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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