Coherence: understanding and making sense of telephone-delivered psychological interventions
Typically, increasing engagement with telephone treatment for depression and anxiety in primary care relies on decision makers such as policy leads and service managers understanding its purpose and potential value, and effectively communicating that down to clinical services.
Participants in the current study displayed consensus in their views of the national policy context supporting the use of telephone treatment, and felt there was a good evidence base to support this position. However, policy documentation was considered to lack clear guidance about implementation at a local level causing regional variations in telephone use.
Although local autonomy and needs assessment were valued, there was felt to be a role for more national policy guidance around implementation, although many were keen to stress this should not be too prescriptive. Local decision makers discussed a lack of guidance on ‘best practice’ in telephone work to support local implementation:
‘I don’t think they were that prescriptive about the telephone use. Indeed with the curriculum it basically says telephone use should be made available, it’s one of the choices and you should offer it but then it doesn’t go beyond that mention. And potentially the implementation in services it says much the same and leaves it to the service to decide themselves about how best to do it.’ (Participant 11, local informant, established use).
The need to offer increased choice, flexibility and personalised care to patients in line with IAPT core aims were the principal drivers highlighted by national decision makers who spoke about how telephone treatments should be part of a ‘suite of different ways’ to deliver NICE approved evidence based treatments. The importance of personalised care was also considered important, with telephone treatment offered as an option to provide a way to deliver choice to patients who want such flexibility.
Patient centred drivers of telephone were also recognised and discussed by local decision makers, however service centred motives, such as cost-saving, were a predominant focus of some interviews with local service and clinical leads. The decision to offer telephone treatment was perceived to facilitate services to overcome financial and associated practical challenges, such as hiring costly clinic space in GP surgeries. It was also seen to provide increased ‘clinical efficiency’ by delivering cost savings to services through the use of telephone assessments, by minimising waiting lists, and by reducing the number of missed appointments:
‘It's largely doing the telephone assessment, it has been a local decision that we've made with the CCG[clinical commissioning group] that…well a service would be a lot more costly if we were to do all face to face assessments. I think there's…I suppose there's a potential saving in doing telephone therapy, but it just boils down to practically whether we can, you know, realise some cash from that saving.’ (Participant 5, local informant, limited use)
Telephone delivery was also considered at the national level as having a variety of advantages for PWPs, and subsequently services. The increased opportunity for flexible working and greater variety for PWPs was identified as important for tackling burnout in the IAPT workforce, along with providing PWPs with a tool to more easily manage and contain sessions. Decision makers acknowledged the importance of providing varied working options such as working from home to support PWPs, noting the potentially
‘draining’ experience of sitting in the same room everyday on the phone. The potential for telephone delivery to facilitate PWPs to contain sessions was also discussed in terms of adhering to agendas while at the same time preventing the perception of being over-managed, contributing to efficiency:
‘So way back when I was a clinical lead…and as a therapist myself, I’d found that telephone and Skype sessions had really beneficial effects, that people seemed to be contained more within the sessions. I felt that agendas could be very strictly adhered to without feeling like you’re being over-managed. I think they can reduce the time spent in a session. Not because the therapist is trying to cut down the session, but because something happens by telephone and by Skype where some of the sessions become incredibly well-structured.’ (Participant 8, national informant)
Whilst it could be argued that both patient and service-centred drivers are important, some higher level decision makers felt the two could be in conflict, where service needs, such as meeting performance targets, are balanced against clinical need and policy mandates around patient choice:
“So from a clinical point of view, I can see that there’s a real choice agenda in widening access. From a, I guess, a service perspective, you’ve also got the issue of how do you meet the increasing targets and to increase access to meet a greater, higher level of prevalence. So the KPI’s [key performance indicators], also, I think, drive the telephone agenda but not necessarily for the same clinical reasons as choice and I think there’s a real tension there… when you’ve got service and performance needs being balanced against clinical need and I think telephone working can start to be used to meet service needs, rather than clinical needs, if that makes sense. That’s my…I think there’s a real tension there.” (Participant 4, national informant)
The understanding of the potential for telephone to offer greater benefit to services rather than patients filtered down to local decision makers, who acknowledged it as a potential barrier to acceptance of telephone use by PWPs. Local decision makers talked about the importance of managing staff expectations, suggesting that persuading the clinical team of the benefits of telephone working was potentially a bigger challenge than convincing patients. This was particularly important in relation to the views that PWPs often feel they are short-changing patients by providing them with treatment which is only offered for financial reasons:
‘I think the staff sometimes feel that they're short changing the patient by doing telephone and again it's trying to shift that attitude that it's not a financially driven thing, it's not about any other aspect other than is it appropriate to do so with this person.’ (Participant 3, local informant, emergent use)
In terms of practicality for PWPs and services, there was additional divergence in views. While there was the view by some that a quiet space is essential for PWPs to work effectively on the telephone
‘You can’t do it in a busy office’ (Participant 16, local informant, limited use’), a number of national decision makers held the opinion that PWPs would be better optimised to work by telephone in an open-plan call centre setting; an idea which aligns with the original IAPT model:
‘I can't see how you can effectively do telephone work unless you’ve got a room like that [call centre]. That’s the way it’s designed to be done. Of course then you have a network of people, so you may have eight people in the room, six people in the room whatever, but you have a group of people who are all doing telephone work, they can support each other and it gives a model of how the whole thing is done.’ (Participant 10, national informant)
Local informants from five different NHS trusts spoke of ‘call centre set-ups’ within their services, and the service benefits to such a system i.e. cost savings on estates, along with some of positives for PWPs (i.e. peer support). However, all those with call centre arrangements also acknowledged negative aspects for both PWPs and patients, most pertinently noise and distraction, which was suggested can affect the way patients perceive how they are valued. The ‘ideal’ provision of quiet spaces was expressed more prominently by local informants in services where less telephone work was undertaken, and by some national informants which contrasted sharply against other national informant views of the call centre environment being ‘the ideal’. The common denominator underscoring diverged views on such practical issues was actual experience; national informants had no personal experience of working in such environment’s leading opinions to be based on personal or policy views. Such disparity in opinions of key decision makers on matters central to the implementation of telephone may provide insight into the reasons for such variation in working practices across services, where local opinions may have more influence in the absence of national guidance.
Whilst some barriers to successful implementation were noted, telephone treatments were on the whole understood to facilitate greater accessibility and choice for a wide variety of patients (such as those with work and childcare commitments, people restricted by location, transport and mobility issues, and those with co-morbid/long term conditions). One participant also highlighted the potential for telephone interventions in tackling shame and stigma:
“One thing I’d say is that telephone for me works well for people with high shame-based presentations…[they] might not want to come into a place and be around lots of people, and so it might be really useful to do that on the phone…they might not want to be identified. So I think there’s an advantage to engaging with hard to reach populations on that.” (Participant 8, national informant)
Although national decision makers felt that telephone treatment aligns with wider health policy (Petrova & Dale, 2006) around patient choice and flexibility, patient choice was not always at the centre of decisions to offer telephone at service level, demonstrating mistranslation of principles from policy level to practice.
Cognitive participation: engagement with telephone-delivered psychological interventions
Successfully implementing telephone interventions into existing practice in IAPT is reliant in part on the engagement or commitment of all stakeholders – both decision makers and front line staff – to new ways of working. Whilst benefits of telephone working were acknowledged by all participants, a significant number of barriers to engagement remain.
The extent to which teams and services commit to telephone working depends on willingness to change, and by how well organisations support staff to make changes. Decision makers acknowledged the difficulty in instigating change, identifying staff confidence and skill-set as important factors. The impact of this was evidenced by one participant who spoke about a tendency to ‘drift’ to old ways of working (counselling) in services where staff had previously worked in alternative roles. This created the need to remodel telephone working in some services to correct this:
‘There’s been within our service a culture, sort of, a bit reluctant to take on telephone work among staff but we’ve had to, sort of, re-focus step two quite a bit anyway in terms of the way that they’re working because I think there’s been historically quite a bit of drift from guided self-help.’ (Participant 13, local informant, emergent use)
Willingness of patients to engage was also an essential factor identified by decision makers, which could be affected by staff attitudes to telephone treatment. Individual experiences of decision makers appeared to influence perspectives of telephone treatment, in particular where they had previously worked as a clinician delivering treatment. In addition, there was a perception amongst decision makers of the need to ‘sell’ telephone interventions to patients, which was a challenge in itself when it was felt there was first a need to ‘sell’ telephone to PWPs:
“I mean I really think it's about capturing hearts and minds, not just of patients but of the therapists….If they don’t believe in it themselves they can't talk about it appropriately to the patient because they can't sell it, and if you can't do that then you're already on to a loser.” (Participant 6, local informant, established use)
Given the impact of personal attitudes towards the use of telephone treatments, such views must be considered in terms of local implementation. Despite understanding the drivers for telephone treatments at policy level, individual attitudes could play a disproportionate role in local variability in the absence of national guidance and standards.
Collective action: implementing telephone-delivered psychological interventions into practice
Collective action is the work that needs to be undertaken by individuals and organisations to successfully implement new procedures and practices. Decision makers were able to identify the work that is needed and the resources and staff skills required to make telephone treatment work in practice.
As discussed above in terms of perception and attitudes, the need to action ‘selling’ of telephone interventions to PWPs was one issue emphasised by decision makers. Incentivising PWPs to make telephone treatment more appealing was the strategy identified for this task, accomplished by providing opportunities such as flexible working, working from home and greater autonomy over managing caseloads. The success of incentivising even just a small number of staff with this flexibility was also identified as having a subsequent benefit to raising acceptability amongst the wider workforce:
‘One lever is giving people the opportunity to work at home which some people really like, I mean, it depends on peoples personal circumstances obviously but for some people that works well. So, you know, that’s an incentive, a useful lever for some……As staff have begun to take on telephone work and have had something positive to say about it, that’s been useful for other staff.’ (Participant 13, local informant, emergent use)
The need to incentivise PWPs was highlighted to be in part related to a lack of skills and confidence, and suggested as being resultant of insufficient inclusion of telephone skills in many PWP training courses. Decision makers identified a significant shortfall in training for working on the telephone, where policy has failed to influence the curriculum. During the focus group with local decision makers, many of whom had completed the PWP course, numerous participants reported experiencing limited training on telephone work, such as a single slide or presentation at University. To address this, many organisations represented by the decision makers had developed or commissioned their own in-house training on telephone working to address skills gaps in the workforce. One participant spoke about the service ‘boot camp’ in which PWPs are intensively trained in telephone working when they commence their role, and subsequent on-going monitoring of practice.
The gap in skill set observed after PWP training was also felt in part by some to be related to the highly prescriptive, protocol-driven approach of the national PWP curriculum, which could be at the expense of teaching the skills needed for practice due to the lack of inclusion of telephone working:
“Certainly the courses that our PWPs go to…it does seem to be heavy on the protocol, heavy on quite a rigid protocol adherence to pass the course, as opposed to the good old-fashioned, idiosyncratic formulation and working within the models that fits within that formulation. It seems to be...I hate to say it, but almost like a cookbook approach to training…So essentially it means that when we have therapists come and join us we invariably are spending a fair bit of time working with them to use telephone working, with mixed results really.” (Participant 3, local informant, emergent use)
In addition to training and incentives, the importance of investment in resources to support telephone working was evident, in particular where services have adopted telephone working as a ‘quick fix’. Issues around IT provision and specific tools to aid telephone treatment were noted as important practical considerations. In addition there was acknowledgement of the essential necessity of basic equipment and suitable working environment for PWPs, but that sometimes such resources are not provided:
“So, the availability for therapists of appropriate equipment that they would need to do the job. So, things like headsets, a quiet space to do the phone calls, things like that, these are often the things that are the last down the list and sort of seem to be a wish list item rather than a necessity, and yet I think that to do the job properly you need the things that are going to help you do that.” (Participant 6, local informant, established use)
Potential obstacles with how face to face procedures are undertaken in telephone sessions, such as completion of outcome measures and engaging in written tasks for treatment, were also discussed. Participants talked about the issue of wasting valuable treatment time when completing measures, and the potential for the development of coercive relationships, where patients feel under pressure to report feeling better than they do due to the on-the-spot nature of completing measures by telephone during the session. Additional practical barriers were identified by decision makers, particularly difficulties resulting from a lack of visual communication, such as undertaking formulations during assessments:
‘One of the problems that we still face with telephone assessments is doing things like drawing out formulations. So, if you're drawing something with a client that's virtually impossible over the phone.’ (Participant 5, local informant, limited use)
Reflexive monitoring: appraisal and future sustainability of telephone-delivered psychological interventions
All participants agreed on the validity and long term sustainability of telephone treatments; that they will remain a treatment option in order to provide accessible interventions to patients. Some were keen to ensure that telephone interventions remained part of a wider offer, noting that the modality will not suit all and choice of treatment should remain the central tenet of IAPT provision. Use of IAPT minimum datasets was suggested by decision makers as one way to monitor efficiency and recovery rates, but difficulties with this and the need for improvements to the dataset itself were noted. Issues regarding the accuracy of reporting mode of delivery for the IAPT dataset were highlighted, along with the current lack of facility for services to extract data specifically for telephone treated patients:
‘I don't think we have a robust way yet of monitoring the vehicle that therapy is delivered by, be that telephone treatment, be that a digitally enabled therapy, because the dataset doesn’t accurately gather that information and we don’t report on it accurately enough, which is why we are looking at revisions to the IAPT dataset so we can much more accurately capture how that's delivered and sort of demonstrate the outcomes for different methods of delivery.’ (Participant 6, local informant, established use)
Interestingly, the suggestion of IAPT dataset use by a local informant contrasted against a national decision maker’s suggestion of using patient feedback data, which appears reflective of the misaligned drivers for telephone at the local and national level described above. Using data available to measure services against key performance indicators, compared to the emphasis of using a measure more greatly focussed on patient experience, demonstrates the divergence in priority between higher level and local decision makers.
A change in recording of telephone contacts in clinical record systems was additionally highlighted as a potential determinant of how PWPs might alter their views of the value of telephone treatment. Some Systems were known to not have the facility to record telephone treatment sessions in the same way, or be given the same weight as face-to-face sessions, potentially contributing to the perception of PWPs that face-to-face delivery is superior:
‘It’s still very difficult for some contacts to be considered as contacts [on the] clinical recording system and given the same weight as…even if those telephone contacts are therapeutic in their delivery’. (Participant 1, national informant)
Additional approaches identified for improving acceptability of telephone treatment included measures to address PWP concerns and anxieties. Decision makers discussed approaches such as providing the opportunity for PWPs to observe telephone working in practice, and the introduction of service ‘champions’ who could advocate for the benefits of telephone treatments:
“I think you have certain people…when you’ve got people around who champion it and talk about the relative merits that it might offer for a service, but outside of that, you know, that tends to be the exception rather than the rule.” (Participant 1, national informant)
The influence of individuals advocating for telephone, demonstrated to be effective by some services already, further indicates the disproportionate effect a single opinion within a service can have in the absence of best practice guidance for IAPT services.
All decision makers commented on the need for a combination of monitoring, PWP training, advocacy for the use of telephone, and the need for clearer guidelines for implementation in order to achieve a more standardised approach to telephone across IAPT services.