Getting Digital Interventions into practice:
Why? And How?
Elizabeth Murray
eHealth Unit
UCL
Why bother?
Digital Interventions
• Small effects
• Most costs incurred
during development;
relatively small marginal
costs per additional user
Implications
• Need lots of users for
population impact
• Need lots of users for
cost effectiveness
• Moral imperative for
academics with public
funding
• Commercial developers
require ROI
Is it happening?
• Not really
• Systematic reviews of DI in diabetes,
hypertension, asthma all show same story: DI
developed, trialled, and then not used.
• A few notable exceptions
– Smoking: Stop Advisor; Txt2Stop
– Mental health: Beating the Blues, Fear Fighter, LLTF
– Alcohol – Down Your Drink Kingston.
How to do it?
HeLP-Diabetes: An (imperfect) case study
• Think about implementation right from the start:
– Writing the initial grant application
– Developing the intervention
– Thinking about what evaluations to undertake
• Use an appropriate theoretical framework
– Normalization Process Theory
http://www.normalizationprocess.org/
Normalization Process Theory
May & Finch; Sociology 2009; 43(3):535-554; www.normalizationprocess.org/
Coherence
Theory
HeLP-Diabetes
Do I understand this “thing”,
and how it differs from
other, similar “things”?
Self-management support
for people with type 2
diabetes
Is it easy to explain and
differentiate?
Yes. Other selfmanagement programmes
are group-based, H-D is
online.
Holistic approach.
Cognitive Participation
Theory
Having understood what “it”
is, is it something I / we
want to take part in?
HeLP-Diabetes
Yes. DH and NHS policy
promotes self-management.
Diabetes accounts for 10%
of NHS costs
Self-management reduces
risks of complications (and
hence costs) in DM
Low take up of group based
education
GPs appreciate holistic
approach
Collective Action: Impact on work
Theory
Interactional workability
(impact on consultations)
Skill set workability (fit with
existing skill sets, need for
training)
Relational integration
(impact on relationships
between different
professional groups)
Contextual integration (fit
with organisational needs)
HeLP-Diabetes
Addressed ++ in design,
user input +++
Initially planned for nurses
to support patients in use,
found HCA better.
Important for all content to
be NICE compatible
Yes at CCG level, variable
at practice level
Reflexive Monitoring
Theory
Having engaged with this
change, does it seem worth
it?
Formal and informal
evidence / feedback
HeLP-Diabetes
RCT:
• effectiveness
• cost-effectiveness
Implementation Study:
• Uptake at practice &
patient levels
• Impact on patients
Informal:
• Patient feedback
• GP / CCG feedback
If that was the plan, what actually happened?
1. Health and Social Care Act 2012 = massive
change in the NHS.
2. GP workload soared – previously acceptable
impact on work no longer possible.
3. QOF reimbursement introduced for “structured
education”. H-D not structured.
Current state:
1. Host CCG(s) very keen and supportive
Good uptake at practice level (2/3)
Variable uptake at patient level (n = 160 after 1 year)
Opportunity to trial multiple implementation pathways:
• practice led, patient led, intermediate services, OPD, IAPT
• Lots of adaptation and change (e.g. HCA to support patient
use; self-registration)
2. Developed & piloting “structured education” (with
email facilitation) for QISMET accreditation
3. Widespread interest from other CCGs
Commercialisation
1. Establish Principles:
–
–
–
Free at the point of use (NHS service; NIHR funding)
Maintain integrity of intervention
Promote future research, development, sustainability
2. Establish a Community Interest Company (CIC)
–
Assistance from UCLB; Improvement Science London;
HeFCE UnLtd; Health and Social Innovation
Programme; NIHR.
3. Obtain Contracts (!).
What have we learnt?
• Implementation is important
• Think about it from the very beginning
• Integrate it into all phases of your research –
development, evaluation,
• Use theory
• Accept the need to be responsive and adaptable
• Approach it as you would any other academic
exercise – seek advice, share learning, generate
generalisable data, maintain integrity.