The National Institute of Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) recommend guided self-help (GSH) and computerised cognitive behavioural therapy (cCBT) for the treatment of depression , anxiety  and bulimia nervosa . In Scotland, the SIGN guidelines are especially influential and again recommend routine use of cCBT for depression .
The main benefit of cCBT is that it reliably delivers cognitive behavioural therapy (CBT) content in a consistent way that adheres to the CBT model, and is suited to use as part of a stepped care model. Stepped care is a flexible model of healthcare delivery in which patients can begin their treatment with a low intensity intervention requiring only limited practitioner support such as guided self-help. These are offered to those with non complex presentations and patients only ‘step up’ to longer (high intensity) specialist face to face therapy if improvements are not seen after a given time . Delivering cCBT as part of a stepped care approach increases service capacity and provides an evidence-based intervention for those individuals with mild to moderately severe depression ,for example, who are otherwise least likely to receive access to specialist CBT .
Patients can work through the computerised packages (online or in CD-ROM format) independently and receive minimal input from the clinician. Short support sessions are key to maximising outcomes, especially for those with depression  and can be provided by a range of healthcare professionals and volunteers via telephone, email, text, instant messenger and Skype; or in brief face to face meetings. cCBT is a valuable alternative to self-help books (bibliotherapy) as it provides another way of accessing help that brings together multiple ways of learning - audio and video clips plus a level of interactivity. Overall cCBT has similar clinical effects as bibliotherapy . User choice is one of the key factors affecting use of cCBT, a treatment option that may be particularly appealing to young people . An argument for offering online cCBT is that users can access online resources at a time and place (e.g. home) they find convenient, thus fitting with busy or complex lives.
Scotland is one of the member nations of the United Kingdom with a population of 5.2 million . There are many rural settlements in Scotland, however around 70% of the population live in the central lowlands in cities such as Glasgow and Edinburgh and surrounding towns. Scotland has a devolved government with control over some key policy areas including health care. NHS health boards are responsible for health policy implementation based on the needs of their respective populations and also provide management and performance monitoring within the 14 regions of the NHS in Scotland. Health boards often work with local councils and voluntary organisations in order to provide the care to patients within their region. The largest health board in Scotland is NHS Greater Glasgow and Clyde which serves 1.2 million people and employs in excess of 40, 000 members of staff across locations including 36 hospitals, 25 mental health resource centres and 298 GP surgeries. In contrast, smaller health board such as Orkney and Shetland serve significantly smaller populations of around 20,000.
There has been a commitment from the Scottish government and health policy makers to improve health and communication technologies within the National Health Service (NHS) in Scotland . The government also aims to increase access to psychological therapies. This includes a specific target to reduce waiting lists for psychology services to 18 weeks by 2014 . The potential for cCBT to reduce waiting lists for specialist therapy is demonstrated in a study of an online CBT package carried out by Learmonth, Trosh, Rai, Sewell and Cavanagh  in which only 30% of 6000 patients needed face to face therapy following use of the online intervention. cCBT is one of a range of therapies offered within the NHS and there is clearly a potential for online guided self-help interventions for common mental health problems to help to reduce therapist input and alleviate the burden on services. This approach could potentially be applied nationally by providing access to cCBT within the NHS in Scotland, thus potentially decreasing the time that individuals have to wait to receive access to an evidence based psychological treatment.
A number of issues would need to be addressed in order to provide such access to online treatment. An argument for cCBT delivered online is that patients can access the resource at a time and place convenient to them, with the assumption this will often be at home. However, the recent 2009–2010 Scottish Household Survey found that at the end of 2010, 30% of Scottish households did not have home internet access. Additionally, the survey results showed that those in deprived areas are less likely to have internet access at home. The impact of deprivation and income on internet access is clearly seen in the fact that 97% of households with annual income of over £40,000 have home internet access compared to just 35% of households with annual income of £6,001-£10,000 . If health boards fail to provide access to dedicated patient computers in the various NHS buildings then these poorer individuals may miss the opportunity to engage with cCBT approaches if they were only offered via online access. This highlights the impact of digital exclusion on health and wellbeing. Other options such as using internet cafes or public libraries may not be attractive for reasons of access, privacy and stigma. In delivering cCBT it is therefore important for services to offer the option of access via existing National Health Service (NHS) facilities.
Currently there is no national policy in Scotland regarding the use of cCBT and therefore decisions are often made at a local level. Therefore access to cCBT varies across the 14 health boards in Scotland. The aim of the current study was to assess the extent to which the NHS in Scotland is providing routine access for patients to utilise cCBT. We therefore surveyed all 14 health boards in Scotland to examine access to cCBT and to better understand how health service infrastructure and information technology (IT) regulations impact on its use.