The typical participant in a randomised trial of online therapy for dementia carers was a woman of about 62, and four in five of the 496 people enrolled were the sole primary carer.  They were recruited because they reported anxiety, and the intervention group was offered eight web-based sessions of acceptance and commitment therapy, each unlocking five days after the last, with written feedback from a supporting therapist. Twelve weeks on, their scores on the standard seven-item anxiety scale were 2.6 points lower than those of carers receiving usual care alone, a moderate effect that persisted in smaller form at 24 weeks. Some 77 per cent of the intervention group achieved a clinically meaningful fall in anxiety, against 52 per cent of the comparison group. 

The programme ran through 20 NHS services in England. Earlier trials of acceptance-based therapy for dementia carers were small, the largest enrolling 92 people, and the cognitive behavioural therapy that dominates the literature has shown benefit for depression without a clear effect on anxiety. 

Current NICE dementia guidance, as the trial authors note, does not address carer anxiety and applies general depression guidance. Here a gap in national guidance has met research funded to close it, through an NIHR programme that exists to tell the NHS what is worth buying. The delivery model deserves as much attention as the effect size of 65 therapists, none held a formal qualification in psychological therapy and 19 held any clinical qualification, such as nursing or occupational therapy. 

All completed two days of training and were offered fortnightly group supervision. Feasibility work put maximum therapist input at 3.6 hours per participant, and completion was high, with 79 per cent finishing at least six of the eight sessions. For services short of accredited therapists, that is the feature which makes scale plausible, since support workers and assistant psychologists can supply it. Whether it will be bought is a separate matter. 

Carers sit in the seam between the NHS and local government, and the anxiety of a wife in her sixties looking after her husband rarely registers on any dashboard an integrated care board answers to. The authors call for sustainable centralised funding models, which concedes that the arrangement used in the trial, with delivery and clinical oversight coordinated centrally, has no obvious owner in a health service organised around local commissioning. A single national purchaser could buy it once. 

Integrated care boards deciding separately would each need a business case, and each would reasonably ask for the cost-utility analysis, which the trial paper reports elsewhere. The evidence has limits that any business case will have to carry. Eight per cent of participants came from non-White ethnic groups, and the authors caution that remote delivery alone may not ensure equitable reach. 

Follow-up ended at 24 weeks, and the comparator was usual care, which leaves open whether another therapy would have done as well. The timing sharpens the question. The Casey Commission, whose remit includes NHS funding at the interface with social care, is due to publish its first-phase report later this year, and its stated direction favours prevention.

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