Factors Influencing National Implementation of Online Computer-aided Cognitive Behaviour Therapy in Primary Care Trusts across England
: A Mixed-Methods Study

Student thesis: Doctoral ThesisDoctor of Philosophy


Many Primary Care Trusts (PCTs) across England adopted NICE-recommended Computer-aided CBT (CCBT) FearFighter™ (FF) for panic/phobia. FFwas clinically and cost-effective in open and randomised controlled trials, but factors affecting its national implementation in the NHS deserve investigation. This mixed-methods study examines factors influencing patients’ uptake, completion rates and clinical improvement with FF at 3 levels: i) PCT (macro); ii) Service Provider (meso); iii) Supporter (micro). Thirty PCTs participated (out of 61 which purchased FF}, totalling 37 teams. Staff from 30 teams were interviewed, as were 6 Nurse Advisors (NAs; company staff supporting FFs implementation). All interviews were analysed with Greenhalgh et al’s (2005) model for the diffusion of innovations in health care organisations. The NAs reported activity (training, workshops, surgery visits), and levels of involvement for each PCT. All 37 Leads reported screening/assessment procedures, other interventions offered, and barriers and boosters. Across the 37 teams, 171 supporters reported length and type of support offered to FF patients, training details, treatment preferences, and opinions about CCBT. Anonymised outcome data for 3,528 FFNHS patients were extracted. Three factors (past experience of the Lead, number of self-help books available and length of assessment) explained 76% of the variance in FPs uptake. Availability of specific self-help books reduced FF completion rates. Phone screening associated negatively with FF clinical improvement. At Supporter level, past experience of CCBT associated with less usage of FF. A flexible and adaptive PCT structure (as rated by the NAs) predicted higher FF uptake. The qualitative analysis revealed that alternative interventions, Supporters’ attitudes and organisational issues were the 3 main barriers to implementation. Like any innovation, CCBT faces obstacles when implemented in routine care.
Attention is needed to how CCBT fits with existing interventions and to the background and attitudes of staff delivering it.
Date of Award1 Jan 2013
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorAndre Tylee (Supervisor)

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