Key learning aims

1. (1) To describe the structure, functions and outputs from a practice research network (PRN).

2. (2) To identify factors contributing to the sustainability of a PRN in the context of publicly funded psychological services.

3. (3) To understand the relationships between evidence-based practice, practice-based evidence and the innovation cycle in psychological therapy services.

Context – NHS Talking Therapies for anxiety and depression

The Improving Access to Psychological Therapies (IAPT) programme was established in 2008 and later renamed as NHS Talking Therapies Services for Anxiety and Depression in 2023. This national programme introduced a new structure to the way in which psychological therapies were organised and delivered in England, supported by new government investment, and premised on national guidelines for the treatment of common mental health problems (Clark, Reference Clark2018). Services are delivered within a stepped care service model, with brief ‘low intensity’ interventions being offered to people with mild-to-moderate anxiety and depression symptoms. These brief and self-help oriented interventions are delivered by Psychological Wellbeing Practitioners (PWPs) which was a new addition to the mental health workforce. ‘High intensity’ interventions are formal psychological therapies provided when patients are ‘stepped up’ from a low intensity intervention or when only a high intensity therapy is indicated by national guidelines (e.g. for post-traumatic stress disorder). The high intensity psychological therapies available in the programme are cognitive behavioural therapy, interpersonal psychotherapy, person-centred experiential counselling for depression, behavioural couples therapy, eye movement desensitisation and reprocessing, and brief dynamic interpersonal therapy.

The Northern Talking Therapies Practice Research Network (NTT-PRN, formerly known as Northern IAPT PRN) was set up in 2014, four years after full, national implementation of the IAPT programme, making best use of the infrastructure for routine outcome monitoring that is a mainstream feature of these services. The PHQ-9 measure of depression (Kroenke et al., Reference Kroenke, Spitzer and Williams2001) and the GAD-7 measure of anxiety (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006) are administered on a session-by-session basis to monitor treatment response. When the PRN was first set up, it consisted of practitioners, academics, and services that had already worked together on practice-based research, including some with a shared historic vision and experience in collecting PBE in psychological therapies and analysing large routine datasets prior to the national IAPT initiative (e.g. Barkham et al., Reference Barkham, Margison, Leach, Lucock, Mellor-Clark, Evans, Benson, Connell, Audin and McGrath2001; Lucock et al., Reference Lucock, Leach, Iveson, Lynch, Horsfield and Hall2003).

The Northern Talking Therapies PRN

The NTT-PRN covered the north of England across three main regions – the North East, North West, and Yorkshire and the Humber – consisting of a population of 15.5 million in mixed urban and rural areas including 17 cities. The PRN initially involved three universities (Sheffield, Huddersfield, and York) and six Talking Therapies services. More details about the network’s initial phase are reported by Lucock et al. (Reference Lucock, Barkham, Donohoe, Kellett, McMillan, Mullaney, Sainty, Saxon, Thwaites and Delgadillo2017). At an initial meeting involving these organisations, a chairperson was nominated, and it was decided to build on existing studies already set up at the time, involving the participating services (e.g. Delgadillo et al., Reference Delgadillo, Kellett, Ali, McMillan, Barkham, Saxon and Lucock2016). A website was set up (www.iaptprn.com), terms of reference agreed, and half-day conferences were held most years (six were held at various venues over the first 10 years with a gap during the COVID-19 pandemic). A process of accepting new members joining the PRN, universities, and IAPT services, was agreed with members. This involved email communications with all NHS Talking Therapies services in the northern regions of England, requesting interested services to nominate a local research lead who would complete an online survey to provide their contact details and to be included in regular email updates coordinated by the chairperson.

Sustainability of the PRN

Research outputs – publications in peer-reviewed international journals

Over 20 studies have been published in international peer-reviewed journals since the inception of the PRN. These include different types of research, such as clinical trials of innovative digital health technologies (Delgadillo et al., Reference Delgadillo, de Jong, Lucock, Lutz, Rubel, Gilbody and McMillan2018; Delgadillo et al., Reference Delgadillo, Ali, Fleck, Agnew, Southgate, Parkhouse and Barkham2022), the development and evaluation of brief psychological interventions (Kellett et al., Reference Kellett, Bee, Smithies, Aadahl, Simmonds-Buckley, Power and Delgadillo2023; Lucock et al., Reference Lucock, Bartys, Cupac, Delgadillo, Denton, Gaines and Stebbings2018; Lucock et al., Reference Lucock, Borthwick, Cupac, Elliott, Howell, Kendal and Tolley2022), reporting on longer-term outcomes and relapse rates after routine care (Ali et al., Reference Ali, Rhodes, Moreea, McMillan, Gilbody, Leach and Delgadillo2017), evaluations of the effectiveness of group-based psychological interventions (Delgadillo and Groom, Reference Delgadillo and Groom2017; Delgadillo et al., Reference Delgadillo, Kellett, Ali, McMillan, Barkham, Saxon and Lucock2016), investigations of factors affecting clinical outcomes including the dose–response and early response effect (Robinson et al., Reference Robinson, Kellett and Delgadillo2020), and predictors of treatment attendance and drop-out (Bowker et al., Reference Bowker, Saxon and Delgadillo2024; Sweetman et al., Reference Sweetman, Knapp, McMillan, Fairhurst, Delgadillo and Hewitt2022). These involve a range of methodologies and share the characteristic that is most important in a PRN: practice-based research involving collaborations between researchers and clinicians. This collaboration is also reflected in the number of practitioners who were sufficiently involved in the research and preparing the manuscripts to be included as co-authors. These include psychological professionals and service managers, as well as academic researchers.

Impact on services

The aim of health research is to improve clinical care, through effective interventions and improvements in the organisation, access and delivery of services. Although PRNs support practice-based research, which can immediately impact on routine service delivery, there are significant challenges in scaling up innovations and effective service developments and sustaining these changes over time. Some of the PRN studies are at the intervention development, pilot or feasibility stages, and require a stronger evidence base to support wider implementation (e.g. Lucock et al., Reference Lucock, Borthwick, Cupac, Elliott, Howell, Kendal and Tolley2022). For these developments, the next step is to apply for funding to support fully powered clinical trials that could influence future clinical guidelines.

However, some PRN studies have led to improvements in service provision and/or recommendations. Some examples are new clinical guidelines available on the PRN website for large group psychoeducational CBT (Delgadillo et al., Reference Delgadillo, Kellett, Ali, McMillan, Barkham, Saxon and Lucock2016) and the widespread use of outcome feedback to identify ‘not on track’ cases (Delgadillo et al., Reference Delgadillo, de Jong, Lucock, Lutz, Rubel, Gilbody and McMillan2018). The latter is an example of an evidence-based digital innovation that has been widely applied across NHS TT services and has also influenced clinical guidelines in other countries, such as the American Psychological Association (APA) professional practice guidelines on measurement-based care (Jensen-Doss et al., Reference Jensen-Doss, Barber, But, Cooper, DuBois, Gato, Orimoto, Scot and Wright2024).

The sustained impact of PRN supported research on practice is also subject to the contextual factors that may act as barriers or facilitators. For example, the feedback research and implementation has benefited from the ROM system already implemented across all NHS TT services, whilst the SMArT intervention (Lucock et al., Reference Lucock, Borthwick, Cupac, Elliott, Howell, Kendal and Tolley2022), which is at an earlier stage in developing a robust evidence base, has met with barriers to wider implementation because of the emphasis in NHS TT services on recovery and treatment completion rather than long-term improvement and relapse prevention.

The role of innovation in the PRN

Innovation is seen as critical to health services, to ensure its sustainability and deliver better health outcomes (www.england.nhs.uk/ourwork/innovation) and is necessary to improve effectiveness, efficiency, and access to services. It can refer to either the implementation of what has worked elsewhere in a different context, or it can refer to developing new interventions, products, models of care delivery, etc. Literature on this topic has mostly focused on the role of PRNs as an infrastructure to evaluate outcomes and processes of routine clinical care, supporting continuous service improvement. However, the outputs associated with the NTT-PRN demonstrate that PRNs can also help clinical services to generate innovations. Examples are the development of new interventions based on psychological theory (e.g. relapse prevention based on implementation intentions theory; Lucock et al., Reference Lucock, Bartys, Cupac, Delgadillo, Denton, Gaines and Stebbings2018), the use of digital health technology (e.g. feedback technology based on routine outcome measures; Delgadillo et al., Reference Delgadillo, de Jong, Lucock, Lutz, Rubel, Gilbody and McMillan2018), and the development of brief and more accessible low intensity versions of traditional psychotherapeutic interventions (e.g. guided self-help based on cognitive analytic therapy; Kellett et al., Reference Kellett, Bee, Smithies, Aadahl, Simmonds-Buckley, Power and Delgadillo2023).

Related to the above point about funding, PRNs can offer an infrastructure that enables the development and evaluation of innovative treatment approaches and technologies, which in turn provides a solid case for attracting competitive research funding. In other words, innovations that are enabled by a PRN form the necessary track record to attract research funding, which in turn helps sustain the activities of the PRN. In this way, as illustrated in Fig. 1, practice-based evidence and evidence-based practice should be seen as complementary approaches that support innovation and which can inform and continuously improve clinical care.

Figure 1.

Synergies between basic science, evidence-based practice, practice-based evidence and innovation.

Challenges

The PRN has encountered several challenges during the last 10 years. Dependence on ‘soft funding’ (i.e. time-limited research grants) is a common issue that risks making long-term initiatives precarious. The PRN has relied on relationships, a shared vision, and commitment to PBE, to make it resilient to the ebbs and flows of research funding. Many other similar initiatives, funded by the NHS, regional health providers, and pump-priming funding from universities, have disappeared over time because they did not survive the perils of dependence on short-term funding sources. Another challenge is ensuring that the constituent organisations making up the membership of the PRN are kept up-to-date and involved in network activities. This requires a lead person or core team to coordinate communications and events to keep the momentum and interest going, and to renew the membership in situations of staff turnover in clinical services. Given the importance of openness and collaboration in a PRN, it is important to keep everyone involved and ensure they have a stake in the network; for example, ensuring that all affiliated clinical services know about upcoming opportunities to participate in new projects, such as multi-centre clinical trials.