Open Access Highly Accessed Open Badges Research

Delivering stepped care: an analysis of implementation in routine practice

David A Richards1*, Peter Bower2, Christina Pagel3, Alice Weaver1, Martin Utley3, John Cape4, Steve Pilling5, Karina Lovell6, Simon Gilbody7, Judy Leibowitz4, Lilian Owens8, Roger Paxton9, Sue Hennessy7, Angela Simpson7, Steve Gallivan3, David Tomson10 and Christos Vasilakis3

Author Affiliations

1 Mood Disorders Centre, Washington Singer Building, University of Exeter, Exeter, EX4 4QG, UK

2 Health Sciences Research Group, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, UK

3 Clinical Operational Research Unit, University College London, Gower Street, London WC1E 6BT, UK

4 Camden and Islington NHS Foundation Trust, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PE, UK

5 Centre for Outcomes Research and Effectiveness, University College London, 3rd floor, 1-19 Torrington Place, London, WC1E 7HB, UK

6 School of Nursing, Midwifery and Social Work, University of Manchester, University Place, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK

7 Department of Health Sciences, University of York, University Road, Heslington, YORK, YO10 5DD, UK

8 'No Panic', 93 Brands Farm Way, Telford, Shropshire, TF3 2JQ, UK

9 Newcastle, North Tyneside and Northumberland Mental Health Trust, Modular Building, St Nicholas Hospital, Jubilee Road, Newcastle upon Tyne, NE3 3XT, UK

10 Collingwood Surgery North Shields, Hawkeys Lane, North Shields, NE65XH, UK

For all author emails, please log on.

Implementation Science 2012, 7:3  doi:10.1186/1748-5908-7-3

Published: 16 January 2012



In the United Kingdom, clinical guidelines recommend that services for depression and anxiety should be structured around a stepped care model, where patients receive treatment at different 'steps,' with the intensity of treatment (i.e., the amount and type) increasing at each step if they fail to benefit at previous steps. There are very limited data available on the implementation of this model, particularly on the intensity of psychological treatment at each step. Our objective was to describe patient pathways through stepped care services and the impact of this on patient flow and management.


We recorded service design features of four National Health Service sites implementing stepped care (e.g., the types of treatments available and their links with other treatments), together with the actual treatments received by individual patients and their transitions between different treatment steps. We computed the proportions of patients accessing, receiving, and transiting between the various steps and mapped these proportions visually to illustrate patient movement.


We collected throughput data on 7,698 patients referred. Patient pathways were highly complex and very variable within and between sites. The ratio of low (e.g., self-help) to high-intensity (e.g., cognitive behaviour therapy) treatments delivered varied between sites from 22:1, through 2.1:1, 1.4:1 to 0.5:1. The numbers of patients allocated directly to high-intensity treatment varied from 3% to 45%. Rates of stepping up from low-intensity treatment to high-intensity treatment were less than 10%.


When services attempt to implement the recommendation for stepped care in the National Institute for Health and Clinical Excellence guidelines, there were significant differences in implementation and consequent high levels of variation in patient pathways. Evaluations driven by the principles of implementation science (such as targeted planning, defined implementation strategies, and clear activity specification around service organisation) are required to improve evidence on the most effective, efficient, and acceptable stepped care systems.