Jen Martin: using digital technology to access mental health care

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Dr Jen Martin, Programme Manager at NIHR MindTech Healthcare Technology Cooperative, gives an overview of initiatives across the NHS that are using digital technology to increase and improve access to mental health care.

This presentation was recorded on 8 September 2015 at the Increasing access to mental health care conference.


Good afternoon everybody and thanks very much for the invitation to speak today. So today I’m going to be giving a high level and quite a brief overview of some of the initiatives that are going on across the NHS at the moment that are using digital technology to improve access or allow people to access mental health care or support.  I’m going to be trying to cover as much as I can so not going into any one thing in loads of detail, but if there’s anything that you do want to hear more about please do contact me and I’ll be very happy to send you a load of slides, send you some videos or have a chat on the phone about that.

So just to say a little bit about MindTech, which is the organisation that I am from, we are funded by the National Institute for Health Research NHS’s research organisation and we’re a partnership between the University of Nottingham and Nottinghamshire Health Care NHS Foundation Trust, and we’re one of eight of these health care technology cooperatives which were set up to identify areas where there was high unmet need and where technology could potentially have a role to play and we are the mental health and dementia one. MindTech’s role is very much about trying to understand exactly what the clinical need and the unmet needs are and how technology might be able to contribute to that, to work with developers, start-ups, SMEs, industry in general and the NHS to develop solutions and they’re very much about collecting evidence both on effectiveness and cost effectiveness but also in terms of implementation and how they meet local priorities.

It’s been really good to hear digital mentioned quite a lot today already and the opportunities for digital mental health are clearly there. Psychological therapies are particularly suited to digital delivery and we already know that many people are already using digital technology to support themselves, to seek help and to manage their own mental health and that’s happened very much naturally.  It’s been a completely ground up movement of using things like Facebook, things like Twitter.  I don’t know if you’re familiar with the #BigMadChat but that’s something I think it goes on on a Tuesday night completely user led, every week they have a topic which they focus on and it just unites people across this country and across the world talking about mental health, talking about their experiences.  It’s hugely interesting to look at that and look at people’s experience of services and living with mental health difficulties.

Digital tools and services I believe have got the potential to provide much more flexibility, choice and control, giving people access to things when they need them at that point of need when services might be closed and also to shake up the model of how traditionally services might be delivered instead of like a one hour appointment face to face with somebody. Different models when you need it, top ups between appointments, follow on supports when you’ve been discharged from the services.  I think that mental health is comparatively immature compared to a lot of health care areas in terms of digital and that’s been driven by people who are really creative, passionate and generally talented whether or not they’re service users or technologists.  I think one of those people we heard from earlier today which is Sarah Armani who I think was one of the real people who started this whole movement which was great.

I’ve got a question mark with this, the UK is ready for digital mental health access. It’s a big issue, people talk about the digital divide, but the increase in internet use around this country is now extremely prevalent and has increased a lot over the last few years and what’s interesting in the last ten years is the biggest increase in the user group is with older adults. So although access and equity of access is an issue less of an issue now than it perhaps once was.

So today I’m briefly going to talk about initiatives, most of which actually MindTech aren’t that involved in. One of our roles that we see is trying to find out what’s going on around the NHS that’s good and just coming to events like this and shouting about it so that people aren’t starting from the same position, people can learn from what’s going on next door.  One of the things that I think is a real problem and it was eluded to earlier on is that we don’t learn enough from successful and non successful case studies that are going on across the NHS.

So I’m going to be talking about what can be done with off the shelf technology, things that you can just lift and start using immediately and also bespoke solutions and the learning and learning about all the challenges that people have overcome with that and then also talk a little bit about what I think the future should look like. There was some discussion about digital earlier and I’m very struck by the fact that digital in mental health is in its absolute infancy.  If you looked at what was going on in five years ago and three years ago and compare it to what might be happening in a couple of years’ time services are developing really quickly, products are becoming increasingly sophisticated and complex and it allows us to do so many different things in different ways so we need to speed up development, learn from things and do thing better in the future.  So how do we get to a more exciting future and digital 2.0 or something as I believe people call it?

So the first thing I wanted to talk about was video calling technology to improve access to therapy and for this I was just going to use a project that we’ve been working on with Nottinghamshire Health Care NHS Foundation Trust. The problem that they identified that led to them looking to do this was the fact that there was low take up and high drop out of psychological interventions.  So the evidence based proven therapy people weren’t getting access to it for various reason and they identified two particular groups; adults with health anxiety and children and young adults who had experience of self harm.  So the evidence was based on the fact that there was good evidence that remote delivery can be as effective as face to face.  So could video technology be used to improve access to this?  So we worked with them looking at the different options.  I’m sure you’re aware that there’s a wide variety of things from things that are free or almost free like Skype or Facelook and things like that all the way to things that are completely secure, hard wired into people’s homes that cost many thousands of pounds.  They also vary massively in terms of security and functionality.  So we’ve developed a decision support tool which allows services to look at the options that are available for them, specify their own requirements to help them select the right provider in order to be able to do this.

Notts Health Care decided to use a commercial off the peg teleconference system, WebEx I think it is. They did this for a number of reasons predominantly because it was low cost both to start and ongoing.  This was very much a small study for them.  They wanted to start small and hopefully grow it from there rather than make a huge investment at the beginning.  Importantly it was also acceptable to the local IT and information governance people albeit there were huge, as you can imagine, teething problems and glitches.  

What was really interesting about this was that it gave extra functionality which the therapists were really quite excited about. So to be able to test the thought that not only could it be as effective as face to face but it could or potentially be better because of the additional functionality.

So the next thing I just want to talk a little bit was the idea of technology to give people access to peer support, to enhance peer support as something that is very much with a clear evidence base. So I guess the most well-known of these is the Big White Wall and I’m sure most of you will have heard of that.  It’s a closed online peer support network that’s moderated, also provides people with access to courses and it’s already commissioned in quite a few places around the country and being used in a different way either in combination with IAPT or also in a public health approach but it’s something that’s available to lots of people in a geographical population you can self refer in.  We’re doing quite a bit of work to look evaluating Big White Wall, trying to look at that whole thing of the evidence not just on effectiveness but how it can fit within IAPT services and whether or not it reduced costs, whether or not it improves access particularly access in certain groups.  Do people use it in the short term and the long term and how can it best be implemented and taken up?

We’re working on a project across Derbyshire at the moment which the take up is really looking really quite encouraging. I think it’s interesting especially following what Gregor was saying earlier on in that in Derbyshire it has very much been promoted as part of a public health approach of the county and so the public health, health and wellbeing practitioners are going out promoting this, talking to community groups and employers to try and make people aware of it and what it can offer.

Another really great example of this is Elefriends which you might have heard of which is Mind’s online peer support network and I think what’s really great about this is that it was very much again user driven user led. It started off as a Facebook group and it became so popular and so big that Mind realised that they needed to dedicate some investment to this and worked with a really great development company to set up on a separate website.  There is some moderations, users don’t have to be anonymous and there has been some evaluation done of this where they’ve shown that they’re is a real sense of community and trust, as you might expect, but I think we can also learn a lot from this because I think when you see how people are using it it’s often because there’s a lack of services or perceived inadequacy of those services and so people are looking for support elsewhere.

Also at the moment Leeds and York NHS Foundation Trust are working to take this model and develop a Leeds version of it which I think would be a bit more closed in order to particularly enhance their existing peer support services which is really quite exciting, and another great initiative which you should really look up is Berkshire’s Eating Disorder Service and they’ve built their own peer support network which also has involvement with clinicians working from within the Trust and they’ve had really fantastic results in terms of recovery and that speaks to our … I can’t remember who mentioned it before but the idea of once you’ve been having quite intensive access to services what happens then once you’re discharged from this? I think that’s what this is particularly aimed to do is providing a support while people are having services but then it’s also things that they can continue to use as they move away from the service.

This is a really neat project that’s gone on in Leicester using text messaging. Text messaging is becoming so much easier and cheaper for NHS organisations to implement and this has won all kinds of NHS innovation awards, Chat Health.  The problem that they were trying to address they decided they were going to develop their own bespoke technology, 13% of young people estimate try to hurt themselves at some point and young people can’t get access to the help that they need when they need it.  So they developed the Chat Health text messaging service and app as part of their school nursing service.  So completely anonymous and confidential, people can just text a question or something or other to this number.  It’s not manned 24 hours seven days a week but users are signposted to other services when they can and they found that their effectiveness is so much better.  They’re dealing with more contacts for the same amount of investment and they’re also able to move people on much more quickly to appropriate services, so deal with small simple requests for information very quickly, to be able to dedicate more time to people who need more complicated help or more in depth support and they’ve found that one nurse can handle all of the in hours messages from across the whole county and about 50% of young people who have used this identify themselves at some point and then their info can be easily transported into the electronic patient record. This model is owned by Leicester Partnership Trust and we’re aware of a number of other Trusts that are looking just to licence that off them and take it exactly as the same model and put it into their own area.

I’ve got a really nice video which shows some of the feedback about this which I haven’t got time to play today but if you’d like to see it, it’s on YouTube, but there’s a couple of quotes, it’s been really successful.

So what other technologies for mental health? I couldn’t do a talk on this without talking about apps.  I must talk about apps all the time, apps, apps and apps.  This area has absolutely exploded in the last couple of years certainly since MindTech has been going.  We know that some are evidence based, some are user led, some are recommended by Royal Colleges, most aren’t.  Lots are free, others require some sort of purchases, some others require subscriptions and the majority are very much based on mood disorders, on self management.  I guess somewhat simple at the moment but hugely increasing in complexity and I think that is going to increase massively over the next couple of years.  I think here that’s where the potential is really huge.  I guess maybe two years ago when you were thinking about digital things you might have things like Big White Wall and Psychology Online or Ieso or Beating the Blues, those things which are services, mental health services and then on the other hand you might have mood rating apps things like that or information and I think those things are increasingly coming together and that’s where the potential is really huge.  So how can existing services use technology to enhance things, to provide support out of hours?  How can providers start working together to come up with a package of care and a choice of different things so that people can customise and create their own service in a sense rather than having to take the one size fits all of this area commissions Beating the Blues so that’s what‘s on offer if you don’t like that there’s nothing else.  That’s where I see the real potential for this.  
We’re aware of lots of Trusts that are starting to write their own apps that are specific for their local needs and this is becoming increasingly easy I guess as people come into the workplace with these skills and also affordable. This is Silver Linings, interestingly this was funded by NHS England innovation money so there is money available to NHS organisations to start doing this and they worked with the wonderfully named Appadoodle developers who are based in the West Midlands I Think.  This very much focused on psychosis and very much user centred, lots of involvement with young people to allow them to identify targets and set goals and importantly digitising the content so that it’s there in people’s pockets when they need it not on horribly photocopied tatty workbooks and things like that which it’s something which value has been on and it’s given to people and said, “We think this is really important, we’ve invested in this please take it and use it.”  Also importantly users are in control of this, they control who they share their data with in terms of parents, clinicians that kind of stuff.

Also there’s a really good one based in the East Midlands I think it’s Nottingham City have developed something for young carers which is really nice as well and really quite low cost. I think you’re talking around £10,000-£15,000, not outrageous amounts of money.

So my view this is the market that is really underdeveloped, the one that’s got the real potential. So how do we allow people to identify things that might be effective and provide value for money either for the NHS if the NHS is going to be paying or for users?  If we’re saying that if the NHS is going to start recommending things to people and say, “We think this is worth £5/£10/£3.50 a week for you to use,” how can we identify those and reward the products that are great and also to encourage people to move into this area?  NHS England and NICE you may be aware of are working on an accreditation system which I think is due for piloting towards the end of this year early next year, so I think it will be really interesting to see how that develops.  It’s a mixture of self assessment, crowd sourcing and traditional trials for the most promising products.

So that’s a summary of some things that are going on. It’s a very much a whistle stop tour.  Do come and talk to me if you want to know more.

What should the future look like? I’ve actually added to this during today because, as I said, I think this area it’s really immature, we’re just learning, we’re in the foothills as somebody said earlier on.  So I think the future should look real choice about people to be able to identify something that’s going to work for them not just a one size fits all model.  So real choice for patients, providers and commissioners, access to a variety of things that are evidence based or have shown promise and also the ability to get services that blend technology with traditional services.  It’s not an either or.  Things that are user led, that are engaging, that encourage long term use, that look good, that look comparative to other things that we’re using.  I think that’s maybe what we’re seeing now.  There was a lot of research done on digital technology maybe five years ago, it was all sounding very promising, but those things have stayed somewhat the same and now they look quite old hat and you look at them comparatively with other things and they look quite old fashioned and quite out of touch.

Also I think if we do that then we’ll have a digital mental health market that encourages creative talented people to move into this and they can see a sustainable business model to be able to encourage long term investment in this area. I think what’s also really exciting about digital is that it allows you to collect so much data.  So it’s not just like old fashioned trials where you develop something, you spend three years doing a trial and then you go.  You can make changes, you can know within a few weeks whether or not people are using it more, what time of day are they using it, what parts are they using the most, where do they get turned off, if you start giving people notifications does that help?  What if people build their own notifications is that better?  We can do so much more and I think there needs to be a national leadership to be able to come up with systems and a process to be able to take care of people’s data securely but also share it in a way that we can get benefits from that while also obviously being careful about confidentiality and governance. 



Retired from University of Liverpool but still researching,
Liverpool University and my colleague Prof Sharma, Chester Universty
Comment date
03 March 2017
Very interested in your article. Over 40 years we have been undertaking epidemiological research in countries in Europe and Asia using standardised diagnostic and assessment methods funded by Wellcome., MRC, DoH and EU Biomed II. On retirement some 20 years ago we have been working on practical methods for overcoming the psychiatric inadequacies in primary care and the lack of psychiatrists worldwide. We have published a 15 minute primary-care interview given by a briefly trained technician, taking no longer say than an ECG. It provides the psychiatric diagnosis, subsidiary diagnoses, suggested pathways of care, including NICE guidelines, when repeated can show progress in symptom reduction over time. Provides a full print out of patient details, diagnosis and treatment etc. developed by our small team including general practitioners. We are now about to send two papers on the secondary care version for where there is no psychiatrist dealing with an extensive computer algorithm for diagnosis of all serious mental illness, pathways of care etc which can be administered by a health worker with say 5 days training. Although intended for low-income countries we believe it could radically reduce costs and increase efficiency in the NHS if introduced at primary care and mental health triage levels. Incidentally it can be presented as an app on a handheld android device. We lack ideas on how to bring this to the notice of the NHS although we do have ideas on how it could be introduced and have discussed this with local practitioners. Would you have any suggestions how we might progress?

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