Over 400 fully licensed therapists deliver one-to-one therapy via written (typed) conversation in a secure, online therapy room.
This innovative delivery method is highly convenient for patients, who can access therapy wherever and whenever it suits them from their smart phone, tablet or PC, and also allows us to deploy a uniquely powerful approach to therapist support, supervision and training thus improving clinical quality and helping more people to recover more quickly.
Highly Commended in Innovation in Digital Health category - #MHAwards18
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Ieso Digital Health is the UK’s leading provider of online CBT.
We are transforming the lives of people suffering with common mental health illnesses by using advanced technology to deliver high quality, evidence-based therapy. Over 400 fully licensed therapists deliver one-to-one therapy via written (typed) conversation in a secure, online therapy room.
This innovative delivery method is highly convenient for patients, who can access therapy wherever and whenever it suits them from their smart phone, tablet or PC, and also allows us to deploy a uniquely powerful approach to therapist support, supervision and training thus improving clinical quality and helping more people to recover more quickly.
Where the team is being set-up, stage of development and expected completion date (e.g. planning, in progress, evaluated)
Ieso has been treating NHS patients within the IAPT program for over 5 years and is now a mature organisation which, in many parts of the country, is a key component of local service delivery.
Your approach to development and/or delivery (e.g. co-production, pathways, team structure, co-location of staff
The core Ieso method, based on its guiding clinical principles, is now well established but remains under constant review with enhancements made whenever evidience exists that those enhancements will improve service delivery or patient recovery. In addition we have become expert at working with many different local services, varying our approach as necessary in order to best support local pathways and methods, but without compromising on our core strengths.
What makes your service stand out from others? Please provide an example of this.
Our unique method of providing online therapy through written conversation, along with our strict adherence to evidence-based specific treatment protocols, results in the following key service delivery differentiators:
Quality
Our written delivery method means there is a full transcript of every session so, for the first time ever, we can see exactly what happens in every therapy session. This means that we can deliver an extraordinary level of supervision, training and support to enable our therapists to continuously improve and enhance their work. This has been a key enabler in delivering best in class recovery rates, consistently above IAPT targets (see outcomes section for more detail)
Convenience
Patients can access therapy from any connected device at a time and a place to suit them. Patients often have therapy sessions from the comfort of their own home, or by booking a meeting room for an hour at work, with no need to travel or otherwise disrupt their daily routine. This helps us achieve DNA rates that were 22% better than the NHS average in 2017. Our therapy is available 24 hours a day, 7 days a week. Almost 7 out of 10 Ieso therapy sessions happen outside the traditional Monday to Friday, 9 to 5 window.
Access
We do not have a wait-list. With over 400 BABCP therapists supported by a full clincal team and a professional, back-office patient services team to handle administrative support for trusts and patients, we are able to bring patients into therapy very fast, often in just 2-3 days if that meets the patient’s wishes
In addition the technology we deploy and the clinical approach we adopt has allowed us to create a unique dataset which now includes the transcripts of over 20,000 patients. Through this we have created differentiators in other key areas too:
Research
Our platform acts as a standing and continuously expanding research platform and has allowed us to conduct primary research in many key areas associated with the future improvement of patient care. One recent key success is evidence of sub-types of depression which will allow an improvement in future recovery rates through deployment of differentiated treatment protocols
Training and development
The Ieso platform is an effective pedagogical tool that we take into the classroom to teach the clinical skills and competencies required to ensure we are equipping trainee clinicians to deliver highly effective Cognitive Behavioural Therapy to NHS patients. Ieso runs an extensive programme of collaboration with a number of Universities in the UK, including Hertfordshire University, The University of Surrey and Royal Holloway with whom we work together to train the clinicians of the future.
How do you ensure an effective, safe, compassionate and sustainable workforce?
We know that therapists are the critical ingredient in achieving great outcomes for patients. Because of this we invest in helping our therapists to be the best they can be with a significant package of proactive support, training, case management, reflective practice and clinical supervision.
We offer all of our therapists an extensive, flexible and free Continuing Professional Development programme aimed at ensuring reflective practice is built directly into their work with Ieso and thus help them to deliver sustained high outcomes to patients.
Using our technology, we have the ability to provide quality control and auditing of the therapists interaction with patients, assisting therapists to notice ‘blind spots’ and ‘learning edges’ in real time. The illustration below depicts the range of support available to our therapist network.
This programme also includes yearly conferences which are free of charge to our therapist network to attend. This includes the chance for therapists to meet the wider clinical and non-clinical teams, with high quality workshops being delivered during the day by our learning and development team as well as key national and international speakers and trainers.
All our therapists are provided with extensive quantitative feedback about their clinical work. Because, for the first time ever it is possible to see what therapists are doing in the therapy room, this feedback is derived directly from the clinical transcripts of their work with Ieso patients and is therefore uniquely powerful. That means that we support and enable our therapists to continuously improve and enhance their work, ensuring that more patients get better. Our therapists tell us how much they value the support, feedback and continuing professional development they receive at Ieso. Our improving patient recovery rates are a testament to this unique methodology.
In conjunction, we offer support to our therapist network through an extensive Supervisors’ CPD Programme to ensure that we invest directly in those front-line supervisors who are on hand to support our therapists to be the best they can be. This golden thread of working together to enable more patients to get better, runs through our organisation.
Who is in your team?
We have an incredibly talented and experienced team who are extremely passionate about improving access to evidence-based mental health therapy.
Therapy is delivered by over 400 BABCP accredited high-intensity therapists who are contracted to Ieso under the terms of a standard Clinical Affiliate Agreement.
These therapists are supported by a fully resourced clinical team including:
Our Chief Clinical Officer, who leads our clinical operations and strategic vision ensuring that the organisation is clinically lead in all aspects of the business
A Clinical Lead who oversees and manages the operational delivery of our service across the UK. Liaising directly with providers, commissioners and academic institutions, his role is to ensure we deliver safe and effective care pathways and that high levels of care are routinely delivered to all patients who access the service
Two full time Clinical Team Managers who manage and look after the day-to-day running of the service. They manage our therapy network and are on hand to deal with patients and therapists questions and enquiries.
We have 14 further members of staff across our learning and development team, clinical supervisory team and network management teams. This includes those involved in project mobilisation, patient allocation and clinical marketing all of which are crucial to the day to day delivery of the services Ieso provides.
Administration is provided by our Patient Services Team from the company’s head office. The team have had extensive training in supporting patients to access the service and have a strong reputation for having effective interpersonal skills when communicating with sometimes very vulnerable patients. In addition the Patient Services Team liaises directly with CCGs and NHS Trusts enuring that key administrative tasks, such as data updates are completed on time.
Behind these front line teams are a variety of other back office teams, primarily focussed on the longer term enhancement of the service. These include technical development and support teams and scientific research and data analytics teams.
How do you work with the wider system?
We work very closely with the wider system. We meet regularly with all our partner services and providers to review clinical pathways and interface protocols to ensure that the care delivered is to the highest standard. In those areas where we are commissioned directly we have strong and well-established relationships with our commissioners regularly reviewing performance data
We network extensively in these areas of the country to ensure that other local authority, voluntary sector and physical/mental health services are aware of the benefits Ieso will have for patients, clients, carers, family or friends. We speak directly with post and peri-natal networks across the UK, as well as expansion now into connecting with closer partnership work with health care professionals.
In addition, Ieso runs an extensive programme of collaboration with a number of Universities in the UK, including Hertfordshire University, The University of Surrey and Royal Holloway. Working together to train the clinicians of the future is essential work. The Ieso platform is an effective pedagogical tool that we take into the classroom to teach the clinical skills and competencies required to ensure we are equipping trainee clinicians to deliver highly effective therapy to NHS patients.
The nature of the Ieso Method of delivering CBT means that teaching staff and supervisors have access to the live therapy material that the trainee therapist has delivered. In essence they can see what the trainee is doing (or not doing) with their patients. This has never been possible before.
Commonly trainees struggle with the “theory, practice” divide. This is where it is hard to translate what you have learnt in the classroom to what you do with a patient. The Ieso platform enables trainees to practice what they are learning and get immediate feedback, and feedforward. The trainee can also reflect on their own practice by reading through their own transcripts. Once you can see what a trainee therapist is doing it becomes possible to enhance and amplify their practice.
Ieso is working in partnership with NHS England as a member of the Digital Improving Access to Psychological Therapy (IAPT) Expert Reference Group. We are working together to ensure that NHS patients have wider access to psychological therapies that really work.
Ieso is working with research partners to explore new and innovative methods of treating anxiety and depression with the aim of increasing recovery rates that have stagnated across the world.
Do you use co-production approaches?
As our approach has evolved over the years we have held service user feedback groups up and down the country, to gain insights into our service and to inform improvements. This has included a children and young people’s innovation session in Sheffield to support the early planning phase of delivering therapy to young people digitally. This has played an important role in our recent pilot in this area and desire to expand further into looking at the efficacy in an area where the need for early intervention and enhanced evidence based therapy is needed.
We are currently reviewing our service user involvement framework and expert to enhance this further in future.
Do you share your work with others?
We believe in sharing and disseminating our findings and learnings with the wider healthcare networks. We have a robust programme of research planned in 2018 and beyond, much of which we expect to result in publication in peer reviewed journals. We regularly present at Expert Reference Groups up and down the UK.
We actively offer speakers from the organisation to talk at local, national and international events not just about ieso but the value of incorporating technology into therapy clinics, debunking myths and concerns about perceived barriers to adoption and importantly presenting balanced feedback from what patients are saying about a service such as ours.
Ieso has published in a number of forums including professional journals and peer reviewed journals. Our most recent significant publication, with collaborators, was “The Use of Internet-Enabled Cognitive Behavioural Therapy in the Treatment of Depression and Anxiety amongst Older People” which was published in the December 2017 International Journal of Aging and Society. It showed how rapidly increasing levels of internet access amongst overs 65s, means that that the number of seniors now receiving online cognitive therapy (IECBT) in the UK is a significant and growing cohort.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Ieso reports to the NHS digital data set for Improving Access to Psychological Therapies (IAPT).
In the monthly quality reports published for the IAPT data set between January 2017 and December 2017 Ieso achieved greater than 80% validity (their measure of completeness) as an organisation for every month in the reporting period.
Ieso uses a wide range of PROMs including PHQ-9, GAD-7, WASAS and a wide variety of Anxiety Disorder Specific Measures (ADSMs). These are administered as online questionaires at every therapy appointment as a standard part of the therapy session with answers automatically recorded in our secure therapy system.
Ieso therapists may use a range of CROMs including risk assessment and severity ratings. Ieso has developed its own CROMs tools based on The Ieso Method framework. These tools support the therapist to reflect ‘in’ and ‘on’ action, guiding clinical decisions such as diagnosis, protocol selection and self assessment of clinical effectiveness.
How the data are used (e.g. progress and recovery, service development). Please provide results if available.
Your outcomes and how they demonstrate improvement:
In addition to its use in completing the standard Minimum Data Set requirments within IAPT the data is used for ongoing research to drive service improvement. We have been following this approach for a number of years now and it is a key reason why many of our Key Performance Indicators have improved consistently across that period. For example our recovery rates have improved year or year and have always been significantly ahead of the IAPT target:
More qualitative data also demonstrates improvement. For example:
Therapist feedback – 83% of therapists are extremely likely to recommend Ieso (Q4 2017)
PEQ data (PREMS) – 82% of patienst rate Ieso very good or excellent (Q4 2017)
Has your service been evaluated (by peer or academic review)?
Yes, our service has been evaluated in a peer reviewed journal. Kessler et al published “Therapist-delivered internet psychotherapy for depression in primary care: a randomized controlled trial” in The Lancet in 2009.
This BUPA foundation funded controlled trial demonstrated efficacy and cost effectiveness of the method in clinical depression across a 300 patient randomised control trial
2007-2009
Patients allocated online CBT or standard care
At 4 months 38% recovery (Beck Depression Inventory <10) in intervention group vs. 24% in control group
Effect maintained at eight months – 42% vs. 26%
Median of six sessions needed for benefit
Severely depressed benefited most
Many patients found it easier to talk when not face-to-face with a therapist.
Following this Lancet published proof of concept the solution has since been demonstrated practically with the thousands of patients that we have treated within IAPT with depression, anxiety and many other conditions in the last few years.
How will you ensure that your service continues to deliver good mental health care?
Ieso has already delivered in excess of 100,000 hours of therapy to patients across nearly 40 CCG regions in England and is actively sharing this best practice model with those organisations. Ieso’s service is highly scalable and easily adopted by other CCGs and Trusts where the benefits and outcomes can be rapidly delivered.
Ieso senior staff regularly speak at conferences and other outlets to make other Commissioners aware of what the service can do. For example, in December 2017 Ieso and Sussex Community NHS Foundation Trust jointly presented a case study illustrating digital pathway excellence at an IAPT conference in Manchester and multiple other IAPT service providers have since asked to discuss how this might be deployed in their regions with Ieso. More recently, in March 2018, Ieso spoke at an IAPT conference in Yorkshire and Humber and in June our UK Managing Director will be speaking at the NHS Confed event in Manchester.
According to data from the Deloitte Fast 50 (December 2017) Ieso is the country’s fastest growing digital health business, and in September 2017 achieved a further £18M of funding from some of Europe’s largest investors in digital health.
What aspects of your service would you share with people who want to learn from you?
There are many key learnings that we work hard to share with people across the mental health arena. Perhaps the most important is to understand that digital services differ widely in terms of the service delivered and the outcomes, engagement rates and efficacy achieved
Ieso is different to all other digital therapies: all our therapy is delivered by a one-to-one relationship between a patient and therapist. This is the same as “normal” IAPT one-to-one therapy, it’s just that we deliver our therapy digitally.
Although we are actively involved in networks such as the NHS England Digital IAPT Expert Reference Group, chaired by Prof David Clark, further work and education for commissioners, providers and patients needs to be championed in order to move this debate forward and release the productivity and cost saving benefits of delivering therapy to patients who are well informed and opt to receive therapy digitally.
Other key lessons include the results achievable – we genuinely do help more people get better more quickly (see detail above on recovery) and the fact that digital Health is not discriminatory based on age or gender. In fact we have discovered that as people’s age increases their ability to benefit from a digital delivered evidence based therapy such as that provide by Ieso also increases. As an illustration of this, you can see the profile of patients accessing the service in 2017.
A recent peer review paper “The Use of Internet-Enabled Cognitive Behavioural Therapy in the Treatment of Depression and Anxiety amongst Older People” published in the December 2017 International Journal of Aging and Society showed an increased representation of males in the age bracket of 65+ compared to cohorts of the same profile in traditional primary care IAPT services
How many people do you see
For example
Total number of referrals and referrals accepted in the past 12 months (please include date range in response)
In Jan 2017 to December 2017 Ieso received in excess of 14,000 referrals of which nearly 8,900 patients went on to attend treatment sessions with Ieso therapists.
Number of webpage visits and downloads (All patients have to join therapy via one of our web portals)
How do people access the service?
For example:
Referral sources including self-referral
Patients can enter the Ieso service through multiple avenues including (but not limited to) self-referral, referral from a trust or GP and also as waiting list reduction programs.
How access is promoted/encouraged for people who find it difficult to access the service
66% of Ieso treatment appointments take place outside of standard office hours (Ieso at a glance Q4 2017)
Process for managing referrals, triage of new referrals.
Ieso Digital Health allocates patients to a therapist on the same day as the patient has opted in and confirmed they are ready to start treatment.
An initial triage in undertaken to socialize the patient to the treatment process and ensure the patient is suitable for treatment. This is followed by a full assessment which focuses on the presenting problem, a basic risk assessment and referral on to other agencies, if appropriate.
(see also answers below on ‘referral process’ for further detail)
How long do people wait to start receiving care?
For example:
The mean and maximum wait time from referral to access (where applicable specify if wait time is to assessment or treatment
Patients who self-refer to Ieso are able to start therapy in just 2-3 days. Any delay to the start of therapy is only due to the patient and not the Ieso service. (Patients have to choose when they would like their first appointment etc.)
In Jan 2017 to Dec 2017 patients who chose to self-refer to Ieso and finished a course of treatment in this time period waited a mean of 20 days from referral date to the attendance of their 1sttreatment appointment (patients would also have attended an assessment session with this time frame).
96% of patients finishing a course of treatment in Jan 2017 to Dec 2017 (self-referred) attended their 1sttreatment appointment within 6 weeks of their referral
Where relevant please indicate how you compare with national or local access and waiting time standards.
The Ieso service regularly performs better than the national waiting time targets set by the NHS for the IAPT sevices (75% patient finished treatment waiting less than 6 weeks and 95% patients waiting less than 18 weeks)
For example: In December it was stated that nationally 89.7% of patients finishing a course of treatment waited less than 6 weeks and 98.8% waited less than 18 weeks
Ieso self-referral patients recorded figures of 96% and 100% respectively over the same time period.
How do you ensure you provide timely access?
A referral system exists that is simple, consistent and easily understood by professionals and the public:
a)Source:Ieso Digital Health is able to accept referrals from multiple sources including:
GP’s
Other healthcare professionals
Other statutory and third sector organisations
Self-referral
Employer
Insurance providers
b) Referral route:
The service is able to receive referrals from both professionals, others services and patients:
Electronically Telephone In all instances, Ieso Digital Health ensures that the relevant clinicians/service is informed about the patient referral (with patient consent).
Ieso Digital health utilises an opt-in processes therefore ensuring that patients are engaged and prepared to commence therapy. However, this process does not hinder ease of access by people with common mental health problems. Significant efforts are made to assertively contact both new referrals and those people for whom the service has lost contact during a treatment episode.
c) Assessment / screening
Ieso Digital Health allocates patients to a therapist on the same day as the patient has opted in and confirmed they are ready to start treatment.
An initial triage in undertaken to socialize the patient to the treatment process and ensure the patient is suitable for treatment. This is followed by a full assessment which focuses on the presenting problem, a basic risk assessment and referral on to other agencies, if appropriate. This will include the following elements:
A comprehensive ‘patient centred’ assessment that clearly identifies the full range and impact of their mental health problems and any linked employment, social and physical health issues.
Risk (suicide, harm to others, etc.) is assessed at initial contact and at each contact thereafter.
Clinical, work and social outcomes are assessed using standardised measures that are appropriate to the conditions being treated. Key measures are given at each treatment session so that a clinical end point is available even if patients finish treatment early. People identified to be at high risk (e.g. suicidal ideation, severe self- injurious behaviour, psychotic symptomatology) will be urgently referred to the appropriate mental health service /crisis support services. The access standard for referral is the same day.
What is your service doing to identify mental health inequalities that exist in your local area?
Equality of Access
The IECBT method of delivering evidenced based psychological therapies enables the service to facilitate ease of access to a wider range of people across the entire country (our “local area” is the entire country).
Ieso Digital Health:
Provides a “whole person” approach to the delivery of the evidenced based psychological interventions which takes account of the person’s socio demographic characteristics, health comorbidities and lifestyle. Patients who might struggle to access treatment because of a health condition, fear, shame, caring responsibilities etc are not disenfranchised.
Promotes recovery and minimises the disabling effects of mental ill health supporting people in employment, education and meaningful activity.
Promotes access to services from all sectors of the community including traditionally underserved/socially excluded groups.
Promotion of recovery and positive mental health provides an opportunity for collaboration and partnership with other services and interventions as part of each local service delivery (e.g. employment, social care, housing, environmental services, education, criminal justice agencies, substance misuse services, physical activity and leisure services, black and minority ethnic focused services etc.). Ieso also has an active outreach programme where Ieso staff will meet with sectors of the community who have been identified as being poorly served by existing mental health services in order to improve access.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Ieso Digital Health allocates patients to a therapist on the same day as the patient has opted in and confirmed they are ready to start treatment. An initial triage in undertaken to socialize the patient to the treatment process and ensure the patient is suitable for treatment. This is followed by a full assessment which focuses on the presenting problem and a full risk assessment This will include the following elements:
A comprehensive ‘patient centred’ assessment that clearly identifies the full range and impact of their mental health problems and any linked employment, social and physical health issues.
Risk (suicide, harm to others, etc.) is assessed at initial contact and at each contact thereafter. People identified to be at high risk (e.g. suicidal ideation, severe self- injurious behaviour, psychotic symptomatology) will be urgently referred to the appropriate mental health service /crisis support services
Clinical, work and social outcomes are assessed using standardised measures that are appropriate to the conditions being treated. This includes routine use of validated standardised measures such as PHQ-9, GAD-7, WASAS, Anxiety Disorder Specific Measures, Phobia Scales, Patient Experience Questionnaires, Diabetes Distress Scale, Pain Scales, Pain Catastrophising Scale, Linton and Halden Questionnaire and Alcohol Scale. Key measures are given at each treatment session so that a clinical end point is available even if patients finish treatment early.
How do you meet the needs of people using the service and how could you improve on this?
Meeting the needs of people using the service and continually working to improve the service are of critical importance to Ieso. Shown below are extracts from some of our internal service delivery and improvement manuals that best illustrate this aspect:
Cognitive Behavioural Therapy (CBT) is already a highly efficacious intervention for a wide range of common mental health disorders (Roth and Fonagy 2004). Ieso Digital Health has demonstrated how the processes of CBT can be amplified in order that:
Patients who might not otherwise access treatment feel able to have therapy.
More patients are able to access treatment
More patients stay in treatment
More patients experience an improved outcome.
These outcomes are only possible through the Ieso Method. This unique method of delivering CBT is best described as an amalgamation of evidence based psychological therapy delivery, unique clinical and operational processes amplified by the use of cutting edge data science.
The Ieso method encourages patients to engage in therapy due to ease of access, convenient appointment times and less anxiety provoking processes which are both discreet and congruent with a patient’s day to day living
As the overarching aim of CBT is to enable patients to learn more about their presenting problem/s and what they can do manage their symptoms, any process that amplifies learning is likely to improve clinical outcomes. Further amplification occurs when patients regularly access their own therapy transcripts, which serves to further consolidate learning.
In addition to these therapeutic processes The Ieso method enables senior clinical management teams to have complete accessibility to every therapy appointment and all communication between patient and therapist. When it is possible to explicitly identify therapist behaviour it suddenly becomes possible to enable therapists to become the best they possibly can be.
The triad defines the processes that are involved in ensuring that:
Only the most competent and clinically effective therapists are selected to deliver CBT with Ieso services.
That a unique blend technological and clinical processes are employed to support and enable therapists to provide gold standard treatments
That clinical data is used to support and enable therapists to provide the better outcomes.
What support do you offer families and carers? (where family/carers are not the service users)
Ieso works together with family members and carers in a number of ways. In many cases we are able to offer 1:1 support and guidance delivered by own clinicians. Where this is not possible we signpost to a range of services. Where appropriate and with patient consent we offer carers and family members joint therapy. This is more common with spouse and partners – eg behavioural couples therapy for depression.
Webpage for service:www.iesohealth.com
Hours the service operates: Patients can book therapy 7 days a week, 24 hours a day.
Population details
Brief description of population (e.g. urban, age, socioeconomic status):
Ieso works in a wide range of geographic areas treating predominately the adult population (over 18) including older adults (65+).
Ieso works in both urban areas and rural areas and is available to all demographics.
The areas Ieso currently covers have deprivations scores (IMD 2015) ranging from 9.4 to 26.9.
Size of population and localities covered:
As of March 2018 Ieso was working with 37 CCG’s within NHS England. These CCG areas comprise of 9.7 million patients registered with GP’s in these areas (over 18’s).
In addition to our adult service Ieso also works with Children and Young people in Oxfordshire, Wiltshire, Aylesbury Vale and Chiltern.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England):
Ieso is directly commissioned by:
NHS Surrey Heath CCG
NHS North West Surrey CCG
NHS Guildford and Waverley CCG
NHS Surrey Downs CCG
NHS East Surrey CCG
NHS East Riding Of Yorkshire CCG
Provided by (e.g. name of NHS trust) or your organisation:
In addition to the directly commissioned services referenced above Ieso also provides treatment to patients on behalf of many NHS Trusts including; Dorset Healthcare University NHS Foundation Trust (DHUFT), Healthy Minds Buckinghamshire, Sussex Community NHS Foundation Trust, Addaction, Insight Healthcare, South London and Maudsley NHS Foundation Trust, Lincolnshire Partnership NHS Foundation Trust, Camden and Islington NHS Foundation Trust, Cambridge and Peterborough NHS Foundation Trust, and others.
