colleagues understand more about the service, our remit and how students can access us, as well as the purpose, function and role of the Mental Health Guidance and Liaison Desk. Redesigning and delivering our service offered a good opportunity to ensure information about our service is widely distributed. Since the start of term, we have undertaken a ‘roadshow’ to several departments and services, highlighting our new service redesign.

It is also worth considering how communication takes place, particularly to faculties. We believe that there is significant value in a joined-up approach, whereby faculties learn about what is on offer across all services, rather than focusing solely on individual services, thereby limiting colleagues’ understanding of the connections or interactions between all available services – both inside and outside the university. Actions under this point will be addressed later, under confidentiality and information sharing. 

Actions taken – communication, identity, branding, service definition

We drafted a refreshed vision and service definition, which is now in use, as a working model. It reads as follows:

Our embedded Mental Health, Counselling and Therapies Service is the mental health and psychological therapies provider for students at The University of Sheffield. As a comprehensive in-house clinical service, we provide a range of clinical interventions, consultation, community education, training, and conduct research into student mental and psychological health. Our Mental Health Guidance and Liaison Desk offers a key point of contact for internal and external colleagues to discuss students of concern. Our mission is to support students’ mental health and psychological wellbeing as they pursue their academic and career goals. Essential to this mission is fostering a welcoming and affirming environment which honours diversity, values individual and cultural differences and is trauma informed.

We revised the service structure name and branding, ensuring any branding and service definition were clear and easy to understand. Our service is now referred to as Student Mental Health, Counselling and Therapies Service. This service name is clear, descriptive and unifying. The titles of SAMHS and University Counselling Service have now been retired from use.

Going forward, we will use the following service structure terminology:

Service Name: Student Mental Health, Counselling and Therapies Service.
Teams:
– Mental Health Team
– Counselling and Therapies Team
– Service Support Team
– Research and Training Clinic Team

The service managers for each of these teams form a management team led by the Head of Service. The management team holds overall responsibility for the clinical governance and day-to-day operation of the service.

Confidentiality, information sharing and working with others.

As a service, we must hold a tension between service users’ needs and their right to confidentiality with non-clinical staff, who need to understand what care (if any) is in place. These staff are often seeking reassurance that the student is in receipt of support. There is also a clear need to support our clinical and professionally regulated staff to work within and uphold their professional ethics and codes of practice. There is a further need to uphold our legal responsibilities in relation to data protection, minimising the transmission of health information, given the stronger legal protection that is in place for this more sensitive information.

Actions taken – confidentiality, information sharing and working with others.

We were explicit about what and when any information is shared or not shared, and with whom, in our client contract and website.

We worked with the Director of Student Support Services to agree a confidentiality agreement, which covers both clinical and non-clinical services. This work took account of some current key documents:
– SPEQS toolkit¹
– BACP – UC and UMHAN Information Sharing
and Student Suicide report²
– Student Mental Health Charter³

We ensured that any changes to our confidentiality agreement support staff to work within their professional code of ethics.

Going forward, as an accredited service with Accreditation Programme for Psychological Therapies Services (APPTS), we will need to ensure these changes are cognisant of the APPTS standards.⁴ We have a new confidentiality agreement in place and this is now
being implemented across Student Support Services.

Increased demand – waiting times and access

The last academic year saw the highest number of students register for our service since the data have been collected. There is no evidence to suggest that this trend will change significantly. While we cannot be sure what is driving the increasing demand for our services, it does not appear that the introduction of the Wellbeing Service has reduced the demand for our services and there is a suggestion that, in fact, it may have increased demand because of increased focus and more access points for students to present for support. From our feedback, it appears there is a level of confusion about the purpose of different support services, how we work together and which services are accessed and when. This confusion has also resulted in a delay for both staff and students gaining the appropriate access to clinical advice or support. There is a significant piece of ongoing communication required to ensure that any concerns relating to mental health and risk land within our clinical service. The consultation raised issues relating to the need for service availability and a reduction in waiting times and making sure that processes do not unnecessarily restrict access. We must manage this tension against a background of static resources and increasing demand.

Actions taken – increased demand – waiting times and access

Introduce a self-referral form to ensure students don’t have an unnecessary wait for our service.

Following receipt of the screening form, we can assess suitability for counselling or other psychological therapy. The screening form can be reviewed and assessed within three working days, ensuring that students get to the right place more efficiently. Student feedback following triage frequently highlighted frustration about waiting for an appointment to then be signposted outside our service. This self-referral form seeks to help identify the most appropriate service in a timely way, ensuring we see students who will benefit from our service.

Continue to work proactively with the NHS and third-sector partners, ensuring we continue to build solid working alliances.

To cope, defend and manage demand out-stripping supply, we need to avoid creating a service that has unnecessary processes in place to cope with overwhelming demand. We need to ensure our processes are as clean as possible, while being transparent about the necessary limits to our service offer. This will require ongoing communications and stakeholder engagement with our NHS clinical colleagues, ensuring we have the necessary care pathways and relationship of trust to support escalating and de-escalating students who are at risk. We have already initiated embedding a trauma-informed approach within our service, and are rolling out this way of working across all support services. Embedding
this approach helps to ensure our service remains as accessible as possible. Taking a trauma-informed approach fundamentally moves services away from thinking about what is wrong with a service user, or, in our terms, a student, to thinking about what has happened to them. It focuses on realising how many people have experienced trauma and recognising how trauma can impact people and their behaviours/reactions. Services are organised and delivered to help people feel safe and empowered, and to build trust. When taking a trauma-informed approach, every interaction counts and has the power and capacity to both prevent any further activation of trauma, and to repair trauma. Taking this inclusive and relational approach enables the individual to develop and strengthen a coherent narrative about any trauma. Having a coherent narrative about our experiences is critical to enabling us to have a sense of self-agency and supports emotional resilience.

Refocus from speed of access to continuity of care.

Continuity of care is significant to the students who access our service. Our previous process focused primarily on ensuring speed of access. Going forward, we will ensure our service design has at its heart continuity of care. Figure 1 illustrates our new model of care. Sitting alongside this will be a new process to ensure a higher degree of continuity of care, allocating returning clients to the same clinician, unless students state otherwise.

Our model of care has at its heart our primary goal of helping students maintain their autonomy and develop their ability to thrive at university and in their lives. Our approach is trauma informed, using attachment-informed interventions, and we base assessment of need on risk and an internal attachment working model. We use the least intrusive and most effective interventions for symptom reduction, and students are offered continuity of care throughout their engagement with the service.

Embedded Student Mental Health Research and Training Clinic

We have developed a Research and Training Clinic to enhance mental health outcomes for students and ensure that we offer the latest evidence-based interventions for our students. This is a joint initiative between the Student Mental Health, Counselling and Therapies Service, the Clinical Psychology Unit and the Department of Psychology. The clinic aims to design, deliver and evaluate evidence-based interventions that contribute to improved mental health and academic outcomes for our students. Its specific goals include:
1) Offering clinical placements for doctorate Clinical Psychology students
2) Offering research placements for Psychology undergraduate and MSc students
3) Testing new ways of working to improve student mental health outcomes.

The clinic provides a central hub for a range of our ongoing research activity into student mental health and counselling effectiveness. Examples of our research projects include developing a toolkit to foster partnerships between university and NHS services Student Services Partnerships Evaluation Quality Standards (SPEQS), improving the quality standards of data collected in counselling services, and measuring student wellbeing during university transitions. Further information on the clinic and our research activity can be found on our dedicated research webpage.

Figure 1, Student Mental Health, Counselling and Therapies Service Model of Care

How is the clinic supporting and evaluating the changes?

Our vision is for the clinic to provide the necessary research and data to inform our decisions about future service change and staff training needs. Critically, it will provide a safe space to develop, pilot and evaluate new interventions, resources, measures and training, without directly affecting the day-to-day running of our service. We have already observed benefits from the clinic’s research activity and its ability to inform our service development. An example of this includes our current student summer research placement, which consulted staff from across all clinical and non-clinical support services to identify the service and staff training needs to better support students with complex needs.

Projects such as this will help to shape future and ongoing changes within our service. The clinic will support us in evaluating this scheme of changes and will offer an evaluation report by April 2023.

Conclusion and summary

We took care to respect and consider the feedback we received from our stakeholders. Starting in the summer of 2022 and continuing throughout this academic year, we intend working hard to ensure the changes brought about by our redesign are fit for purpose. Pulling this work together in a relatively short space of time is a testament to the hard work and teamwork within our services. Not for one second do we believe we have solved the insoluble problem of meeting the demands placed on us. Between the three of us, we have considerable clinical experience within HE. We unanimously agree that meeting all the demand is neither doable nor desirable, ie we hold in mind ideas about spontaneous recovery, autonomy and the importance of managing student expectations. By changing how we operate, we opened up effective lines of communication with both students and staff. This allows our clinical staff to be engaged in fresh and creative ways with their work and colleagues. We are too often confined and constrained by the walls of our consulting rooms, and stepping outside with a new message about ourselves has been revitalising.

We are left with a few questions on which to ponder. For several years, the perennial problem services such as ours have grappled with has been what to do about wait times. While we believe this will always be an important concern, we are seeing a shift in emphasis, as expressed by our students. They are concerned about both clinical quality and quantity – they need a reasonable number of sessions to reach a point of recovery.