Striking the balance: hybrid care in mental health

Louise Morpeth, chief executive officer at Brain in Hand, analyses the balance between using technology and giving in-person support when treating mental health.

Hybrid care – the combination of human intervention and digital tools - is set to become the norm in post-covid health and social care services. With the NHS and local authorities at breaking point - 222,000 vacancies across health and social care in 2019[1], a burnt out workforce (44% feeling unwell from work related stress[2]) and the highest number of people awaiting treatment (4.7m) since records began in 2007 [3] - hybrid care that reduces burden on staff, releases capacity and fosters self-management of patients has to be part of the future service landscape.

At Brain in Hand, digital hybrid support has been at the heart of our products and services since the beginning, before hybrid became a buzzword in care. From our experience of working with autistic people, we know that practical, hybrid support personalised to someone’s needs can make a significant contribution to their self-management and independence. Yet, the current failure to adequately support autistic people costs the UK over £32 billion per year in productivity losses and provision of services[4]. This is quite apart from the human cost of wasted potential.[5]

Well-used by autistic people, our digital hybrid solution combines virtually-delivered solution-focused coaching, digital tools and 24/7 on-demand, human support.  We focus on each person’s needs, helping them to develop bespoke, practical strategies for achieving their goals for independence. By providing a safety net of human support people are enabled to do more for themselves knowing that someone is on hand if they need them.

This approach turns the traditional model of service delivery on its head: (1) available when the user wants help regardless of the time or day; (2) putting them in control – it’s in their hands to determine their own needs, (3) offering ongoing, practical support rather than time-limited interventions.

As a hybrid solution, we are constantly looking at getting the balance between human and digital right. A fully digital solution is cheaper and more scalable but adherence to stand alone digital tools, even very sticky ones, is low. However, digital tools can do things that human intervention simply can’t replicate. For example, our software provides users with feedback on mood, activities and their strategies enabling deep reflection - an essential skill for self-management.

We believe that digital hybrid is about harnessing the best of technology to perform repetitive, daily, time-consuming tasks – reminding people to eat or take medication - whilst adding in the value of in-depth data analysis and AI, and combining that with the best of human intervention – bespoke, paced, user-led guidance that enables a person to flourish and grow towards independence. 

We see at least four places in the clinical pathway where digitally enabled self-management could add value: as a complement to clinical interventions; as a tool for those awaiting a diagnosis/treatment; to support step down of services; or to maintaining mental health and preventing escalations.

The challenge for innovators in medtech is to provide credible evidence for commissioners. Not only of impact, such as increased quality of life and jobs retained, but also economic benefit. We have to prove that hybrid self-management is an investment for health and social care, not a cost. The onus is, I believe, on us as a medtech industry to build the case with public sector commissioners.  

The recent ORCHA report on standards of evidence lays bare the challenge of applying the one-size-fits-all approach of randomised controlled trials and traditional health economic analysis to the wildly heterogenous array of digital health technologies.

They argue that evaluation should be proportionate to the complexity and risk of the technology (the proportionality principle) and should take account of the agile and iterative approach of product development (the lifecycle challenge). They propose a requirement for (1) evidence of comparative effectiveness (2) human factor analysis – how end users engage with and use the technology and (3) evidence of economic benefit.[6]  All of which is echoed in the NICE evidence standards for digital technologies[7].

With help from NHS Innovation Accelerator fellowship and an NHS England Small Business Research Initiative Phase 2 grant, we are grappling with the challenge of attaining Tier 3 status on the standard. As an innovation that spans health and social care, and that can be deployed in multiple pathways, we are drawing the road map for demonstrating ROI and working closely with our commissioners to collate that evidence. I believe this is essential for scaling hybrid care solutions and supporting a sustainable, cost effective healthcare system.  

[1] https://commonslibrary.parliament.uk/the-health-and-social-care-workforce-gap/

[2] https://www.bmj.com/content/372/bmj.n703

[3] https://www.health.org.uk/news-and-comment/news/significant-investment-needed-as-waiting-list-for-routine-ho

[4] Lemmi, V, Knapp, M, & Ragan I (2017) The Autism Dividend London, London School of Economics and Political Science. https://nationalautistictaskforce.org.uk/wp-content/uploads/2020/02/autism-dividend-report.pdf

[5] National Audit Office (2009) Supporting people with autism through adulthood, London, The Stationery Office

[6] https://orchahealth.com/how-do-digital-health-standards-assess-evidence

[7] https://www.nice.org.uk/about/what-we-do/our-programmes/evidence-standards-framework-for-digital-health-technologies