The scale of digital mental health, its impact and success has increased greatly over the last 5 years and continues to grow at pace in Scotland.
The scale and breadth of mental health services means a diverse and varied landscape across a wide range of applications, specialties, patient and staff groups for digital mental health to operate. With opportunities at national population levels and locally through mental health service delivery digital has proven its ability to directly deliver treatment and support, contributing significantly to prevention and self-management of mental health conditions while significantly enhancing existing service provision and delivery.
As the capability to deliver digital increases so does the national ambition and in 2020, emphasis was placed on the need to provide strategic direction, infrastructure and support at a national level that would guide through leadership, expertise and advice. As a consequence a national role was created to act as an advisor to Scottish Government and in 2021 the national Digital Mental Health Programme (DMH Programme) was established with the advisory role leading the programme.
Digital Mental Health Programme
The national Digital Mental Health Programme responds to the increased demand for mental health services through maximising the use of technology, ensuring sustainability and expansion of evidence-based digital therapy and self-management services. It acts as a focal point enabling the coordination of development and delivery activity across a range of cross sectoral stakeholders.
The programme works at three levels:
- National Level: the programme creates the conditions to support adoption with delivery partners, drives scaling up of new technologies, develops partnerships with key national and international stakeholders, designs national pathways, service delivery models and delivery infrastructure, addresses risks to patient/user safety, establishes evidence of effectiveness, assesses and procures digital technologies, overcomes cultural barriers to adoption, supports workforce education, gathers learning from others including international sources, facilitates knowledge exchange and sharing of good practice to inform ongoing implementation across Scotland and wider.
- Local Level: the programme builds digital capacity and capabilities while providing implementation, operational oversight, ensuring efficiency of transformation, stability and quality of service delivery. It ensures high levels of adoption through the management of marketing and communication activities and the full integration of digital into clinical, care and community services. This enhanced by continuous evaluation of service, extensive clinical engagement, expanding expertise and establishing greater leadership within the workforce.
- Long-term Sustainability: the programme encourages and promotes innovation, works to embed digital in health and care practice, develops a digitally enabled workforce, improves understanding and acceptance of digital through shared learning, overcomes societal barriers to digital adoption i.e. digital exclusion, data poverty, identifies and tests new technologies and approaches.
Key Programme Roles
National Advisor/Head of Programme
This role sits across the Digital Health and Care Division and Mental Health Directorate in Scottish Government, providing leadership, drive and expertise to policy teams in each area, the 14 territorial National Health Service (NHS) Health Boards, NHS national Health Boards, social care and voluntary organisations while working collaboratively with international and UK partners.
The role gives support and advice to a range of projects and activities either as part of professional advisory groups or on an ad-hoc basis and is the head of the national programme.
In this capacity the role manages and oversees national and territorial digital mental health services and implementation programmes. Being responsible for strategic direction, service development and ongoing delivery management, the port-folio of implementation and innovation projects, management of national procurement and contracts, evaluation and service improvement with an emphasis placed on continued expansion of impact, adoption and reach of digital within mental health in Scotland.
National Programme Team
The national programme team created an implementation structure and provides operational support to services while ensuring successful implementation, adoption and quality of service.
The national programme provides a centralised coordinated approach aligned to wider policy and strategic objectives. It provides insight and assurance into the development and delivery of digital mental health in Scotland. The team is uniquely placed and has developed the expertise required to work across both the digital and mental health settings.
Additional Key Roles
- Digital Mental Health Policy Lead, supported by the national advisor is responsible for the development and integration of digital mental health into national policy
- Digital Mental Health Innovation Lead, a commissioned role responsible for the development and management of the national Digital Mental Health Innovation Cluster.
This a structure that supports and coordinates digital mental health innovation activity in Scotland.
Approach to Scaling Up
Within the programme scaling up digital focuses on four broad areas of work:
- Digital system assessment, procurement and implementation
- Service transformation, design or redesign, development and delivery
- Development of infrastructure for sustainable delivery
- Driving up adoption through cultural change and inclusion
Upscaled implementation consists of a number of iterative stages during which the approach transitions from a testing and learning phase into a large scale systematic process driven implementation approach.
The test and learn phase is facilitated through adopting improvement methodologies such as test of change or small scale proof of concept projects that prioritise:
- the testing of the technology and identification of its implementation requirements
- the design/redesign, development and refinement of service pathways and delivery models
- defining the service implementation approach
- risk management and workforce aspects
- clinical and information governance
- staff training
- development of a foundation of acceptance to increase early adoption
- identification of barriers and facilitators that positivity and negativity influence the outcome of the implementation
- rapid evidence gathering of impact, value and effectiveness, needed to gain wider acceptance
The outcome from the test and learning phase is the development of standardised approaches to the IT implementation, change management, workforce training, service development, delivery and identification of sustainability requirements. This approach provides a “step by step procedural” approach and mitigations against potential barriers. Working closely with locally identified delivery partners the standardised approach is then replicated across each locality/geographical area to facilitate the scaled implementation. During both the test and learning phase and the scaled process driven implementation, infrastructure is developed to ensure a successful transition into a business as usual delivery.
In parallel work is done to improve adoption through cultural change designed to develop greater acceptance, improve understanding and address negative perceptions while integrating digital into clinical and care practice. This is achieved through engagement, promotion and marketing work to inform and educate while addressing significant barriers that limit uptake of digital services or solutions.
Established Digital Services and Infrastructure
To date the national programme has developed a range of diverse digital services utilising multiple digital technologies, these working across the population of Scotland and fully integrated into local service provision.
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Digital Therapy services established with full national coverage including:
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cCBT Adults – computerised CBT, for adults
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cCBT Perinatal – for parent in perinatal period
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cCBT CYP – young people and parent/carer support
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cCBT LTC – depression and anxiety treatment, relating to long term conditions
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cCBT Higher Education
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cCBT Prisons
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ieCBT – internet enabled CBT, therapy delivered through written word webchat
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Digital Therapies Supporting Infrastructure
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14 digital therapies teams within territorial NHS Health Boards
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National digital therapies workforce model
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National data reporting system for digital therapy referrals
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National training platform developed for staff delivering digital therapies
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Increased clinical leadership through creation of digital therapy lead posts
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Video Enabled Therapy
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Video Enabled 1 to 1 Therapy
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Video Enabled Group Therapies
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Cross Region Video Enabled Group Therapies
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Remote Monitoring
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National PROMS Pathway
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Innovation
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Digital Mental Health Innovation Cluster
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National Online Resources
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NHS Inform Online Interactive Self-help Guides
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Mind to Mind, lived experience lead mental wellbeing
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Currently there are 37 evidence-based treatments available in all health territorial areas of Scotland this via referral and self-referral with Digital Therapies Services receiving over 70,000 referrals a year, having received over 300,000 since the start of programme.
Online self-help and self-management resources are visited on average 38,000 times per month with resources visited more than 1.8 million times since start of programme. 14,000 video therapy session take place per month and over 150 group sessions.
Moving into the Future
Scotland has become a global leader being seen as a frontrunner and a pioneer in the development and delivery of large scale digital mental health services with the approach and success having been recognised both nationally across the UK and internationally. Despite the progress and recognition emerging technologies such as AI and extend reality (VR) coupled with new digital approaches to healthcare delivery will mean greater opportunities but more complexity in digital mental health delivery in the future.
There is a need to protect, improve and expand what we do currently while still striving forward with new innovation. For Scotland this means the need to establish a more sustained, permanent approach and structure that continues to provide the required expertise, strategic planning and specialist, implementation, development and delivery capability beyond the lifecycle of the current programme. This with the expanded focus to address the wider leadership and governance needs, create stable finance models, build greater expertise and experience while increasing skills and capability, developing the appropriate data and service infrastructure that supports long term delivery.
To define this new structure three pieces of work have been completed:
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the development of a Sustained Delivery Framework
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determining the requirements of a wider digital mental health ecosystem
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identifying and mapping the current programme activities and dependencies
The work aligned current areas of activity, dependencies and legacies of the DMH Programme onto 6 broad themes identified as key areas of investigation and exploration within the Sustainability Framework:
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Leadership and Governance
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Finance
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Service Delivery
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Information and Research
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Products and Technology
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Workforce
The work broadened to identified key outcomes within these areas that would shape, inform and create the wider digital mental health ecosystem, outcomes including:
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Progressive continuity
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Stability and opportunity
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Adoption and scale up
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Insight and evidence
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Emerging technologies
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Capacity and capability
Finally from within the current programme 17 interlinked areas of sustained input were identified that are needed to ensure the continued delivery, development and progression of digital mental health in Scotland:
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Strategic planning and delivery
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Governance (operational, implementation and clinical)
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Monitoring (development, implementation & delivery)
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Data collection and reporting
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Quality assurance
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Financial management
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Procurement and contract management
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Equalities and inclusion
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Infrastructure development and management (innovation, staff training, product management, data)
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Operational delivery
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Benefits realisation
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Planning (service, development and sustainability)
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Implementation oversight
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Adoption
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Workforce management and development
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Stakeholder and communications management
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Evaluation
The work to define a new approach and structure is ongoing, complex and the outcome is not certain however what has become clear is that the current Digital Mental Health Programme while having been effective at driving forward digital mental health in Scotland is limited by the legacy activity created through the collation of work during this and previous iterations of the programme. This and an inflexibility caused by a programme structure means taking on additional work or changing direction to respond to new priorities can be difficult.
Through this work it has becomes apparent that a blend of ongoing national oversight, management and support of existing digital service provision and infrastructure is required to work along side a progressive development capability aligned to the priorities of policy.
We in Scotland will continue to consider the needs and options available to us to establish a more sustained approach to the national coordination and delivery of digital mental health across health and care services, beyond the current lifecycle of the DMH Programme.
