by Judith Gellatly, EQUITy Programme Manager


 The Problem

Increased demand for NHS talking treatments delivered by telephone

The EQUITy 5-year National Institute for Health Research (NIHR) Programme Grants for Applied Research (PGfAR) aims to co-develop a quality improvement intervention to improve telephone delivery from patient and practitioner perspectives within UK Increasing Access to Psychological Therapies (IAPT) services.

Following the global COVID-19 pandemic and subsequent lock-down measures, IAPT mental health services were faced with suspending the face-to-face delivery of psychological therapies (talking treatments), switching to remote delivery models where possible. This presented an immediate NHS and societal problem. IAPT receives up to 1.6 million new referrals per year, including many people with co-morbid long-term conditions, such as cardiovascular and respiratory disorders, who are designated as vulnerable groups in current COVID-19 guidance [1, 2, 3].

The remote delivery of talking treatments is not standard. Some practitioners in IAPT use the telephone as a modality across Step 2 (low intensity CBT) to support individuals with mild-moderate depression and anxiety. However, we know from our research [4, 5] that many practitioners still do not feel confident delivering treatment this way, report being poorly prepared and indicate more support and guidance is required. For others, such as those supporting individuals at Step 3 (high intensity CBT), telephone services are a completely new approach. Practitioners working within higher intensity services are thus identified as the group most likely to require immediate confidence and skills-based training and supervisory support.

We have extensive research evidence relevant to the training needs and service pressures faced by this workforce, and we are able to tailor our intervention to rapidly respond to the current needs of these practitioners. Rigorous research evidence demonstrates the clinical and cost effectiveness of higher intensity CBT delivered by telephone for people experiencing anxiety and depression, but translation to practice is lacking. Research highlights a common set of implementation barriers and skill-based training needs [6, 7, 8].

A strategic priority for the NHS is to treat the immediate consequence of COVID on physical health, but the immediate and longer-term impacts will be on mental health and mental health providers, service users and carers. As enforced social isolation, disrupted routines and financial pressures rise, it is likely that national demand for mental health services will also rise.  Increased service demand combined with an ill-equipped workforce needs urgent redress.

High quality and effective telephone delivery is therefore essential to reduce footfall at clinical sites and relieve acute pressure on general hospital services. Remote delivery is necessary, under COVID-19 conditions, to reduce the incidence of depression and anxiety and their impacts on quality of life and physical health.


Rapid response using our research knowledge

Our research aligns closely with the immediate NHS priority of providing all non-essential clinical services by remote means. Given our current research plans are on hold (in line with CRN and NIHR guidance on the stand-down of research activity during COVID), we were in a position to rapidly address this identified need.

Our aim is to respond rapidly to assist with the implementation of effective, high quality and acceptable telephone services to prevent or ameliorate depression and anxiety in IAPT services.

We identified three key areas of support provision:

  1. Providing a remotely delivered training package for Step 3 practitioners
  2. Supporting the changing needs of PWP courses and trainees
  3. Disseminating our research in practical ways

Further details regarding these three areas follow. This shift in focus to provide support to others was endorsed by our funders, the NIHR.


  1. Providing a remotely delivered training package for Step 3 practitioners

The most urgent need was identified among Step 3 practitioners where, unlike those working at Step 2, the vast majority had never received any training around remote delivery. Given the experience of members of the PGfAR team in the development and delivery of brief psychological interventions, a growing number of enquiries for robust, rapid training for higher intensity practitioners to help them deliver care remotely were received.

We proposed a rapid change in our focus by adapting our existing quality improvement behaviour change intervention for Step 2 practitioners to improve telephone delivery among Step 3 practitioners. The intervention is underpinned by evidence including data collected in the first Workstream of EQUITy and our previously published work.

As part of the existing EQUITy intervention, we have already developed a two-day, face-to-face training programme to support the delivery of psychological interventions by telephone. The training is underpinned by research. Its overall aims are to improve knowledge on the origins, drivers, and processes for telephone delivery, to develop practitioners’ telephone skills, and to dilute negative preconceptions about telephone treatment undertaken with both lower (Step 2) and higher intensity (Step 3 and above) practitioners.

We rapidly amended our training materials to ensure they were relevant to the current COVID-19 situation (e.g. wording, images, case examples) and our training was adapted for remote delivery (via Microsoft Teams or Zoom). The training content was also shortened to a 3-hour session to support distance learning, optimise engagement and enable contemporaneous skills practice and education.

By adapting our current training materials and using the staff we have in place, we are able to deliver a programme of evidence-based training for higher intensity practitioners, dependent upon service preference and need. Training is approached in a serial fashion imposing minimal burden to patients and staff, with uptake based on service willingness. Our original programme was based on an efficient design and proposed the use of routinely collected data for outcome assessment. We will retain this ‘low burden’ approach to evaluate our rapid response intervention but will suspend additional research-based measures to focus on these routinely recorded patient outcomes to streamline the study during this period of low resource.

Pre-and post-training, we will explore potential implementation challenges through a brief, validated questionnaire (ORIC) and additional practitioner confidence and attitudinal questions. Post COVID-19, we will seek ethical approval to explore real implementation challenges through in-depth qualitative interviews and purposively selected case studies. We will synthesise our findings according to the Consolidated Framework for Implementation Research’s rapid-cycle evaluation approach. This rapid response work will also help us to generate a new understanding of the issues in rapid health service implementation and health professional behaviour change, with potential for transferable learning.

610 practitioners have attended to date (March-June 2020) from 3 NHS Trusts, 1 voluntary organisation delivering IAPT interventions and practitioners from a University research trial.


  1. Supporting the changing needs of PWP courses and trainees

In addition, we identified that our research, and specifically the research that had been published to date or in press, could be of benefit to IAPT trainees and course leads. The impact of the pandemic has resulted in teaching and training materials being delivered remotely. In discussion with one of the University of Manchester IAPT trainee course Leads (MSc/PGDip Primary Mental Health Care pathway – APIMH – it was established that an online EQUITy resource could be developed. This resource development is in progress. It is anticipated that it will incude training slides, research evidence providing clear advice/suggestions for practice and links to other relevant research/strategic publications. Once finalised, there may be the opportunity to offer  training courses at other institutions and more widely among the IAPT community.


  1. Disseminating our research in practical ways

Two of the EQUITy team members led the production of a document offering some practical suggestions to help practitoners and services with the transition to telephone delivery of psychological therapies, based on our ongoing research into the delivery of IAPT by telephone. This document has been disseminated among IAPT teams and posted on the EQUITy research website [9].


Ongoing EQUITy work

Other elements of the EQUITy programme include patient resources and service recommendations, developed as part of the EQUITy multiple component behaviour change intervention, and a user-centred smartphone app. The content of these EQUITy outputs was derived from research evidence, including early EQUITy exploratory studies that sought to explore the needs and experiences of key stakeholders (IAPT patients, practitioners and key informants/decision-makers) through qualitative interviews, analysis of telephone assessment and treatment sessions that were refined during stakeholder consensus days.

Patient resources

Working with our Patient and Public Involvement Advisory group (EQUITy LEAP) we have identified how to present the information we have collated to best help patients understand what telephone-delivered treatments are like, maximising patient engagement and benefit. A leaflet, poster and appointment card have been produced to provide detail on the information deemed important such as the nature of the treatment patients have been refered to, who will be supporting them and how the treatment works.

Service recommendations

A booklet outlining key findings and recommendations relating specifically to practice within IAPT services has been produced. The booklet covers 5 key areas identified by the research that could be important to enhance the implementation and delivery of interventions by telephone:

  1. Promoting telephone work
  2. Incorporating key elements of telephone work
  3. Addressing work environment and resources
  4. Boosting practitioner telephone skills
  5. Promoting reflection

Service managers will be encouraged to work with their team to identify how some or all of the recommendations can be implemented.

Smartphone app

We are in the initial testing stages of the EQUITy stakeholder co-developed smartphone app, which aims to improve therapeutic information exchange in telephone-delivered psychological interventions. It is hoped that the app will make it easier for patients to use telephone treatments, by helping patients and professionals exchange important information during treatment.

The app has a number of functions including assistance with the collection and tracking of routine outcome measures (PHQ-9, GAD-7, Work and Social Adjustment Scale, Phobia Scale) in order to facilitate treatment sessions. The app also includes an animation for patients detailing information about Step 2 treatment over the telephone, a ‘Frequently Asked Questions’ section containing the answers to questions deemed important by patients during co-design workshops, and diagrams of treatment models to assist patient understanding. In the first instance, the app will integrate with PCMIS supported systems only. More rigorous testing will take place in Autumn 2020.


EQUITy Contact

If you have any enquiries or you or your organisation would benefit from the opportunities that EQUITy can provide, please contact the EQUITy Programme Manager:

Dr Judith Gellatly


Twitter: @EQUITyMH




  1. Health and Social Care Information Centre (2014). Psychological therapies: Annual report on the use of IAPT Services 2013/14. Experimental statistics. HSCIC. [Accessed 18 June 2020]
  2. Health and Social Care Information Centre (2019). Psychological therapies: Annual report on the use of IAPT Services 2018/19. Experimental statistics. HSCIC [Accessed 18 June 2020]
  3. National Health Service (2020). Who’s at higher risk from coronavirus. NHS website. Available from [Accessed 18 June 2020]
  4. Rushton K, Fraser C, Gellatly J, Brooks H, Bower P, Armitage CJ, et al. (2019). A case of misalignment: The perspectives of local and national decision-makers on the implementation of psychological treatment by telephone in the Improving Access to Psychological Therapies Service. BMC Health Services Research, 20:36.
  5. Faija CL, Connell J, Welsh C, Ardern K, Hopkin E, Gellatly J, et al. (in press). What influences practitioners’ readiness to deliver psychological interventions by telephone? A qualitative study of behaviour change using the Theoretical Domains Framework. BMC Psychiatry.
  6. Bee P, Lovell K, Airnes Z, Pruszynska A. (2016). Embedding telephone therapy in statutory mental health services: a qualitative, theory-driven analysis. BMC psychiatry, 16:56.
  7. Gellatly J, Pedley R, Molloy C, Butler J, Lovell K, Bee P. (2017). Low intensity interventions for Obsessive-Compulsive Disorder (OCD): a qualitative study of mental health practitioner experiences. BMC Psychiatry, 77.
  8. Irvine A, Drew P, Bower P, Brooks H, Gellatly J, Armitage CJ, et al. (2020). Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders, 265:120.
  9. Irvine A & Drew P. (2020). Telephone delivery of the NHS’s IAPT service providing low-intensity psychological treatment for anxiety and depression disorders [accessed 22 June 2020]