Telephone First Consultations Fail

IAPT is synonymous with telephone first consultations, but the first independent study of this intended cost saving device, with GP’s, has shown it fails to deliver. An editorial in this week’s British Medical Journal on the Newbould et al study* (2017) states:

‘ Telephone first systems alone will not solve the perennial problem of ensuring timely, safe, and equitable access….It is also yet another reminder of the importance of independent evaluation of initiatives before investment in widespread implementation’

Instead of piloting and having an independent evaluation, IAPT has ploughed on regardless. Accountability is a major issue for IAPT, it positions itself between primary  and secondary care but is accountable to neither. It claims comprehensive data collection on almost all its clients. Yet in the authors examination of 90 cases (In preparation) that went through IAPT, for clients having two or more treatment sessions, before and end of treatment psychometric test data was given to GPs in less than half of cases. One quarter of cases did not clear the first hurdle of either ringing IAPT for a telephone assessment or IAPT being unable to contact the person. Whilst 13.3% ‘attended’ only the initial assessment. Thus IAPT is failing to engage just less than 4 out of 10 clients.

 

In GP practices with telephone first consultation the proportion of patients who would recommend their practice to friends fell. There was also a reported increase in emergency admissions associated with telephone first systems.

Clinical Commissioning Groups should insist on IAPT reforming itself, by dropping telephone first consultations.

* Newbould et al (2017 Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ: 358:j4187

Dr Mike Scott

IAPT Behind Closed Doors – Like Jumping Into a Cold Plunge!

Throughout my time in IAPT in Lancashire (I had 2 separate occasions working there) I was employed as a PWP and was taken on to “get the waiting list down” in terms of the volume of cases which had been referred, predominantly by GPs.  I am an Agency Nurse who has worked in many roles across the country, but this was my first role as a PWP.  The first thing that occurred to me was how little awareness the PWPs had about mental health and how people were allocated to various parts of the Service.  There seemed to be an emphasis on “clearing the lists” because lengthy lists would not be favourably looked upon by the commissioners and may affect the funding already provided for the Service, but also future funding.

My PWP colleagues were very new in practice and many of them had only recently qualified and as I have previously outlined, they had little or no experience around mental health.  I was initially asked to “look after them”, since it was very common when working over the telephone to find a suicidal patient on the other end and have a colleague not know what to do.  I was often asked to sit in the room with my colleague and to support through the assessment, as I was in a position to know when to call an ambulance or to get further assistance, where often they did not.  Many patients who were referred to IAPT services, especially at step 2, were referred wholly inappropriately.  My colleagues were subjected to a degree of unnecessary distress and pressure by these inappropriate referrals, as they knew that they were inappropriate, but were expected to treat them in any case.  In cases of face to face referrals, the situation was often worse, since inexperienced colleagues very often were asked to give 6 or 8 sessions to someone who had been referred who was actively psychotic, but whom the PWP did not recognise as being psychotic.  The result of this at best, was that the patient never got better and at worst, may have harmed either themselves or another person.  There were also safety issues in terms of lone working in buildings which were vacated at 5 pm but in which it was expected that workers would have to receive patients because the Service was open until 7 pm.

Anonymity protected – Dr Mike Scott

Failure to ‘Watch and Wait’ Results In Unnecessary Treatment

I doubt that ‘watchful waiting’ has been applied as a policy post the Grenfell Fire, as it is not usually operative in the aftermath of more everyday trauma.  Distressing emotions in the aftermath are oftentimes ‘pathologised’ instead of being seen as part of normal healing process.

A client of mine was involved in a bad car accident, saw her GP who identified whiplash and was concerned that she was troubled by memories of the incident and referred her to IAPT. At IAPT she was offered a choice between a 10 week waiting list for face to face treatment or immediate treatment via telephone counselling. She wanted face to face counselling  and so instead took up her employer’s offer to provide counselling. The two sessions did not help and did not involve cbt.  All this took place within weeks of the accident.

There is a pressing need for GP’s, IAPT and counsellors to be seen to do something, but in all this haste, in the aftermath of a destabilising incident there had been no reliable definition of the problem. Further there was no recognition that typically those destabilised generally find that their own resources are, given time, sufficient to help them regain their balance.
In the event when I saw her 4 months post incident she simply needed CBT for a phobia about driving and travelling as a passenger.
Operating a Watch and Wait over the first 3 months would have resulted not only in a far better use of resources but also the development of a necessary therapeutic alliance. It also advances ‘Saving Normal’ the title of an excellent book by Allen Francis.

Watchful waiting is nothing to do with administering a PHQ-9 every month for 3 months and then concluding ‘something’ must be done if a high score is maintained or the score worsens. Rather it involves the careful tracking of a reliably identified disorder/difficulty.

Discussion With National Audit Office Re: IAPT

On Monday I received a thoughtful, considered and detailed response from the National Audit Office with regards to my submission re: the IAPT investigation. I’ve just penned the following response:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.
  1. I am unsure whether the National Audit Office are aware of the paper by Griffith’s and Steen (2013) [Improving Access to Psychological Therapies (IAPT) Programme: Scrutinising IAPT Cost Estimates To Support Effective Commissioning, The Journal of Psychological Therapies in Primary Care, 2, 142-156]. that suggest that the cost of IAPT therapy sessions is 3 times more than the Department of Health Impact Assessment estimates and this may lead to very different conclusions about the cost-effectiveness of IAPT. For ease of reference I attach a copy of this paper.
  2. How has the IAPT data set demonstrated that it offers added value over a) services as they existed before IAPT b) non-IAPT services in Wales, Scotland and Northern Ireland? In the absence of such a demonstration it can be questioned whether IAPT overs value for money.
  1. It may be that one part of IAPT say high intensity therapy, is value for money but say low intensity (the most common modality) is not but no such analysis has been proferred. Why?

 

Dr Mike Scott

CBT for Addictions – As Likely As Winning At Roulette

There has been an outbreak of smashing fruit machines in Liverpool: this week a man was given a 12 month suspended sentence for wrecking a well known Bookmakers machines, he protested that they were not helping him overcome his addiction! This followed hot on the heels of the brilliant fictional TV series ‘Broken’ (filmed in Liverpool) which showed identical behaviour in the wake of the suicide of a gambling addict.

A person I saw recently Mr X ,with a lifelong gambling addiction told me that the longest period he had been without gambling was when he bet a fellow gambler who would last longest, he lasted 2 weeks. Sadly his experience of IAPT was woeful he was introduced to the discredited stop technique to distract himself when he had the urge to gamble.  He said that he had a few sessions with the therapist but the therapist left and he was given a new therapist.  Mr X said that a questionnaire was then administered and because he got below certain thresholds it was deemed that he did not need counselling and the therapy was terminated.  He said that he was alarmed at this because he felt suicidal and he wrote a letter of complaint and was then offered further sessions but declined them because he had lost trust in the enterprise.

Addiction services have been managed by local authorities since 2012 , but with typical cuts of 30% many services struggle. People can fall between services as a tender is often times switched after 3 years.

CBT for Severe Mental Illness – Does It Reach the Parts That Matter?

Is IAPT overeaching itself by straying into the Severe Mental Illness arena? ‘Ian’ had a life long history of psychosis, he had a great deal of support/treatment over the years from Richard Bentall, author of the brilliant book ‘Madness Explained’, for which the family were most appreciative.  Unfortunately Ian had his benefit withdrawn on the grounds that he was ‘fit for work’ and I was asked to help. Within  two minutes of my seeing  Ian it was abundantly obvious to anyone that he could not work, he was so agitated,  his visits to coffee shops often curtailed by his paranoia.  In the event I produced a report, which alongside a letter from Richard resulted in his benefit being reinstated, his parents were delighted. I did offer Ian the opportunity to look at better ways of handling his paranoia etc but he declined.  I felt desperately sorry for him and reflected that even if he had taken up my offer I doubt that I would have made a real world difference, at best he would have been thankful for my efforts. I wonder whether CBT for psychosis has been oversold.

In using the term ‘severe mental  illness’ I toyed between this term and psychosis, I was trying to use a common language with the reader and in writing my report to the DWP I said that Ian met the DSM diagnostic criteria for schiziophrenia. Labels can be problematic and indeed might not have a biological basis but they give a direction for treatment and influence eligibility for benefits. Richard Bentall et al wrote an Expert review ‘Drop the language of disorder’ in Evidence Based Mental Health, February 2013 and recommended a ‘problem definition, formulation’ approach rather than a ‘diagnosis treatment’ approach, but in my view it is not a matter of ‘either or’ but a matter of both.  Notwithstanding our differences neither of us were able to make a real world difference in what I would see for want of a better term is Ian’s schizophrenia.

IAPT has a demonstration site for Severe Mental Illness for people with psychosis, bipolar disorder and personality disorder, before disseminating such a service there needs to be independent verification using clinician-rated measures (PSYRATS for hallucinations and delusions, SCID for personality disorders) that such a such service would add anything over and above support in the community, otherwise it is just extending an empire.

Dr Mike Scott

‘Too Complex for IAPT’ – Dumping on Secondary Care?

I work in secondary care as a band 7 CBT therapist within a CMHT. Often I will have referrals sent directly from IAPT who describe the patient as being too ‘complex’. Indeed this seems to have become an actual care pathway (not that we have too many of those). As far as i can tell at this stage  the patient may have not had a face to face assessment, rather has been deemed too complex simply because of the stated diagnosis e.g if they have a so  called personality disorder. I have also been told that if someone scores a above a certain score on the HADS scale (I don’t understand why this particular measure is being used as the ‘cut off’)  they too are apparently ‘too complex’. I am also told that  the outcome measures used by IAPT apparently mean that the ‘too complex clients’ would impact on these performance scales which in turn  could mean further funding for the service is jeopardized.

This concerns me on two fronts. Firstly in principle… this seems to completely  go against the ethos  of  the IAPT envisioned by Layard & Clark (although how workable or realistic this ever actually was in another thread) and another example of how it  seems management  are ‘cooking the books’ . Secondly on a more  personal level  I am employed in same Trust as a band 7 cbt therapist , i have no support from care coordinators and supposedly have the same amount of sessions to offer patients so how can possibly i offer anything different to IAPT? I suspect management know I can’t , but i ( and my colleague) serve as  i convenient sponge to soak up all the pts that may threaten the outcome measures…

 

I wonder has anyone else working in secondary care had  similar experiences  or is this an isolated thing ?

Wasting The Taxpayers Money – Fire and Fury Over CBT

‘The results are, at best, unreliable, and at worst manipulated to produce a positive-looking outcome’ so write the editors of the current issue of the Journal of Health Psychology, (http://journals.sagepub.com/toc/hpqa/current). They are writing in relation to a study of the efficacy of CBT for chronic fatigue syndrome ( CFS – the PACE trial). The essence of the editors’ criticism is that when objective measures of outcome were used the effectiveness of CBT disappeared, but the authors of the PACE trial relied instead on subjective self-report measures to ‘promote’ the cognitive behaviour therapy and graded exercise therapy protocols that they themselves had developed. The Times of August 1st 2017 reported a ‘trade’ of ‘insults’ between both sides.

                       PACE Trial £5 million

                                                                                           IAPT £400 million +

But the same criticism that the editors make of the evaluation of CBT for CFS can be applied to how CBT for ‘depression and anxiety’ (the alleged focus of IAPT) is evaluated in routine care in the UK Government’s IAPT Service. Evaluation is entirely based on subjective measures (the PHQ-9 and GAD-7), there is no objective measure (a standardised reliable diagnostic interview), assessment has been entirely by the service providers with no independent assessment. The cost of the PACE trial was just £5 million, a drop in the ocean compared to the cost of IAPT which saw the Coalition Government invest up to     £400 million over the four years to 2014–2015. [Department of Health (2012). IAPT Three-year Report—The First Million Patients. London: DH] .

Dr Mike Scott

 

Mental Health Services Expansion Before Completion of Investigation!

On July 31st 2017, the Health Secretary, Jeremy Hunt announced funding for an extra 2,900  new therapists in Adult Mental Health talking therapy services. A week earlier the National Audit Office invited submissions for its’ investigation into IAPT, with a closing date of this Autumn. It is clearly the time of the year for the Mad Hatter’s Tea Party:

 

be careful that you don’t mutter under your breath at such gatherings that ‘evidence should precede action’, if heard it could be ‘off with your head’.

But beware, the historian High Trevor Roper wrote in the Last Days of Hitler ‘mythopoeia is a far more common characteristic of the human race than veracity’. The wholesale endorsement of IAPT by BABCP and to a lesser extent by BPS reflects mythopoeia:

 

IAPT with its low intensity modality has attempted to make therapy ‘simpler’ than simple, resulting in ineffective treatment.  When it comes to the high intensity modality it has made matters ‘simpler’ than simple, by abandoning reliable diagnosis/high specification of problem/s as a Sat Nav for treatment again often resulting in ineffective treatment.

 

Dr Mike Scott

 

National Audit Office IAPT Investigation, Whistleblowers

Below is the National Audit Office’s request for evidence re: IAPT, I note they have a whistleblower’s policy. It may be possible to ask for anonymity. I would hope that BABCP and BPS would make a submission to the National Audit Office, but to my knowledge this is not on the agenda of either, why not?

Investigation: Improving Access to

Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to

National Institute for Health and Care Excellence approved treatment for depression and

anxiety disorders. In October 2014, the Department of Health and NHS England

jointly published Achieving Better Access to Mental Health Services by 2020. This set new

standards for the time people should wait for mental health treatment and the care they should

be able to access. In the case of IAPT services, the standards are that 75% of people referred

should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of

those who complete treatment will recover. NHS Digital publishes monthly statistics

that report performance against these standards. This investigation will establish the facts

around how the national statistics are prepared.

If you would like to provide evidence for our study please email the study team on

enquiries@nao.gsi.gov.uk, putting the study title in the subject line. The team will consider the

evidence you provide; however, please note that due to the volume of information we receive we

may not respond to you directly. If you need to raise a concern please use our contact form.