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

Sampling

Stakeholders of relevance to this study included commissioners, managers, MBCT practitioners and teachers, and people living with depression with experience of MBCT. To ensure geographical representation we sampled within the following NHS regions: England (North, Midlands, South and London), Wales, Scotland and Northern Ireland (see Chapter 3). Preparatory work involved securing the engagement of a key stakeholder within each of these regions, namely someone who had good knowledge of MBCT service delivery across the region. At the funding stage, the board asked that we randomly sample some of our participants to reduce the risk of positive accounts. Therefore, following interviews with key stakeholders within the regions we developed a list of potential participants that represented each of the groups described above in each area. We then randomly sampled from that list within each of the stakeholder groups (see Chapter 3, Sample).

Semistructured interviews

We conducted semistructured audio-recorded interviews in each site, these were our primary source of data. The interview schedules were initially informed by the findings of phase 1 so that we could test out the ideas that came from phase 1; however, in order to build up an explanation in phase 2, as data collection and familiarisation progressed, we revised the schedules to enable us to build up an explanation over cases. As such, the interview schedule evolved as we progressed with the case studies, to enable us to begin explanation building (see Appendices 1–3 for some examples). Interviews were mainly conducted face to face, but in a small number of instances where face to face was not possible, they were conducted by telephone. We stated in our protocol that we would interview up to 20 participants in each site, but as a result of reaching a point of data saturation, fewer than 20 were interviewed in some sites. A decision to stop data collection was reached by discussion between FG, HOG, JRM and WK.

We were interested in exploring some of the features of the framework that we developed from phase 1 data analysis (see Appendix 4), and, as such, questions about this were built into the schedule. Therefore, the schedule included questions relating to the MBCT implementation story, the mixture of factors that mediated the implementation of MBCT, including issues concerning the evidence base and the context of implementation.

Non-participant observation

We sought opportunities to observe naturally occurring meetings and events within each site. It was anticipated that this would provide an additional opportunity to gain insights into the context of service delivery in which MBCT may be being delivered. Observations, which were written up as field notes, were guided by drawing on a framework that included paying attention to space, actors, activities, objects, acts, time, events, goals and feelings. 79

Documentary analysis

A range of documents was collected to help contextualise and complement other data sources (see Appendix 5). We requested documents that may help us understand the implementation of MBCT in specific sites; as such, they differed across sites. Specifically, we asked for any strategy and/or policy documents about MBCT services, which would facilitate an understanding about where they were positioned within the structure of the organisation and pathways of care delivery. Additionally, we requested any meeting notes from MBCT planning meetings, business cases/proposals, service evaluations and any reports of relevance to MBCT. We were also open to the offer of relevant documents from site participants.

Context analysis

In order to gain an understanding of the broader context we gathered publicly available information about socioeconomics, ethnicity and mental health metrics (see Appendix 6). We also drew on site-specific, publicly available data, which is not referenced in order to maintain site anonymity. In combination with qualitative information gathered within sites, this enabled us to build up a description of each case (see Chapter 4, Case summaries).

The non-participant observations were conducted, and documents were gathered in order to confirm or refute claims made in the interviews.

Sampling

Use of the framework approach

We used the phases of the framework approach in the following way within each phase.

Case study analysis

The framework approach that was applied to data analysis in phase 1 facilitated the development of a conceptual map (see Figure 2) that enabled us to move to phase 2 data collection and analysis in a purposeful way (i.e. it provided an opportunity to seek further explanation, in contrast to more description).

To create a ‘case summary’, information was gathered from interview data and then observations and documents were checked to confirm or refute (refutation rarely occurred) statements made in the interviews. This was done by reading and reviewing documents and field notes against the coding frameworks developed from interview data.

Consistent with the comparative case study, each case was viewed as ‘whole’, in that data were analysed within it before being considered across sites. A pattern-matching logic based on explanation building was used. This strategy allowed for an iterative process of analysis reflecting the variety of data sources, and the potential insight each could offer in meeting the study objectives.

Confidentiality and anonymity

Each participant was assigned a unique numerical identifier following the data collection episodes. To ensure anonymity and confidentiality, role descriptions (e.g. teacher, manager, commissioner or service user) have been used to describe participants in this report. To ensure anonymity we have also assigned each participant in phase 1 a number, and each case in phase 2 a name (see Table 5).

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).

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.

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

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.

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).

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.

Overview

Oak had developed a strong network of implementers across all levels of the organisation over a 10-year period (Figure 4 shows a timeline of key junctures). Implementers made use of and developed facilitative contextual factors, including a supportive trust board and chief executive, and widespread grassroots interest in mindfulness from staff. Engaging staff through MBCT classes to promote staff well-being seemed to be key. Implementation was across services [adult, Child and Adolescent Mental Health Services (CAMHS) and recovery college] and levels of care (primary, secondary and tertiary). The development of an embedded training pathway and governance structure in year four, and the establishment of a Centre of Mindfulness in year six were key junctures.

FIGURE 4.

Oak timeline. CAMHS, Child and Adolescent Mental Health Services; CEO, chief executive officer.

Context

This health-care organisation was established in 2006 and became an NHS foundation trust with teaching status in 2008. It provided mental health, learning disability and substance misuse services to a population of around 1.6 million people within a mix of urban and large rural areas across three local authorities. The trust merger in 2006 had implications for implementation as two early adopters located in different parts of the previously separate trusts were readily connected and had gradually built a reputation for mindfulness work since 2001. This also coincided with the national IAPT programme implemented in 2009, and the founding chief executive officer (CEO) being keen to champion MBCT.

Training and service provision

The main implementer had independently taken their training to teacher training retreat level 3 and regularly self-funded external supervision. The trust had established over the years a foundation teacher training programme with a 1-year supervised training pathway (including, among other elements, weekly supervision, eight ‘practice-ship’ modules, monthly seminars and trainees co-running MBCT with experienced teachers – especially in staff groups). This teacher training had been enabled through two teacher trainers who had been trained by the Centre for Mindfulness Research and Practice. They had a lot of experience in continuing professional development and they released a publication about their training pathway and its potential for wider application in the NHS. A hybrid of MBSR and MBCT was provided in both primary and secondary care settings. By the nature of provision in both primary and secondary care, services were provided to a mix of various populations outside the NICE remit, as well as being offered in many other services and including staff groups. By the time of our visit, this site had 23 trust-approved teachers (12 in secondary care, the rest in primary care and CAMHS).

There were an average of five staff mindfulness groups per year running for staff well-being (11 in the previous year), and the comprehensive research programme with numerous research publications focusing on the implementation of adapted mindfulness interventions with groups not traditionally offered MBCT.

Overview

In Pine there was a team including the local collaborator, clinical lead, senior academics as well as middle and senior management, who took a business-minded approach to implementation. A core group of two or three key implementers worked together on the implementation agenda, which included developing a range of implementation documents and activities in order to achieve a sustainable service. This included audit reports, strategy and governance papers for the training pathway (2010) business plans and strategy papers for IAPT and secondary care (around 2010–11), a CEO mission statement (2011), biannual reports since 2013, governance and operating guidelines (2013–14), values and strategy papers produced (2014), as well as sharing best practice through national networks since 2014 (Figure 5 shows a timeline of these key junctures).

FIGURE 5.

Pine timeline. APPG, All Party Parliamentary Group; LC, local collaborator; LD, learning disability; TTR2, teacher training retreat 2.

Reaching a critical mass of 30 trained MBCT teachers through an internal training pathway was a critical juncture and later in 2015 (after our site visit) a mindfulness centre of excellence had been established.

Context

Pine is a large provider of mental health, intellectual disability and community health-care services seeing about 190,000 people every year with 8800 staff. It had an annual budget/income of > £400M and was awarded foundation trust status in 2015. The trust provided services across the county for people with mental health needs, with needs relating to drug or alcohol dependency, mental and physical health services for people with intellectual disabilities and community physical health care. Implementers described an open culture, with stakeholders at different levels being supportive of MBCT. The CEO was a non-clinician, supporting and speaking out about experiencing mindfulness.

Training and service provision

Implementation comprised establishing an internal training pathway, which provided supervision in a 1.5-hour session every month in groups of two or three, a monthly peer supervision session and attendance four times a year at a 1-day silent retreat. This was all provided in house and in participants’ work time, and provided by the clinical lead with no external costs.

Pine recruited staff by a trust-wide advertising event (200 staff) and introductory day for those wanting to know more (100 staff), then interested staff applied to do the training (around 50 applications), of whom around 30 went on to complete the 12-month training pathway.

There were around 30 staff running MBCT groups across the trust (10 in IAPT) and an outwardly visible mindfulness centre of excellence had been established within the trust in 2015 (post site visit). MBCT (delivered as close to the manual as possible) was embedded within both secondary and IAPT services, and a mix of patients beyond the NICE remit were included. This entailed recurrent/remission and active levels of depression.

Overview

Elm’s implementation story began in 2000 when an early adopter started with a bottom-up approach using a lot of their own resources, autonomy and undercover strategies. After 6–7 years they started to receive some organisational (top-down) investment (Figure 6 shows a timeline of key events).

FIGURE 6.

Elm timeline. LC, local collaborator; PCT, primary care trust.

The site featured a mindfulness clinical lead (not funded) with a long-standing interest in mindfulness who had an experienced mentor helping them to develop teaching skills. This led to setting up a service for adults in 2007 after receiving NHS psychology service support and funding for five to six courses in adult services. In 2011, funding came from NHS health education for five staff courses. There was no other evidence of top-down support and investment.

At the time of data collection visits, a training pathway was currently on going and there were up to 30 MBCT teachers in five IAPT services. Following a critical juncture in early 2015 (after our site visit) when IAPT services made significant cuts, the training pathway and MBCT provision was stopped as it was deemed to be financially unviable.

Context

The services provided by the trust included community services such as health visiting, podiatry, sexual health and dentistry as well as inpatient and community mental health services. The trust covered the whole of the county footprint and employed around 7000 members of staff across > 400 sites. It provided health and well-being services for a population of around 1.4 million people.

During data collection we saw that the trust headquarters had instigated a ‘hot-desking’ environment in their offices in order to save building costs, and we observed a sitting group in this busy environment put together by a senior manager who was championing mindfulness (this person had left their post since the site visit).

Training and service provision

For many years an early adopter and current mindfulness clinical lead led pilot groups under the radar, using their own resources. The site reached critical juncture in 2007 when NHS psychology service support and funding enabled implementers to run six courses in adult services. In 2011, MBCT implementation plans developed for IAPT services and funding given for five 8-week courses for staff.

A 12-week teacher development programme including teacher trainee placement and supervision had been established, and they had recruited self-funding NHS professionals from other trusts. During our visit we found teachers struggling with demand and trying to keep up the throughput of training/supervision.

We found up to 30 teachers in five IAPT services actively delivering services across the county. MBCT was offered in several IAPT areas with accessible, adapted resources developed by implementers with the help of and for service users. Services were offered to a mix of populations (including staff groups) wider than the NICE guidance remit.

However, in the year following data collection the service faced pressures and changes in IAPT services; supervision was first halted and then later all MBCT provision and related training stopped.

Overview

In Mangrove, implementation of MBCT had started with three committed implementers working independently and with little official resources. This had resulted in them pursuing their own intentions in their own time. In this site there had been > 10 years (Figure 7) of grassroots service development with some ambition for an internal training pathway and centre of excellence, but as a result of different agendas and lack of middle-management buy-in, there were no obvious critical junctures that enabled MBCT to become embedded.

FIGURE 7.

Mangrove timeline. LC, local collaborator; MBA, mindfulness-based approach.

Context

This mental health trust provided the widest range of NHS mental health services in the UK, with 230 services including inpatient wards, outpatient and community services (foundation status since 2006). It had one of the largest mental health research and development portfolios in the UK through academic partnerships including various organisations.

Mangrove provided services to people living in four urban boroughs, comprising inpatient care for approximately 5300 people each year and > 45,000 patients in the community. The trust had about 4800 staff serving a local population of 1.1 million people.

Training and service provision

At the time of data collection, MBCT delivery had been developed in separate services by at least three implementers. This included secondary care services and Community Mental Health Teams (CMHTs), IAPT services, staff drop-ins and staff mindfulness groups offered across the trust, and some developments in specialist services (psychosis, cancer), as well as some mindfulness teaching at the local university. Within secondary care mental health services, MBCT groups had been offered by a psychiatrist teacher since 2005/6 with some IAPT populations referred, but also delivered to a mix of populations in CMHTs.

Mindfulness-based cognitive therapy was also offered (run by a service manager in their own time) within one of four IAPT services across the trust, with five groups per year currently offered depending on a waiting list. The type of group-based service included MBCT for depression, a MBCT/MBSR hybrid for long-term physical health conditions/medically unexplained symptoms (pain or fatigue), with a quarterly open follow-up offered to both.

Groups were a mix of presentations (option in care pathway and on website) applying loose criteria wider than the NICE remit (not currently in remission, some actively depressed, fatigue too, and generally more anxiety based than depression focused).

In terms of staff mindfulness and teacher training, the mindfulness clinical lead in secondary care started offering mindfulness to staff groups in 2003, conducted a research pilot that was published in 2013 and, with other implementers, started two apprenticeship pilots of an internal training route in 2014 and 2015 (with five places in each). This internal training pathway developed selectively in terms of recruitment and limited resources, with monthly drop-in sessions but insufficient funds/opportunities to expand.

Overview

In Bamboo implementation started around 2003 when an early adopter became a member of the advisory group of a national depression programme. This provided 3 years of funding to train NHS mental health practitioners in MBCT, and some leftover monies were then used to establish a national mindfulness teaching role for two implementers. These roles were crucial for the establishment of a small-scale national training pathway and also provided a regular network opportunity for implementers. There were six or seven implementers altogether, working across different services. In 2006, there was a country-wide strategy for depression published, and also around this time, seven teachers across two sectors (mix of primary and secondary care) received funding to run five MBCT groups per year. In 2008 and 2011 national guidance to deliver evidence-based interventions mentions MBCT for relapse prevention. A research and audit on mindfulness conducted by the local main university partner started in 2014, without significant external funding (Figure 8 shows a timeline of these key junctures). At the time of data collection the implementers were planning to progress from partially embedded provision to further embedding through the development of a training proposal, which would help ensure that more staff were trained to deliver MBCT groups.

FIGURE 8.

Bamboo timeline. MBA, mindfulness-based approach.

Context

Bamboo is an integrated health-care organisation that was formed in April 2006 by combining two smaller organisations. It served a population of 1,190,856, with 44,000 staff delivering services in the organisation as well as regionally and nationally.

There was a culture of a strong public service ethos, which included developing its own policies and systems, which had a slightly wider remit than the NICE guidelines. In terms of fit with organisation priorities, at the time of data collection MBCT was not recognised as a priority by middle and senior management. (Although since the site visit the overall lead for all psychological therapies across the site has asked for a strategy document for MBCT and a steering group for mindfulness interventions.)

Training and service provision

There were pockets of MBCT provision as a low-intensity intervention for depression across all adult mental health services, adhering closely to the original manual but with wider inclusion of patients including eating disorders/obsessive compulsive disorder and generally offered at the end of the care pathway.

As a consequence of the establishment of the national training pathway, a network was developed and met on a monthly basis which provided supervision and workshops as well as being an opportunity for people in the training pathway to connect. There was an annual teacher training attended by staff from both mental health (inpatient and community) as well as staff from the acute hospitals.

The service user service that started in 2006 also doubled up as opportunities for interested staff. Places were left for staff on all the MBCT groups, which had become an accepted route for training and also for staff wanting to develop mindfulness purely for personal reasons.

Two implementers secured one-off funding for courses in 2013–14 (including co-facilitating with trainees). The capacity within this service included seven MBCT teachers (one not yet ready to run groups) with a supervision group and practice maintenance group run in the evening (in their own time with no central funding).

In addition to mental health services, we also visited a specialist centre for complementary medicine (totally separate from mental health services but still a NHS facility delivering services free of charge), which also offered MBCT to patients with a wide range of physical and mental health conditions. Out of this wider network of stakeholders came the formation of a community interest charity offering teacher training to NHS and social care staff. Another source of teacher training was through a national NHS provider, which was not prescriptive to the MBCT manual and that allowed most national sites to work with either, both or hybrid MBCT/MBSR programmes.

Overview

Following the departure of an early adopter in this site, there was no evidence of a roll-out of MBCT services in Birch. The focus of recent activities had been mostly driven by external implementers (the previous early adopter) at the academic centre of excellence, and in developing the MBCT teacher training for staff.

There was evidence of some MBCT being delivered by a third sector consortium (commissioned by the health board), but there was uncertainty about how quality assurance was managed and whether or not the providers were appropriately trained to deliver MBCT.

This site experienced a critical juncture in 2012 (Figure 9) when the site received funding from local government to build capacity in psychological therapies. The psychological therapies lead in this site was part of a psychological training institute, which was a local initiative that made decisions about allocating and co-ordinating budgets around psychological therapy. The first wave of funding included a specific recommendation from the government to prioritise developing a range of options of psychological therapies. The decision was made by the psychological therapies lead and the psychological training institute to use this funding to fund the first cohort of MBCT trainees. They later received a second wave of funding, which funded a second cohort of trainees. Trainers and trainees reported that there was a lack of co-ordination between the commissioning of training and the transition from training to delivery. As a result of a lack of clarity about who was leading, implementation of the training proved challenging. Birch have since appointed a co-ordinator who leads in organising resources and supervision for trained staff.

FIGURE 9.

Birch timeline.

Context

This organisation was established in 2009 as a part of the devolved government reform programme for the NHS, which brought together a number of organisations with responsibility for delivering all NHS health-care services within a large geographical area. This large health board provides a full range of primary, community, mental health and acute hospital services for a population of around 687,000 people across the six counties. The site employed around 16,500 staff, and had a budget of around £1.3B.

The implementers stated that the contextual conditions for implementation were not supportive, with the organisation operating on short-term funding and people being rushed to hit targets. In this region of the UK, health is the responsibility of the devolved government, and initiatives such as IAPT is not in existence. There was not an explicit depression care pathway, which made it impossible to demonstrate and report impact of MBCT for particular populations.

Other relevant contextual factors described by implementers related to re-organisations and competing priorities, which meant that MBCT kept dropping down the priority list. Implementers told us that the board’s answer to that was to ‘squeeze’ MBCT delivery in with existing job roles, which was perceived to be unsustainable in the long run. Implementers had not managed to raise a high profile within the board to ensure their buy-in.

Training and service provision

At the time of our study, we found one official way to publicly access MBCT from within primary care. This was a health board-commissioned third sector consortium delivering MBCT groups. There was uncertainty about how quality assurance and good practice was managed. Managers within this service also described issues around appropriate referral as people who were currently well did not usually access their services. They therefore had varied and different populations accessing the service. We found implementers and emerging trainees operating across secondary care services, sporadically running groups or applying skills in one-to-one service delivery.

Between 2010 and 2015 implementers had two funding streams for psychological therapies, which enabled them to fund two cohorts of teachers trained in 2013–14 and 2014–15 (a total of 22 staff). With the first trained cohort there were a few difficulties in translating their training into practice. There was no funding or time being allocated to deliver MBCT in their individual services, and staff struggled to start anything up in their service. Following this they appointed an internal mindfulness co-ordinator to support the transition from training to delivery, and to organise practical and financial resources. This role was an add-on to the post-holder’s current role and existing workload, so no extra time was dedicated to it. At the time of our site visit we estimated that fewer than half of those in the first cohort were running groups, and the second cohort of staff were completing their training.

Overview

In Hazel, there were individual, privately trained and personally funded practitioners who were not really aware of each other. They had personal interests in building their own skills and either a lack of experience or confidence to start teaching/supervising others within the trust.

For 5–6 years individual implementers ran workshops, taster sessions and staff groups, and in 2005 one implementer started a MBCT service for older adults, partly in their own time. Between 2006 and 2012 (Figure 10 shows a timeline) efforts appeared to be hindered by a trust merger, at which time competing priorities related to reorganisation and to a strategic focus on upskilling staff in other modalities other than MBCT. There were still pockets of activities across the trust but, as a result of a very pressurised context driven by targets, implementers reported feeling like they were hitting a brick wall, which resulted in them delivering what they could within their own local service.

FIGURE 10.

Hazel timeline.

In 2012, there was an audit in the trust of mindfulness facilitation capacity in order to gain an idea of who was still practising and levels of training, which was jointly completed by a consultant psychologist, a psychologist and an occupational therapist. The results of the audit were sent to commissioners with no obvious outcome. Implementers expressed hopes for their new CEO, who had been recently appointed at the time of data collection (2014) and who had spoken at the first annual general meeting about their own history of depression and personal experience of mindfulness.

Context

This trust is one of the largest mental health and disability trusts in the UK. It was created in 2006 following the merger of three trusts covering a large geographical area totalling 2200 square miles, working from > 60 sites with a number of regional and national specialist services and a budget of > £300M. The organisation was authorised as a NHS foundation trust in 2009. It provided a wide range of mental health, learning disability and neurorehabilitation services to a population of 1.4 million people, across two UK counties.

Hazel had a long history of inpatient care in Victorian-built facilities and was in the process of shifting services into the community and investing in preventative and integrative care addressing multimorbidity and deprivation in suburban areas. Primary care services partly sat outside the trust and were provided by a third sector provider. Two senior managers had initiated a huge roll-out training programme of 1600 staff in 4200 days of training in six modalities including dialectical behavioural therapy, CBT for psychosis, Wellness Recovery Action Plan intervention and family therapy, but not MBCT.

Training and service provision

A number of MBCT practitioners had been trained but this had been predominantly through self-funding, with occasional pots of money being made available by immediate line managers. Clinicians with an interest/training in MBIs were based in various geographical areas, with pockets of services based in third sector IAPT, primary care, secondary care, specialist CBT services, well-being services (and recovery college), physical care and learning disabilities. Practitioners in these different services did not appear to know of the existence of each other within their own trust.

In terms of setting and referrals we found partially embedded islands of MBCT provision in eight different services (three primary care, four secondary care, one physical care), although this did vary from pure MBCT, as stated in NICE guidance, to hybrids of MBCT/MBSR or using elements of MBCT in one-to-one therapy. The population who were offered the MBCT group intervention fitted well with NICE guidance. A third sector IAPT service provider who had held a three-way contract in the previous 3 years between the trust, Clinical Commissioning Group (CCG) and local council provided MBCT, with the option for a stand-alone intervention, but the intervention was mainly offered after previous treatments.

In 2015 a peer group devised a 10-week course of MBCT to be used for patients with depression, but it was never rolled out for patients in a systematic way.

Overview

A clinician with an interest in MBCT had been trying for a number of years to generate interest and apply for MBCT training, but had not been successful. In Juniper the only juncture that had experienced a positive impact happened in 2013 (Figure 11), when a fully trained (in MBIs) implementer joined the trust (on a voluntary basis) to focus on running MBCT groups. They facilitated five MBCT groups per year.

FIGURE 11.

Juniper timeline.

At the time of data collection Juniper had undergone a recent reorganisation and was commissioned to see a large number of people per month. This meant that clinicians were under a lot of pressure to cover more screening slots and were less able to facilitate groups and that individual and group waiting times increased. Clinicians reported that they were under-resourced to deal with the additional screening, the one-to-one and group work.

Context

This mental health foundation trust (since 2008) served a culturally and socially diverse metropolitan population of around 1.2 million and is one of the largest mental health foundation trusts in the country. The trust had > 4000 dedicated staff and operated from > 50 sites in a variety of settings, from community-based mental health teams through to acute wards and day centres.

We collected data in a NHS primary care psychological therapies service spread across three area teams (East/North, Central, South). MBCT implementation in this service began during the third wave of IAPT restructuring.

Training and service provision

A volunteer working full time in the East and North team was the only person running 8-week MBCT groups, and facilitated around five groups per year. This person was also working on adapting MBCT to be delivered to anyone who wanted it (e.g. those with bipolar depression, obsessive–compulsive disorder, stress, chronic fatigue, irritable bowel syndrome). Anyone who was interested in incorporating mindfulness in their own work was able to sit in on an 8-week MBCT course as a participant, and then introduce elements in their work if they believed it would be useful (working with the volunteer to adapt). The volunteer implementer would also help direct those who wanted to train further towards external teacher trainers. There were three clinicians who had adapted the classic 8-week MBCT approach by adding a compassionate-mind element to the MBCT manual and running two or three groups per year.

In terms of training, there were a variety of sources of training, two staff members were trained to a certain level, and core funding for five staff in each of the three teams was then released to receive an introduction to MBCT from a neighbouring university (5-day training for £650 each). There was a lack of clarity between training provider and manager about what the 5-day training would entail and the cost of it represented an issue as a 5-day course was a prerequisite for training (i.e. a personal/experiential practice development rather than developing nursing staff for professional service delivery, which is what the manager had envisaged). Those who had attended the 5-day course were expected to use the skills learned to introduce mindfulness into their work. There was also an internal CBT supervision group in which MBCT teachers were allowed to bring MBCT issues forward (some peer supervision).

Training levels varied; one clinician based in one team had developed an informal interest at university 15 years previously in a Buddhist centre and had then sporadically used mindfulness in one-to-one work. This person received no further training since and reported feeling like they were ‘learning on the job’.

Overview

In Beech the implementation journey began around 2006 (Figure 12) when an early adopter became interested in MBCT and personally funded their training in MBCT. This person led their first patient MBCT group in secondary care in 2007 with a co-facilitator, who at the time of data collection was Beech’s implementer. By 2009 they had two or three groups running per year, and by 2010 had developed an internal teacher training pathway. Beech had a juncture in 2012 when a trust merger happened and they adopted large waiting lists, which hindered implementation. Practitioners were diverted by a new manager to clear waiting lists for people needing individual therapy. This led to frustration by the early adopter who left the trust.

FIGURE 12.

Beech timeline. LC, local collaborator.

This left the remaining implementer struggling to do what they could with minimal support and resources. No MBCT 8-week groups had been delivered since December 2013. They experienced a secondary care service redesign in 2014, which meant that staff were assimilating to the new structure and new ways of working. A new MBCT group was scheduled to start in 2015 (post data collection).

Context

Beech was formed in 2006 and later integrated with community services from another trust in April 2012. The organisation aspired to obtain foundation trust status as soon as possible and was awaiting an inspection of services by the Care Quality Commission in 2016. It provided services from > 60 locations and employed > 4200 staff. Beech provided inpatient, community and day clinics, as well as specialist services, to a diverse population of about 1 million people living in a city/metropolitan borough.

A trust merger in 2012 meant that they adopted long waiting times. This was then followed by a redesign of the secondary care mental health services in 2014. A service manager indicated that with time, the service redesign could have positive implications for MBCT. This service redesign in secondary care meant that CMHTs were transformed into integrated practice units (IPUs), which are organised around ‘care clusters’. For example, IAPT is care cluster 1–2 sometimes 3 on border to site local collaborator’s own service based at 3–10 (anything but psychosis), IPU 10–17 is psychosis and IPU 18–21 is older adults, etc. This meant that the service ended up with different IPUs with different flows in of referrals with the following implications of the redesign on MBCT: (1) implementers would be able to target a particular group of patients more easily (i.e. to concentrate on care clusters 3–8), and (2) IPU interventions had to be NICE compliant so this would help the argument of providing MBCT.

Training and service provision

Internal training existed between 2010 and 2012, which was set up by the MBI-qualified early adopter. The trust merger interrupted the training pathway when a new manager was put in place and was presented with the task of tackling long waiting lists. The training pathway was put on hold, and later the early adopter was told to freeze all group intervention training and activity in order to focus on one-to-one interventions.

At the time of data collection we found services embedded in IAPT, where four or five of those who had completed the MBCT internal training pathway were actively involved in the delivery of group therapy. This was not MBCT groups as per the manual, but elements of MBCT were used in other group-based interventions.

Within secondary care mental health services between 2009 and 2012, two or three MBCT groups per year had been conducted by the local collaborator, carved into their current role. The first MBCT group since 2012 was scheduled to start in April 2015. The pre-course assessments and introduction session had just been set up and sessions were about to start following data collection.

Overview

It was very early days for this site in terms of their implementation journey (Figure 13). In Wisteria the implementer sat primarily within an occupational health department. This site featured MBCT (with a focus on stress in place of depression) for staff only. The main implementer was also raising awareness of MBCT within physical health through their part-time role in this context. This was a hospital-based service, and the implementer’s role in physical health comprised inpatient/outpatient with lots of group work (e.g. acceptance and commitment therapy). In addition to the role in physical health, the implementer came to the occupational health service with a remit of introducing group-based interventions.

FIGURE 13.

Wisteria timeline.

They had advertised for some staff to take part in a pilot group for staff in 2014, but had an overwhelming response of 197 applications within 3 days. Applications were reviewed and places offered on a first come first serve basis in accordance with information provided within the application form. Those who were not offered a place on the programme were later invited to a 1-day introduction to mindfulness workshop.

Context

The trust formed in 2007 after the merger of six trusts and was delivering integrated health and social care to around 340,000 people. The organisation had an annual budget of approximately £1B (spending about £3M each day) and employed 20,000 staff making it one of the largest trusts in the UK. The large number of staff was relevant in terms of implementation because as an occupational health department they were facing huge demands from staff with limited resources to implement and deliver MBCT to staff.

Training and service provision

The trust ran a pilot in 2014, and had an overwhelming response. The pilot attendees came from across departments and professional groups (no medics/not a lot of clinical staff – mainly nursing, management, human resources).

The curriculum followed the course content of manualised MBCT because some staff were experiencing depression due to stress. The timing of courses was an issue, with the pilot being offered in the evenings after work. Being a lone teacher also represented a challenge. At the time of data collection a second group orientation was planned.

Presence of implementer(s)

Our data are densely populated with examples of enthusiastic and passionate individuals who were acting as local leads and champions (implementers). The starting point for implementation in all sites was the presence of these implementers who acted as champions and change agents rather than a more strategic and/or commissioner-led initiation of MBCT within sites. The majority of these implementers were self-selected or had been nominated by their local team(s). Only one site (Pine) in this study had an official, designated and funded mindfulness lead role.

Most implementers had initially worked alone in driving forward the intervention and, as such, services had grown organically from the ground up. As each site was at a different stage in their implementation journey, correspondingly the presence of an implementer varied according to the starting point and history of the site in initiating MBCT. Implementers in Bamboo, Elm, Beech and Oak could be described as ‘early adopters’ in that they developed an interest, practice, research and championing activity before the intervention had been included in NICE guidance. Through the work of these early adopters and over time, there was a greater awareness and acceptance of MBIs in general, which paved the way for the potential of MBCT in particular in these sites. Some of these early adopters had been able to pass on a legacy to a second generation of implementers, who were equally committed to championing and leading the MBI agenda. In these cases MBCT had a greater chance of continuance (Elm, Oak, Mangrove, Hazel, Bamboo and Birch).

Implementer capacity varied across sites ranging from individuals working in isolation to those who worked as part of a small team committed to MBCT. For example, in Elm there had been a reliance on one implementer in a clinical lead role, and in other sites there were more implementers working at various levels of the organisation (Table 8).

Given the mainly self-selected nature of an implementer, it was perhaps unsurprising that individuals in sites where MBCT was less available did not have protected time or resources to undertake implementation-related activity; for example:

The way we’ve organised it so far is to identify a lead practitioner within the XXXX [trust] who has this as part of her remit, XXXX, but she’s had this sort of crowbarred into her ordinary job description and like a lot of psychotherapy training and treatments sometimes it just has to run on enthusiasm rather than organisation oomph if you know what I mean and some of the personal commitment that people bring is what keeps it going.

Head of psychological therapies, Birch206

Pressures have changed over time, everything is more rushed now so it’s very difficult to prepare, rush around and then lead a group. Managers have other pressures – relationship between manager and teacher becomes difficult – ‘leaves a sour taste’ – ‘I’m offering to deliver this service, in addition to my full working week, and you don’t give me the support that’s needed’.

Observation notes – peer supervision meeting, Elm

In contrast, in sites where MBCT was more embedded they had access to greater resources, including dedicated time to work on implementation activity:

. . . that’s just a combination of that network thing, just myself and XXXX [local collaborator] were friends personally and it was just having that connection and a willingness like XXXX [local collaborator] to give his time, his manager to allow him to give his time and my clinical director saying yeah let’s give it a go, not done it before but you’ve got some expertise coming in willing to help us, it fits what we’ve been commissioned to deliver so let’s go for it.

Clinical lead/manager within IAPT, Pine201

Implementer characteristics and skills

Data show that the characteristics and skills of an implementer were critical to role success, including their deployment of implementation-related activities.

It’s generally being conducted by enthusiasts . . . if you have experienced enthusiastic, committed, well trained, clever people, do almost anything, you know it’s gonna have a good outcome.

Associate medical director mental health, Bamboo201

Characteristics such as passion and dedication, role seniority and personal credibility, and implementation skills such as effective engagement and delivering activities were critical success factors, and were more evident in sites where MBCT was more embedded.

Consistent with findings described in Chapter 3, these implementers went over and above their professional roles because they were passionate about MBCT and to their own personal mindfulness practice; for example:

Because it needs the old grass roots as it were, it needs the people who are going to be delivering it to be the starting point in terms of their own personal interest and commitment to mindfulness and MBCT because without that of course there’s nothing; it doesn’t exist.

Mindfulness clinical lead, Pine101

However, although passion and commitment to the intervention was both the starting point and a driver, in sites where this was combined with other characteristics and implementation-specific skills such as engagement and communication (e.g. diplomacy, speaking the language), business sense (selling) and research (evaluation, demonstrating impact, intervention development), a greater chance of implementation success through mediating barriers and leveraging facilitators could be achieved:

. . . they don’t understand that there needs to be nuts and bolts to it with the costing and how they can go about influencing people. I think it’s that the skills that they need to understand what they need to do if they like and knowing where to go and who to speak to as well, that can be quite difficult and they have to be quite tenacious and not give up you know when they meet a barrier.

Research and innovation lead, Elm205

However, passion, enthusiasm and commitment were in themselves not enough for successful implementation. This had to be complemented by support from the organisation, particularly senior managers (see Top down, bottom up for more detail).

An implementer’s seniority or perceived credibility was also instrumental in enabling appropriate level decision-making, and in garnering support and resources. More progress was made in sites such as Oak, where implementers were in positions of authority and autonomy, and there was a cross-organisation network of implementers. In contrast, for example, in Birch, the sole implementer working in a clinical co-ordinator role was not in an appropriate position of authority, which resulted in ‘her hands being held behind her back a lot of the time’ (early adopter, Birch202). The level of authority also seemed to be associated with levels of confidence, with some implementers being more comfortable approaching and pitching their ideas to senior managers than others:

I think that’s where I fall down . . . I’d rather be working on a newsletter to encourage mindfulness participants, to stick with the practice, stay at it, get the benefits, rather than planning a presentation that’s going to make me knees knock in front of senior management, who are then going to ask me really hard questions about throughput . . .

Local collaborator and former mindfulness clinical lead, Elm101

This may have partly explained why MBCT had not progressed as far in some sites (e.g. Beech and Birch) or why activities were stopped (Elm) in contrast to other sites where there was both authority and confidence in a team of implementers (e.g. Oak and Pine).

Implementer activities

The implementation activities we heard about in phase 1 interviews were also reported by participants in phase 2 (see Chapter 3, Bottom up). Activities ranged from taster sessions/workshops to pitching the idea and making a case by using pilots and evaluations, and diversifying to generate income to sustain branching out to other services within the trust (Table 9). Within phase 2 data we saw that the range of activities corresponded with the degree of development of MBCT services. Sites where there was more embedded MBCT (e.g. Oak and Pine) had success in combining a number of strategies that involved different types of stakeholders in the organisation on a more continual basis, which seemed to have had a greater impact. However, it is difficult to disentangle whether or not their ability to be able to use a multistrategy approach was because these sites had a platform of greater organisational buy-in to delivering MBCT and, therefore, more resources (including financial and capacity) to support implementation activities (see Context for further details). This contrasted with sites where there was less evidence of MBCT delivery, which was arguably a function of a lack of organisation buy-in to MBCT and, as a consequence, less resource to support implementation activities, resulting in implementers working (often alone) within a strategic vacuum.

The issue of fit and intervention integrity (in relation to alignment with the way that MBCT is recommended within NICE guidance) are described in other sections (see Chapter 3, Evidence fit with patient and practice), and is further described by those in implementer roles. Implementers were giving themselves ‘the freedom to adapt’ (Oak101) in relation to the clients who were coming through the service:

I have a kind of stock phrase that guidance is guidance and it probably fits 70% possibly so you’ve got 30% play room and guidance isn’t fixed law that you must do this and the real life presentations of people don’t always fit the protocols so you need to have things that will cover a variety of different ways of people presenting. So it’s having wiggle room within the guidance, so the guidance gives you a sense of which direction to travel.

IAPT clinical lead, Pine201

There was also consideration of other factors such as additional research evidence that was emerging to inform current practice, which was also being weighed up:

Well if you’re strictly adhering to NICE guidance then it’s for relapse prevention in depression is the main index for people who’ve had three or more episodes but there was additional evidence coming in just about the time when our committee was meeting which was in 2010, so early papers in the Journal of Affective Disorders and several things since then about its effect in acute depression too, so symptomatic depression and that has been reinforced since . . . it was kind of helpful evidence for us because we wanted to show this as something that could be more effective across a broader range of things than just relapse prevention in depression.

Senior academic and clinician, Pine303

Networks

Lone implementers struggled to build momentum on their own, those who were more successful had greater levels of formal and informal support. Early adopters (particularly) had been lone champions working in environments and structures where MBIs and MBCT were not included as a service priority or at that time little was known about it. As such, they created and/or sought out informal structures and networks around themselves:

I guess meeting with other practitioners is also helpful because you can share ideas, and also share things that perhaps don’t always go according to plan, which is often more useful than positive ideas. You just feel like a community, so they’ll be people now that I know from other courses that work in other teams, and because I know them through the practice days etc. they’ll say oh you handle this, what would you do, would this person be suitable? So you’ve got all that informal, so it’s not only the formal structure, it’s the very informal structure.

Clinician, recently completed internal training, Pine103

This approach to seeking out and/or creating a supportive environment through informal and formal networks of various types, including virtual networks locally, regionally and nationally, resulted in implementers being able to share issues, learning, solutions and expertise (Table 10). We found that the more active, established and closer the networks (to the implementers) were, the stronger the support system.

Teachers there quite relaxed and format of the meeting was relaxed. Felt very informal and the teachers looked relaxed. A chance to for teachers to be re-assured and build on their confidence – ‘it’s ok, we’re dealing with the same thing’ or ‘that’s exactly how I feel’ type of feeling . . . This Peer Supervision session is a chance to learn about people’s challenges and use to arrange better for the future and learn how others overcame their obstacles.

Observation notes, peer supervision meeting, Elm

Often these networks would start with the local relationships and mentorships between MBCT and/or MBI exponents. Relationships and therefore networks took time to develop: those sites (e.g. Oak) that had more established provision had the time to build a range of networks such as a supportive network of colleagues and managers within the service; external networks of regional and national implementers; training and supervision networks; and research and development networks.

This paper outlines interventions that XXXX [Oak] can offer to partner organisations to introduce mindfulness in the workplace . . . this paper describes who we are, how mindfulness interventions can be offered to staff, the ways in which training would be evaluated and the costs.

Document, MBIs for staff, Oak

Furthermore, in more embedded sites there was a greater mix of formal networks such as supervision and special interest groups, and informal networks such as peer support:

I also started organising the Mindfulness Special Interest Group and I mean that’s something that’s grown very organically; so when it started off with three of us sitting and looking at a journal together and it’s grown so that we, normally do two or three events a year, sometimes we hold days, sometimes with internal speakers who’ve got some work to present and sometimes with external speakers.

Interest group facilitator staff mindfulness teacher, Mangrove102

Observational data of peer supervision sessions confirmed the importance of developing and sustaining implementer groups in the absence of formal supervision. For example, in Elm and Bamboo we observed a well-attended peer group of five MBCT teachers. We also observed a newly formed Mindfulness Special Interest Group in Beech that seemed to be less attended, due to the geographical dispersion of the various teams:

XXXX arrived saying she felt a bit guilty for coming but said they weren’t often held, only been once before. 2nd woman arrived, introduced herself . . . had travelled from XXXX, 35 minutes away.

Observation notes, Mindfulness Special Interest Group, Beech

Geography: the trust is quite spread out, seems that there’s more happening where the local collaborator is based. The further away from that, the more difficult it seems to be.

Field notes, Beech

I don’t think pretty much any of us go to the mindfulness groups (special interest group) and I would take a guess that we would all love to but when you’re talking about tolerated rather than encouraged we wouldn’t get any time to . . . it would be a whole half a day.

Clinician, Beech105

The opportunity to be part of a training and supervision network enabled a continuity of clinical support, as well as opportunities to learn from others’ experiences, which resulted in implementers feeling more networked. The closer the implementers were to the support system the further they moved away from being the lone enthusiast:

I think one of the things that they have done really well in [Pine], [local collaborator, Pine] has done really, really well, is trying to develop a network and he has tried to develop some benchmarks for practice, he has insisted that people come for supervision, he has insisted that people go through the training.

Consultant in psychological therapies, lead for depression service, academic, Pine204

Some successful implementers had also developed networks and links with universities. These links, which were strongest in sites where MBCT was more established (e.g. Pine, Oak) often started with audits, then built up to service evaluation, through to the development and evaluation of new MBIs. Additionally, closer links with universities had enabled research and development of new mindfulness-based courses (e.g. Pine, Birch, Mangrove and Juniper).

Service pressures

Findings from phase 1 described some of the challenges that the NHS context was presenting to the implementation of MBCT (see Chapter 3, Fit of mindfulness-based cognitive therapy in the current NHS). Case study Beech (and later on in Elm’s journey) shows patterns of similar challenges and provides some explanations as to why these issues challenged implementation efforts:

. . . because of the redesign of the psychology service told me to put all my training activities on hold and to not provide any further mindfulness training . . . because of the service redesign, I was told to freeze all of my training activities and I was diverted to clearing the waiting list for individual therapy.

Retired early adopter, Beech101

Data show a reiteration of the comments about the challenges of the fit of MBCT in the NHS, and we also heard (particularly from sites were there was less evidence of MBCT) about the importance of the presence of a culture of innovation for implementation of new initiatives to be more successful:

A lot of it is about culture to be honest isn’t it? It’s about the culture of an organisation and what’s open to your staff and how encouraged they are to innovate and implement and being given permission to do it and then support it.

Research and innovation lead, Elm205

In this example, the sole implementer in this service had found it challenging to sustain their implementation activities.

One contextual factor that explained some implementation challenges was that of frequent changes in service structures, with reorganisations affecting the availability of resources to run existing services:

. . . from a practical point of view I found that a lot of people in the trust have got heavy workloads, so all the things you hear in the media about pressure on the NHS with resources and staffing levels and things like this. So my experience is that a lot of the psychological therapists and clinical psychologists are so busy doing their normal job that reduces the time that they’ve got for innovation like reading research papers and introducing new treatments like MBCT.

Volunteer, Juniper103

Second, there were challenges in prioritising the investment needed to initiate a new service such as MBCT, when service priorities were frequently changing and resources were limited:

In common with many organisations [Birch] has, well the culture of a lot of organisations in an environment where there’s been a pressure to reduce cost, I mean our organisation isn’t unusual in that regard and I think then it becomes very difficult for managers to prioritise new investment, well not new investment in terms finances but kind of investment in changes in working practices because in a sense they are trying to run to keep up with doing what they were doing with maybe less than what they had . . . So I think the context is difficult.

Academic and dialectical behavioural therapy implementer, Birch204

In addition to the email below from [service manager], I spoke to [team manager] yesterday about the need to resource classes. [Team manager] has asked me to send her costings, but unfortunately she is of the opinion that the XXXX Government money can’t fund the equipment side of things, only the actual training.

Document, e-mail 2, co-ordinator to manager, Birch

An extreme example of service pressure impact was found in Elm where a considerable amount of work had been invested in MBCT teaching and teacher training, but was halted due to reorganisations, pressures from different targets and a retendering process for service provision:

So there’s been very big shifts on all the CBT therapists having a minimum of 25 contacts per week which used to be 15 so it’s a heck of a change in how the workforce are working. Very little preparation time, having to be very lean within the therapy hour that it’s 50 minutes so you have 10 minutes to write your notes up before the next person comes in . . . [it] became very very much forced by the summer of last year, summer 2014, and we were told at the time that it was necessary because we were being recommissioned if we didn’t succeed . . . And so they put the thumb screws on in early 2014 for us work on this 25 contacts per week to try and get the commissioning.

Local collaborator and former mindfulness clinical lead, Elm101

Furthermore, constant changes to personnel, particularly managers, meant that implementers, who relied on tapping into supportive networks (see Implementers), had found it difficult to know who to relate to when trying to make progress:

I guess the person behind the door is changing so much now that if you build an alliance with one person behind one door, you blink and that person has moved to another role, or has just been given three more roles as well as their role, and so there’s less opportunity to build those kinds of alliances with the higher management that ever before, because everybody at every level of the trust is so stretched.

Local collaborator and former mindfulness clinical lead, Elm101

The result of frequent changes to staff also helped to explain the stalling and fragility of implementation journeys in some sites. For example, in Beech an active early adopter facilitator left the service causing activity to halt for some time, and in Birch people were retiring and/or leaving, which left non-trained staff to run MBCT groups.

Drivers and priorities

At a national policy level, drivers around IAPT (although this specific political driver was of most relevance to English sites, see Chapter 1, National context for psychological therapies generally and mindfulness-based cognitive therapy specifically), widening access to psychological services, recovery and prevention, and health and social care integration have been positive drivers for MBCT implementation. Additionally, as described in Chapter 3, the inclusion of a recommendation within NICE guidance provided a lever for paying attention to its implementation. Furthermore, although it was perceived that the NHS is focused on medical rather than well-being interventions (see Chapter 3, Fit of mindfulness-based cognitive therapy in the current NHS), there was a sense that in some sites this emphasis had been shifting, which provided a positive context for offering low-intensity treatment options such as MBCT:

. . . the kind of conversations they were having 10 years ago are well you’re mentally ill and you’ll be mentally ill for all of your life and keep taking these tablets and keep coming back to see me and there’s this massive change in terms of actually no we don’t think that’s right; we’re not telling anybody that they should be forever in mental health services, it’s much more about that empowering, that collaborative relationship . . . We will assist you, we can help you, we can give you tools to do that.

Operational manager in adult mental health directorate, Pine202

Within the offer of low-intensity treatment options includes those that may be offered more cost-effectively as group options, such as MBCT. We explicitly asked participants whether or not cost-effectiveness was a motivator for facilitating implementation, and if they were collecting any cost-related evidence as part of implementation activities. Although there was a perception that ‘group work is more cost effective and efficient for a service than individual mindfulness sessions . . . that’s the evidence base on delivery of groups work . . . so I think it’s cost effective’ (talking therapy service lead, Oak211), cost(s) were not reported as an explicit driver, and evidence about costs of implementing MBCT within sites was not available.

In contrast to drivers, priorities that were often enacted through performance targets had presented challenges to MBCT implementation. One CEO described a ‘cocktail’ of competing priorities:

. . . we are struggling with year on year of historic disinvestment with escalating activity pressures due to the changing nature of urban boroughs, problems with staff, recruitment in terms of quality and all of those can add up to a pretty difficult cocktail when you’re trying to transform the way in which you work with people and do business.

CEO since 2013, Mangrove202

Such a context, which was commonly expressed across the sites engaged in this study, may leave little space or opportunity for prioritising interventions such as MBCT:

. . . although we’d celebrated getting mindfulness into the service operational plan as something that was routine across all services which felt like a real milestone last year, it felt with the shifting targets and the shifting landscape that nothing was safe, nothing was sacred and it all just became about targets.

Local collaborator and mindfulness clinical lead, Elm101

Professional Participant and very recently a service user; Attended a staff 8 week course. His manager not supportive at all – stopped the staff sessions because of financial cuts etc therefore competing priorities get the attention.

Observation notes, mindfulness awareness day for staff, Elm

Additionally, as a consequence of attempting to meet commissioners’ aims (as opposed to clinical aims, which were perceived to be at odds with each other in many participants’ accounts), there was evidence of expanding the target group of MBCT presenting a tension for the integrity of intervention delivery, as expressed by this psychological therapies consultant:

My original intention for our specialist depression service was to have groups for people solely with depression because that would be the NICE-recommended intervention and I think the whole thing has been a lesson really in how difficult it is to implement evidence based practice in an NHS setting because staff have their own views based on their own models and their own prejudices, like how things should be done . . . the difficulties with NHS practices is that there aren’t necessarily benchmarks for practice and because things are often operationally led by managers who are not clinicians rather led clinically led I think that can often be a point, and commissioners are the same . . . so what they commission may not necessarily be in context the best thing to do. I think what is always a concern to me is that MBCT is a highly effective intervention in certain groups and one of the dangers is that it can be so diluted that it ends up being used inappropriately but then it’s seen not to work and it’s the therapy that gets blamed for that rather than how the intervention is delivered

Consultant in psychological therapies, lead for depression service, academic, Pine204

A further consequence of not having MBCT embedded in service strategies (e.g. Beech, Hazel, Mangrove, Juniper and Wisteria) was that competing targets got priority. Additional activities, of which MBCT was one in those contexts, meant that they were happening ‘under the radar’, leading to more personal (rather than organisational investment) in implementation, a lack of support, and leading to patchy, unsustainable services (e.g. Elm, Mangrove and Hazel).

Hard to speak with managers. Introduced to 3 but they didn’t have time, they just said ‘XXXX [volunteer implementer] will tell you everything you need to know’. Same attitude was seen trust wide; Volunteer was passionate and so left to do everything. If XXXX [volunteer implementer] left, there would be no MBCT 8 week courses . . . Management have monthly meetings with different topics (raised by managers themselves) but apparently Mindfulness never seems to come up in those meetings.

Field note reflections, Juniper

Perhaps linked to the level of organisational commitment or priority around implementing MBCT, findings show that in sites where MBCT was more embedded there was evidence of a greater level of support, particularly from managers. The converse was the case; in sites where there was less evidence of MBCT, implementers had access to less support:

. . . my sense is our representation, psychology representation at senior management level and the kinds of forums where senior management sit isn’t there. We used to have an Associate Director of Psychology and that person I think did sit on the board possibly or one of the committees just down from the board and that was really important. That post went quite some time ago so there is no one now that holds that position and so I don’t know how far up the hierarchy the psychology influence goes. So that’s one possible explanation as to why there hasn’t been a top-down approach as well. It might be to do with the insufficient psychology representation at the very highest level.

Local collaborator, Beech102

The support from managers, aligned with organisational level buy-in (see Fit) led to a more supportive network and access to resources such as time during working hours to develop the service, and funding and time for training and implementation activities:

I think we’ve been very lucky in this trust that the number of elements combining to make it more possible . . . having a chief exec[utive] that was open to it, having a few people in the organisation that were keen for it to happen, a couple of consultants, [lead for depression service, academic, Pine204] helped to get it started . . . They’re all at different levels in the organisation but they’ve all got influence so I think that creates an environment in which it can happen . . . if you’ve got people in the organisation saying ‘yes we want this to happen’ this enables the people lower down.

Local collaborator, Pine101

Resources

Perhaps unsurprisingly given what has been described above and in other sections, the dedicated resources underpinning a commitment to MBCT were variable. Some sites had received some funding from a country-wide investment in psychological services (IAPT), but this had been relatively limited with respect to MBCT. As a result implementers had to make do and/or think creatively about resource use.

Having dedicated human resources greatly helped with the implementation of MBCT and with sustaining the service. Oak and Pine had part-time dedicated clinical lead roles (i.e. people were allowed the time and resources, which was enabling). A mindfulness clinical lead role existed informally in Mangrove and Elm; however, as there was no protected time or associated resources this meant that those implementers were having to do the majority of activities in their own time and under the radar. In Birch, the co-ordinator role had been recently established, but carved into existing workloads. In Juniper a lead role was filled with a person on an honorary contract, and in Bamboo the clinical lead role was also more on a voluntary rather than formal basis. In Beech there had also ‘never really been any recognised designated time’ (Beech102) for the implementer. As such, where MBCT was not part of an organisation’s strategy and plans, resource to deliver was scarce and, as described in previous sections (see Implementer and Chapter 3, Fit of mindfulness cognitive therapy in the current NHS), much of the burden then fell to those in championing positions.

There were examples of specific financial investments being made to kick-start or sustain implementation, including in Pine where £80,000 was allocated from a fund to increase access to NICE-recommended treatment for service users, and £68,000 from the regional authority was provided for training and a conference. In Oak the trust had invested in staff well-being (i.e. provision of mindfulness sessions) and in other sites (Bamboo and Birch) funding was available for training, although there was a sense of frustration in Birch that funding beyond training to support the delivery of the service was not in place:

I was hoping to bring this up with you next week, but I guess now is the best time as ever! There is a sense of frustration and despondency from some of the teachers that the go ahead to the funding of the basic resources for the Mindfulness classes has yet to be confirmed. Some were hoping to have run a course before Christmas but as funding for the venue, mates and books etc has not happened, delivering classes has not taken place. Whilst I understand that training more teachers is important, I also feel it is imperative that these practicalities are acknowledged as a very important part of service.

Document, e-mail from co-ordinator to service manager, Birch

Often research grants were helpful in progressing developments, most notably in Oak and Pine, which had strong links to local universities and good clinical academic capacity. However, in other sites, such as Elm, a lack of financial investment had a ‘detrimental effect’ on planning for the future:

There has not yet been a confirmation of the funding necessary to set up and run courses planned in 2012. This has previously been agreed by XXXX [manager] who will be leaving her post in the near future. The lack of confirmed funding is having a detrimental effect on future planning and perhaps to inform XXXX [different manager] of this problem.

MBCT practitioner meeting minutes, Elm

Given the patchy and usually short-term nature of resource allocation, some sites reported their success in and plans for income generation, which led to opportunities to fund and grow activities where resources had been scarce:

All of the investment has been a bit sort of sideways . . . So in terms of income we’ve been able to grow things on the basis of selling training places and that’s been very successful.

Training director, line manager of mindfulness clinical lead, Oak209

It’s been looking at using mindfulness as an income generator, because there’s huge pressures in terms of savings required annually, and mindfulness is very much in demand across all spheres of health and other organisations as well. So I think there is a demand for training, so that’s what I’ve been looking at more recently.

Head of psychological therapies, line manager of mindfulness clinical lead, Pine206

There is now a budget for overheads: XXXX [local collaborator] has generated income through offering the training courses. We can now request funding for CDs etc.

MBCT development meeting minutes, Elm

Evidence and fit with practice

Mindfulness-based cognitive therapy is not an intervention that provides ‘a quick fix’ (Commissioner, Wales) and, as such, in many cases it was perceived to be at odds with the pace and pressure of current health services. MBCT also aligns with a model of care that places people as active agents in their own recovery and promotes mental health and well-being, rather than a medical model. In NICE guidance, MBCT is included as a prevention intervention delivered further on in the treatment pathway to keep people well. As such, consistent with the findings from phase 1 (see Chapter 3), sites that were implementing MBCT had adapted the inclusion criteria stated in NICE guidance because they were seeing people who were not well:

Mindfulness is more of an exit strategy so within CAMHS in XXXX [town] MBCT hybrid is used as an exit strategy for young people who’ve had CBT or other kinds of 1 : 1 and the implementation there is much stronger because there’s a better fit between mindfulness and as an exit strategy.

Teacher trainer, Oak111

Adaptation of the intervention to service and population need was a frequently used implementation strategy (see Chapter 3, Adaptation). This included, for example, services trying to fit their offer to the needs of presenting clients:

I think the main focus is secondary care but it does vary and the clinical reality of working in NHS department somewhere is that you’re meeting a mixed group and this is true of any of empirical evidence applied to clinical issues; it’s interpreted with a view to the needs of the people who are presenting, so it’s interpreted slightly broadly according to clinical need . . . you know people are well, they’ve had two or more episodes of depression, in other areas it’s a more mixed group, primary care for example and there’s also the issue of client choice as well, and again in [Bamboo] which I know we started with giving people a choice, that mindfulness if it was something they felt they would find helpful.

National NHS training provider, Bamboo102

She mentioned the criteria had changed over the years to suit the demand. When they first started the NICE guidelines’ criteria was adhered to (3 or more episodes). Then in the past 2 years it’s been an anxiety and wellbeing course. And now with self-referrals in place it more of a preventative and wellbeing course.

Observation notes, peer supervision meeting, Elm

In Birch there was an uneasy fit due to pressures to adapt MBCT to a mix of patient populations. Added to this was the reliance on an external teacher, who in this site was the sole implementer and who wanted to ensure that MBCT was used in line with NICE guidance, which did not fit with other clinicians’ perspectives and current pressures in the trust.

So we were looking at the mix of population, what was needed, because the pure three or more episodes of depression, there weren’t enough people to have a class, so it was ‘what it was going to look like on the ground’ . . . there were lots of issues around the team not particularly wanting group work and there being pressure, waiting lists and them wanting this to be around more individual people on caseloads, they didn’t see the benefit of having groups at that point. So it was a bit of a challenge with only half the team on board.

External trainer/supervisor, Birch203

Fit and local context

Where there was a good fit between the aims of the MBCT intervention (recovery, keeping people well) and the organisation’s strategy, implementation had been more successful. For example, in Oak, mindfulness aligned with the CEO’s priorities:

. . . you have to decide which horse to back, you can’t do everything. For me mindfulness, equality, diversity and human rights and a few other, well the anti-stigma work . . . they were who I decided to prioritise on.

Retired CEO and campaigner, Oak212

Furthermore, MBIs ‘tied in nicely’ (board member, Oak213) with their research strategy and theme around ‘mood anxiety and mindfulness’. In this site, there was a cadre of clinical academics who were bridging the practice research boundaries to focus on mindfulness-related research as well as practice. Pine was another site where there was a strategic focus on mindfulness and on a ‘wellness and recovery ethos’ (mission statement document, Pine), and from that focus, the subsequent alignment of other agendas including resources and research to support the MBI agenda. As such, there was a number of senior people in the organisation who were supportive of the intervention (i.e. it was a good fit with their intention and mission):

. . . we’ve been very lucky with the board, and in fact our chief executive has led breathing spaces in her leadership briefings before, and she practises mindfulness and is very keen on it. In fact a lot of the senior directors are interested in it. So like I mentioned the finance director asked me to do a session for the finance department. The director that’s involved with staff well-being is very keen on developing it. There’s also another director who’s interested in sort of marketing it. So we’ve got lots of senior people I suppose who are right at the top of the organisation who are very keen on it and I think that’s very significant.

Mindfulness lead, Oak101

The opportunity that the early implementation of IAPT offered had also been seized on by Pine:

I think we were one of the first IAPT services to run mindfulness, there may have been others but I think we were one of the first IAPT services to do it [. . .] it fits what we’ve been commissioned to deliver so let’s go for it.

IAPT clinical lead, Pine201

In contrast, IAPT had been a barrier for others because ‘the IAPT menu does not have MBCT on it’ (former mindfulness clinical lead, Elm101). However, documentary evidence from November 2015 shows some changes to IAPT in which ‘mindfulness’ interventions are in the menu of services on offer,83 but does not detail the exact nature of the intervention to be offered (i.e. whether group or individual appointment). 84

Evidence from other sites showed a lack of, or poor fit between, the service delivery model and/or strategy/priorities of the organisation and the requirements of implementing MBCT. For example, in Hazel, MBCT was not a service modality that fitted a service reorganisation aimed at reducing costs alongside a focus on pharmacology rather than psychological therapies. Similarly, in Beech a service and organisational restructuring was focused on reducing waiting lists, which did not:

. . . fit within our recovery model. [. . .] From a service management point of view, as soon as somebody is below a certain point on their questionnaires they’re recovered and therefore you don’t need to carry on offering them treatment and obviously the ideal thing with MBCT is that it’s a relapse management prevention thing, so people should be relatively well going into it, which obviously doesn’t fit at all with that model of offering therapy . . . as the service works at the moment they get paid if somebody recovers on their figures, it’s not helpful, particularly to make sure they don’t come back, from a financial point of view. So to be offering them what is an expensive form of therapy when it’s not actually going to earn them [the trust] anything?

MBCT teacher, Beech105

Strategic versus local solutions

Evidence of an organisation’s strategic investment in MBCT through training and supervision being part of the governance structure around provision was most obvious in Oak. In this site they had developed an ‘apprenticeship model’ of MBCT teacher training. In the context of ‘proper training because the trust governance spells it out’ (Oak112); implementers in this site had produced a set of publicly available governance criteria, organised nationally visible research and teaching conferences and practice days. The embedded nature of training and supervision was also obvious in an observation of a management meeting (with two research and training directors, and local collaborator) in which training was a standing agenda item. In this site, the embedding of training and supervision had been led by people with ‘passion and knowledge’:

. . . there’s something about the thoroughness and thoughtfulness that’s been put into the in-house training programme and how considered that’s been with [Oak101] and [Oak111] and [Oak112] who’ve, I suppose [Oak101] has led the training from a trust perspective but certainly they’re delivering the training . . . there’s a sense of people feeling confident in the quality of the training that they feel able to train in ways and feel safe.

Research lead, Oak101

This site through one of the leads was also well linked in with regional and national networks, including being involved in the UK network listing working party29 in the development of national standards for mindfulness-based approaches including MBCT:

I’m very involved in the UK Network Accreditation Working Party, I’m chairing it at the moment. My sense is that it needs to be held by the UK network, the accreditation process. What we do fits the good practice guidelines for people who want to train so we’re quite confident . . . So I think our training is a very high quality product within the mindfulness training world.

Teacher trainer, Oak111

In contrast to Oak’s approach and progress with embedding training in their service model, other sites had developed training organically, and without resource because of a lack of organisational buy-in. For example, in Mangrove they had piloted an internal training pathway on a ‘shoe-string’ (Mangrove102), in Hazel an implementer had ‘paid for supervision out of [their] own pocket’ (Hazel101) and in Birch at the start of their implementation journey people were ‘learning on the job’:

. . . they would have had to have done the 8-week course themselves with encouragement to keep up their own practice but in terms of the groups they would have joined a group as a participant/observer with clients before eventually co-facilitating and taking maybe a slightly lesser role with meditation practice . . . so it was a gradual thing.

MBCT teacher in NHS organisation, Birch107

In contexts where there was a lack of structure, capacity and resource there was also a challenge with access (physically and financially) to ongoing supervision and opportunities for co-facilitation (a feature of majority of training pathways or post-training guidelines, and of MBCT being adapted to fit different patient groups than those recommended in NICE guidance), which left those delivering services feeling ill-equipped:

So I did two groups but the difficulty has been having someone to run with them with really, so I haven’t done any groups since . . . I haven’t done one for a couple of years . . . the general message when I go to the special interest groups is don’t run them on your own it’s just too much and it is quite a lot on your own, to be doing every aspect of it isn’t ideal. So hence I haven’t done one since.

Clinical psychologist trained on internal pathway, Beech103

This less strategic approach to establishing and maintaining training and supervision was a function of a (mainly) bottom-up approach to establishing MBCT (see Chapter 3, Bottom up). As a consequence this had resulted in considerable personal, and often financial, investment by individuals attempting to introduce MBCT provision locally (see Implementers). All early adopters (apart from in Pine where there had been funding to initiate provision) started off with personal investment in training or supervision due to their personal interest and in the context of MBCT not being yet introduced to the NHS through NICE guidance. More embedded sites had later been met by top-down support for training pathways and supervision, which meant that the current trainees did not have to personally invest in the same way as those early adopters.

Gold standard versus good enough

Related to the findings described in Chapter 3 (see Quality of teaching and provision), there were also some tensions about maintaining the integrity of the intervention in NHS contexts that were time pressured and resource constrained. This ended up with some implementers negotiating and compromising on some elements of what was required in terms of training:

This [resourcing retreats] is a sticky point at the moment, the requirements for the best practice, so where people have to go and do retreats that can be quite a lot of time and that’s the bit where I end up negotiating with the service managers about we’ll pay for it or we’ll let people have time off and then you have to compromise with the staff to do that. It’s just unfortunately now, previously we would have funded everything but just at the moment there isn’t the money available.

IAPT clinical lead, Pine201

Arguably, the success that Oak had achieved with training and supervision was likely in part to be due to their approach in finding a middle road model by pragmatically meeting the standard of national guidance29 in the development of an affordable and timely teacher training pathway. Here they had developed what they perceived to be a quality, practice-based training provision that was fit for purpose:

4-year courses were just you know great but unfortunately unrealistically long and expensive for a lot of people. So we tried to develop something that kind of took down the middle road and met and would enable people to meet the good practice guidelines, so it was a year’s supervised training, and we put much more, it’s not actually linked to a university, it’s just our own sort of mindfulness centre training. So it’s got a much less academic kind of focus. There are some reflective pieces that people need to write. But the main emphasis is on people’s own practice. [. . .] sort of an apprenticeship model, so we get people fairly quickly into practicing leading practices in the workshops that we have and the seminar groups that we have.

Local collaborator and mindfulness clinical lead, Oak101

However, some implementers had not been prepared to compromise. For example, in Elm there was a lone implementer who was passionate about teacher training and had established an internal (to the service) training pathway, and had also started to generate income as an external training provider. As the organisation came under some scrutiny and reorganised, this person had been asked by senior management to ‘look at mindfulness provision and that it was impossible to support MBCT groups continuing with two CBT therapists providing the courses . . . we could either stop mindfulness provision or we could change what we were doing’.

I gave slightly different models but really felt that I had come into line with their needs, which was one teacher per group. So I was asked to attend a meeting . . . And the first thing they asked me was, ‘is there a light version of MBCT’, ‘is there something that’s shorter, less intensive, fewer hours and more easily provided without such stringent guidelines?. And I said well I said there’s lots of other people doing that, but I said ‘no, we’ve an NHS provider service, we provide as per the NICE guidelines and we’re working with people who have mental health problems and deserve the evidence based intervention . . . So I said I will not support the trust in delivering a light version of MBCT, so no’.

Local collaborator and mindfulness clinical lead, Elm101

In this site, MBCT was withdrawn from service delivery after we had finished data collection there.

Data show a fundamental tension with respect to the delivery of MBCT due to the links with Buddhist psychological frameworks. In an interview with a national teacher supervisor who was consulted by various implementers in the sites we visited, there was a lot of reference to the Buddhist background to MBIs. This participant expressed a belief that the delivery of mindfulness training (for patients) should be secular, but that ‘teachers need to have an understanding of the Buddhist foundations’ (Mangrove103). Furthermore, there was a clear expectation that to be a mindfulness teacher ‘you have to have an 8-week course and then I want you to practice for at least a year’ and that ‘Mindfulness supervision has to include looking at the teacher’s personal meditation practice as well as their work and their life and how well they all integrate, rather than just on the work itself’ (Mangrove103).

My concern with some of the applications I have seen so far is that they have been clear that whilst they have attended a (training) course they are not currently practising mindfulness regularly, if at all . . . Personal practice strongly supports and informs how we teach mindfulness . . . Maybe there could be an understanding that unless people can establish a reliable, regular personal practice during the course they will not be encouraged to teach through their work role until this is so?

Documents, e-mail from trainer and supervisor to service manager, Birch

Views about what mindfulness is, and what it should entail, had been challenging to implementation because of varying views about integrity and quality within the context of a resource constrained NHS, as this participant articulated:

. . . there’s an issue there in terms of challenge is about what’s the culture of mindfulness within the organisation, you know I think people can brand it, misunderstand it as just another form of relaxation treatment or something like that and ensuring the quality of the input is an issue . . . there is a certain sort of uniqueness to the adventure of mindfulness which is difficult to then quality assure. Speaking as somebody who’s been in involved in commissioning it as it were one of the things I have to marry up here is the gold standard mindfulness training that our local centre provides, versus working out the politics of financing all of that and for us to be happy with an imperfect but nevertheless good enough level of provision . . . reflects something about the sort of politics of interfacing with independent training providers and the sense of this being a very popular growing area of practice and presumably that must bring a certain market dynamic to the provision which might mean that what feels like pretty penniless NHS organisations are sort of struggling.

Head of psychological therapies, Birch206

Scope existing provision of mindfulness-based cognitive therapy in the health service across England, Northern Ireland, Scotland and Wales

The first phase of our work involved 68 interviews with a range of stakeholders (MBCT teachers, managers, clinicians, commissioners, referrers and service users) in 40 NHS sites across all four UK nations. This covered primary and secondary care, and a range of different health and mental health services. Although the work was not designed to be a fully representative definitive survey, nonetheless a picture emerges suggesting that the provision of MBCT is becoming more widely available but that the access and format of MBCT provision across the NHS remains variable, even within the same region and site. NHS services have typically adapted MBCT to their context using a hybrid of MBCT/MBSR; indeed, 34 out of the 40 sites offered mindfulness-based services that did not fully match the recommendations in NICE guidance, including people who are currently depressed and those who have other physical/mental health conditions.

The integration of MBCT into care pathways was also highly variable, with some offering it at the end of the pathway for those who have received other treatments, others offering it to those on the waiting list for one-to-one therapy and others offering as an opt in/direct referral option within their service.

Since we started the work, from 2015 the NHS IAPT services workforce census started to collect data on numbers of MBCT trained teachers. The 2015 census reports that 256 IAPT staff self-identify as trained to teach MBCT, comprising 93% of whole-time equivalent staff and 2% of the IAPT workforce. Reporting by the CCG suggests that > 60% of CCGs had no trained MBCT staff. 88 The report points to the unreliability of these data, but it does highlight that less than half of the English NHS has no therapists trained to deliver MBCT in primary care IAPT services.

Although there appears to have been progress since our feasibility study,64 the accessibility of MBCT continues to be both limited and variable.

Develop an understanding of the perceived benefits and costs of embedding MBCT in mental health services. Explore barriers and facilitators that have prevented or enabled services to deliver MBCT. Articulate the critical success factors for enhanced accessibility and the routine and successful use of MBCT as recommended by National Institute for Health and Care Excellence

In the following sections we use the PARIHS framework6 elements to describe our findings and then give further consideration to our framework (see Figure 21) that helps to explain how MBCT becomes sustainably embedded in NHS services.