The head of Lincolnshire’s steps2change service tells PublicTechnology about its use of online CBT and how the digital therapy landscape might evolve
Launched in 2008, the Improving Access to Psychological Therapies (IAPT) programme has had a transformative effect on the NHS’s provision of adult mental-health services in England.
Successive governments have continued to expand the programme, which now treats more than 900,000 people each year. There is a target to expand this to 1.5 million by the 2020/21 year, with recent NHS guidance effectively mandating IAPT services to offer talking therapies not only to those referred for mental-health problems, but also to patients suffering from long-term physical health conditions, such as diabetes or chronic obstructive pulmonary disease, and “medically unexplained systems”.
As IAPT’s remit expands and its targets rise, one way of ‘improving access’ to the treatments it provides is to employ the use of technology.
The steps2change IAPT service is part of Lincolnshire Partnership NHS Foundation Trust, a specialist trust for helping people with mental-health conditions and learning disabilities. The IAPT team serves the 700,000-plus citizens of Lincolnshire, and also works with patients from other parts of the East Midlands.
For the last three years or so, steps2change has incorporated an online offering in its provision of cognitive behavioural therapy – the cornerstone of most IAPT services.
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“At the time, the CBT waiting list was a bit longer than we wanted,” steps2change service manager Nick Harwood tells PublicTechnology.
Nearing the end of the fiscal year, the service had a small chunk of budget available to invest in the use of online CBT services provided by Ieso Digital Health – a Cambridge-based company that works with health insurers and employers, as well as with NHS clinical commissioning groups in places such as Camden, West Kent, and East Riding of Yorkshire.
“They have a track record in delivering CBT, and it is all qualified therapists who understand IAPT,” Harwood says.
The service offered by Ieso is based on a live text-based web chat with a CBT therapist. It takes place in a “secure virtual therapy room”, the company’s website claims.
The nature of the therapy precludes its use for patients without who are not fluent in written English, as well as for those who lack access to a computer with a reliable high-speed internet connection – something that is not always a given in the rural parts of Lincolnshire, according to Harwood.
But a digital service does bring some singular benefits, he adds.
As well as allowing steps2change to offer treatment at evenings and weekend, online CBT also has the potential to provide a more permanent record of sessions, when compared with a 60-minute conversation – some of the finer points of which might be forgotten in the hours and days that follow.
“One of the benefits is that patients get full transcripts after the session has ended, which can help remind them of the things that have been suggested by the therapist,” Harwood says. “But the main factor is the flexibility around times, and the ability to sit in the comfort of your own home – as people can still find visiting a centre stigmatising.
“But it has to be right for the patient, and there is never any pressure to use it.”
A range of talking therapies are offered by steps2change, including CBT, counselling, and interpersonal therapy. These are used to treat patients with conditions such as depression, anxiety disorders, phobias, obsessive compulsive disorder, and post-traumatic stress disorder.
CBT is a talking therapy that, according to the NHS, “is based on the concept that your thoughts, feelings, physical sensations, and actions are interconnected”. The therapy aims to help patients get out of negative thought and behaviour patterns by making small, discrete changes in their daily lives.
Low-intensity CBT courses offered by the NHS feature somewhat less one-on-one therapy, and a greater amount of guided self-help. They are is used to treat mild to moderate anxiety and depression. High-intensity treatment courses are typically longer, and are used for more acute conditions.
Online CBT has thus far been primarily used by steps2change to try and alleviate its waiting list for high-intensity treatments. About 150 patients wishing to use the digital service have been referred to Ieso each year, with around two-thirds of these going on to be deemed suitable to receive treatment. Last year, the Lincolnshire IAPT service also trialled the use of online CBT with about 50 low-intensity patients.
A contract to deliver online CBT to 100 people across the county this fiscal year is shortly to go back out to tender, with potential bidders invited to respond to a recently published prior information notice.
Harwood says that, while it has offered text-based therapy to date, steps2change is open to hearing from any qualified providers – whether they represent the NHS, or the private or third sectors – and would consider video- or voice-based options, if applicable.
“One of the benefits… is the ability to sit in the comfort of your own home – as people can still find visiting a centre stigmatising.”
Nick Harwood, steps2change service manager
Indeed, the service has recently taken on a therapist who will be trained in offering therapy via Skype, a treatment option which steps2change intends to trial over the coming months.
The service also uses a number of computerised CBT programmes, in which patients can work their way through low-intensity online courses, while receiving weekly supervision and guidance sessions from therapists.
Digital offerings may have a greater role to play in therapy-provision in the years to come, Harwood believes, particularly as IAPT services are increasingly called on to treat patients with long-term physical conditions.
The NHS is also currently working with the National Institute for Health and Care Excellence on a two-year programme to assess 14 different digital therapy products for possible use in the delivery of IAPT services – a process in which steps2change is taking part, Harwood says.
But, as is currently the case with CBT patients in Lincolnshire, technology will always remain a supplement to the hard work and clinical expertise of therapists.
Or, as Harwood puts it: “One of the fundamental aspects of any form therapy is the ability to develop a rapport between patient and therapist.”