Month: March 2023

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The National Audit Office Confers With Mental Health Powerholders and Not Patients


Unsurprisingly the surveyed integrated care board (ICB) mental health leads and mental health trusts tell the NAO what a great job they are doing.  The NAO also interviewed mental health stakeholder organisations such as the BPS and BMA. On this basis, the NAO [“Progress in improving mental health services in England”] declared last month, that ‘the government has achieved value for money’. The yardstick used by the NAO was whether the surveyed bodies ‘met ambitions to increase access, capacity, workforce and funding for mental health services’. No attempt to access the voice of the people. 

Interestingly the NAO did not even attempt to make the claim of the prime movers in IAPT Layard and Clark (2015) that the Service costs nothing, due to savings on welfare benefits and physical healthcare costs!  The response of the great and the good in mental health (the NHS Confederation, SANE and Mind) has been, that the report highlights the need for increased funding, to recruit and retain more staff. No awareness that more of the same is unlikely to make any difference to patients.

 

The report reveals that £752 million was spent on NHS Talking Therapies predecessor, IAPT, in 2021-22. But when the NHS acquired IAPT earlier this year no audit of the latter was conducted. No business would behave in this way. Yet the NAO report re-iterates the target of ‘at least 50% achieve recovery across the adult age group’. No mention that there is no independent evidence that this has ever been achieved. With the best evidence Scott (2018) suggesting that only the tip of the iceberg recover. What sort of auditors are the NAO? Under their watch acquisitions can be made without credible scrutiny.

In 2018 the NAO jettisoned an enquiry into the Improving Access to Psychological Therapies (IAPT) Programme. In response to a Freedom of Information request, the NAO responded on February 17th 2020 ‘We commenced work on the IAPT programme in 2017-18. However, the work on this programme was curtailed in June 2018 by the Comptroller and Auditor General (C&AG) of the time in response to changing priorities. The alterations to the work programme were made so that the C&AG could respond quickly on important topical issues, such as work on the UK’s exit from the European Union, the government’s handling of the collapse of Carillion, and on significant NHS spending increases in 2017- 18 on generic medicines in primary care’.

Dr Mike Scott

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NHS Talking Therapies – Wasting Access to Psychological Therapy

by reliance on two screening instruments. Coupled with a failure to conduct an interview that would reliably confirm or reject the impression given by the tests. The effect is that  many are treated needlessly, as most score above the designated cut-offs on the tests [IAPT Manual 2018)]. Further, diagnostic possibilities are constricted by the scope of the 2 instruments, depression (PHQ-9) and generalised anxiety disorder (GAD-7). The message from this Government service is:

 

Usage of the 2 screening tests would not rule out that a person had say an adjustment disorder triggered by job loss, marriage breakdown, serious illness, bereavement or an accident.  But such difficulties are not the domain of the disorders that are the focus of the randomised controlled trials of cbt for depression and the anxiety disorders. Yet such difficulties are the common currency of primary care. Thus the application of the cbt protocols for these disorders to those with these difficulties is not evidence-based and is a waste of resources. It is likely a matter of pathologising normality.

 

One third of those attending NHS Talking therapies have a low intensity intervention alone, i.e they are not treated by a psychological therapist, but by a Psychological Wellbeing Practitioner (PWP) [IAPT Manual (2018)].  But the PWPs do not know the diagnosis of any patient, as they, like all NHS Talking Therapies clinicians are not trained to diagnose. The allegation is that they deliver CBT, but for what?

The evidence-base for low intensity interventions is weak, in that, there is an absence of attention control conditions and independent blind assessment. The evidence that PWPs implement the low intensity interventions from the weak trials is weaker still. There have been no fidelity checks on PWPs ministrations i.e independent assessments of treatment targets and matching treatment strategies. 

Almost half of those entering NHS Talking therapies never progress to treatment defined by the Service as attending 2 or more treatment sessions. This is likely a ‘thanks, but no thanks’ response on behalf of patients. There is a monumental waste of scarce resources. Unsurprisingly I found that only the tip of the iceberg recover.  

The trajectory of patients in NHS Talking Therapies is rather like that of horses entering the Grand National. There were 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions). The much vaunted ‘50% recovery rate’ that this Governmental service boasts about, refers to the significant minority who cross IAPT’s finishing line. Thus even using IAPT’s own yardstick  the true recovery rate is much less than 50%.

With regards to those who cross IAPT’s finishing line, there is no indication that their ‘success’ is lasting. It is not known what proportion of them ever ‘race’ again. 

The NHS Talking Therapies is an exemplar of what happens when there is an unaccountable Service. In which a therapist’s unfettered judgement, on how to treat a patient, is allowed to rule. Opinion-based treatment withers on the vine.

 

Dr Mike Scott

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In NHS Talking Therapies We Doubt

 

This is the take home message of a just published study in the British Journal of Clinical Psychology. Capobianco et al (2023) The authors conclude “Significant questions must remain concerning how effective the treatment element actually is and how much time is needed to realise an adequate dose”. With mean improvements of 2-3 points on the PHQ-9 between 1st and last session and a mean 3 point improvement on the GAD-7 between 1st and last appointment, whether or not treatment was conducted remotely or face-to-face. They further add “however, we are not arguing the treatment was effective and therefore the cause of the changes observed. Such changes could be accounted for by a range/ combination of factors including regression to the mean or spontaneous recovery over time…….. It seems that clinical improvement was slow, and patients do not appear to be receiving the required length of time in order for outcomes to reach the required cut of”.

Their data reflect the failure of NHS Talking Therapies to engage clients thus, “between March 2020 and September 2020, 5515 patients attended at least one session, with 2553 (46%) patients attending at least two treatment sessions.  Similarly pre Covid19, 9199 patients attended at least one session, with 4625 patients (46%) receiving at least two treatment sessions. Participants attended a median of two remote therapy sessions and a median of three in person therapy sessions’. By anybody’s reckoning the median dosage of therapy is sub-therapeutic.

Dr Mike Scott

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NHS Talking Therapies – Doublethink Without Informed Consent

 

In practise clients begin their journey through NHS Talking Therapies at the promptings of the least qualified clinicians, Psychological Wellbeing Practitioners (PWPs). They are not trained therapists. I am not aware of this NHS service formally seeking any informed consent, it is likely unique in this regard. But the public have a right to know what they are letting themselves in for and the effectiveness of the said interventions. If pushed most PWPs would probably reiterate the mantra of its employer that 50% of people recover. But there has been no independent verification of this claim. Rather the best independent evidence suggests that the tip of the iceberg recover. It would not be a sufficient justification for a PWPs action to claim that he/she was only doing/saying what most colleagues are doing. How can there even be an ‘informal’ informed consent if the PWP does not make it clear that they are not a trained therapist, there is an absence of transparency. Further it is doubtful that they have the expertise to advise clients of the sequelae of different pathways.

Would a client who did not make the progress he /she had been led to expect be able to make a claim? Would the family of a client who committed suicide be able to claim that there had been no informed consent garnered at the outset of treatment?

I ran these concerns via a Barrister who opined ‘In principle, however, a person who is given inaccurate or misleading information about the chances of successful treatment, or about the qualifications of a person treating them, may well be found not to have given informed consent’.

 

Dr Mike Scott