Talking therapies – such as Cognitive Behavioural Therapy (CBT) – are well-established (and well-known) treatment options in the NHS for conditions including anxiety and depression.
However, the effectiveness of CBT in treating sleeping issues such as insomnia, is perhaps less well-known. Yet, the National Institute of Clinical Excellence recommends CBT as the first line of treatment for those with long-term insomnia.
The effectiveness of CBT in treating sleeping issues such as insomnia, is perhaps less well-known
Traditionally CBT for insomnia (CBTi) has been delivered face-to-face with a psychologist and as a result, in many parts of the country, there are long waiting lists for patients once they’ve received a GP referral. However, due to technological advancements it’s been possible to make it more accessible and scalable by offering digital versions of the programme - ICBs and primary care commissioners now have the option to commission “dCBTi” for their patient population.
Nevertheless, as is the case with all digital adaptations of traditional in-person clinical services, there are variations on what is available from these online support programmes, which subsequently have an impact on user take-up, sustained engagement and importantly, clinical outcomes.
The options range from a fully automated model that provides a ‘virtual therapist’ and e-learning apps (without any sort of therapist insight or interaction) to a hybrid model that provides a ‘digital front door’ via a remote care pathway while still including access to human therapists.
Improving patient outcomes
Real-world evidence from the most widely used hybrid-based service in the NHS – based on analysis of a snapshot cohort of 16,000 patients across 41 Integrated Care Systems (ICSs) during 2023/24 - has shown that this specific approach delivers higher efficacy rates than fully automated options (with and without a virtual therapist) and even traditional, face-to-face appointments.
The human element in digital CBTi is critical to achieving benefits, as warmth, empathy, and genuineness are proven human qualities that make talking therapies so successful
84% of patients experienced clinically meaningful improvements in their symptoms and 62% of patients who had been taking sleeping pills stopped using them completely by the end of the course.
Over two-thirds of those with moderate or severe depression associated with their sleep problems also reported a clinically meaningful reduction in the frequency and severity of their symptoms of depression. And by equipping these NHS patients with the skills and knowledge to create better sleeping habits, they also become empowered to self-manage their symptoms better.
The human element in digital CBTi is critical to achieving these benefits, as warmth, empathy, and genuineness are proven human qualities that make talking therapies so successful. These qualities are notoriously difficult to replicate with a virtual therapist, which struggles to provide personalised feedback and build the same level of rapport and trust with the recipient.
Reducing pressures on services
This model is also proven to reduce pressure on NHS services as it can be offered to patients immediately once they’ve been referred, either by a GP or self-referral. There’s no need for them to join a waiting list that can take many months to get an in-clinic appointment. The individual can also be given access to the remote support team straight away and progress through the programme whenever and wherever they want to.
With no waiting lists, these digital sleep services can help prevent the insomnia from getting worse and/or exacerbating other issues such as anxiety or depression (which are often linked), which can occur when patients wait months for in-person sleep appointments. And it means follow-up GP appointments (or even A&E admissions) during this time can be avoided or at least reduced.
Traditionally CBT for insomnia (CBTi) has been delivered face-to-face with a psychologist and as a result, in many parts of the country, there are long waiting lists for patients once they’ve received a GP referral
Looking at examples from patients in the North and South of England, in Blyth, the rollout of a hybrid dCBTi service across the PCN led to 91% of patients seeing meaningful clinical improvements to their sleep patterns and it has been rated 4.8/5 by users. Plus, the clinical team have seen benefits in relieving pressures on their services, with patients being able to self-refer.
Likewise in Richmond, the GPs and wider staff have welcomed the relief of being able to offer patients an efficient and easily accessible option, which includes human support, to help with what is a common problem with no ready fix or solution.
Scaling effective digital tools
As we see a greater push from government to shift to a ‘digital NHS’ as part of the longer-term plan to tackle the pressures on the healthcare system, it’s critical that the differences between methods of digitisation are fully considered. So that safe and effective tools that are scaled across the NHS are in alignment with national objectives and quick and easy for primary and secondary care teams to refer to—all the while meeting the needs of patients with insomnia, which currently accounts for c4 million people in the UK.
This model is also proven to reduce pressure on NHS services as it can be offered to patients immediately once they’ve been referred, either by a GP or self-referral
NHS commissioners can only be empowered to do this by having the right information available and understanding the significant variation of impact from these different models, preferably by drawing on current real-world evidence and impact analysis. And most of this can be surfaced by knowing the right questions to ask when making commissioning decisions, such as ‘Does this digital solution include human support and/or access to a sleep therapist or is it simply digital self-help advice?’
With gathered momentum from the centre and an expected (and welcomed) increase in attention on improving mental health and wellbeing services following the introduction of the Mental Health Act in Parliament, now is a critical time to get digitisation right, for patients and providers alike.