Northpoint is a third sector commissioned provider of mental health services in Yorkshire, which include child and adolescent mental health services and school therapy services. In 2019, Northpoint explored whether any of the SilverCloud adult mental health digital treatment programmes would be suitable to offer to young people. At this time, demand for support in relation to children and young people's mental health was increasing at pace. NHS Digital (2022) confirmed in their follow-up review of the 2017 Mental Health of Children and Young People's survey, that rates of probable mental disorder ’in children aged 7 to 16 years rose from 1 in 9 (12.1%) in 2017 to 1 in 6 (16.7%) in 2020’. Improving access to support was a key motivator for Northpoint. They were committed to reducing health inequalities and wanted to ensure that children and young people had access to appropriate support and intervention, including reducing waiting times and stigma, and ensuring equitable access to the right services at the right time. Northpoint was passionate about bringing positive change within this priority area, as well as informing future service provision and delivery in relation to children and young people's mental health services.
In terms of national policy, Northpoint has embraced the transformational approach of Future in Mind (Department of Health and NHS England, 2015) and the 2017 green paper (Department of Health and Social Care and Department for Education, 2018). As a provider working as part of a multi-agency consortium, Northpoint respond to the goals of Future in Mind in both their schools and child and adolescent mental health services. As Lamb outlined in Future in Mind (Department of Health and NHS England, 2015): ‘We need a whole-child and whole-family approach, where we are promoting good mental health from the earliest ages. We need to improve access to interventions and support when and where it is needed, whether that's in schools, GP practices, hospitals or in crisis care’.
The SilverCloud platform has a strong background in working with the NHS to develop and deploy programmes for adults. The platform is also backed by 20 years of research around its adult programme offerings. It was clear that an equivalent treatment offer was needed for children and young people to support with the increasing mental health needs and gaps in service provision being faced by children and young people.
Impact of the pandemic
This all took place before the pandemic. The further impact of the pandemic on the mental health needs of the population made an existing problem even more complex. For a substantial period of time, people relied on technology to be able to support, connect and communicate with others – De et al (2020) acknowledged that ‘The COVID-19 pandemic has led to an inevitable surge in the use of digital technologies’. As a provider that also delivers adult services as part of Improving Access to Psychological Therapies in Leeds, Northpoint already knew that digital support could enable swift access to support, as it can be offered at the point of receiving a referral when suitability and service user motivation allow. The additional capacity that a digital offer could bring to children and young people's services was already understood, in that a practitioner can oversee four users within the programme during the equivalent time of one face-to-face session, making digital provision a cost-effective treatment option.
Programme design
Northpoint were interested to understand whether having a digital early intervention offer in their children and young people's services would enable young people who required face-to-face therapeutic treatment to be able to access that support quicker and ultimately bring down the overall waiting times for support. When children and young people do not receive the right support at the right time it can have long-term consequences. A systematic review by Radez et al (2021) stated that: ‘Untreated mental health disorders in children and adolescents are related to adverse health, academic and social outcomes, higher levels of drug abuse, self-harm and suicidal behaviour and often persist into adulthood’. Motivated by the concept that digital support for young people could be beneficial to not only young people but to the whole mental health system, Northpoint worked in partnership with SilverCloud to develop the first programme on their children and young people's platform.
Anxiety is one of the most common mental health issues faced by young people, and this escalated further during the pandemic. In 2021, the World Health Organization reported that: ‘It is estimated that globally 3.6% of 10–14-year-olds and 4.6% of 15–19-year-olds experience an anxiety disorder’. Anxiety is also the most prevalent issue for young people in Northpoint's schools therapy service, averaging 38% of referrals received. Therefore, supporting people with anxiety was selected as the focus for the initial programme.
Working closely with the clinicians and the product design team at SilverCloud, a steering group was set up which included young people who had been service users and who volunteered to test the programme as it went through its development and design stages. The group consisted of young people aged 13–19 years, ranging across diverse communities and protected characteristics including representation from minority ethnic, children looked after, special educational needs and disabilities, lesbian, gay, bisexual, transgender, queer +, and gender groups.
‘Anxiety is … the most prevalent issue for young people in Northpoint's schools therapy service, averaging 38% of referrals received. Therefore, supporting people with anxiety was selected as the focus for the initial programme.’
The young people wanted the option of a support intervention that could be accessed at their own pace and at a time that suited them, that was not structured to a set time each week in a particular venue, and one that would support barriers to access for those where there is social stigma or logistical challenges in terms of accessing mental health support. The group rigorously critiqued the programme's content, the visual images and interactive elements of the design, giving feedback at each stage of its development. The SilverCloud platform responded to this and made the relevant changes.
This led to the development of a digital Cognitive Behavioural Therapy guided self-help programme to treat mild to moderate presentations of anxiety for young people called ‘Space From Anxiety’. The programme is online and accessible from any mobile device, tablet, or computer. The format of the programme is based on cognitive behavioural therapy principles, with specific modules that the user is encouraged to work through. It offers multimedia elements to assist with the learning of knowledge and skills. The programme can be accessed 24/7, so is flexible and responsive. It provides interactive tools that follow best practice for usability, accessibility and clinical safety.
The guided self-help element of the programme is the ‘supporter’ who is an experienced children and young people's mental health practitioner and who acts as the human link. As the programme itself is the therapeutic intervention, the supporter does not need to be a qualified therapist eligible for professional registration, they need to have experience of working in a mental health service or similar organisation supporting children and young people. The supporter oversees, motivates and responds to the young person while they work through the programme modules. The role of the supporter is an essential element to the offer and, in Northpoint's experience, often determines whether a young person will engage with the programme or not. The supporter sends out bespoke welcome e-mails and messages, offers weekly reviews, and can unlock further modules to best meet the needs of the user such as ‘exam stress’ or ‘bereavement’ modules. They also act as a point of contact for queries, monitor clinical risk and safeguarding, and support onward referrals for further or alternative support where needed.
Clinical risk is monitored through alert systems that are built into the platform. The user is asked to complete a short questionnaire each time they log on. Email alerts to the supporter are triggered if the user shows a negative change in scores on psychometric tests or if there is concerning content outlined in their diary or other tools, as this indicates either a decrease in mood or an increase in anxiety which the supporter can then review. Supporters also monitor journal entry content and follow organisational safeguarding and clinical risk policies and procedures as required. In addition, local and national crisis support numbers are built into the platform for reference and information.
Possible barriers to implementation
In terms of barriers to implementing digital interventions, Williams et al (2020) highlighted that: ‘Few commissioners have a wealth of experience of commissioning digital health solutions or the models by which this is best done’. Initially Northpoint's commissioners raised concerns that digital support would encourage young people to spend even more time online. In many ways the internet has transformed people's lives for the better and young people exist in a world where the majority of their social interactions, support and learning take place online. Ofcom (2022) stated: ‘Nearly all children went online in 2021, with the majority using a mobile phone or tablet to do so’. Their research also indicates that it is not necessarily the time spent online that is the issue but what is being accessed. If used in a positive way, there can be many advantages: ‘In addition to keeping children connected and entertained, being online can help them to learn and develop new and existing skills’ (Ofcom, 2022). However, it is important that children and young people are safeguarded against the potential dangers of the internet.
The workforce themselves could potentially be a barrier to digital transformation, in that digital provision could be misinterpreted and viewed as some form of threat to their role, in that it could be seen as a ‘replacement of’ healthcare professionals, rather than recognising digital as an ‘additional offer’. In response to this, Northpoint ensured that the team was involved from the outset, inviting clinicians and practitioners to trial and feedback on the programme as it was piloted. Leadership played a key role in supporting this, as the National Institute for Health and Care Excellence (2018) outlined: ‘Leaders need to create change agency: the power individually and collectively to make a positive difference. This empowers everyone to push the boundaries of what is possible and make change happen more quickly; transforming care and services’. Identifying the innovators and early adopters within the team was crucial as they helped bring other members of the team on board.
The team soon began to recognise that this digital provision allowed more choice and capacity, that it strengthened the service model and supported capacity, not only for service users but also for the workforce. Staff in mental health services are at risk of burnout following the pandemic, largely as a result of the increased demand of mental health need, staff resource and ongoing recruitment challenges. A report by the British Medical Association (2019) before the pandemic outlined that: ‘Mental health professionals say that their workload is unmanageable and that they are too busy to provide the care they would like’, and this workload has only increased. Northpoint has found that digital provision can help support these challenges.
There may be concerns in terms of General Data Protection Regulations and data protection when using a digital product, but to date Northpoint has not encountered any problems in this area. As with any therapeutic work they work to the relevant legislation, ensuring all client records are stored safely and securely. Records are stored electronically on a secure patient management system (IAPTus CYP, Mayden). IAPTus is used in over 100 NHS organisations across the UK, and SilverCloud and IAPTus have developed technology together, which enables the two systems to communicate. Only minimal data are held by SilverCloud for login purposes; personal sensitive data are held by Northpoint as the provider/service. Referrals are inputted on the patient management system, invitations to the programmes then go out from the patient management system to the user's email address, and once the invitation is accepted the user is brought into the SilverCloud platform. This technology has been fundamental in terms of data security, administration efficiency and enabling all clinical contacts from the supporter reviews to pull back through to the patient management system. This means that data flow from the digital support offer to the NHS Mental Health Services Data set in the same way as for all other interventions, which is a requirement of Northpoint's health commissioning. Full details about SilverCloud's data protection can be found at https://www.silvercloudhealth.com/uk
Since the first programme was developed, SilverCloud has developed further programmes which are available on their children and young people's platform. These include programmes to support young people in relation to low mood, and comorbid presentations of anxiety and low mood. In addition, there are parent/carer programmes which are designed to help support an anxious child or teenager, and programmes to support children and young people with neurodevelopmental conditions are being piloted. The parent programmes have been a valuable addition to the platform; as Lawrence et al (2019) identified: ‘where parents had an anxiety disorder, offspring were significantly more likely to have anxiety’. Referrals are received into the service in the name of the child or young person and the programmes enable the parent to support their child or teenager in dealing with their anxiety while learning how to support their own anxiety and understand how their responses are impacting their child and family dynamics.
How digital treatments are supporting schools
School staff members are facing substantial challenges in terms of supporting the mental health needs of their pupils. NHS Digital (2022) reflected in its key findings that: ‘11 to 16-year-olds with a probable mental disorder were less likely to feel safe at school. They were also less likely to report enjoyment of learning or having a friend they could turn to for support.’ Schools have particularly valued having a digital support option for their pupils that can be offered with such swift access. Key referrers in school, including pastoral leads and heads of year, all work to referral criteria in terms of suitability for the programmes. Northpoint works to a guideline that the digital offer is for young people aged 14 years and above, and the reading age of the platform is 12 years so literacy issues need to be considered. However, on a case-by-case basis Northpoint supports a number of young people through the programmes from 11 years and over where appropriate. In addition, Northpoint is able to offer the parent/carer programmes to parents of primary school-aged children, to help them support their anxious child. This means the digital offer is for the whole school population, benefiting children and young people across both primary and secondary schools.
Digital provision is also able to support harder to reach client groups including young people who are not attending school. Attendance difficulties at school are still a significant issue following the pandemic. Dame Rachel de Souza, the children's commissioner for England, recently told The Times (Kendix and Woolcock, 2023): ‘The new figures out today lay bare the scale of the school attendance crisis. Three years on from the pandemic, school absences remain at unprecedented highs. “We are failing to get children back to school”.’ Mental health can have a detrimental impact on a child's attainment and attendance, and low attendance at school also means access to support services for some young people can be difficult. It is possible that digital support could be part of the solution to this crisis. Northpoint has been able to support a number of young people who were not attending school because of their anxiety with the ‘Space from Anxiety’ programme. This has enabled them to work towards returning to school, developing strategies to help understand and manage their anxiety. If needed, face-to-face therapy can be continued once the child is back at school.
Having now worked with over 250 primary and secondary schools across Leeds, the programmes have supported over 1500 users. With an average of 650 children and young people in treatment at any given time, 20% of referrals in service are currently accessing the digital programmes as a treatment option. The average overall service wait time for support is 5.5 weeks with 40% of clients waiting less than 1 week to be seen, because there is the digital treatment option within the service model. Since SilverCloud was introduced, the overall service wait time has reduced by 57%.
It is also not just within schools that digital solutions can be of benefit to young people. We have successfully tested and established additional referral pathways within child and adolescent mental health services, Leeds secondary care clinics in paediatrics and within a single point of access service where all health professional and self-referrals for children and young people's mental health are triaged. The programmes can be offered as a sole intervention, as a holding support while waiting for face-to-face therapy and as a follow on from therapy to help sustain strategies going forwards.
Clinical outcomes, qualitative data and research
Northpoint uses the Revised Children's Anxiety and Depression Scale to assess clinical outcomes. Developed by Chorpita et al (2000), the Revised Children's Anxiety and Depression Scale is a self-report questionnaire that assesses symptoms of anxiety and depression in children and adolescents. The measures are built into the programmes and evidence of clinical improvement is seen through the pre- and post-intervention scores. In addition, high percentages of engagement and qualitative feedback are received. The overall satisfaction rate with the programmes at ‘agrees’ or ‘strongly agrees’ is 94%. The account activation rate for the programmes is 75%, with an overall completion rate of 83%. If a user does not activate the programme, the supporter would follow this up accordingly. Sometimes it could be because of a technical issue such as the email invitation going into a junk folder. However, if a young person does not engage with the programme the supporter would explore alternative options of support with them, such as face-to-face therapy. An early value assessment from the National Institute for Health and Care Excellence (2023) has recommended that four digital technologies, including SilverCloud, can be used in the NHS for guided self-help digital cognitive behavioural therapy for children and adolescents with mild/moderate symptoms of anxiety or low mood while further evidence is being generated.
Conclusions
Whatever one's opinions, the reality is that young people will continue to live a substantial part of their lives online. With digital technologies constantly developing and mental health needs increasing on a daily basis, technology solutions will be an essential part of the mental healthcare system going forwards. Having seen the benefits that digital provision can bring, commissioners and service providers should look to integrate digital treatment options for children and young people to best support their mental health needs.