Some respondents gave overarching detail of their provider's e-therapy provisions, while other responses were broken down at the level of individual Improving Access to Psychological Therapies (IAPT) services hosted by a given IAPT provider.

Freedom of Information (FOI) requests rely on the expertise of those responsible with handling FOI requests in any given organisation. FOI responses may have varied in their degree of thoroughness, and this information was not always available to the research team.

Introduction

The combination of increased demand and financial pressures has forced health services to explore new and innovative methods of delivery at minimum cost. The internet and connected devices offer one potential solution to this challenge, which governments have begun to recognise, encouraging the use of digital services (see Australia's digital hospital1) and internet mental health services in Norway and Sweden.2 However, it is unclear to what extent these initial steps are exploiting the digital potential in some countries. In the UK, according to a survey published in 2014, only 2% of the population reported any digitally enabled transaction with the National Health Service (NHS) despite an estimated 59% of the UK citizens possessing a smartphone and 84% of adults using the internet.3 In England, the underuse of digital platforms in the NHS has been recognised by the publication of a 5-year plan to reshape care delivery and use technology in the delivery of all kinds of healthcare.4

The current paper focuses on e-therapy in England, where the landscape of digital mental health service provision is not well delineated. This can be attributed to several factors: inadequate reporting; changing service recommendations; nationwide reorganisations of service provision infrastructure; and the rapid development and growth of the digital sphere itself. What is clear, though, is the increasing need for such services: a 2014 survey suggested that one in 10 people in England wait more than a year for mental health assessment,5 and in the UK as a whole, it is estimated that by 2030 there will be 2 million more adults with mental health problems.6 E-therapy has the potential to reduce waiting lists, make treatment more cost-effective, reduce the time and expense of travel, stimulate self-management7 ,8 and decrease the workload of mental health professionals.9 ,10

The current study is based on requests made under the provisions of the UK Freedom of Information Act 2000 in 2015, and systematic enquiries on NHS websites. Under the Freedom of Information (FOI) act, publicly funded bodies are obliged to respond to requests for certain information from members of the public. The resultant data document the current state of digital mental health service provision in England, identifying what e-therapies are used and recommended across the NHS.

There are multiple ways in which e-therapies have been defined and categorised in the literature. Riper et al11 describes e-mental health as ‘the use of information and communication technology (ICT)—in particular the many technologies related to the Internet—when these technologies are used to support and improve mental health conditions and mental health care’. Other researchers have categorised e-therapies according to the amount of therapist support in them,12 or the exact manner in which the web is used to aid delivery.13

Modes of delivery have also changed, with technological advances. Early e-therapy was sometimes packaged on CD-ROM and operated in a ‘stand-alone’ fashion on a PC, whereas practically all such tools are now accessed in one of two forms: as a web-based application (‘web app’), accessed via a conventional web browser, or else as a smartphone/tablet app, installed on (typically) the service user's mobile device. The distinction is somewhat arbitrary, but since smartphone apps represent a relatively more recent development in the digital domain, and a significant one too, in terms of popular uptake, it is convenient for this paper to consider e-therapy as divided into two main categories: web apps and smartphone apps.

Policy history The National Institute for Health and Care Excellence (NICE) is a non-departmental public body, responsible to but operationally independent of the UK Department of Health. Its function is to provide guidance to the NHS in England (although its advice often extends to the other constituent nations of the UK) for clinical practice, including what treatments should be offered for diseases, on the basis of published evidence. This remit includes the use of health technologies for mental ill health. NICE recommendations stand until they are revised or replaced. In 2006, NICE issued its first specific guidelines for e-therapy, recommending two computerised cognitive–behaviour therapy (cCBT) web apps for the treatment of mild to moderate depression and for panic/phobia, for which it was deemed there was sufficient evidence of clinical effectiveness. In 2009, these specific recommendations were withdrawn by NICE. At the time of writing (August 2016), NICE guidance for mental health practitioners is that cCBT can be offered for persistent subthreshold, or mild to moderate depression;14 however, reference to specific tools (with published evidence) has been replaced by general guidelines for cCBT.14 ,15 CCBT is recommended for research purposes only for generalised anxiety disorder (GAD)16 and is not recommended at all for adult phobias.17 Recent technological developments Since the first NICE recommendations for e-therapies,14 the use of smartphone and tablet computer has fundamentally altered the way that people interact with technology. On these devices, a plethora of health-related and mental health-related apps are available at very little or no cost to the user. However, the quality and effectiveness of these apps is often questionable, with no general requirement to demonstrate beneficial outcomes through clinical trials or other means. While recent policy changes mean that currently, some stand-alone software including smartphone apps installed onto a device for a medical purpose are now considered a ‘medical device’18 ,19 and must be registered with the Medicines and Healthcare Products Regulatory Agency (MHRA), registration is not in itself an indication of efficacy.20 Meanwhile, the next generation of web apps includes features such as social networking which can lead to complex and dynamic interactions among users and technology. Unfortunately, the pace of change in smartphone and web health app development frequently renders the research community unable to evaluate programs fast enough to endorse or reject new interventions on the basis of evidence as potentially effective components in routine care. This shifting policy and technological landscape means that consulting NICE guidelines is no longer an effective way to find out which e-therapies are being routinely used and recommended across the NHS in England.

Access to digital mental healthcare in the NHS in England Understanding the digital mental health service landscape requires consideration of the methods of access to NHS-recommended digital healthcare in England. There are several points of access including referral and self-help routes. Referral Improving Access to Psychological Therapies Much of the primary mental healthcare provision in the NHS in England currently comes through Improving Access to Psychological Therapies (IAPT) programme. IAPT was launched in 2007 to improve access to NICE-recommended psychological therapies for depression and anxiety disorders.21 IAPT services are provided on a local basis, sometimes alongside other health services, and offer direct routes to assessment and treatment by specialist mental health professionals without the need for general practitioner referral. Owing to current NICE guidelines making general, rather than specific recommendations regarding e-therapies, practitioners in IAPT services are free to judge which apps are appropriate to use. Consequently, it is unclear which e-therapies are currently being recommended to and used by clients. Since mental health services in England are no longer exclusively provided by the NHS—charities, social enterprises, non-profit and limited companies can also provide IAPT services—variation compounds this lack of clarity. NHS Mental Health Trusts In addition, IAPT services can also be provided by Mental Health Trusts, which cater for severe mental health problems.22 In the same period in which rapid technical developments have fundamentally changed the way that people expect to access services in general, the NHS in England has undergone profound infrastructural changes in mental healthcare provision. Collectively, these factors make for a very unclear picture of what e-therapies are used and recommend by the NHS across England. Self-help In addition to accessing digital mental services via traditional face-to-face services (IAPTs or NHS Mental Health Trusts), there are also two avenues through which the NHS has sought to guide people's use of digital self-help for mental health concerns. NHS Health Apps Library In keeping with the NHS goals of becoming ‘more digitised’, and with providing service users with access to tools to support their own well-being, The NHS Commissioning Board launched the NHS Health Apps Library in March 2013.23 The library was a subsection of the NHS Choices website and provided a portal through which the public could access a selection of smartphone and tablet apps reviewed by the NHS. However, the library was shut down on 16 October 2015 after the publication of two papers that questioned the methods of evaluation of the apps recommended by the library. Specifically, the evaluation of apps' data security24 and clinical effectiveness25 were criticised. NHS online Mental Health Apps Library NHS Choices in March 2015 published a webpage entitled Online Mental Health Services.26 This page existed separately from the now-defunct NHS Health Apps Library, and, at the time of writing (August 2016), provides a list of six apps, all web apps, that have ‘been approved for use by the NHS’, although by whom and on what basis is unclear, and in fact seems to run counter to current NICE advice.