One in six adults in London will experience mental ill health in any week but almost two-thirds of those in need are not accessing support services. If we are to make London the healthiest

city in the world, we need to support people with anxiety, depression and other conditions in new ways — including through online self-assessment. This is where the Good Thinking digital

mental well-being service (https://www.good-thinking.uk/) plays a vital role. The first phase of setting up the service involved detailed discovery work to test our belief that some

Londoners want alternatives to traditional services when seeking mental health support. We also understood that many Londoners feel ‘time poor’ and that any alternative should embrace the

other words, help should be literally at hand. SAFETY BY DESIGN But our goal was not just to offer effective support; it should also be safe. After many years of working in digital health

and with UKCIS (the UK Government’s advisory body for online safety and security), I recognised three principles for digital health: 1. Individuals with every level of need may access the

service, including those in need of urgent support. 2. Those seeking help for a mental health concern may be struggling with other issues that contribute to it, such as a physical health

problem, an abusive relationship or financial stresses. 3. Further information about the problem would be required and systems must be in place to ask for that information — it cannot be

shared naturally, as it could be offline. Whatever the nature of the problem and whatever the level of need (including if someone is in crisis), it should be possible to get advice on what

to do next. This presented us with a challenge: How do we progress the development of our end-to-end digital service using the principles of ‘safety by design’? After reviewing the available

symptom checkers and decision aids, we chose to work with Doctorlink whose algorithms had been thoroughly reviewed and tested in clinical settings for over a decade. We then set about

creating a bespoke algorithm for those with sleep problems. The logic here was that sleep problems are common and distressing but we cannot assume depression or anxiety are the most likely

causes — sleep apnoea is a common cause of sleep problems, for example. The Good Thinking Self-Assessment tool asks an individual questions about all relevant areas of their life (e.g. shift

work), physical health (e.g. chronic pain) and mental health (e.g. stress at work). At the conclusion of the assessment they could receive up to 1,700 pieces of advice, relevant to their

situation. It’s reassuring that we can address the sheer breadth of what causes sleep problems in a manner that perhaps only GPs can. When you seek specialist help, there’s always a risk

that some areas are relatively neglected. So, in addition to information about mental health and free, high-quality apps to help Londoners improve their mental health, there is also a safety

net on Good Thinking — a self-assessment tool for that rare individual who needs help to understand their problem better. Well, that was the plan. MOVE FAST AND BREAK THINGS The famous

Facebook mantra “Move fast and break things” fits very well with the agile nature of our project. Yet we underestimated that some of the things we would break would be our own ideas about

the service and what was important within it. Very soon after launch, Self- Assessment became the most popular resource on Good Thinking. That was unexpected and we then had to understand

whether or not this was even a good thing. Could there be unintended consequences? Fortunately, we were able to monitor these concerns and test the Self-Assessment tool which has now

developed beyond the sleep algorithm. You can now directly access self-assessment for anxiety, low mood and stress too and we want to expand the choices further. But why were Londoners so

keen on Self-Assessment? In retrospect, I think we were witnessing a revolution in health and some further discovery work helped us to understand the processes at work. We have recently been

talking to young people about the obstacles they might face in accessing mental health support. One of the most poignant issues that has emerged was that they are often unsure whether their

problem is “bad enough” for them to deserve support. In mental health, it is common to feel bad about feeling bad and individuals often feel someone else deserves the help more. When you

add in the frequent media messages about overstretched and struggling health services, it is perhaps not surprising that some wait until they are very ill, or perhaps in crisis, before they

seek help. It should not be that way. People also have to struggle with the stress of information overload, even when it comes to their health. For all of the advice that might be helpful

from a health peer in an online community, there will be dissenting voices suggesting something else. A Google search does not spare you from commercial interests when it comes to your

health or from those that have spread misinformation. So an individual may not be sure if they deserve help and, even if they are confident about seeking it, the range of information and

advice is often overwhelming. The uncertainty as to whether you deserve help can be paralysing. It’s like sitting in a waiting room, feeling that a health problem has now improved and

worrying that you’re about to waste a doctor’s time. THE FREEDOM TO EXPLORE Self-assessment is empowering. It asks for information and gives you clarity followed by a nudge about what to do

next. With the Good Thinking Self-Assessment tool, you will always get some advice on how you can improve your mental health. The computer never says ‘no’. The process helps you understand

yourself better and what you need — it leads to good thinking. But there is something even more important that is making self-assessment such a revolution. It relates to the possibilities of

exploring and learning, which can enrich how we make use of health services. To understand this, it’s useful to go back a few decades when a Canadian Psychologist, Donald Hebb, discovered

that when we are free to explore, learn, even play, our brains develop better, we can solve problems more easily, and have healthier and longer lives. He described the situation of having

opportunities to roam and learn as one of an enriched environment. When we are restricted, there can be negative health consequences. The neuroscientist Susan Greenfield describes how an

unboundaried and enriched environment can have a hugely powerful and positive impact: “More formal studies have shown just how powerful a factor the environment can be, when it is

stimulating and novel and invites exploration…This type of stimulating environment, where there is no fixed task to perform but which nonetheless generates different types of experience, can

have a surprising impact even when destiny seems otherwise to be determined strongly by genes.” (“Mind Change”, Greenfield 2013) How often in health settings are we free to roam and

explore? There is usually barely the time for a decision to be reached and curiosity and choice are often rare luxuries for both clinician and service user. Of course, there are occasions

when immediate action is required (a health crisis, for example), but freedom, both in terms of time and choice, would be fantastically helpful in other situations. HELPING 250,000 LONDONERS

Here at Good Thinking, we’re working hard to provide an enriched health environment that can be trusted to support an individual explore a mental health issue and reach some understanding —

at a pace, at a time and in a place that is right for them. This may be at 3am on a weekday or on a Sunday afternoon. It may be for a 57-year-old who can’t sleep or a 21-year-old

experiencing exam stress. With the launch of Good Thinking in November 2017, London became the first global city to deliver a city-wide digital mental wellbeing service. Since then, it has

helped more than a quarter of a million Londoners and many have used the Self-Assessment tool. On the service, there is no judgement over what or how much help is needed — you can just

explore what you need for free. What started out as a safety net has become a doorway out of the limitations of our health services. Self-assessment is not just empowering, it is liberating.

GOOD THINKING: HTTPS://WWW.GOOD-THINKING.UK/