Title: Enhancing the quality of psychological interventions delivered by telephone (EQUITy)
Funder: Department of Health and Social Care

Abstract: Background: Telephone-delivered psychological interventions are clinically-effective treatments recommended by NICE for mild-moderate anxiety and depression. However, they are not used consistently across IAPT and when they are, patient engagement is often not sustained. Potential barriers include a lack of bespoke training for telephone treatments, professionals' beliefs about treatment consequences, variable organisational support and the expectations and experiences of telephone treatment among patients. Aim: To increase engagement in telephone-delivered psychological interventions for mild-moderate depression and anxiety in IAPT, and improve their clinical and cost-effectiveness. Methods: Our 5-year programme is organised into 5 separate, inter-related workstreams: Workstream 1 seeks to understand the clinical and organisational contexts in which telephone treatments are used. We will conduct interviews with patients, professionals (n=30 of each) and key informants (n=20). We will complete conversation analysis of 120 assessment and 120 telephone therapy calls, and analyse national routine datasets. Workstream 2 will use the Behaviour Change Wheel to explore the best ways to facilitate telephone treatment. We will iteratively develop with service users/carers, IAPT professionals and service leads (4 consensus meetings, n=36), a feasible and acceptable behaviour change intervention to enhance engagement in telephone therapy. Workstream 3 will develop a smartphone app to enhance information exchange during telephone treatment. We will work with patients and professionals (n=30 of each), conduct focus groups (12 patients, 12 professionals) and host co-design workshops (n=45 mixed stakeholders). Using agile software methodologies, we will rapidly develop a smartphone app, and combine this with our Workstream 2 outputs to produce a 'complex intervention.' We will iteratively evaluate the feasibility, usability and acceptability of our combined intervention in a minimum of three purposively selected IAPT sites. Workstream 4 will assess the clinical and cost-effectiveness of our complex intervention via a cluster-randomised trial (n=26 sites, 13 per arm). Our primary outcome will be mental health symptoms measured by the PHQ-9/GAD-7. We will combine data routinely collected within IAPT with bespoke research data to assess outcomes at baseline, 6 and 12 months follow-up. Economic evaluation will assess whether the intervention is cost-effective in the services and participants in our trial (within-study analysis) and outside the trial setting (decision analysis). Decision analysis will model effects over the longer term (5 and 10 years) and over the wider IAPT setting. A nested process evaluation will conduct semi-structured interviews to explore the impact of our intervention on service users (n=30) and professionals (n=30). Workstream 5 combines traditional dissemination with effective knowledge mobilisation. We will provide all our resources free of charge to IAPT services wishing to improve patient access to telephone treatments. We will host a one-day mixed-stakeholder dissemination conference and engage directly with national IAPT leads, service commissioners, and managers. We will link with accredited IAPT training programmes and national professional networks/organisations. Our social media strategy will raise awareness of best-practice, motivate staff to deliver high-quality telephone-delivered interventions, and stimulate patient choice. We will monitor the reach and impact of our intervention components. Deliverables: Our programme will increase engagement with telephone-delivered psychological interventions for depression and anxiety. Deliverables will include staff training and supervision, patient-mediated materials, a smartphone app and best-practice referral and implementation guidelines. We will have experience of embedding best practice across our trial sites, and will be well-placed to implement our intervention at scale. Importance of the Proposed Research: Our research aligns directly with the Five Year Forward View for Mental Health which proposes new ways of working, prioritising access, quality and integration. Improving engagement in telephone treatments offers a unique opportunity to extend the reach and effectiveness of IAPT services, reduce treatment stigma, and respond directly to policy mandates to increase patient access and choice. Programme Impact: If successful, our programme will ensure that more patients are offered high-quality telephone-delivered treatments, that more patients take these up, and that patient improvement and recovery rates increase. Economic benefits will include lower treatment costs, increased service efficiency, and reduced healthcare use and productivity losses. Research Team: Our team is multi-disciplinary with significant content, methodological, academic, lived experience and clinical expertise. Our proposal is strengthened by close, working relationships with IAPT and third sector organisations, the CRN, the MAHSC-CTU and the MRC HeRC and Farr Institutes. We have been recognised by the MHRN and CRN for exemplary carer involvement. PPI Involvement: We have PPI representatives as named programme co-applicants, service-user researchers, advisory panel members and advisory panel chair. Our service-user researcher will contribute to qualitative and quantitative research, and lead meetings on intervention development and app design. Our PPI advisory panel will meet 6 times a year. PPI co-applicant and researcher time is costed into our proposal. Advisory panel members will be reimbursed in line with INVOLVE guidance. Research training and mentorship will be provided.

Lay abstract: Depression and anxiety cause substantial difficulties for people who experience them. The NHS has created a world-leading psychological therapy service, called Improving Access to Psychological Therapy (IAPT) , to help people with these conditions. To help people access IAPT, many thousands of the sessions they offer are delivered by telephone. Telephone-delivered treatments are helpful and are recommended by the National Institute for Health and Care Excellence for depression and anxiety. We know from previous work that many patients like the idea of telephone-delivered treatments because appointments are easier to access and less stigmatising than attending mental health clinics in person. In the NHS, however, a significant number of people are not starting or finishing telephone treatment, which means that they may not be getting all the help they need. Part of the problem is that the professionals who deliver telephone treatments do not receive enough training to do so. Patients and professionals do not always feel that they get enough support. We want to improve the way that psychological interventions are delivered over the telephone so that we can make sure that people get the care they need. We will explore IAPT data to understand which groups of people have the greatest difficulties with telephone-delivered treatments. We will work with patients and professionals to understand their experiences of telephone treatments and the types of challenges they face. Once we understand the problem, we will develop an intervention to help services improve the quality of telephone treatments. Our previous work suggests that this intervention will need to include several different parts including professional training, educational materials to help patients understand what telephone-delivered treatments are like and best-practice guidelines/workshops for IAPT teams. We will work with patients and professionals to develop a smartphone app to make it easier for patients to use telephone treatments, by helping patients and professionals exchange important information during treatment. We will test whether the introduction of our intervention means that more patients finish telephone treatment, and whether this has important benefits for their health and wellbeing. We will check the number of treatment sessions that people attend and how they feel, comparing services that receive our intervention with ones that do not. We will combine our data with data already available to see if our intervention has long-term benefits. We will talk to patients and professionals about their experiences of telephone treatments following our intervention. We will use different ways to tell patients, professionals and service managers what we find. We will offer our resources and consultation free-of-charge to NHS services and charities when our programme ends.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH