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The IAPT (Improving Access to Psychological Therapies) programme has recently had its tenth anniversary and there is much to celebrate. It now helps almost a million people with anxiety and depression each year and plans are afoot to reach 1.5 million by 2021.
This seems like good news for patients with mental health problems.
But there’s a more complex reality to IAPT, masked by these impressive figures, that raises important questions about how scarce mental health funding is spent on psychological therapies.
The planned expansion of IAPT requires thousands of extra therapists to be employed in the NHS, costing our 200 or so CCGs (clinical commissioning groups) around £1m to £2m each.
Some CCGs have received one-off funding but are expected to pay for the expansion themselves once this runs out. How can they afford this? Well, NHS England has stated that, by extending IAPT to patients with long-term conditions and medically unexplained symptoms, ‘significant savings’ will be released, making the services ‘fully sustainable within 12 months’.
So savings will fund the expansion. Or so we’ve been told. It’s an ambition reminiscent of ‘psychiatric liaison services’, which were expected to save £4 for every £1 invested.
In reality, despite the evidence, psychiatric liaison savings proved tricky to identify, and even harder to extract from acute trusts.
Furthermore, IAPT was created for people with fairly straightforward, mild to moderate common health problems. However, arguably, the biggest savings can be made by helping those with more complex and severe problems, who are admitted to hospital frequently. Expanding IAPT to reach this group is problematic within its current framework, which sets limits on the kind of therapy used, the number of sessions offered and includes recovery targets that don’t tend to suit more complex patients.
All this casts doubt on whether CCGs can realistically fund the expansion through savings, which the service itself generates. So what other funding options are there?
In theory, CCGs are supposed to be raising mental health spending, in line with acute spend increases. But there is evidence that many CCGs are not doing this.
There are also other draws on mental health growth money, like funding crisis services. Then there’s a proposed cut in funding of IAPT trainee placement salaries, a substantial extra cost to IAPT, just to stand still.
All this may leave mental health commissioners little choice but to fund an expansion in IAPT by transferring funds from other mental health investment areas - most of which are connected to more severe mental health problems.
This raises an obvious question about social inequality.
Patients with severe mental health problems tend to have lower incomes than those in the mild to moderate range, who can access IAPT. Furthermore, funding for specialist psychological services for patients with more severe problems has for some time played second fiddle to IAPT funding. Waiting times tend to be much longer than IAPT with year-long waits being fairly typical. Despite this, many services show good outcomes for admission avoidance.
But as the IAPT spotlight continues to shine on mild to moderate conditions, the funding scales can only tip further away from therapies for patients with more serious ones.
None of this takes away from IAPT’s achievements over the past decade. IAPT has delivered the world’s largest programme of publicly funded psychological therapy. It’s rigorously monitored and easily accessible. However, surely it’s now time for psychological therapies for those with more severe problems to share both the rigour of IAPT reporting and also some of the investment.
This could happen by adding another step for more complex and severe patients to the IAPT framework. This step could have its own separately reported measurements, allowing: longer treatments, a broader range of therapy and therapy qualifications, and more realistic outcome measures such as ‘reliable improvement’ rather than ‘recovery’.
If we don’t something along these lines, then we risk diverting resources from severe and complex patients to mild to moderate patients with all the issues of social inequality this entails.
Dan Burningham is mental health programme director at City and Hackney Clinical Commissioning Group
Read more about the impact of treatment delays
This is a great piece and raises fundamental questions about where we are going with IAPT. Mental health chief Claire Murdoch admits IAPT is no panacea, but it feels like for some time now people with severe mental illness - the ones psychiatrists treat - have been losing out to those with mild to moderate mental health problems.
This is an excellent piece
The author would know-and I am sure is supportive of -the Tavistock and Portman NHS Foundation Trust who run an inspirational service in Hackney, and in Camden, using well qualified therapists and psychologists. The clinicians work in GP practices , reaching these complex patients.
Independent Health economics evaluation shows it is great value for money. GPs and patients are very satisfied with this service -in other words ,IAPT can do SOME things, but more sophisticated therapists are needed both for some more complex patients, AND for working closely with GPs who have to manage quite complex emotions with complex, demanding patients in a world of cuts and austerity.
So, I fully agree- an exclusive focus on IAPT is too narrow, potentially discriminatory, and not justifiable. It might be an easy option for commissioners-but that isn't good enough
Yeah RECOVERY Assistance Dogs work brilliantly with the 'Doing' Ethos. Getting you out the house, helping you eat, stopping panic attacks. They are brilliant with severe Mental Health problems where talking doesn't help but being & doing does.
To my mind, the 'significant savings' that MUS are supposed to release to pay for IAPT haven't been adequately examined or challenged. The information presented to commissioners has included exaggeration of the rate of MUS in outpatients and exaggeration of the overall cost of MUS to the NHS as % of total budget.
The Bermingham et al 2010 study on which the MUS figures are based had significant limitations including a possible 30% margin of error. The study included 'subthreshold' somatizers and used a controversial diagnostic definition for these. Without this subthreshold group the cost of somatization to the NHS would have been less than £1 billion instead of the £3 billion reported. It also used a rate of MUS in outpatients that was no more than 16%, but medics and commissioners at conferences and training days are often told that the MUS outpatient rate is around 50%. Quite a discrepancy. The study from which the 50% rate has been drawn did not meet the required sample size and may have exaggerated the MUS rates. Check it all out for yourself in the relevant JCPMH Guidance references.
The overall cost of MUS as % of total NHS budget has also been exaggerated in some conferences and published papers with the assertion that MUS accounts for 10% or 11% of the total NHS budget. This is incorrect. The Bermingham et al study reported that MUS costs the NHS 10% of the money that is spent on the working age (18 to 65) population group only. It did not include spending on paediatrics or the elderly; these groups have lower reported rates of MUS. I would imagine that this has been done to convince commissioners that the IAPT model will work and that these 'significant savings' will in due course be delivered by the IAPT/CBT strategy to the mental health budget. What if they're not? Where will the money for mental healthcare come from then?
I appeal to commissioners to look closely at the detail. Do not blindly accept what you are being told, there is too much at stake.
An excellent and thoughtful piece. The idea to add another step for the more severe & complex patients must be taken seriously.
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tell me how does a young person fully qualified and with relevant experience who was planning to go on the advanced IAPT training now progress when funding has been taken away at short notice as has been the case and/or what are their career alternatives given a background of relevant and in depth experience at say the age of 28 with a degree and therapy and mental health related work experience?. I'd love to know how to advise my daughter
This Tory plot does not merit the quality if professional analysis it is patiently and expertly afforded here. Any arse can see that its a crock of shite.
I am just qualifying as a high intensity CBT therapist and starting work in the IAPT service. Previously I worked in secondary care services for 20 years. I have seem wonderful work done in IAPT and lots of recovery even with quite complex people. Its a myth that IAPT are seeing only mild to moderate, as the client are quite complex. However the point I want to make is my years of frustration working in secondary care with very complex clients who would have recovered more if we had the kind of training I have been fortunate to have this year. People with complex mental health problems in my experience have periods of stability where psychological therapies would help them to develop skills. i asked for years for this training but there was not the funding. it did not make sense financially or ethically to keep clients in the service without the psychological expertise available to them. My colleagues in IAPT was shocked when I told them how little psychological intervention there is in secondary care.The assumption is that we are all adequately trained. This is not the case. Thats which it feels more like containment that recovery services.
The evidence base for IAPT for long term conditions and medically unexplained symptoms is completely flawed, but nobody questions the evidence these days it seems. If somebody from above says that it is so then, like sheep, everyone follows, even when they contradict themselves left, right and centre. This spells disaster for our health services with patients' reports of their symptoms (and their severity) no longer being believed by doctors who instead reach for a psych explanation. High misdiagnosis rates have been brushed under the carpet. Alarmingly, the increase in life expectancy is already stalling in the UK, so how long before life expectancy starts decreasing due to the unquestioning belief in an unproven hypothesis?
This is an interesting article. However, IAPT is definitely not aimed at people with mild-mod MH conditions, unless you are specifically talking about the pwps. As their aim is to increase the through put of service and see people with a lower threshold of distress.
IAPT is very well aimed at people with mod-sev MH conditions and is not just a single modality such as CBT, as it also covers differences therapies.
I feel that funding for IAPT is very worth while as we do not want to medicalise everyone and pop them on medication. Especially in CYP services, as per NICE guidelines.
IAPT is most definitely aimed at those with mild to moderate MH conditions as Layard and Clark intended it to be. It is not geared towards those with more serious problems. I believe that Dan Burningham is correct to say that NHS England claims that significant savings released by treating MUS and long term condition patients will make the IAPT programme sustainable. Unfortunately, there appears to be no good evidence to support this claim, it is just a pie-in-the-sky theory. In fact the evaluation project showed that rather than it costing the NHS less for these patients, it actually cost the same or more, and the economists involved in promoting this treatment have seemingly admitted to there being a lack of evidence that treating long term conditions and MUS with psychological therapies will deliver the savings. But someone made the decision to roll it out and for 2/3rds of the expansion of IAPT to be directed at LTC and MUS patients. Hmm. So where does that leave those people with the most serious mental health problems when the NHS budget is being used up on a scheme that will likely not deliver?
I totally agree that IAPT has its place - but I struggle very much with the idea of extending IAPT to more complex conditions. This is what the DClinPsy (a doctor of clinical psychology is for). The idea that people can train in IAPT, with no psychology under graduate course, or masters and then learn at a level 7 to treat complexity’s that are at times difficult for a level 10 doctorate to treat, just isn’t in the best interest of the patient. I’ve just finished a masters, have seen plenty of IAPT work and I worry about IAPT stepping into the DClinPsy patients - which just wouldnt be enough training to manage the patient morally and appropriately.
I felt really down, spent ages on the phone answering questions. Rang the following day to check when my appointment was likely to be. Zilch. No appointment. I didn't fulfil the criteria, whatever that may be besides feeling low and needing help. Disappointed? Not much.