Phase 1 findings

Jo Rycroft-Malone; Felix Gradinger; Heledd O Griffiths; Rebecca Crane; Andy Gibson; Stewart Mercer; Rob Anderson; Willem Kuyken

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Rycroft-Malone J, Gradinger F, Griffiths HO, et al. Accessibility and implementation in the UK NHS services of an effective depression relapse prevention programme: learning from mindfulness-based cognitive therapy through a mixed-methods study. Southampton (UK): NIHR Journals Library; 2017 Mar. (Health Services and Delivery Research, No. 5.14.)

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Accessibility and implementation in the UK NHS services of an effective depression relapse prevention programme: learning from mindfulness-based cognitive therapy through a mixed-methods study.

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Chapter 3Phase 1 findings

Introduction

Over the next three chapters we report the findings of this study. In this chapter we report on the findings from semistructured interviews with a sample of participants from a cross section of regions in the UK. This account is a description of stakeholders’ perceptions about the extent of accessibility to MBCT, and the factors that have both facilitated and hindered its implementation. In Chapter 4 we provide a high-level description of each case site, before moving on to a cross-case explanatory account of the different factors and features of the implementation stories participants recounted to us. Our intention in reporting our findings in this way is that we build up an increasingly rich and explanatory account of the data.

Sample

Participants in phase 1 were drawn from 40 NHS sites. The balance of participation across the UK regions is seen in Figure 2.

FIGURE 2

Map of phase 1 sample. Contains Ordnance Survey data © Crown copyright and database right 2010.

As described in our funded protocol,⁷² we sampled to ensure a variation of perspectives about MBCT. With the overall aim to interview up to 70 people, we wanted to make sure that data were collected from at least one key informant per region. In the first wave of data collection we therefore collected data from champions who were either clinicians (n = 27 MBCT teachers) or clinicians with a management role (n = 20). Next, and to ensure representativeness across other stakeholder groups, we created a sampling pool of a further 91 candidates, which included 39 managers, 23 commissioners, 16 service users and 13 referrers. We then randomly sampled (as requested by the funder) across this participant pool and interviewed seven managers, four commissioners, five referrers and five service users. Our total sample for phase 1 was 68 participants. In the interests of not revealing the identity of participants, we reference the region [England (South, London, Midlands, North), Scotland, Northern Ireland, Wales] rather than the trust or health board name.

Findings

The findings are reported below using the overarching structure offered by the PARIHS framework: evidence, context and facilitation. Overall, reports from participants showed that access to MBCT was patchy, even within the same region. There were no discernible patterns in the accounts of people between the different regions or between different types of participants, but where there were differences these are noted. However, MBCT teachers shared more information about activities, facilitators of and barriers to getting MBCT used in practice as they had been at the forefront of implementation efforts and, as such, we refer to these participants as implementers in the narrative that follows.

Types of evidence

National Institute for Health and Care Excellence: brand/badge – making a case

Participants often made positive reference to the fact that MBCT is recommended within NICE guidance. Those in the position of championing MBCT stated that the fact that it appeared in NICE guidance was helpful for making the case for commissioning MBCT and/or for convincing chief executives that they should be providing it within their service and allocating resources to it. The majority of MBCT teachers identified that the NICE badge helped by giving credibility to their efforts to raise awareness of and to support implementing the intervention. The NICE badge had also been used to secure funding for training. As NICE guidance is ‘based on evidence’ (teacher, North) and associated with ‘excellence’ (manager, London), implementers said that quoting it gave them ‘ground to stand on’ (teacher, South) if questioned about implementation activities. Furthermore, it was perceived that the NICE badge had ‘opened the door’ (teacher, South) and helped to progress implementation:

I would say another facilitator is the NICE guidelines. I mean that really sort of just opened the door I would say. I think without . . . just having MBCT in the NICE guidelines, just creates a legitimacy in people’s minds that . . . I don’t think we or others could have got nearly as far with this, you know without that, and without the other research that’s you know mushrooming now in mindfulness, and that we can refer to.
Teacher, South

Evidence fit with patient and practice

Although the NICE badge was viewed positively to help make the case, the fact that MBCT was part of NICE guidance was also referred to as a ‘double edge sword’ (teacher, South). Participants expressed challenges with applying MBCT in strict accordance with the NICE recommendation(s). As such, practitioners were adapting and adopting MBCT in flexible ways:

I guess in terms of MBCT, we don’t focus specifically on relapsing depression, so we’ve kind of opened it up a little bit more, where we accepts referrals for anxiety disorders . . . we’ve had to move away from this sort of strict MBCT recurring depression, because . . . I don’t know if we get enough referrals for that.
Teacher, Scotland

Some teachers welcomed the specificity of the recommendation and were trying to remain ‘faithful to the NICE guidelines and to the evidence base, so that if we are questioned, we are stood on very solid ground’ (teacher, London). Additionally, clinicians were sometimes asked to apply MBCT to other populations not included in NICE recommendations, in these cases the guidance was used to defend decisions not to widen the criteria:

. . . and I have a sort of mindfulness operational policy document [. . .], and I guess I’m keeping it quite strict to the NICE guidance in that there’s lots of requests for clients to come who have other challenges or difficulties, but the service is quite clear, that we’re only offering it to people with recurrent depression.
Teacher, South

However, there were examples from implementers of widening the NICE-recommended criteria to make it accessible to the sort of patients they were routinely seeing. In reality practitioners reported seeing patients who were more complex than those who were ‘currently well and have had three or more episodes of depression’ so that, if they ‘stuck tightly to the NICE guidelines’ (teacher, South), there would be limited opportunity for using MBCT. The inclusion criteria were widened because participants saw ‘applicability beyond’ (teacher, South) what NICE guidance recommended:

. . . we didn’t really have many people in the services who would meet that criteria. But there was a starting BDI [Beck Depression Inventory], Beck depression score of around 19 as opposed to about 10 as I think it is in the kind of original trials that are in NICE. But still sort of mildly, sort of mildly getting towards moderately depressed. But as time went on in secondary care, the group we are running, and you start to think well I can see how this might be helpful . . . that’s just how then it started to expand if you like . . . because you begin to the see the applicability beyond that group, even though you’re moving away from NICE guidelines.
Teacher, Midlands

After seeing some benefits to a wider population than those referred to within NICE recommendations, some questioned the relevance of NICE guidance. There was also a question about whether or not the evidence underpinning the guidelines may be out of date, particularly in the context of research emerging about the relevance of MBCT to other populations (e.g. from teachers from North, South and London).

Clinical judgement

As well as the NICE guidance, participants who were actively implementing MBCT talked about needing to bring in other types of evidence from their practice to delivery, implementation and evaluation activities. Some questioned the process of how trials and guidance are developed, emphasising that their own clinical judgement was equally important to delivering and evaluating a service:

. . . a reality with randomised control trials and who gets picked . . . how they’re done and who pays for it, and then guidelines being written, and yet there’s many treatments or many developments that are not there in the guidelines that are useful; there’s a way of having clinical judgement and being able to say why it’s useful, justify your decision, justify inviting somebody to the group.
Teacher, Scotland

Client feedback

Participants also reported supplementing trial evidence with client feedback to help with tailoring of the service locally, and as evaluative information to improve provision:

. . . our course has evolved partly from feedback from the participants, and from the facilitators, on what has worked and what hasn’t, and it actually is tailored to the needs of the local population rather than to you know university studies that may not entirely be the same in terms of population as ours.
Teacher, Scotland

Although participants expressed some challenges with collating feedback, partly because of being constrained by resources, there was evidence that some had used such information systematically by collating feedback and presenting it in a way that could help with evaluation:

We have an evaluation at the end with each of the clients and what I’ve been able to do is collect their own personal feedback from their perspective and collate in a kind of graph and actually it’s quite interesting because I’d noticed particular themes that were rising from that feedback.
Teacher, Midlands

In contrast to relying on anecdotal feedback, participants from 40 sites (19 including English IAPT services) reported including the collection of standardised information from clients/patients. Standard measures included the Patient Health Questionnaire (PHQ-9) for depression and the Generalised Anxiety Disorder-7 (GAD-7) pre and post intervention. The Center for Outcomes Research (CORE) measures seemed to be prevalent in secondary care settings, and the Hospital Anxiety and Depression Scale (HADS) used mostly in Scottish sites (see Appendix 8 for examples of measures used).

Mindfulness-based cognitive therapy: the intervention

The following sections describe findings related to the acceptability, accessibility and adaption of MBCT.

Acceptability

Participants often referred to an awareness of ‘mindfulness’ within their organisation and more generally within the community, owing to the increasing media attention. However, there was a perception that there was less awareness of what MBCT is as an intervention. Teachers reported that they had experienced challenges in educating managers about MBCT and what it entailed, and some managers interviewed also stated that they were not aware of the full extent of formal training, supervision, personal commitment and practical needs of MBCT:

. . . there’s MBCT and then there’s mindfulness, and I guess mindfulness feels easier to talk about. I’m aware in terms of formal MBCT training, that’s not something I think we as a service has engaged in.
Manager, Wales

There were some examples of scepticism in the data whereby teachers reported that in trying to inform managers and colleagues about the intervention it had been perceived as a ‘bit of luxury’ (teacher, Scotland) because of its preventative nature, with doubts expressed about what it entails:

There are staff and managers who think that you know you do an 8-week group as a participant and then you’re off. You know, you read the Green Book and then you can teach it. So you know that attitude is a barrier, and then convincing those people that they need to do quite a bit more, can be a challenge, and that this is a therapeutic intervention, it’s not just a bit of sitting on a cushion.
Teacher, South

Data also showed that there was some scepticism among commissioners; for example, that MBCT was viewed as a little ‘alternative’ (teacher, South) and only going to be accepted by people with a ‘particular world view’ (teacher, Scotland).

The media reporting had also been seen as providing advantages as well as disadvantages in that more and more people were hearing about ‘mindfulness’ and were wanting ‘to ride along with the wave’ (teacher, Scotland). In contrast, some managers said they were hearing about ‘mindfulness’ being used across different settings, and growing perceptions about it being some sort of panacea:

. . . we need to be slightly careful about what it is and what it isn’t . . . at the moment you would almost think it was a panacea sometimes . . . any age group . . . from school children to older adults . . . almost any setting . . . from primary schools to prisons, to hospitals . . . almost any condition from psychosis to depression . . . Now I’m happy to believe that’s true, but there’s a sceptical side of me.
Manager, Scotland

Accessibility

The majority of individuals accessed MBCT service by being a patient who was already known to the service, and who had previous interventions such as CBT, so they were being referred on from within the service (e.g. teachers and managers, South, London and Scotland). Others got referred by their GP (teachers, Midlands and Scotland), and data show that increasingly trusts and health boards were accepting self-referrals. There were some examples in our data of reports of GPs being less likely to refer straight to a MBCT service; for example:

I have to say our greatest referrals have been through primary care. We did do road shows to GPs, who were very receptive, but as far as referrals go, really quite poor in directly referring.
Teacher, South

Following on from referral, many sites took steps to ensure that suitable people got access and that those being referred to the service were appropriate. Those steps included an assessment usually over the telephone and an orientation or introductory session (teachers from South, London, Midlands, North and Wales). Although it was reported that demand had increased in some sites, the amount of people who fulfilled the criteria was relatively small (teacher, North); therefore, the screening and assessing process was essential to ensure that the correct people got access. Where a thorough screening and assessment had been made, it was reported that it was less likely that people dropped out (teachers, South).

To ensure that the service was accessible, implementers reported being flexible in their delivery, such as putting on evening sessions for clients who worked during the day. Such flexibility had been important to service users:

. . . we did have to wait a bit because we did want it to be an evening group and they had to wait until there were enough people who would be doing that . . . making it accessible to people who are employed is really important . . . whereas medical appointments, employers can be flexible . . . but to have 8 weeks . . . and because it takes at least half a day because of the length of the session . . . very few employers are happy for someone to use their worktime.
Service user, London

Waiting times varied across sites, and sometimes varied within the same site; as such, some participants expressed that access was a bit of a ‘post code lottery’ (manager, Midlands; teachers, Scotland). As a result of some sites only having one or two members of staff running MBCT groups, patients could be waiting at least 2 months or sometimes longer if the service only ran one or two groups a year. Service users reported waiting a couple of weeks (North) to over 1 year (South).

. . . it was probably 3 or 4 months to starting the 8-week course, from self-referral basically, but then there was another sort of 3 months before that to find the information to know I could self-refer . . . and then it was another 3 or 4 months of the XXXX [county] experience . . . so from the decision to do something about it, to actually starting the course, it was definitely 12 months, possibly longer I would say.
Service user, South

To facilitate access to the intervention, some sites chose to use the intervention as a ‘well-being’ intervention rather than a ‘therapy’ so that it could be viewed as a self-help intervention rather than one related to mental health. This strategy had also been used in several sites where courses were being made available to staff, for example:

I think it’s kind of just by chance we have taken it as being . . . sort of being pushed as a staff well-being thing. I think that’s been quite helpful because it gets, we’re getting people who are coming along and its part of them, you know it’s their own practice, rather than necessarily selling it as something you do to patients. So I think we’re getting people who are on board with their personal practice, rather than coming along just to be facilitators. That’s been quite helpful.
Teacher, Scotland

Adaptation

As outlined earlier, MBCT had often been adapted from what is stated within NICE guidance to reflect the local service needs. Some sites had an open to everyone approach in cases where it was felt that the client would benefit. Practitioners were delivering the intervention to different populations such as those with chronic pain, anxiety or stress and also adapting to include clients who were presenting as not currently well (teachers, South and London). Some teachers reported that if patients were in partial recovery and were well enough to engage in the course, then MBCT was offered and that if they adhered to the NICE recommendation many patients would not be able to access the service and groups would not be filled.

We’re much more open with who comes onto the course, so we’re not strictly seeing people who have had three or more episodes of depression and in recovery now. We have quite a mix, so we will have people who are still feeling somewhat depressed, but they might have had a CBT intervention. We’ve had people who have had anxiety problems and they’ve had interventions in the service. We have people who are in recovery following intervention, and we have people who are non-clinical as well.
Teacher, London

There were also examples of implementers branching out to diagnoses other than depression and anxiety, and tailoring the intervention to individuals, rather than at a group of people with the same diagnosis (teachers and managers, South and Midlands). This was done partially because they see the potential benefit of the intervention to these groups (teacher, Northern Ireland) and also because of pressures from the service to include more people (teachers, Northern Ireland and Midlands) and to ‘relieve some of the waiting times for the other services as well’ (teacher, Scotland).

Our data show that there were a number of models of delivery, from pure MBCT, as stated in NICE guidance, to hybrid MBCT/mindfulness-based stress reduction (MBSR) or MBCT/Compassionate Minds models.⁸¹ Some practitioners reported that having the flexibility to switch from one model to the other, depending on their client group, was important and enabled responsiveness to client and local needs.

Context

Data show that context is a potentially powerful moderator of whether or not MBCT was available and accessible. The following sections identify the key contextual issues that emerged from discussions with stakeholders from across the UK regions.

Culture

Fit of mindfulness-based cognitive therapy in the current NHS

Pace

As described by participants, MBCT is not an intervention that provides ‘a quick fix’ (teachers, Wales). As such, it contrasts with the pace of health services in the UK, which resulted in a number of challenges reported by participants. Practitioners stated that within a pressurised, fast-moving NHS environment it was:

. . . quite a struggle . . . to deliver the programme in a mindful way, so like all the administration around it and so on, because the culture of IAPT and primary care therapy . . . tends to be therapy on roller skates, that’s the whole culture, its bums on seats, quickly in, quickly out, have we got to recovery, off we go, quick team meeting, you know, rush, rush, rush.
Teacher, South

Furthermore, it was reported that the pace of the environment presented challenges to upholding the integrity of the approach, with some feeling pressure to deliver the intervention in fewer than eight sessions, running larger and more diverse groups with less training and supervision, described by this participant as:

. . . a real tension between integrity and fast implementation. It was quite difficult to hold the line there, and really not be drawn into providing a level of service that just didn’t seem appropriate.
Teacher, Midlands

Medical model

In contrast to many interventions delivered within health services, MBCT is concerned with well-being ‘rather than about medicine, whereas the NHS mostly is about medical treatment . . .’ (teacher, South). Some accounts from commissioners also described the predominance of biomedical approaches:

GPs are interesting . . . they’re like many doctors, more inclined to prescribe medication than they are to recommend therapy. The NICE guidance points out that a combination of both talking therapy and prescription is likely to get the most sustained and reliable outcome, but they seem unwilling to do both.
Commissioner, South

A focus on physical health, the need for recovery, and a lack of understanding or awareness of the underpinnings of MBCT, resulted in frustration for some practitioners:

. . . the medics still don’t get it. [. . .] it’s not just another treatment that helps people cope with pain . . . Because you’re working in a context that’s based on a different personal physical paradigm, and they’re not even aware that they’re based on a paradigm . . . ‘oh can you give me some CDs [compact discs] so I can give them out to patients and use them like relaxation tapes’.
Teacher, South

Competing priorities

Commissioners described tensions between finances, in general ‘most things that we do is around potential saving that can be made . . .’ (teacher, London), and for mental health services in particular:

I’m trying to get more mental health funding from the CCG [Clinical Commissioning Group] because we feel that it’s underfunded . . . but of course that is a big challenge because of the big acute trusts swallowing up all the resources.
Referrer, London

Furthermore, a tension was described between the need to deliver outcomes at pace:

We’re required to move at a pace that’s more challenging and deliver savings that are more immediate, and I think that creates a conflict between us as commissioners and the provider.
Commissioner, South

Some accounts from managers also highlighted the difficulty of managing competing pressures of throughput and quality:

. . . the commissioners are only interested in whether we meet our targets or not . . . they are interested in numbers entering treatment and moving to recovery figures . . . they’re not really interested in the quality, as long as we get our 50% moving to recovery.
Manager, Midlands

It is possible that the tensions described by commissioners and managers led to a feeling by some practitioners that MBCT was not at the forefront of priorities:

I think that sometimes sort of the MBCT stuff gets pushed to the background sometimes. That’s certainly I think been the issue, not just with the therapists but the sort of more senior staff within the service.
Teacher, Midlands

Change in the NHS

Frequent changes, organisational complexity, ‘tradition’ and ‘hierarchies’ were mentioned by participants as a challenge for changing services of any kind, and for implementing MBCT in particular. Over half of our sample described the NHS to be in a constant state of flux; for example:

. . . a massive service structure as well, so change in their service structure, and we’re going through a period of flux of it, I think for them at the moment it’s not their priority to think about it.
Teacher, South

The type of changes that were noted by participants varied, but challenges included a ‘muddle’ of services working in isolation from each other within trusts (teacher, South), changes to regional service boundaries (manager, London), attempts to integrate service pathways via ‘internal reorganisation’ (teacher, South) whole teams being moved across trusts in an ‘amalgamation of services’ (teacher, South), primary care services being merged into IAPT since 2009 (teacher, South; manager, London) with some integrating MBCT from the start and some not.

Although described as a challenging implementation context, some also recognised the potential in this by, for example, seeing an opportunity to ‘use the chaos to embed MBCT’ (teacher, South) and enabling implementation to go forward ‘under the radar’ (teacher, South).

Resources

Our data show that MBCT work was frequently informally resourced. That is to say, it depended on the enthusiasm and commitment of individual people and the goodwill of senior managers. Frequently, it appeared to be not well embedded in budgets or in staff or organisational objectives. This meant that it was consistently at risk and that improvements in delivery achieved within a trust could easily be lost due to changes in personnel or changes in budgeting. The following sections describe findings that relate to different sorts of resources.

Human resources

Participants described a lack of dedicated human resource to deliver MBCT. In areas where MBCT was being implemented, implementers tended to be lone champions. Generally, a lack of qualified teachers was described, and where there were fully trained and accredited teachers it was rare that they were dedicated to delivering MBCT; these individuals were developing MBCT services in addition to their existing role and responsibilities.

Staffing and having enough qualified teachers was described as a ‘continual headache’ (teacher, South) in the majority of regions. It was reported that in sites where there was only one qualified teacher, champions relied on support to co-facilitate from individuals who had not been trained. Furthermore, the amount of human resources could vary within one organisation; for example, one region had three or four groups per year, but in other parts of the same trust groups were not running because of a lack of qualified teachers. This resulted in potentially fragile services where there was a perception that ‘if I was to leave tomorrow, essentially that mindfulness service would die with me’ (teacher, South).

In addition to teaching and delivery resource, practitioners delivering MBCT also reported that administration support was challenging, with many relying on goodwill: ‘. . . we have to buy her an awful lot of chocolate’, with none, or ‘little admin provision’ (teacher, Scotland).

Financial

The costs associated with setting up a MBCT service were acknowledged by many participants we spoke to: ‘if you want a good solid service that is delivered because it’s based in evidence . . . yeah it costs’ (teacher, South). This included the cost of training and continued supervision. This cost was set within the context of what was described by some commissioners, as a greater challenge of funding for mental health services and of under-resourcing more generally for health services:

. . . (what’s most pressing is) trying to find ways of increasing investment in mental health services because we know that generally they are under-resourced . . . and working within a very cash-limited environment.
Commissioner, South

This included balancing resources across different psychological interventions; for example, ‘carving out this job for this MBCT practitioner, meant there was less resource for our conventional services’ (teacher, London). As such, cost was described as a barrier to the implementation of MBCT.

The consequences of these funding challenges were that often practitioners had invested their own money in developing services by, for example, delivering it in their own time, paying for their own training and ongoing supervision, and paying for venues. Practitioners reported that they had made this investment by choice because of their interest and personal commitment to MBCT.

Time

Time manifested as an important resource factor for implementation. Frequently practitioners described the relationship between funding, staffing and time as a major implementation challenge because there was a lack of capacity and capability to be able to set up and maintain a new service. As such, they spoke about feeling the pressure to deliver something as quickly as possible with no funding and, as a consequence, had invested their ‘personal time to get it up and running’ (teacher, South). Additionally, there had been challenges, with some implementers being able to ring-fence the time for attending training sessions, some being able to take time ‘in lieu’ and others working in their own time because they were unable to secure managers’ agreement.

As described earlier, the need to deliver quickly was in conflict with a therapy that requires more than attendance at a short training course. Additionally, those delivering services described that it took time to embed a new MBCT service because of the need to develop appropriate links and raise awareness with referrers. Practitioners also described the nature of the intervention and time required to deliver MBCT groups, in contrast to other group interventions:

. . . the difference between running a mindfulness group and say running one of our stress management or move management groups, which are much, much quicker to prepare and deliver.
Teacher, South

Time was also described as a barrier to getting started or making a case for MBCT: ‘we haven’t put much effort into that, because it takes too much time [. . .] it’s just unbearably time consuming to get money’ (teacher, London). Additionally, participants described time as a barrier to conducting evaluative activity:

. . . a full time clinician has to see 25 patients a week . . . It doesn’t leave you much time to do anything else . . . that’s another reason why we’ve not been able to do any evaluation and audit of our course.
Teacher, London

Practical

Many implementers talked about practical resources being the major barrier to delivering MBCT groups. Adequate physical space, in the context of many NHS organisations reducing costs by selling buildings, a lack of money to hire rooms and challenges with finding appropriate rooms (for delivering the intervention), was a challenge. There were a number of consequences of a lack of appropriate space related to intervention accessibility and delivery (Table 3 shows a summary). In contrast, those services that had more developed services did have dedicated and free access to conduct group treatments.

TABLE 3

Access to practical resources

Additionally, other resource challenges for implementers related to materials:

. . . just simple things like photocopying, you know getting CDs [compact discs] and stuff like that, you know. It’s those sorts of added costs in terms of resource that aren’t really factored in unfortunately.
Teacher, Midlands

Other practical resources such as mats, cushions, compact discs (CDs), etc., were often provided by the implementers as there was no funding for such equipment from trusts or health boards.

Money, money, money, money, oh my god, one year, in order to get CDs for the course, I had to dig up all the strawberry plants out of my garden, and sell them, and colleagues helped, and we had a cake and plant sale, and raised £400 and then bought our CDs for the courses. Getting mats, I’ve had to beg and borrow every March from senior management.
Teacher, North

Facilitation

Champions and championing

Implementation of MBCT appeared to be driven by ‘passionate’ champions who were ‘willing to go the extra mile’ (teacher, South), who invested a lot of personal time and effort into making it happen and who (it was reported) would ‘probably do it for free’ if they had to (teacher, North). As described above, implementers made personal and financial commitments to initiating and sustaining services. MBCT was reported to be a big part of their personal and professional life (teacher, South) and champions often talked about ‘embodying’ mindfulness (teachers, South and Midlands), and the importance of starting off with a personal practice (teachers, Midlands and North):

I believe in mindfulness, and I do the same thing whether it’s my NHS work or my private work. The message is basically the same . . . I’m kind of encouraging people to set up the practice and then practise themselves . . . the message is please don’t use it, unless you do it yourselves.
Teacher, North

Most implementers often worked alone in championing the intervention and, therefore, services grew from the ground up through the work of MBCT practitioner/teachers. This left services fragile with concerns that losing individuals would lead to services being stopped:

. . . the champion’s stepped aside now she’s still in the background but I have a worry and a concern when the champion’s moved ’cos we’re kind of I’ve only got 2 years to go before retirement my colleague is in that place as well so I have a worry about the loss of the service yeah.
Teacher, Midlands

Data show that these ‘champions’ had particular skills in pushing and driving implementation. Their stories show that they were constantly spreading the word and talking to others about how to implement and how to make MBCT more accessible. Additionally, the position or seniority of a champion was perceived to make a difference. For example, when the drive and enthusiasm came from GPs (teachers, Midlands, North and Scotland) or from a senior manager (teachers, South, Midlands and London) it helped to keep MBCT on the agenda at senior board meetings. Seniority also created and element of credibility, which had been facilitative:

. . . we created a new job that is explicitly the specialist care pathway lead for MBCT . . . it’s easier for me to get these things done because of the position I hold and it was easier for me to create a post and sort of empower this individual to do this project.
Manager, London

There were also examples of service users becoming champions and playing an important role in implementation activities, for example adapting course materials, setting up a service user website, co-facilitating groups or talking about their experiences at taster sessions.

Then this year or last year, October, November, we went on this time’s training course with XXXX [person] running it, and a guy called XXXX [person], another therapist, but were a lot more involved this time, because we weren’t participants. We told stories like I’m more or less telling you now, and at this time I’d made a list of hints and tips of things I’d learnt about leading a practice, which I sent to XXXX [person], and she said oh yeah, do a PowerPoint[^® Microsoft Corporation, Redmond, WA, USA].
Service user, North

Although many participants reported that they were ‘lone’ champions within their service, being involved in a network of champions and being able to connect with other peers, from within and outside their service, who were ‘hugely enthusiastic and interested in mindfulness’ (teacher, South) had been helpful. Networks had been opportunities to share ideas and feedback so that they did not feel alone. Implementers reported creating new networks around them through graduate groups, local special interest groups, drop-in sessions and online peer support.

Strategies

The data showed us that implementation was mostly happening through ‘bottom-up’ initiatives and strategies, with some examples of a mixture of ‘bottom up’ and ‘top down’. This section describes factors that both hindered implementation and the strategies used to support or facilitate implementation.

Bottom up

Raising awareness

Earlier we described that knowledge and awareness of MBCT as an intervention varied within trusts. A frequently reported strategy for starting implementation activities was to raise awareness about what the intervention entailed. Practitioners ran introductory days, conferences, workshops and lunch time sessions where they introduced the ‘background and theory to MBCT, what it is’, why they do it and how it works. As such, attendees got to experience what the client would experience, which would then give them a better understanding of it as an intervention and in turn, more and appropriate referrals:

So people’s awareness of the therapy has been a bit of a barrier, but that’s shifting over time, again the more people who come to the staff groups, the more they get the approach and the more referrals you get. It has been a very, that’s been very clearly evidenced in the staff groups, high number of people from XXXX attending and we get the most referrals.
Teacher, London

To support the delivery of the workshops and taster sessions, implementers had invited individuals who could have an influence, or create a sense of credibility, for example a senior colleague who was willing to talk about how ‘mindfulness is now very much accepted within the NHS’:

I mean last year having XXXX [person] over, and having the Chief Scientific Officer for XXXX [country] speaking at the conference, is in a way a sign that mindfulness now is very much accepted within the NHS. I think it was probably a struggle at times to be accepted within a medical system because it doesn’t quite fit within a medical model, mindfulness, and I suppose there’s always that worry that it’s kind of associated with Buddhism and therefore, ‘oh is this acceptable?’.
Teacher, Scotland

Others had invited service users to share their real-life experience, and invited figureheads such as Mark Williams to be involved in training (teacher, North).

Practitioners also described constantly having conversations (teacher, London) and trying to ‘keep the flame burning, and continue to educate’ and ‘sell MBCT to the senior managers’ (teacher, Midlands) to align with service’s priorities. In contrast, one teacher reported that they found ‘convincing’ senior staff difficult and time-consuming, and that they would rather prioritise the time with mindfulness participants (teacher, North).

At an organisational level, some trusts/boards were raising awareness through disseminating leaflets, creating newsletters and building websites to advertise the service they are providing. One trust had web pages dedicated to help keep people informed and linked in, and included useful links and downloads to help patients and staff continue with practice. They had a web page dedicated to staff and another dedicated to service users, which was designed and maintained by a service user volunteer (North):

. . . we have two websites, one for service users, and one for teachers. Teachers obviously has a lot more detailed stuff on like practices and scripts and PDF and PowerPoint presentations that I’ve made. The service user one is mainly practices, but a lot of photos that I’ve found and things like that off YouTube [YouTube, LLC, San Bruno, CA, USA], video links, booklets, reunions, websites, and were using it now in sessions instead of CDs, were just giving a website link and they can download that practice for that week when they need it.
Service user, North

Relationships

Another strategy that implementers reported using was in building ‘good relationships’ (teacher, South) and ‘key alliances’ (teachers, Midlands) with senior management to enable good communication between them and to facilitate a shared understanding about priorities and service delivery, because if they were ‘on board’ they were influential decision-makers:

I think you need key people at all levels. So you need to have some key teachers, you need to have some key people in NHS management; you need to have some key people in commissioners. I don’t think you necessarily need everyone on board, but you need to have a few people that can help steer decisions and budgets . . . So I think you know there’s a long history of good relationship that allowed it to come to fruition.
Teacher, South

Some implementers had also been building relationships and collaborating with neighbouring universities to build on evidence, access training and supervision, help with evaluating services through doctor of philosophy (PhD) and master’s projects, and collaborating on new research into using MBCT in different populations. Other than universities, practitioners were building relationships with other organisations in order to help facilitate activities. One clinician had made connections with a third sector organisation in order to get sponsorship to complete their training (South) and another clinician had got in touch with a local venue to offer free spaces on their course to their staff if they were able to use the venue for free (Scotland).

Building a case

There were a number of examples of implementers writing business proposals/cases to share with management (Midlands and North). These included different strategies, for example developing their own training pathways and proposing that in-house training would be more cost-effective (Midlands), and developing an ‘apprenticeship model’ (South). Additionally, some implementers had been piloting the service and then using these to demonstrate impact and apply for funding (South, Midlands and Scotland). As described earlier, many implementers were also evaluating their service and using those figures to demonstrate impact to senior managers (South and Scotland).

Controlling scope and scale of implementation

Although some implementers were doing all of the above activities to build the profile and spread of MBCT as widely as possible, others had intentionally kept the growth and development of the service deliberately slow and ‘undercover’ (teachers, South). One said that they did not want to overstretch as ‘they already had a steady trickle so they didn’t want to push it any bigger as they wouldn’t be able to cope with the demand’ (teacher, South).

There was some evidence of working under the radar without management knowing about it so that they had a chance to develop skills before provision became formal. One person reported that it had been challenging to find the balance between ‘pushing it forward’ while also keeping the integrity of the intervention. In addition, keeping MBCT provision small meant for one person they were able to stay ‘hidden’ while ‘nobody is looking’ at them, and were then able to ‘duck a lot of the pressures’ (teacher, South).

Quality of teaching and provision

Assuring and sustaining the quality of teaching while rolling out services quickly and maintaining quality and integrity was a balance:

It’s a difficult one isn’t it because it’s a bit supply and demand. I suppose the demand for mindfulness has mushroomed, but the amount of people that fulfil the criteria for ethical practice is relatively small, and it’s how you can match supply and demand in that way . . .
Teacher, North

What participants referred to as training varied. Some training included graduating from university-based study and training, and others had been on a training pathway over an 18- to 24-month period. Some referred to other opportunities such as 5-day teacher training retreats (South and Midlands) to come out as fully qualified MBCT teachers, and going through an 8-week course as a participant, which as described would not meet the current minimum training and practice guidelines. There was also some concern expressed by teachers that buying the Green Book¹⁶ and then running mindfulness interventions was all that was expected. Some sites had actively discouraged such developments, by using national best practice guidelines, and by setting up training and supervision pathways.

The quality of teaching was also confounded by the fact that there are currently no official accreditation systems in place. In many accounts, practitioners were intent to abide by national teaching guidelines and explained that these are not a ‘set of techniques that you kind of pick off the shelf’ (teacher, South). Referred to by one participant as: ‘Purist theoretical model v. practical realities’ (teacher, South), there was also a tension expressed by managers in wanting to implement MBCT while adhering to quality standards and minimising costs:

It feels like a challenge in terms of mass roll out. I also wrestle a bit with this issue of professional standards in term of what you need in order to be able to discuss or deliver an idea or a concept . . . So I guess the point I’m making is about standards of proficiency, and that slightly worrying thing as a service lead, where you want to make a therapeutic idea or concept or modality as widely available as possible, but you also don’t want to fall short of the standards or training that are required, and that feels like a really live tension for me.
Manager, Wales

Some managers also expressed the challenge of understanding that those delivering services must practise mindfulness themselves and how this would be different from other treatment modalities, putting MBCT ‘in a very different league to other treatments’ (manager, South).

Service user interviewees were asked how they would know whether or not the MBCT practitioner was fully qualified. Some said that they would expect that in the NHS you would assume they abide by professional standards, but other accounts acknowledged that there were ‘blurry lines’ and ‘grey areas’ (teacher, South), and that they would not be able to tell (teachers, North and London).

Supervision

Supervision seemed to be a key element of maintaining and ensuring good quality service delivery. Often this happened informally from peer to peer, and in some cases using video and online forums. External supervision also functioned as an important aspect of implementation, by providing personal support, contact with national networks and guidance about developing local services based on experienced supervisors.

In sites with more embedded training pathways, supervision was part of maintaining the standards of service delivery:

. . . if you’re embedding something into the NHS it’s important to get all the clinical governance in place and all the standards in place that will protect it but also being very very mindful that we’re not going to dilute things; that we want things to be as authentic as possible and the other way to do that is to fit in with the standards and ensure that we’re supporting people through supervision.
Teacher, Midlands

Maintaining and sustaining

One of the ways many implementers maintained the service was by keeping staff and current and previous service users linked in, and providing support for them to maintain their practice. Implementers organised top-up days, drop-in sessions, silent meditation days and one had developed a special interest group to get more staff interested so that if one or two of the champions or trained staff left the service, there would be interest from others to keep it going.

Top down

In only a few examples, MBCT had been facilitated through a steer from board or commissioning levels, and where there was evidence of commitment and drive coming from senior levels of the organisation:

We’ve got lots of senior people I suppose who are right at the top of the organisation who are keen on it and I think that’s very significant.
Teacher, South

In one region in particular funding had been dedicated through a national programme to fund staff to do the teacher training (Scotland). In a different region and site, in a bid to reduce waiting times and reach targets, there was a steer from management level that they should all commit to doing groups and they included MBCT as one of the groups (teacher, Midlands). In another two sites, a dedicated role had been put in place to develop MBCT within the service; for example:

So my role is, my job title is Mindfulness Based Cognitive Therapy Clinical Lead for XXXX [trust]. So that involves overseeing developments within our health trust, which is a mixture of primary, involves secondary care and also IAPT services. So overseeing developments in terms of mindfulness based cognitive therapy across those areas. That involves training staff to deliver MBCT across a whole range of clinical areas, and then providing supervision, and sort of co-ordinating the delivery of MBCT groups within services.
Teacher, Midlands

Other implementers had referred to a lack of top-down push, and that leadership from higher levels of the organisation was hard to achieve. Without leadership from the top, traction was hard to achieve:

So essentially what you have is a lot of very busy overworked service leads, doing their best to think about both the strategy in their own organisations, but also know about how that might be made consistent . . . but all of us will respond to influences and dynamics and tendencies within our own organisation, and those don’t quite match . . . we haven’t had the kind of leadership that they’ve had in XXXX [country] to get that really clear consistent approach.
Manager, Wales

Summary

Findings from phase 1 show that accessibility to, and implementation of, MBCT is patchy across the UK, including within regions. Participants’ accounts came together to create a picture of MBCT implementation comprising of various components. The drive and commitment of implementers who, from the ground up, took on implementation activities and were met with more or less commitment from the top down. Their stories provided an account of their implementation journeys. NICE-badged evidence appeared to be both a catalyst (as a selling point) and restraint (target patient group). As such, different forms of evidence seemed to inform the adaptation and implementation of MBCT. The context comprised a number of features including resources and culture-mediated implementation by creating more or less favourable conditions for the intervention and for implementers’ activities. Stakeholders’ receptiveness, engagement and buy-in also influenced the potential of MBCT implementation.

These findings facilitated the development of a provisional conceptual map (Figure 3), which supported us in making the transition to phase 2. Phase 1 was concerned with description and phase 2 aimed for explanation. As such, the provisional map provided a way to design data collection tools and orient thinking in initial data analysis activity. This supported phase 2 data collection in being as rich as possible in terms of developing an in-depth explanatory account.

FIGURE 3

Provisional conceptual map of MBCT implementation.

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