The Scottish Government’s Mental Health Strategy 2017–2027 aims to improve access to appropriate support and effective care for all, while the Digital Health and Care Strategy lays out the role of digital technologies in contributing to this aim. These strategies set out a commitment to increase access to evidence-based digital mental health treatments, products and services.
Togetherall is targeted at a population level, offering psychosocial support, educational and self-care intervention including peer interaction with clinical moderation. Togetherall is a multi-component intervention targeted at providing a broad range of support to a wide spectrum of individuals with mild to moderate mental health and well-being concerns. As such, establishing evidence for its overall effectiveness is challenging.
The platform has the potential to reduce some aspects of inequalities through offering access in areas that cannot be reached by existing services and providing support for those who may not necessarily be comfortable seeking physical help through existing conventional services. As with any digital health intervention, it may increase inequalities for those with no or limited digital access or capabilities.
Togetherall can be used as interim support while someone is waiting for a clinic-based service.
Togetherall is a digital health technology that functions as an intervention, as it is designed to provide guidance and affect behaviour change. The evidence for Togetherall has been considered in relation to tier C of the NICE Evidence standards framework (ESF) for digital technologies.
In-keeping with the NICE ESF, two randomised controlled trials (RCTs) were identified, one conducted in Canada and the other in the UK aimed to assess the clinical effectiveness of Togetherall:
- statistically, but not clinically, significant improvements in mental health recovery were noted in a Canadian population with symptoms severe enough that they had been referred for specialised mental health support, who received immediate access to Togetherall compared with a delayed access control group
- in the UK study, low adherence meant the study was underpowered to detect a difference, and in a population with mild to moderate symptoms, no statistically or clinically significant differences in self-rated mental well-being scores were observed for Togetherall compared with an online information only platform.
There is an existing evidence base to support the mechanisms of action of the components of Togetherall, which demonstrates the application of appropriate behaviour change techniques within the platform.
No concerns around technical assurance, and data security, protection and privacy were identified using the NHS England Digital Technology Assessment Criteria as part of the assessment of Togetherall.
Togetherall has been assessed in relation to clinical, data and usability standards by ORCHA (Organisation for the Review of Care and Health Applications) and found to be a viable quality assured application, achieving an overall score of 87 %. ORCHA deem 65 % to indicate satisfactory baseline compliance.
Several published evaluations of implementation and case studies are available to show the relevance of Togetherall to current care pathways in the UK health and care system. These reports provide an indication of uptake and interest among different population groups. Anecdotal evidence from Scottish local authorities on the benefits of Togetherall is available, but no studies or evaluations have been completed.
Overall usage of the platform was low across all studies. How usage may vary from studies to real world settings is not known and what constitutes appropriate usage is unclear. Promotion of the platform is likely to increase uptake. Usage may also vary according to aspects such as user perceived benefits, initial level of well-being and early experiences of the platform.
Togetherall and their technical development team work with users to ensure that the platform meets their user or technical needs. Outstanding accessibility concerns are listed on the Togetherall website along with means of addressing these. No specialist knowledge is considered necessary by Togetherall to use the platform.
Research studies do not specifically cover the safety of the platform, but do not note any increased risks of harms associated with its use. Togetherall has continuous professional moderation in place to monitor user posts and interactions and escalate concerns to their senior clinical team as required.
No cost-effectiveness analyses of Togetherall were identified. Some limited costing data are available which illustrate potential cost savings when comparing direct costs of Togetherall and traditional therapy or care avoided.
In summary, the combination of technical assessments (including DTAC and ORCHA) providing verification of quality assurance, and limited evidence from outcomes effectiveness studies suggests that Togetherall can play a role in supplementing conventional mental health services. Research into the effectiveness of Togetherall is ongoing, including in Scotland, and it will be important to continue to collect evidence to demonstrate the impact of Togetherall on clinical outcomes and patient benefits, and to establish the acceptability of Togetherall with users.
What were we asked to look at
What is the added value for individuals in Scotland and NHSScotland of providing access to Togetherall (formerly Big White Wall), an online mental health and well-being moderated support platform, as an option for all individuals in Scotland seeking such support, in addition to currently available care?
Why is this important
Togetherall is an anonymous professionally moderated community to connect with others, peer support - share thoughts and experiences, express feelings, undertake courses, goal setting and progress monitoring, online courses, journaling, access to self-help and information, professional clinical ‘guides’ [in some areas there is access to F2F therapy online with therapists from Togetherall or from the NHS service]