Preserve Us From Specialist Units – The Need for Proper Audit

 ‘Complex’ clients tend to gravitate to Specialist Units, but their focus is overwhelmingly on the disorder that they were set up for, recommending anything else outside its’ remit is dealt with elsewhere. The problem is it doesn’t actually work! I recently saw a client with a 10 year history of bulimia, alcohol abuse/dependence. The file was enormous as the Specialist Units had each made their contributions as the client went at greater speed through the revolving door.

 

In fairness there was one letter from the alcohol Unit that suggested that the ‘underlying cause’ for these problems should be sought, now there is a novel idea! But neither of the Specialist Units took this responsibility. IAPT sent  a letter asking the client to telephone to arrange an assessment which was not acted upon and promptly discharged the client. When I saw the client I found that the underlying problem was social anxiety disorder, which pre-dated all the other problems. The records did mention in passing that the client was anxious in social situations, but this had never been a therapeutic focus. The client readily appreciated that there had to be a comprehensive/holistic treatment approach and not the piece-meal approach followed by the agencies. Changing their modus operandi is a monumental task, as there are so many vested interests. But a starting points is to insist on independent audit of recovery rates along the lines that I have pursued re: IAPT.

Dr Mike Scott

Rules of Thumb That Can Sabotage The Treatment of PTSD

In routine practice the treatment of PTSD is often ineffective, IAPT’s recovery rate with this disorder is around 16%. But the operation of certain rules of thumb sabotage treatment across the board. Which, if any,  of the following saboteurs do you operate on:

  1. It is probably PTSD because it was an awful incident
  2. It is probably PTSD because there arte flashbacks and nightmares
  3. It is probably PTSD because of a high score on the Impact of Event Scale
  4. Whatever it actually is trauma focused CBT/EMDR offers the best way of resolving it
  5. Formulation rules anyway
  6. You can’t treat more than one disorder at a time
  7. Issues need to be resolved first

 

In January 2018 I was due to make a presentation at an Improving Access to Psychological Therapies (IAPT) Conference, titled ‘Approaching Patients With Trauma – Can IAPT help patients with trauma?, but was overtaken by my own trauma of falling down the stairs at home! Here is the link to the presentation:

https://www.dropbox.com/s/21ye8ewczvmfamn/IAPT-January-23rd-2018-Birmingham-City-Football-Ground.pdf?dl=0

The good news is that I was able to specify how IAPT might change its’ practice, but unfortunately the chances of this happening anytime soon are remote, openness to debate with those outside of IAPT is conspicuous by its’ abscence.

Dr Mike Scott

Supervision Of Most IAPT Workers Is Not Supervision – Monumental Waste

Alexandra Painter was for 2 years a Psychological Wellbeing Practitioner, in her doctoral thesis *, she reviews her experience and that of other PWP’s.  She notes that in the so called ‘Case Management Supervision’ that PWP’s are subjected to, a core component of supervision, the opportunity to reflect on practice and talk about how you feel about cases is routinely absent. Alexandra calculates that approximately 2.5 minutes is allowed to discuss each case! It seems that the PWPs, who are the most numerous of IAPT workers, are at the ‘front line’, most commonly they have been health care assistants in the past,   unlike the high intensity therapist’s in the rear with often clinical or counselling psychology backgrounds. In this war against mental ill health it is more likely that the troops at the front will bear the brunt.

Leaving the troops fearful of going over the top and disobeying commands from on high. The PWP’s plight resembles resembles the Charge of the Life Brigade, in that the powers that be refuse to accept that they are not on solid ground intent on reaching their target at all costs. There are no evidence based techniques, only evidence based treatments and all the so called EBT’s in low intensity treatment fail to meet criteria for evidence based treatment [ Scott (2017) Towards a Mental Health System that Works London Routledge].

  • At least two randomised controlled trials, on a clearly specified population, with independent assessment by a blind rater using a standardised interview
  • At least one of the rcts conducted by researchers independent of the developers of the treatment
  • Replication in routine practice using non-expert clinicians

How long will it be before there is a national outcry about such waste. Unfortunately the National Audit Office is still undecided about whether to publish its’ investigation into IAPT. People including myself and BACP made a submission to the NAO fully expecting the latter’s findings would be made public, if they and I knew that this was not necessarily the case, we would have wondered whether it was worth the effort! At the moment they appear to be countenancing a letter to NHS England, inspection of their website shows the latter’s wholesale support for and funding of IAPT! The NAO, to date, seems no better than Carillion’s Auditors!

Dr Mike Scott

* Painter, A. (2018) Processing people! The purpose and pitfalls of case
management supervision provided for psychological wellbeing practitioners,
working within Improving Access to Psychological Therapies
(IAPT) Services: A thematic analysis. DCounsPsych, University of
theWest of England. Available from: http://eprints.uwe.ac.uk/33351

Current Supervision Practices Have Not Prevented the Poor Outcomes In IAPT

 

With a 10% recovery rate in IAPT https://doi.org/10.1177/1359105318755264, serious questions have to be asked about the quality of supervision.  But it could be that Supervisors in IAPT feel that their role is constricted or the use of practitioner league tables sabotages their endeavours. Clearly something is going badly wrong. However it could also be that current supervision practices whether or not they take place in IAPT are not fit for purpose, they are eminence rather than evidence based.

 

‘Its’ about monitoring, personal development – a bit like treating a client, has to be tailored to the supervisee’ this seemed to be the consensus at a BABCP Supervision Workshop I attended with about 40 others in Liverpool last week.  The presenter Jason Roscoe, asked the 40 attendees what model of supervision they followed, there was a deafening silence. He then presented the Roth and Pilling competencies for supervision, I opined that just looking at the rows and columns gave me ‘mental  indigestion’.  Given the outbursts of laughter I think that this was a widely shared view.  I had a sense that people feel rudderless with regards to supervision, and there was no enthusiasm about becoming a BABCP accredited supervisor.

I suggested that the prime function of supervision is to act as a conduit for evidence based treatment. Since the Workshop I have reflected that no alternative definitions of the prime  function were offered rather the Bennett-Levy model of supervision involving 3 different types of knowledge declarative, procedural and reflective was recommended. The implication was that one might need to do more or less on any one of these forms of knowledge with any particular supervisee. Hmm I thought, this is no different to what one would do with a client in treatment. The offering at the Workshop was I found typical of what passes for evidence in BABCP with regards to supervision, but there is sparse evidence such supervision makes a real world difference to client’s lives. What is known is that supervision has been an integral part of randomised controlled trials and that type of supervision can be considered evidence based. It follows that to the extent that this type of supervision is adopted, with its’ emphasis on reliable diagnosis and fidelity checks for adherence and competence one is still in the ball park of evidence based supervision ( see Simply Effective CBT Supervision London: Routledge).

Dr Mike Scott

House of Lords – Expansion of IAPT into ME Despite Not Knowing How Such Clients Have Already Fared In The Service!

Chronic Fatigue Syndrome: Written question – HL7468

Asked by The Countess of Mar
Asked on: 01 May 2018

Department of Health and Social Care
Chronic Fatigue Syndrome

HL7468
To ask Her Majesty’s Government what are the recovery rates of patients with myalgic encephalomyelitis who have received treatment under the Improving Access to Psychological Therapies programme.

Answered by: Lord O’Shaughnessy
Answered on: 15 May 2018

This information is not available

 

 

Whatever happened to evidence based CBT?

 

Dr Mike Scott

Medical approaches to suffering are limited, so why critique Improving Access to Psychological Therapies from the same ideology

This is the title of James Binnie’s commentary on my paper, he adds that my findings of a 10% recovery rate in IAPT are ‘quite shocking’. His paper and mine are available by clicking the following links:

https://doi.org/10.1177/1359105318769323

https://doi.org/10.1177/1359105318755264

Commentaries and my commentary on the commentaries will be available in a Special Issue

of the Journal of Health Psychology this Summer. It’s great to get some public debate, it has been difficult because many are not in a position to voice their concerns openly.

 

Dr Mike Scott

 

 

National Audit Office IAPT Investigation ‘progress..slipped substantially….

We have not yet made a firm decision about whether or not we will publish a short report on IAPT in due course…We may choose to simply write a management report’, my communication received from the NAO today. I have made a Freedom of Information request re: the decision making and communications, which legally I should have in the next 10 days.

 

 

Given that £1bn has been spent on IAPT not to have an independent audit/assessment  seems scandalous. Claims of competing pressures is not terribly convincing.

Dr Mike Scott

 

The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution

This is the title of a Commentary on my paper ‘IAPT – The Need for Radical Reform https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/ published in the Journal of Health Psychology, by Sami Timimi the link is: Article first published online: March 30, 2018

https://doi.org/10.1177/1359105318766139 

 

Two further commentaries are in the pipeline, with my commentary on the commentaries to be published in the Summer, in a Special issue of the Journal. Timimi’s comments/data on Childrens and Young Persons IAPT are particularly interesting.

Special thanks to Donna Botomley for all the help she has given in the construction and maintenance of this site and she is retiring from this role. As many of you might know technology, particularly social media is not my forte, any comments always welcome.

Regards

 

Mike Scott

Clinical Commissioning Groups (CCG’s) Incredibly Naive Re: IAPT

CCG’s are rubber stamping the funding of IAPT services, without questioning the alleged 50% recovery rate for depression and the anxiety disorders. But CCG’s would never give approval to the dissemination of a psychotropic drug based solely on the manufacturer’s claim. It seems that GP’s on CCG’s are too busy to critically appraise IAPT’s claim.  CCG members need to ask why £1bn has been spent on IAPT services that have never been independently evaluated using a rigorous methodology.  My own, by no means definitive study of 90 consecutive attenders at IAPT suggests a 10% recovery rate [ the paper ‘IAPT The Need for Radical Reform’ can be accessed by selecting below and right clicking https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/].  CCG’s are like the Titanic, heading towards an iceberg, on board are not only depressed and anxiety disorders passengers but a recent cohort of those with long term physical health conditions and medically unexplained symptoms:

 

 

Via my MP, Maria Eagle I put the following questions to the Liverpool CCG, (one of the CCGs covering the IAPT clients I examined in the North West) and their response dated March 6th 2018 was as follows:

Question 1.

 

Are the CCG aware that the recovery rate in the IAPT Service they fund is just 10% (far short of the 50% recovery rate targeted by Alan Johnson, then Labour Minister in 2007 when the service was set up).

 

Response 1.

 

Latest local data indicates that the current recovery rate for the service stands at 50%, targets for access and recovery are under regular review with performance reported to NHS England and published nationally and through LCCG Governing Body papers.

 

Question 2.

 

What, if any independent data do the CCG use in assessing the IAPT Service? Response 2.

All IAPT services must assess their performance using nationally mandated measures contained within the IAPT Minimum Data Set (v1.5). Information on these measures and the outcomes achieved by IAPT services can be obtained from NHS Digital.

 

Question 3.

 

Why have the CCG never asked IAPT service users their opinion of the service? Response 3.

All IAPT services routinely ask every IAPT service user their opinion of the services using 2 measures, the Patient Experience Questionnaire (Assessment) and the Patient Experience Questionnaire (Treatment). Information on these measures and the patient satisfaction levels achieved by IAPT services can be obtained from NHS Digital.

 

Question 4.

 

Why do the CCG consider it acceptable to continue to fund a service, were assessments are conducted by telephone by the least experienced and qualified staff? Are they supporting a double standard for physical and mental health?

 

Response 4.

 

LCCG has commissioned a service in line with NICE guidance both in terms of accessibility and responsiveness, but also the required skills of staff employed by the service.

 

Question 5.

 

What steps will the CCG take to ensure that evidence based treatment takes place in IAPT? Response 5.

All treatment provided by Talk Liverpool conforms to the following NICE Guidelines which lay out the evidence based therapies that should be offered for disorders of anxiety and depression:

 

NICE Guidance for depression in Adults (CG90)

NICE Guidance for Depression in adults with a chronic physical health problem (CG91) NICE Guidance for Common Mental Health Problems (CG123)

NICE Guidance for Generalised Anxiety Disorder and Panic Disorder in Adults (CG113) NICE Guidance for Obsessive Compulsive Disorder and Body Dysmorphic Disorder in Adults (CG31)

NICE Guidance for Post-Traumatic Stress Disorder (CG26) All the above can be accessed through;

https://www.nice.org.uk Question 6.

How will the CCG ensure that GPs are given comprehensive data on the functioning of their patients? Currently data is supplied to GPs on less than half of patents and purely in the form of psychometric test results, there are no ‘gold standard’ diagnostic assessments conducted at all. How will the CCG remedy that IAPT workers do not know what they are treating?

 

Response 6.

 

GPs are informed of the outcome of all their patients’ therapy episodes with Talk Liverpool. This includes both psychometric scores and clinical information. With regard to “gold standard diagnostic assessments”, the IAPT service is a treatment service and not a formal diagnostic service. Talk Liverpool provide problem descriptors (and not formal diagnoses) as mandated by the IAPT Dataset V1.5 set out by NHS England, using the nationally mandated psychometric tests (details of which can be found in the IAPT Data Handbook published by NHS England).

 

Links:

 

http://content.digital.nhs.uk/iapt

 

http://ipnosis .postle.net/PDFS/iaptoutcomestoolkit2008november(2).pdf

 

Further information relating to IAPT nationally can be obtained through the National Collaborating Centre for Mental Health and NHS England who have recently published the IAPT Manual which outlines the model that all IAPT services should follow (including some of the procedures implemented by Talk Liverpool including some outlined in the responses given above).

 

Links:

 

http://www.rcpsych.ac.uk/workinpsychiatry/nccmh/mentalhealthcarepathways/improvingac cess.aspx

 

https://www.york.ac.uk/healthsciences/pc-mis/newsarticles/lAPT%20Manual 30OCT17.pdf

 

 

I hope that you and Dr Scott this information helpful.

Yours sincerely

 

Ian Davies

Chief Operating Officer

 

Liverpool CCG show no evidence of having bothered to read my analysis of 90 cases, and have not answered my questions, they have simply acted as the mouthpiece for IAPT.

 

Dr Mike Scott

National Audit Office Not Publishing Its’ IAPT Investigation?

Whatever happened to transparency and accountability! Last year the NAO invited the public to make submissions for its’ IAPT investigation, but it seems a letter from the NAO dated February 14th 2018  obtained under Freedom of Information (FOI) by a Dr Elizabeth Cotton states ‘you requested information …. that relates to the decision not to make the report publicly available  … correspondence and any documents sent by the NAO to the UK health bodies involved that outline the key findings of the inquiry…. The NAO is still drafting its findings and these have not been communicated to any of the health bodies’.

 

 

Under the FOI there is an exchange of e-mails between NAO and NHS England, one from the NAO dated June 28th 2017 is titled ‘NAO investigation into the integrity of IAPT performance data’ and strangely states ‘we have not yet decided for definite whether we will publish a report’.  I made a submission to the NAO on July 25th 2017 and I, like all those submitting evidence which ran to Autumn 2017, would have assumed a report would be published, otherwise they might have considered it a waste of energy!

I have e-mailed the NAO and await a reply.

 

Dr Mike Scott