National Rollout of cCBT

Using technology is now a necessity.

Demand Continues to Grow 25-30% of all GP consultations involve depression, stress or anxiety Prescriptions of anti-depressant has doubled in 5 years Demand on specialist psychology services has doubled in 10 years 75% of people with common mental health problems do not seek treatment

Offering large scale, low cost, high capacity solutions Technology is Part of the Solution Offering large scale, low cost, high capacity solutions cCBT = Computerised Cognitive Behavioural Therapy Video Conferencing = Attend Anywhere Remote Monitoring = Flo Text Messaging Artificial Intelligence = Interactive Self-help Guides SMS Online Digital Therapy Chat Bots

cCBT in Scotland An online self-managed treatment programme Uses evidence based cognitive behavioural therapy Been around for over 13 years Recommended by NICE and SIGN Consists of 8 weekly 1 hour sessions Complete in persons own homes or in community locations

Services can be delivered at scale

2013: EU MasterMind Project, 3 years 2016: cCBT TEC Programme, 2 years Implementation Programme Programme funding across 2 phases 2013: EU MasterMind Project, 3 years 2016: cCBT TEC Programme, 2 years This was a planned approach for the systematic up scaling of cCBT

Progression of cCBT in Scotland DUMFRIES & GALLOWAY BORDERS HIGHLAND WESTERN ISLES AYRSHIRE & ARRAN LOTHIAN ORKNEY GLASGOW & CLYDE GRAMPIAN FIFE LANARKSHIRE SHETLAND 2007: 11% of national population 2015: 44% of national population, funded EU MasterMind Project TAYSIDE FORTH VALLEY 2018: 100% of national population, funded by TEC

Use the right model

Nationally Support Implementation Existing services feed into national expertise and directly into implementing boards Expertise and support offered to Health Boards includes policies, key documentation advice and guidance Implementing Boards in MasterMind able to pass on knowledge and experience to other remaining Health Boards 4 Health Boards Remaining Health Boards

Set Phases of Implementation 1st Phase: service development, integration into psychology service model, service opens to psychology, early engagement GPs 2nd Phase: continued development, service opens to GPs 3rd Phase: implement marketing strategy 4th Phase: marketing strategy, service improvement 5th Phase: sustainability of service

Local Service Model Patients complete treatment in their homes or community locations such as Libraries Co-ordinator arranges access to cCBT treatment program Central Coordination of service from within psychology Co-ordinator supports home and community users All referrals come to one central point using same process Run with minimal clinical input but support is there when needed Referrers maintain clinical responsibility and respond to suicide alerts

Key Elements of Implementation Service costs are limited to software licence and administration Multiple referral routes are created across a number of disciplines Selection of the right workforce is vital Early planning and a strategic approach High level support, commitment and effort in participating boards

Data is knowledge

Data Collation & Evaluation Data collated centrally, analyse and outcomes presented at 6 monthly regional meetings

Elements of Continual Evaluation All Health Boards collect same data using same collection tools Collected through routine practice and administration processes Benchmarking data comparing service performance is presented to Boards Service improvements are implemented across all services simultaneously Data is analysis is done by those with the right expertise and understanding Programme of research runs in parallel with implementation  

Service Insight – Patient Contact By Phone 1. Most effective method of contact however more intrusive and time consuming for the service and impacts on service capacity Convenient for patient and unobtrusive, while still feeling personal and direct Text Message 2. Slower and inefficient however formality still inspires good rates of response in patients Letter 3. Email has proven to by the least effective with little patient response and can be unaware that an email has been sent to them Email 4.

Strategy is key

Plan Early for Up Scaling FUNDING STRATEGY SUSTAINABILITY PLANNING MARKETING STRATEGY Mid 2014 Early 2015 Mid 2015 Mid 2016 End 2016 2017 Services Running Milestones of Development Completed Organisational Structures in Place Referrals received and patients commencing treatment Continued Service Development Marketing of Service Monthly Targets Achieved Service Improvement Target Achieved Implementation t Ends Continued Marketing of Service Sustainability Planning

Getting it accepted

Tell Clinicians About It Extensive marketing of service to key referrer groups 2/3 of implementation time on marketing activity Single most important activity in the development cCBT services Is also the most complex and subtle of tasks

Marketing creates expectations that need to be met What is Marketing? Structured, co-ordinated communication Used to shape opinion and address negative perceptions Through consistent messages, prevents confusion and creating clarity Strategies aims to create 7 points of varying contact Marketing creates expectations that need to be met

Use a Strategic Approach Co-ordinates activities and message Define and understanding of objectives Creates targets that define successful outcome Identify assets, resources and required man power Focuses approach Develops understanding about what can and cannot be achieved

Services becomes more efficient and cost effective with increased use Marketing Works Use increases dramatically and continues to increase inline with marketing activity Average cost per patient <£60 Services becomes more efficient and cost effective with increased use

Does it work?

“I didn't need the talking therapy and I've had my medication reduced” Patient’s Perspective “Few methods of CBT I learned will be invaluable to my progression to better mental health” “Was really easy to use and after only a couple of sessions I started to feel better” “I didn't need the talking therapy and I've had my medication reduced” “I thought the program was excellent, just the right amount of information” “Thanks to the cCBT treatment I have reduced my anti-depressants and have a lot more confidence”

Evidence shows patient improvement from Session 1 Clinical Outcome Data Moderate 1.5 – 1.9 Moderate to Severe 2 – 2.49 Mild 1.0 – 1.49 Low Level 0.6 – 0.9 Healthy 0 – 0.59 Clinical Cut Off Evidence shows patient improvement from Session 1

2017/18 – cCBT receives 12,634 referrals Demand YEAR TOTAL REFERRALS 2013 1,340 2014 1,370 2015 5,529 2016 7,050 2017 10,553 2016 - Shetland refers most per head of population, showing value of technology to overcome barriers of traditional therapy approaches 2017/18 – cCBT receives 12,634 referrals

Attitude is everything

Always Learn and Improve The way people engage with technology has changed Self-management of conditions at home is untested so hard to predict Use of cCBT at home requires different approach to patient engagement Need to better manage speed of growth

The Right Approach Build sustainable services, no pilots Maintain focus and drive Trust the technology Be ambitious Make it undeniable