eClinics Proof of Conceptdigitalinclusion.pbworks.com/w/file/fetch/108971701...•eClinics provide a more compelling proposition than ‘Doing Nothing’ (which fails to meet future

Project Evaluation SummaryRotherham Doncaster & South Humber Mental Health NHS Foundation Trust | British Telecommunications plc | North Lincolnshire Council Digital Inclusion Unit | NHS Yorkshire and Humber | City of LondonSeptember 2010

eClinics Proof of Concept:Remote Internet BasedPsychotherapy forDepression and Anxiety

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eClinics Proof of Concept:Remote Internet BasedPsychotherapy for Depression and Anxiety

About This ReportThis report was written by the Delivery Innovation Team in the City of London to document a project to test anInternet based service for delivering psychological therapies to suitable patients suffering depression or anxiety. The projectwas a partnership between Rotherham Doncaster and South Humber Mental Health NHS Foundation Trust (RDaSH), BritishTelecommunications plc and North Lincolnshire Council DigitalInclusion Unit who project managed the proof of concept. This is a short summary of a post project review.

AcknowledgementsThe project team are particularly grateful for the support of British Telecommunications plc in helping to deliver thisproject, and NHS Yorkshire and Humber

Full DocumentThe full report can be downloaded athttp://www.esd.org.uk/InnovationToolkit

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The Challenge and OpportunityThe human and economic costs of poor mental health are high.One in six of us experience a mental health problem at any onetime, with at least a third of GP consultations involving mentalhealth. People who suffer severe problems usually end up onlong-term benefits and can endure deprivation, social isolationand physical ill health. The links to unemployment are ofparticular concern. People with severe mental health problemshave the lowest employment rate for any of the main groupsof disabled people; 80% are without a job. Evidence shows thatpeople with severe mental health problems can and do want towork but often do not receive the support they need to findwork. The total cost to employers is estimated at nearly £26billion each year in absenteeism, lost productivity and staffturnover1; equivalent to around £1k for every employee in theUK workforce. Overall it is estimated that poor mental healthcosts the country over £77 billion a year through care services,economic losses and premature death. Many of these costs are felt at a local level and at a time of great fiscal challenge in public services, this is an issue of significant importance tolocal authorities, public sector health service providers andlocal employers across the country.

With depression, anxiety and stress among the most commonproblems, steps to improve the management of these in theworkplace and to promote job retention should yield savingsto employers and reduce the longer-term burden on publicservices. Core to achieving these efficiency gains and tacklingthe human cost of mental health issues is improving access toand choice of effective psychological therapies. Technologyhas a significant role to play.

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The Increasing Role of Technology inService Delivery

There is a growing recognition of the role of technology insupporting those suffering mental health problems and alsotheir carers. In particular computerised cognitive behaviourtherapy has been recommended by the National Institute for Health and Clinical Excellence (NICE) and is now widelyavailable for treatment of depression and anxiety. Internetbased delivery models for therapy and counselling are now also beginning to emerge, along with clinical studies,evaluations and supporting resources such as training coursesto help frontline staff. Much of this evidence and experiencehas been emerging from the independent sector, and incontrast the NHS has been slow to adopt the Internet as a delivery model for psychological therapies.

With ‘remote’ counselling and psychotherapy now largelyavailable via the telephone there is a certain inevitability of theintegration of Internet channels into service delivery models toincrease choice for patients. The Internet clearly has the potentialto increase the reach of therapy to those for whom conventionaldelivery is inconvenient or undesirable such as young males,people with agoraphobia or rural residents. Furthermore, there areobvious applications of Internet based therapy to provide ‘ondemand’ support and to help people in the workplace. Remotedelivery can also benefit frontline workers facilitating flexibleworking, homeworking and shared service delivery models forhealthcare providers, with potential productivity benefits.

The Proof of Concept Project: RDaSH eClinicThe Rotherham Doncaster & South Humber Mental HealthNHS Foundation Trust (RDaSH) partnered with BT in 2008 totest an Internet delivery model for talking therapies. Theproject made use of BTs virtual contact centre platform, theNext Generation Contact Centre (NGCC), to facilitate internetand e-mail based therapy delivery, client drop-in to an internetchatroom, clinic booking, and flexible use of the workforcewith therapists being able to work from home. The project wasmanaged by North Lincolnshire Council’s Digital Inclusion Unit,which also developed the client side web site through whichpatients and therapists could access the services.

The Internet channel offering was integrated into existingservices as a ‘virtual care pathway’, and offered to thosepatients who had been referred for treatment. The websitealso permitted ‘self referral’ by email, eClinic booking any timeduring the week, and ‘drop in’ service one day a week. The localrationale and justification for implementing this project wouldresonate with providers in other areas of the UK, namely:

• The increasing difficulty of meeting current and projectedincreases in demand for therapy

• Budget pressures and the need to deliver ‘better for less’

• Inconvenient modes of delivery and poor accessibility for servicesparticularly in rural areas, and out of normal working hours

• The need to offer more flexible, modern working practices dueto the difficulty recruiting and retaining qualified therapists

• The significant social and economic costs to the area ofabsenteeism and lost productivity to the trust, councils andmajor employers.

• Increased competition and the need for to deliver differentiatedand innovative services to secure and grow future business

The project has been evaluated by Sheffield University in anadditional report However, this short report provides someearly headline findings from a post project review by theimplementation team.

Headline FindingsThe project was very successful at the ‘business change andorganisational’ aspects of implementing Internet based therapy.Despite some minor technological problems that wereexperienced it is clear that secure and robust technology existsto delivery Internet based therapy. While usage volumes werenot nearly high enough to deliver a clinical evaluation in theproof of concept project, the project provided hints of take-up,in the absence of significant marketing, to indicate potentialdemand. The service has a potentially compelling business case,and one which demands further exploration and quantificationthan was possible in this project. Taking each of these in turn:

Business ChangeThe business change aspects of the proof of concept wereparticularly successful with much progress made:

• Clinical governance procedures and processes were established

• Security processes, data protection and identity managementpolices were developed

• Internet services successfully integrated into existing care pathways

• Participating therapists embraced the technology and clearlyunderstood the business benefits to them

• Training was important because the internet changes thepatient-clinician dynamic and emotional cues available

• GPs and other important intermediaries were veryenthusiastic and willing to market the service

Often the business change aspects of projects involvingtechnology are the most difficult, particularly persuadingfrontline staff of the benefits. In this case there is significantlearning and valuable intellectual property that has emerged inRDaSH to mainstream the service beyond proof of conceptand also to support other health service bodies interested inInternet based services delivery.

TechnologyThere were minor technological issues during the project,which were invariably artefacts of the short-term nature of theproof of concept. Some of these arose at the interfacebetween the Trust’s corporate IT provision and the eClinicplatform e.g. the need for some simple configuration changeson participating therapist PCs that were temporarily ‘non-standard’ compared to other PCs on the network. There wasalso a natural tension within the team between making do withthe ‘vanilla’ off-the-shelf platform to meet the objectives ofthe trial, compared to beginning to tailor the platform asgreater learning and understanding about its potential grew. All these challenges were largely overcome by making thenecessary and sufficient changes to allow the proof of conceptto run. Overall it is clear that the technologies that underpineClinics are generally straightforward, commercially availableand robust. They can also be shaped to meet the securityneeds of the service provider.

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Take-UpUsage of the system was not high enough during the proof ofconcept to enable a full clinical evaluation but there have beenother trials that have already demonstrated clinical efficacy2.Although take-up was low there is cause for guarded optimism:

• The proof of concept was never marketed heavily because itwas a temporary project

• There were hints of real potential with some successfuleClinics held, a number of electronic self referrals from thepublic and some positive response from a small Facebookadvertisement

• There is clear willingness among intermediaries such as GPsto market a future service

• Processes can be established to improve take-up e.g.prescribing a recycled laptop to new patients who chooseeClinics, which they get for the duration of their therapy

• Some patients have requested this service unprompted and unrelated to the proof of concept.

Business Case PotentialA strategic outline business case was developed during the courseof the project. Key findings from the business case work are:

• There is a strong policy and strategic case for eClinics around improving access to psychological andtalking therapies, meeting levels of demand and deliveringgreater choice to patients in an efficient way.

• eClinics provide a more compelling proposition than ‘DoingNothing’ (which fails to meet future demand and the alsofiscal challenges to do more for less). It also is more effectiveand efficient than procuring more traditional therapy to meetdemand, or outsourcing services.

• An eClinic could break even in less than 2-3 years – factoring in:

o reductions in medication costs and concordance,

o estimated therapist productivity gains through flexibleworking and time savings using internet channels,

o reduced workforce absenteeism,

o fewer missed appointments.

This business case exercise has highlighted significant potentialareas of benefit but further work is required to determine themagnitude of benefits that can be realised in practice.

ConclusionsMuch has been learned from this proof of concept projectabout the business and technical challenges and opportunitiesassociated with delivering Internet based therapy. Further workis needed in some areas:

• to test and understand the impact of flexible working,

• to develop a better understanding of the demographics of demand for eClinics and how to market the serviceeffectively,

• to test and understand the effectiveness and practicalities of delivery of remote therapy within the workplace,

• to further test and prove the realisation of benefits identifiedin the business case.

The adoption of Internet channels to deliver taking therapies is an inevitable consequence on the demand side of more ITliterate patients requesting such a service, and on the supplyside, the need to innovate and deliver ‘more for less’ inchallenging times. RDaSH supported by its partners, has made a leap forward in developing the working procedures andbusiness processes to make this a reality in public sector mental health services.

Contact usesd-toolkitLocal Government Improvement and DevelopmentLayden House, 76-86 Turnmill Street, London EC1M 5LG

Tel: 020 7296 6572www.esd-toolkit.org.uk

The full document is available on www.esd-toolkit.org.uk

© City of London 2010.

1: Sainsbury Centre for Mental Health, 20102: Lancet2009; 374: Kessler, D. ‘Therapist-delivered internet psychotherapy for depression in primary care’

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