Improving Access to Psychological Therapists (IAPT) or Care Assistants?

The staffing costs of the Improving Access to Psychological Therapies (IAPT) Programme is set to rise to £0.5 billion per year, but the National Audit Office (NAO) has failed to determine whether it is value for money. The average Clinical Commissioning Group (CCG) will need to increase IAPT staffing by 60-75% to meet the 2024 NHS Access Target ,according to the updated IAPT Manual (August 2021). Currently the service employs 8000 staff, another 3,800-6,000 are ‘needed’, taking the total to between 11,800 and 14,000 in the next 3 years.  Assuming a staffing cost of £35K per employee per year and the employment of 13,000 IAPT therapists, annual staff costs will be £455 million a year i.e approximately £0.5 billion per year.  But the true cost will be even greater when overheads  such as rent, phone lines are included. Extrapolating backwards, over £5billion will have been spent on IAPT staff since its inception without independent audit and no intention of NAO audit.

But the pandemic has highlighted the shortage and poor pay of Care Assistants. Drew et al (2021) sampled IAPT therapist-client interactions https://doi.org/10.1016/j.socscimed.2021.113818 and noted a steadfast refusal to let clients tell the story behind their distress. A member of the public listening to these exchanges might contrast them with those of a Care Assistant making visits to a terminally ill patient so they can die at home with their family. The public would I think see the Care Assistant’s work as being more valuable and puzzled that the IAPT worker is paid twice as much.

There is a move to have health and social care under one umbrella, perhaps the NAO might explain why there should not be better pay for the Care Assistants and an increase in numbers at the expense of expansion of IAPT services. I came across this advert for Care Assistants in my area:

a much better investment than Talk Liverpool with a 10% recovery rate, Scott (2018) ‘IAPT- The Need for Radical Reform’ https://connection.sagepub.com/blog/psychology/2018/02/07/.

Dr Mike Scott

The Improving Access to Psychological Therapies (IAPT) Programme and The British Psychological Society (BPS)

 

The BPS has enthusiastically supported IAPT from its’ inception in 2008.  Improving access to psychological therapies is clearly a laudable goal, as most people with a mental health problem are not offered psychological therapy. The Society has led the course accreditation process for IAPT’s, Psychological Wellbeing Practitioners (PWPs) low-intensity training since 2009. Features on individual PWP’s have featured periodically in the pages of The Psychologist. In 2009, The Psychologist published a letter from the then President of the British Association for Behavioural and Cognitive Therapies (BABCP) stating that BPS members on the IAPT Education and Training Project Group supported BABCP’s accreditation of high intensity training programmes and noted that there were BPS members on the Accreditation Oversight group.

But the enthusiasm of BPS to give away psychological therapy has not been matched by a concern, to listen to the concerns of service users. Specifically:

  1. At no point has BPS suggested that it is inappropriate for IAPT to mark its’ own homework. The latter’s reliance entirely on self-report measures completed often in the prescence of the IAPT therapist, should have had any self-respecting psychologist crying ‘foul’ and calling for independent assessment.
  2. A concern for service users, should have led BPS to insist that a primary outcome measure must be clearly intelligible to the client. But there has been no specification of what a change in X as opposed to a change of Y would mean to a client on the chosen yardsticks of the PHQ-9 and GAD-7.
  3. BPS has been strangely mute on the fact that two self-report measures have been pressed into service to validate IAPT’s approach, with no suggestion that such an approach needs to be complemented by independent clinician assessments that go beyond the confines of the 2 disorders (depression and generalised anxiety disorder) that the chosen measures address.
  4. If a drug company alone extolled the virtues of its’ psychotropic drug, BPS members would quite rightly cry ‘foul’ insisting on independent blind assessment using a standardised reliable diagnostic interview. But from the BPS there has been a deafening silence on the need for methodological rigour when evaluating psychological therapy. This reached its’ zenith In the latest issue of The Psychologist, September 2021, when the Chief Executive of an Artificial Intelligence Company, was allowed to extol the virtues of its’ collaboration with four IAPT services. No countervailing view was sought by The Psychologist, despite it being obvious that the supposed gains were all in operational matters e.g reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives.

 

In 2014 I raised these concerns in an article ‘IAPT – The Emperor Has No Clothes’ I submitted to the Editor of the Psychologist which was rejected and he wrote thus ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists.

Fast forward to 2018 and I wrote and had published in 2018 a paper ‘IAPT – The Need for Radical Reform’ https://doi.org/10.1177%2F1359105318755264 published in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10% recovered in the sense that they lost their diagnostic status, this contrasts with IAPT’s claimed 50% recovery rate. The Editor of the Journal devoted a whole issue to the IAPT debate complete with rebuttals and rejoinders. But no mention of this at all in the pages of The Psychologist.

It appears that BPS operates with a confirmation bias and is unwilling to consider data that contradicts their chosen position. If psychologists cannot pick out the log in their own eye how can they pick out the splinter in others? In 2021 I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, https://doi.org/10.1111/bjc.12264 but again no mention of this debate in the Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. It has an unholy alliance with BABCP who are similarly guilty. Both organisations act in a totalitarian manner.

Dr Mike Scott

Notice Served On IAPT’s Claim

of a 50% recovery rate. The Editors of Lancet Psychiatry https://doi.org/10.1016/ S2215-0366(21)00123-1 have challenged researchers to demonstrate that an acclaimed intervention makes a difference that service users would recognise. Thus making the consumer of mental health services centre stage rather than a change in score on a test. In addition researchers are asked to justify their primary outcome measure. In interpreting test results the Editors insist that  author’s must clarify what a change of X would mean to a service user as opposed to a change of Y. A recently published paper in the Journal, using IAPT data, https://doi.org/10.1016/ S2215-0366(21)00083-3 would probably not have been published, if it had not been accepted just before the new guidance was implemented. If other Journal editors follow suit, IAPT’s wings will have been clipped over the claims of IAPT and its’ fellow travellers, such as the British Psychological Society (BPS) and the British Association of Behavioural and Cognitive Therapies (BABCP).  There has been a dereliction of duty by BPS and BABCP.

 

In this connection I have had the following correspondence with the Lancet Psychiatry  Editors:

My letter

When A Difference Makes No Difference

In June this year the Lancet published guidance [Boyce et al (2021)] for mental health researchers to ensure that the primary outcome measure employed in a study needs to be meaningful. Researchers were asked to a) justify their choice of an outcome measure and b) specify what a change of X or Y on a measure would mean for a service user. Contemporaneously, Lancet Psychiatry published a study by Barkham et al (2021) that made no attempt to address the Editor’s expressed concerns.

Barkham et al (2021) chose to adopt the Improving Access to Psychological Therapies (IAPT) primary outcome measures the PHQ-9 [Kroenke et al (2001)] and GAD-7 [Spitzer et al (2006)], without any discussion. There is no comment that these are self-report measures, subject to demand characteristics and that changes are impossible to interpret without comparison to an active placebo treatment.

The Barkham et al (2021) study involved comparison of person-centred counselling and cognitive behaviour therapy (cbt) in a high intensity therapy service delivered by IAPT. Curiously patients were screened for the study using the Clinician Interview Schedule Revised but neither this nor any standardised diagnostic interview was used as an outcome measure. Why such apparent blindness? The answer is apparent reading the declaration of conflicts of interest, the authors are either devotees of person-centred counselling or have links with IAPT. Their take home message is that person centred counselling might be better than CBT for depressed patients. But there is no attempt to address the question of what proportion of patients lost their diagnosis status and for how long, as determined by an independent blind clinical assessment using a standardised interview. Service-users interests are ill-served by this type of study which additionally ignored data that suggest the recovery rate in IAPT is just 10% [Scott (2018)].

References

Barkham, M., Saxon, D., Hardy, G. E., Bradburn, M., Galloway, D., Wickramasekera, N., Keetharuth, A. D., Bower, P., King, M., Elliott, R., Gabriel, L., Kellett, S., Shaw, S., Wilkinson, T., Connell, J., Harrison, P., Ardern, K., Bishop-Edwards, L., Ashley, K., Ohlsen, S., … Brazier, J. E. (2021). Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. The lancet. Psychiatry, 8(6), 487–499. https://doi.org/10.1016/S2215-0366(21)00083-3

Boyce, N., Graham, D., & Marsh, J. (2021). Choice of outcome measures in mental health research. The lancet. Psychiatry, 8(6), 455. https://doi.org/10.1016/S2215-0366(21)00123-1

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16: 606–13.

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166: 1092–97.

 

August 13th 2021

 

Thank you for your letter to The Lancet Psychiatry. We are pleased to see that our initiative re primary outcome reporting has been noticed.  We are applying this now but did not apply it retrospectively to papers accepted before publication. The Barkham et al paper was published online on 14 May, six weeks after the Comment, but was accepted and edited before our new policy was in place. 

For Correspondence, our information for authors states: Letters written in response to previous content published in The Lancet Psychiatry must reach us within 4 weeks of publication of the original item.  We do extend this to after the original item has been published in an issue but I’m afraid that your letter is still outside the window for the Barkham et al paper, so we have decided not to publish it.

Although this decision has not been a positive one, I thank you for your interest in the journal.

Yours sincerely,

Joan Marsh

Joan Marsh MA PhD

Deputy Editor

 

Dr Mike Scott

 

No Reduction In the Prevalence of Mental Disorders Since IAPT

this is the conclusion of Australian researchers https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30040-9/fulltext. Why then have successive Uk Governments spent £billions on the Improving Access to Psychological Therapies (IAPT) since its’ inception 13 years ago? Given that there is no evidence that IAPT represents an added value over pre-existing IAPT services, its’ continued funding suggests vested interests hold sway. The National Audit Office (NAO) had concerns and began an investigation but stopped citing Brexit, Carillion etc. Further following a Freedom of Information request from myself I was informed that they have no intention to restart the investigation.

Curiously the Australian researchers accept at face value IAPT’s claim of a 50% recovery rate, but there has never been any publicly funded independent confirmation of this. IAPT has been left to mark its’ own homework. My own study as an independent Expert Witness to the Court, and using a standardised diagnostic interview suggested that the recovery rate is 10% [Journal of Health Psychology   https://doi.org/10.1177%2F1359105318755264].

Dr Mike Scott

IAPT’s Rigidity – The Antithesis of Personalised Care

 

the mantra is ‘offer just 6 sessions, keep to the therapist’s original formulation of the client’s difficulties, don’t consider alternative hypotheses, even when circumstances change. If necessary offer another 6 sessions’. The case below exemplifies this:

A few years ago Mr X suffered an episode of depression, his GP referred him to the Improving Access to Psychological Therapies (IAPT)Programme were he underwent a telephone assessment. On the basis of the completed psychometric test, he was assigned to a 6 week Group CBT programme with about 12 people attending each session. He found the sessions helpful, in that he then gave less emphasis to work and engaged in more excercise.  However at a telephone follow up interview he relayed, that he had been involved in a terrible house fire, struggling to breathe when he escaped. Mr X was taken to Hospital and treated for smoke inhalation and minor burns. The therapist agreed that he should have a further 6 sessions but this time face to face. When I assessed him at the end of the individual CBT he was suffering a further episode of depression, had many of the symptoms of  PTSD but not the intrusions, was phobic about the possibility of fire and suffering from binge eating disorder. However the sequelae of the fire was not addressed at all in the IAPT treatment, when he tried to make these concerns a focus, they were dismissed and the therapist insisted on recapping what had been discussed in the group. He and his wife commented that this seemed totally inappropriate. (Some details changed to protect confidentiality).

 

Personalised medicine is nowhere to be seen.
 
 
The BABCP has its’ Annual Conference in September in Belfast, the place were the Titanic was built, I very much
 
doubt that they will consider the structural defects of IAPT anymore than the White Star Line were transparent
 
about the failings of their vessel.
 
 
But Mr X is the tip of the iceberg of those failed by IAPT. The Court of Inquiry into the sinking of the Titanic had
 
many vested interests. The IAPT prime movers have powerful connections and doubtless the same would happen if
 
ever there was an inquiry into IAPT, but at least it would be a start. For now IAPT steams forward at maximum speed,
 
with many employees wishing to jump ship, but no vessels nearby and having to contend with the familiar tunes
 
from Belfast.
 
Dr Mike Scott