Whilst recently writing an award submission, I was reminded by a colleague at Berkshire Healthcare about one of the most successful national transformation programmes the NHS has ever achieved, which will probably be unknown to most and a surprise to the rest: Improving Access to Psychological Services (IAPT).
Ten years ago, IAPT was launched to address the issues around capacity, waiting times and inconsistencies in service provision for people seeking treatment for common mental health problems, such as depression and anxiety. Across geographies, there were significant staff shortages, waiting times consistently over 12 months and a system straining to the point of collapse. There was no alternative but to redesign it from the ground-up.
A decade further on and waiting times are now an average of eight to twelve weeks, recovery rates above 50% and the programme has since been expanded to cover children and young people. This way of working has also been exported to other countries and achieved such ‘recognition’ that the NHS Long-Term Plan has set out to invest further, ring-fence spending and increase referrals by 380,000 per year by 2023/24.
So, when many of the NHS Test Beds, new Models of Care and other innovation initiatives have not gained the national momentum that was expected and hoped, what are the key ingredients for success? What can we learn and apply elsewhere?
Workforce transformation: There were not enough trained therapists and so a new grade was developed specifically to help treat people with mild to moderate anxiety or depression – the Psychological Wellbeing Practitioner – which required a year-long training course, not the 3-year minimum of some therapy courses and more often 5+ years. At the time, this was a controversial approach and received a significant amount of challenge from people and organisations taking a protectionist stance. Yet, the new role of Psychological Wellbeing Practitioner has been successful, and they now assist with screening, assessment and providing manualised treatment approaches, such as guided self-help, group therapy and low intensity Cognitive Behavioural Therapy.
Mandatory data recording and outcomes: To demonstrate the impact of this entirely new way of working, a minimum dataset was established to baseline its effectiveness. This was mandatory and services needed to submit data electronically in order to receive funding. Using standardised assessments before and after therapy, along with other key factors, allows the impact, effectiveness and return on investment to be calculated and incorporated in service design and workflow from start to finish.
Digital as business-as-usual (BAU): Like primary care, there is almost industry-wide electronic medical record (EMR) adoption using systems such as IAPTus (provided by Mayden) and PCMIS. This is a technology-enabled workforce and whilst more can be done – for example, training courses should include modules on using digital technologies – the use of electronic systems and the latest digital innovations is part of day-to-day practice and now the standard.
Digital first approach: Digital therapeutics or online therapy is now seen as part of the main treatment approaches for IAPT. Services like SilverCloud, that provide a digital mental health platform with over 30+ programmes and modules, is now used by over 70% of IAPT services and has treated over 275,000 people. Some IAPT services have taken this even further and use SilverCloud (http://www.silvercloudhealth.com/) and its self-sign-up portal as the front door to the service, requiring people to go through the programme before other approaches are considered. This digital first approach, similar to the way other sectors have digitised, e.g. banking, shopping, customer care, increases capacity and outcomes even further.
Defined and recurring budget: Whilst it is recognised that capital funding is required to kickstart transformation, the long-term financing through a dedicated annual allocation is key to success. More recently, commissioners in CCGs are funding digital therapy on behalf of IAPT service providers to ensure a sustainable approach is delivered.
Outcomes and evidence: Eleven out of the seventeen solutions recognised as the highest grade of impact and evidence (Tier 3B) on the new NICE Evaluations Framework for Digital Technologies are mental health. This is the most researched area of digital health with well-defined methodologies and proven effectiveness. The area of digital therapeutics is now well known and yet little heard of and certainly many of the techniques used are not being replicated elsewhere.
These might seem obvious and key ingredients for success and yet IAPT is one of the very few areas to apply them at scale and on a national basis – so why is mental health seen as an ‘island’ of innovation away from mainstream digital projects? We should be using IAPT as a beacon of best practice and teach the other parts of health and care how to digitize different pathways. Mental health itself needs to expand the digitisation to include entire populations.
The problem with big health IT projects is that it is often assumed that technology is the only thing required. Of course, technology is key to transformation but without the other key ingredients it fails to be embedded.
It is with these key ingredients in mind, that SilverCloud is partnering up with the NHS and other organizations to provide a digital mental health platform that integrates easily with existing systems such as IAPTus, PCMIS and others to enhance and existing workflows. This allows for easy data collection, assessment, and cost-effectiveness analysis.
Our new subscription model (www.oneplatformoneprice.com) allows scale to be achieved and to take a population providing a cost-effective way to deliver mental health care at scale across the continuum of experience, with up to 70% clinically significant recovery rates.
SilverCloud has also been working closely with academic institutions to help train the next generation of Psychological Wellbeing Practitioners to ensure that they are comfortable with the effective usage of digital tools."
In summary, I believe that the focus, attention and ‘limelight’ that mainstream large-scale health IT programmes receive should be shared with digital mental health and not forgotten or seen as a specialist area, irrelevant to core service delivery.
Finally, it is worth acknowledging that I am, of course, painting an incredibly rosy picture of IAPT and there are many issues that need addressing, which I shall write about later. Nonetheless, l these are lessons worth sharing. Let’s give digital mental health the voice it deserves.