Health Service Focus

Developing digital at the heart of mental health

Rebecca Cotton, director of mental health policy at the Mental Health Network, discusses the opportunities and challenges in developing digital services for the mental health sector.

The Mental Health Taskforce, formed in March this year, has been given the daunting task of developing a new five-year national strategy for mental health covering services for all ages – due to be published in autumn 2015. 

Speaking to NHE about the future of mental health in England, Rebecca Cotton, director of mental health policy at the Mental Health Network, said there are “very important reasons why digital needs to be at the heart of the NHS’s strategy going forward”. 

She highlighted that in pockets across the country there is some “really interesting” work being done with regards to using digital in the design and delivery of services. 

However, Cotton added that if you take a step back and look at the entirety of the health sector and ask if the NHS, as a major public service in this country, is making the best use of digital technology then the answer is “clearly no”. 

“We are behind other service sectors,” said Cotton, who co-authored the 2014 report ‘The future’s digital: mental health and technology’. 

“Look at what they have done in terms of transforming delivery and then look at the NHS: clearly there is a very long way to go,” she said. “Personal banking, for instance, has changed hugely over the last 20 years. We don’t have so many branches anymore, lots more is done online and you rarely have to go into a branch.” 

Drivers for change  

Cotton identified two key drivers for using big data and delivering more digital services for the NHS and mental health. 

“Firstly, the financial challenge facing the NHS is only going to continue. We have rising demand for all sorts of services, mental health included,” she said. “But that is something affecting the entirety of the NHS. So, how are we going to continue to deliver high-quality services at a time of continuing restraint around funding? You don’t have to look too far to see that digital technology might be part of the solution to that.” 

Secondly, NHE was told that the public’s expectations are changing, as many expect to be able to interact with services through digital technology. If we are going to keep up with the public’s expectations about what they want to see and how they want to interact with services then digital has to be part of that, she added. 

Cotton also co-authored another paper recently, which appeared in the British Journal of Psychiatry, entitled ‘Technical innovations in mental healthcare: harnessing the digital revolution’. Its authors claimed digital technology has the potential to transform mental healthcare by connecting patients, services and health data in new ways.

It added: “Digital online and mobile applications can offer patients greater access to information and services and enhance clinical management and early intervention through access to real-time patient data. However, substantial gaps exist in the evidence base underlying these technologies.” 

Abundance of apps 

The report also highlighted Cotton’s point about the public’s changing expectations. For instance, figures from the Communications Market Report 2013 revealed that 43% of adults now use the internet to seek health-related information, an increase from 18% in 2007.

On top of this, commercial app stores, such as iTunes and Google Play, have an abundance of health and mental health apps available to individuals. It is estimated that there are 100,000 health apps available in major app stores, and it is said that medical apps have generated more than three million US downloads on iOS alone. 

But there is little in the way of a quality filter, or regulation, other than user reviews, applied to the apps available on these stores, so making a judgement about quality is difficult. 

“If you go on iTunes there are huge amounts of apps you can download that allow you to monitor how you’re feeling, [set up] medication reminders and others,” said Cotton. “People do find these apps useful and they will be using these whether they are part of an NHS service or not because they already are using them. 

“The challenge is how to use some of these resources better to provide an improved service to our users.” 

She suggested that, in the short term, practical actions that existing services could take include enabling service users to have the option of booking appointments online, and receive confirmations and reminders by email and text. 

“If you look across the NHS we are still sending out a lot of appointment letters,” said Cotton. “We don’t use email that much for everyday interaction with patients using services.” 

NHE was also told that where clinically appropriate, making available options to access treatment and support remotely via phone and video calling could be the way forward. 

But evaluating the safety and efficacy of mHealth interventions should be subject to the same rigour as evaluations required for new drug or psychological treatments. 

Some examples of apps that have been developed for mental health include ClinTouch, My Journey, Buddy App and WellHappy. Typically, these apps include a symptom tracker and diary function, appointment and medication reminders and motivational prompts. 

Buddy app, for instance, is a high-quality example of a digital tool used to support therapy services. This uses text messaging to keep a daily diary of what users are doing and how they are feeling, helping to spot and reinforce positive behaviours. 

Cotton highlighted that these examples have been developed with user and clinician involvement and incorporate evidence-based principles of care. Although, she noted that further research is needed to demonstrate clinical and cost-effectiveness in routine NHS settings. 

Security concerns 

The ‘Technical innovations in mental healthcare: harnessing the digital revolution’ report concluded that despite the clear potential of digital technology to connect people and health data in new ways, there is “currently insufficient evidence to suggest that this potential is being fully realised, with uptake being limited and outcomes being largely anecdotal and unpublished”. 

It said: “There are a number of key challenges: first, ensuring that patients and their needs remain at the centre of technology development and implementation; second, rapidly increasing the evidence base for the clinical effectiveness of digital technology; third, ensuring that the opportunity provided by data sharing between patients, carers and clinicians does not threaten privacy and undermine public trust.” 

Asked about the security and privacy issues surrounding data, Cotton told us that people’s concerns about security and data affects everything: all the services people use day-to-day. 

“Our data around our health is some of the most personal data that exists about us,” she said. “Sharing that requires a whole lot of trust in terms of where we share that data and who with. I think it is a perfectly rational concern people have. The challenge is two-fold: a) we have to have the trust of the public, so they know their data is going to be safe; and b) while we have to do this we can’t allow it to hold us back from progressing. 

“Clearly, people are concerned about security and about their data being used by service sectors, the NHS is no different. If we are going to have the confidence of the public we need to be reassuring people that their data is going to be safe.” 

It has also been suggested that patients, clinicians and NHS commissioners require an agreed framework to evaluate the core features of new technologies including usability, content, safety, and clinical- and cost-effectiveness. 

“If you look at what is happening out there already in the system, then much of this work around digital services is being driven locally by providers working with their local service users,” said Cotton.  “I think that is where we’ll find the most innovative and interesting services and models that can be replicated elsewhere in the future.” 

She added that the centre’s job, therefore, has to be more about creating an environment where this type of innovation is supported and facilitated going forward.

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