Improving Outcomes through Digital Psychological

Therapies & Digital IAPT

Co-creating services: Integrating digital technology within traditional face-to-face services

Presenter: Grahame Smith

Structure of the Presentation

1. Consider within a digital IAPT context the notion of

co-production

2. Explore how digital IAPT services can be co-

designed to fit the medium of treatment: the

therapeutic relationship

3. Reflect on what a blended service, where

traditional therapies and the latest eHealth

methods are seamlessly integrated, would look like

4. Consider and explore a LJMU integrated approach

Evidence National Institute for Health and Care Excellence. The treatment and

management of depression in adults. London: UK: National National Institute for

Clinical Excellence; 2009. Report No.: NICE clinical guideline 23

National Institute for Health and Care Excellence. Computerised cognitive

behaviour therapy for depression and anxiety. Technology appraisal 97. London:

National Institute for Health and Clinical Excellence; 2006.

Hollon SD, DeRubeis RJ. Effectiveness of treatment for depression. In: Leahy RL,

editor. Contemporary cognitive therapy: theory, research, and practice. New York:

Guildford Press; 2006. p. 45–61.

Mitte K. Meta-analysis of cognitive-behavioral treatments for generalized anxiety

disorder: a comparison with pharmacotherapy. Psychol Bull. 2005; 131(5):785–

95.

Nathan PE, Gorman JM, editors. A guide to treatments that work. New York:

Oxford University Press; 2007.

Hersen M, Sturmey P, editors. Handbook of evidence-based practice in clinical

psychology, volume 2, adult disorders. Hoboken, New Jersey: John Wiley & Sons;

2012.

Potential Benefits

“Some Internet-assisted treatments achieve clinical

outcomes that are broadly in line with face-to-face

therapy (Andersson et al. 2014) but with a substantial

saving in therapist time. Because one of the main

mechanisms of support is asynchronous messaging,

the programs have the additional advantage that

patients can work on their therapy at times that are

most convenient for them (often evenings and

weekends) while therapists can continue to operate

during normal clinical hours.”(Clark, 2018:179)

Current Offer – NHS Apps

Ieso is an online course using instant messaging for

people with mental health problems. The confidential

service puts you in touch with a therapist trained in

cognitive behavioural therapy. The therapy is by text so

you can review your sessions at any time.

SilverCloud is an online course to help you manage

stress, anxiety and depression. You work through a

series of topics selected by a therapist to address

specific needs. The eight-week course is designed to be

completed in your own time and at your own pace.

Challenges

Are they cost-effective? (Richards et al., 2018)

GPs - lack of training and lack of awareness.

Favour guided approaches. (Breedvelt et al.,

2019)

Service users predominately prefer therapists

contact (therapeutic relationship). Materials not

individualised. Better than nothing (Perera-

Delcourt & Sharkey, 2019).

Dependent on technological & digital literacy

skills and preferences (Walsh & Richards, 2015)

The Real World

“The first generation of web-based DMH interventions

have consistently been found to be clinically effective

for common mental disorders, such as depression and

anxiety, in more than 100 randomized clinical trials

(RCTs) and meta-analyses, particularly when

accompanied by low-intensity coaching. However,

these real world implementation efforts have failed,

often because they are not used by patients or

therapists.”(Mohr et al, 2018: 113)

Design Factors

“A flexible programme structure, seeing visible improvement

and receiving help and guidance from an online supporter

encouraged participants to engage with the programme

material. As previously identified within the literature on online

counselling (Joinson, 1998; Fink, 1999; Richards & Viganò,

2013), flexibility and convenience are two common features

associated with internet-delivered therapy that provide the user

with a sense of empowerment and control in the therapeutic

process. Being able to set the tone and pace in which to

access the module content enabled participants to successfully

engage with the programme in a manner which suited their

lifestyle and busy schedules.”(Walsh & Richards, 2015)

Real World Fit

“We must be willing to design new digital

experiences that leverage unique

affordances of technologies and novel

insights they can help deliver. Digital tools

need to fit into the fabric of patients’ lives

and accommodate practitioners’ workflows”

(Mohr et al, 2017: 113)

Co-production

“The co-production concept is broad and can range from service

co-planning and co-commissioning, service co-design and co-

delivery, to co-assessment, co-monitoring and co-evaluation

(Bovaird and Loeffler, 2013). Central to this model of co-

involvement is the active contribution of service users that allow

services to be tailored while also empowering the contribution of

front-line healthcare staff (Needham and Carr, 2009). In the

mental health context, co-production has been reported to

assist in the delivery of services through the equal and

reciprocal relationship between professionals, service users and

their families (Slay and Stephens, 2013).”(Latif et al., 2017: 192)

Co-creation/Co-production

“When we compared the record definitions of co-

creation/co-production, we see that – to a large extent –

both are defined similarly. In both literature streams, citizen

are considered as a valuable partner in public service

delivery (e.g. Baumer, Sueyoshi, and Tomlinson 2011;

Cairns 2013; Bovaird 2007; Meijer 2011)… However, the

main difference in the definitions between co-creation and

co-production is that, in line with the work of Vargo and

Lusch (2004), the cocreation literature puts more

emphasis on co-creation as value (e.g. Gebauer, Johnson,

and Enquist 2010).”(Voorberg et al., 2015)

Co-creation & Living Labs

“The use of living labs (LLs) has emerged as a

popular way to support co-creation by creating use

situations as authentic as possible (Leminen et al.

2012; Bergvall-Kåreborn et al., 2009a). In

comparison to other co-creation methods, LLs

develop strong engagement and empowerment of

users (Bergvall-Kareborn et al., 2009a; Mulder et

al., 2008; Mulvenna and Martin, 2013; Niitamo et

al., 2006).”(Greve et al., 2018)

Living Lab Principles -

Cerbova, 2018

The Centre

The Centre is well-established living lab accredited through the

European Network of Living Labs (ENoLL). The centre is

actively working on research-to-innovation activities through

facilitating users/citizens to engage in a phased co-creation

process. The success of this approach was built on work of the

Innovate Dementia project, which was designed to accelerate

and enhance NW Europe’s capacity to innovate, through

facilitating the development, and sharing of knowledge based

approaches and best practices for people living with

dementia. Since the project completed the centre has widened

its activities to encompass different types of health conditions

including developing a meta-innovation approach - a city as a

living lab.

European Network of Living

Labs (ENoLL) Accreditation

The Centre is currently the only ENoLL accredited living lab in Liverpool City Region. Currently there are around 400 living labs globally, 200 are accredited. In the UK there are 21 living labs, 10 are accredited. The Centre is one of three health focused living labs in the UK (accredited).

The Role of Research

“Research will play a pivotal role in ensuring these

proposed changes are fit for purpose. However, due to

the real-life context of care delivery different types of

research approaches will have to be utilised, moving

away from a one-size fits all approach. This pragmatic

approach, using theory for utility sake rather than for

theory sake, will move research methods away from

just answering abstract questions to addressing real-

life need, a user-centric focus to research.”

(Smith, 2017: 1)

Pragmatic Research in

Action

“Research as innovation can take many forms; a living

lab approach will robustly structure this activity, an

approach used at the Centre for Collaborative

Innovation in Dementia. This approach, accredited

through the European Network of Living labs (ENoLL),

provides; “a user-centred, open innovation ecosystem

based on a systematic user co-creation approach

integrating research and innovation processes in real

life communities and settings.” (ENoLL, 2017).”

(Smith, 2017: 1)

Being Pragmatic

“This does not mean traditional methods are not

valued; they are valued where they have utility and

where they assist the practitioner to understand the

real-life meaning and experiences of the service

user (Greenop and Smith 2016).”

(Smith, 2017: 1)

Integrated Services

“… although generally effective in head-to-head comparisons in

research studies, not all psychological treatment formats are equally

popular on the uptake side in services. Options in IAPT include face-

to-face therapy, guided self-help using workbooks, reading

recommended books and computerised delivery. The latter may

involve either a ‘blended’ approach with face-to-face sessions taking

place alongside online content delivery, or else may be restricted

entirely to digital methods. While computerised CBT may appear to

be both an effective and convenient option for some people, uptake

appears low and dropout relatively high, with only a median of 56%

completing the full course. Because of the low uptake, this has led

some IAPT services stopping providing computerised CBT.”

(Brown, 2018: 1-2)

Multifaceted Model (Gask et al., 2012)

1. Community engagement: to better understand the attitudes and

beliefs of community members to develop more responsive and

sustainable services.

2. Primary care quality: Helping primary care staff to help patients

feel ‘listened to’, to gain more of a ‘shared narrative’ through

training in cultural competence and patient explanatory models.

3. Psychosocial interventions: Designing interventions that are

tailored to the preferences of underserved groups to increase

acceptability, whilst ensuring that core evidence-based

mechanisms are not lost.

(Brown, 2018: 2)

Listening & Co-designing (Rea & Smith, 2015)

Integrated Depression Care Pathway Project:

To explore service users views of their

experience of services for depression

To design an Integrated Care Pathway for

Depression

Partners

NHS England’s Cheshire and Merseyside

Strategic Clinical

Service users, carers, charities and healthcare

commissioners and providers

A mental health expert at Liverpool John

Moores University

Not a ‘perfect’ pathway

Project based on Ed Coffey model which he

called the Perfect Depression Care Pathway

People’s Voice member on the focus group

commented that what might be ‘perfect’ for

one person may not be for another, so it was

renamed the Integrated Depression Care

Pathway

Gathering data

Questionnaires were sent out to GP surgeries and services to find out specific pieces of information.

Service user Focus Groups were held across Cheshire & Merseyside to enable service users and others to complete specific questions to gather their views on

ohow they had accessed services

oand their comments on other aspects of their treatment and support

Service Questionnaire - Findings

Themes

Waiting times too long

Access difficult – physical location, times of services

Access difficult – referral process cumbersome and not

individualised

Communication between services problematic

The need for more services and smaller groups to include more

creativity in service provision

Greater publicising of services

The need for training of people providing services; particularly in

interpersonal skills and signposting

The predominance of what is perceived as ‘short term’

interventions

Results

The Model – A Collaborative process

The pathway has been designed by Liverpool John

Moores University and the Cheshire and Merseyside

Strategic Clinical Network’s Mental Health Network

in collaboration with; Cheshire and Merseyside

Service Users, Mental Health Providers, CCG

Mental Health Commissioners and Clinicians and

voluntary providers, Public Health England and the

North West Coast Academic Health Sciences

Network to ensure a whole systems approach.

Meeting Real Needs

The benefit of people living with depression being

centrally involved in co-creating an integrated

pathway is that the eventual solution is more

likely to be useful, useable, and compatible with

real needs (McKeown et al; 2006; Woods et al;

2013, Hanley et al; 2004; Evans and Jones,

2004).

Sustainability

Involving service users, commissioners and

clinicians and other key stakeholders in this project

facilitated the development of a needs led, value

and evidence based pathway which, it is hoped,

will inform the decision making process of the

commissioners when considering the funding of

mental health services for depression.

Six Dimensions

Safe - that individuals accessing services will feel physically and emotionally safe when being referred, using services and following discharge

Effective - that the individual using mental health services for depression will experience care that helps them on their road to recovery

Patient centred - that the individual and their carers will feel that they are part of a partnership when accessing services for depression and that their role in this partnership is the most important

Timely Care - that services will be available when they are needed, in a timely manner

Efficient Care - that services provided will meet need in a way that recognises individual need and matches this effectively with resources

Equitable Care - all individuals will have equal access to and uptake of services that meet their needs.

The Model - Principles

Meets the needs of the service user with depressionin a timely, collaborative and effective manner

Early identification

Primary care - Access to services – Secondary care

Service delivery; services need to continually evolve to meet individual need

(Zero Suicide) - creating services that are effective in assessing and responding to crisis quickly

Use of media

Coffey’s adapted principles

Safe Discharge - Wellness/recovery -the journey to recovery/ wellness is different for everyone

Integrated Service Recommendations

Reduce waiting times for referral to services, accessing services and then discharge (Safe and timely).

Develop systems which encourage easier and more open access to services (Efficient).

Involve carers more meaningfully (Safe and patient centred)

Increased access to psychological therapies (Timely and equitable)

Ensure that professionals are well trained and are able to engender optimism in a collaborative relationship (Effective, efficient and patient centred)

Provide services that foster collaborative relationships which value feelings and opinions of service users in a meaningful way (Patient centred)

Publicise services and options much more widely (Efficient)

Improve and ensure the availability of robust systems for the collection of mental health metrics and increase the local knowledge base

References Breedvelt, J.J., Zamperoni, V., Kessler, D., Riper, H., Kleiboer, A.M., Elliott, I., Abel, K.M., Gilbody, S. and Bockting, C.L., 2019. GPs’ attitudes

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Brown, J.S., 2018. Increasing access to psychological treatments for adults by improving uptake and equity: rationale and lessons from the

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CerbovaK. (2018) LIVING LABS as one of the example of RRI toolkit: Introduction to the concept –theoretical part. Available in

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Any Questions?