Feature Content, Interview

Interview Series: Heather Cook, UK Director of Big Health on how digital can meet rising mental health needs

Following HTN’s first Digital Primary Care event of 2022, we decided to sit down with one of our sponsors to delve further into how digital can meet rising mental health needs.

We spoke with Big Health, a company which specialises in non-drug digital therapeutics for insomnia and anxiety through its Sleepio and Daylight apps.

Heather Cook, the company’s Interim UK Director, took time to chat about Big Health’s ethos, learnings from the pandemic, the benefits of digital therapeutics for primary care providers, and how Scotland is embracing digital health implementations at a population health level…

Hi Heather, tell us about your career background and how you became a health tech leader?

I joined Big Health relatively recently – at the end of September last year – but I’ve come from a digital mental health background. Previously I have worked as a management consultant in major, public sector-type transformation programmes, this was at a time when digital started to become a key feature of public sector improvement.

About nine years ago, I left the consulting world behind and joined a start-up called Brain in Hand, which blended human support with digital support to help people with autism to be more independent. Although it’s a very different subject area to Big Health, the challenges of adopting anything new into traditional care pathways are very similar.

The early days of my career in digital health were during a time when a paradigm shift was taking place with digital becoming an acceptable adjunct or alternative to in-person care.

I truly, and maybe naively, believed that because a patient said that a digital solution had transformed their life, then a commissioner would want to pay for it. I’ve learnt the hard way that having gold-standard evidence – as well as a compelling, scalable model – is the key to unlocking the potential of digital.

I joined Big Health last year and I’ve been leading the UK team ever since. I’m so excited by what Big Health is delivering in the market, in terms of our standard of evidence and quantification, and in the gains that we can offer to both the system and the workforce.

What support can Big Health offer to the NHS workforce?

We’re a digital therapeutics company and we focus on two areas: insomnia and mental health. What we mean by digital therapeutics is that we take evidence-based, non-drug therapies – which includes CBT [cognitive behavioural therapy] – and fully automate them. We turn non-drug treatments into products that can be digitised. This means that we can provide mental health treatments without the need for clinicians or coaches. We empower patients to take control themselves and self-manage their conditions.

This approach means we can deliver therapy at scale, as consistently as drugs are able to be scaled. It also provides inclusivity that allows for any patient, wherever they are in the UK, to access support when they need it.

In terms of the impact of the pandemic, we think there are significant opportunities for our digital therapies. We also realise that the foundations for our digital therapeutics products comes from having a gold-standard evidence base, and from thinking about innovative ways that reimbursement could happen at a national scale, for us to expand.

Our view is that, over the next five years, digital therapeutics will be scaling to be the size of pharmaceutical businesses, very rapidly. We all know [the phrase] ‘big pharma’ – but there’s going to be ‘big DTx’ [digital therapeutics], as well. Providing behavioral interventions, including CBT, that are efficient, effective, and can be delivered alongside medications to expand access to care is so important for mental health – even before the pandemic, it had seemed to be the ‘Cinderella service’ of healthcare.

How will the expansion of digital therapies impact primary care?

In primary care, GPs are under so much pressure to help with an increase in numbers, almost beyond imagination, of people living with mental health conditions. In August 2021, 1.6 million people were on a waiting list to access mental health support.

The NHS has been great and, for a long time, recognised that CBT should be the first line of treatment for patients with many of the conditions that we support. But we still have the resource constraints – the front door for primary care has a long queue outside it.

Unfortunately, what we’ve seen is that the only access to treatment for most people right now is medication. Because of the lack of therapists it has been the only option. It’s quick and easy to prescribe – with the majority prescribed in a primary care setting.

There are clinical guidelines that say that all patients should have a non-drug option offered to them first, as a first line treatment for mental health. But it can be hard to do so. That’s where our digital therapeutics come into play – they provide access to guideline recommended care, for the first time, at-scale.

We’re at this unique moment of opportunity in the sector, as mental health is now a top priority in the NHS Long Term Plan, around improving access to care and treatment. Patients are now recognising, more than ever, where mental health problems are impacting their lives.

For us, there are shortcomings of these more traditional models of care – human delivered therapy, even when enabled by technology. We don’t believe these models can cope with this ‘tsunami’ of demand, long waiting lists, workforce shortages and stressed workers, as well as rising costs. Digital therapeutics like ours have a real opportunity to help by not only improving outcomes for our health and care system but for patients, with at least 70 per cent of ours seeing significant clinical improvement with their conditions after using our therapeutics.

Where does Big Health fit into the digital landscape?

In terms of patient groups that we feel our therapeutics are most beneficial for…it’s a tiered system. You have wellness projects at the bottom of the tier – the mindfulness or meditation apps – and you can think of those as the ‘vitamins’ for your health. You can take vitamins, but if you have a real health problem, you’re not going to use a vitamin. We are in the middle tier – our digital therapeutics are designed to be a digital medicine.

We can say that because our clinical evidence – over 64 studies and 13 RCTs [randomised control trials] – demonstrates that our digital therapeutics are safe and effective treatments for these conditions.

Thinking more generally about digital therapeutics as a discipline in the digital health arena, the industry is innovating rapidly right now. There’s huge potential to address many of the inclusivity challenges that the NHS are facing, particularly around increasing accessibility for patients and citizens.

This is about providing evidenced based treatment options for everyone in need. They are a fabulous way of automating treatment for everyone. But it must start with the gold-standard evidence.

We’ve been around for over a decade and our founder is Professor Colin Espie, an Oxford Professor of sleep medicine and world-renowned clinical psychologist. He has been focused on evidence generation from the beginning and strongly believes in the importance of validating digital solutions with gold-standard clinical evidence before ever going to market.

That rigour is so important to the credibility of your solution and in helping a system to innovate and adapt to new ways of working.

Do you have any case studies to share – what about your work in Scotland?

During the pandemic, back in April 2020, we offered our digital therapeutics – Sleepio and Daylight – to all staff in the NHS in Scotland, because mental health is not just a patient problem. We’re all human beings and we know the types of pressures that the workforce faced during those horrific early days in the pandemic.

A healthcare worker used them and was so impressed with the difference it made in their life that they made a case to help make them available to anybody who needed them. Eventually, it was presented to NHS Scotland and the Scottish government.

Our digital therapeutics were first used in April and by October 2020 they were commissioned by NHS Scotland – with five health boards piloting their use amongst local populations. The roll-out was successful, with 70 per cent of patients in Scotland, who were using Big Health digital therapeutics, experiencing a significant improvement in anxiety symptoms and gaining an extra seven hours of sleep per week.

In September 2021, after evaluating them, Scotland made digital therapeutics available at a population level. We’re so proud that every adult in Scotland – 5 million people – now have access to our therapeutics. I was looking at a map of adoption yesterday and we’re in Shetland and Orkney, and in the Highlands and Islands, so the coverage and take-up has been amazing. Within a week of adoption, over 1,000 patients had gone into treatment.

We designed our system to be activated by patients and it doesn’t have to be prescribed only by a healthcare professional. If it was only available this way, we’d have those same issues with appointments.

Instead, in Scotland, anybody can refer themselves onto the programme – we have a few questionnaires that will triage and assess your suitability. It means scalability is a reality because patients are triaging themselves and taking control of their mental health condition. All the research shows that if you take responsibility yourself, you’re more likely to achieve a better outcome. This duality of distribution is critical.

We are mindful of the skills gap out there but, fortunately, we have a really ‘low-lift’ model to implement – it takes practically no time for a system to start using digital therapeutics.

I believe Scotland has one of the most pioneering approaches to mental health in the world. It has such an opportunity now to completely transform the mental health of local communities, and to address that mental health crisis at scale.

And finally, how can Big Health’s digital therapeutics help address health equity and ‘levelling up’?

It’s about being able to get treatment anytime, anywhere, any place. You don’t need to be wedded to a geographical location. The solutions are digital but only require access to a browser – there isn’t any difficult-to-use technology or complex interoperability. It’s accessible.

The whole digital agenda, even when I started out nine years ago, had issues around availability of computers, software, and phones. But [now] our target group usually has at least one device or way of accessing treatment.

We can access ‘hard to reach’ patient groups and those who may be reluctant to enter the health system, as well as people who may be unable to recognise in front of a health professional that they have a mental health issue. Patients can assess that themselves and we trust them to make good decisions about their own health. You don’t need someone else to agree with your suspicions that you are living with anxiety or sleep issues.

It also creates room in primary care pathways – if we can stem the tide of people and help to reduce waiting lists, then it creates more capacity in the system for healthcare professionals to see patients for whom digital therapeutics aren’t an option.

To find out more, visit https://www.bighealth.co.uk/lp/primarycare/.



* https://www.bighealth.co.uk/research/

* https://www.nhsinform.scot/illnesses-and-conditions/mental-health/insomnia

* https://pubmed.ncbi.nlm.nih.gov/32725848/

* https://www.bighealth.com/news/scotland-becomes-first-country-in-the-world-to-make-digital-therapeutics-for-anxiety-and-insomnia-available-nationally/