Unregulated Mental Health Service Has Run Away With £4 billion

Following a Freedom of Information request NHS Improvement confirmed to me yesterday that the the total cost of the Governments Improving Access to Psychological Therapies (IAPT) Service in 2017/18 was £394 million.  I had asked them for the annual cost of IAPT since its’ inception, but they said that they were unable to furnish such figures! The service is twelve years old, thus conservatively it has likely cost the taxpayer £4 billion. 

For Rail and Road we have a regulatory body the  Office of Rail and Road, that monitors the performance of Network Rail and the varying train operators, but for mental health there is no such independent regulatory body. IAPT polices itself, and makes unexamined claims of recovery rates to secure funding from Clinical Commissioning Groups, who have never performed an independent audit. In my own area, Talk Liverpool last October publicly claimed an 87% recovery rate  for those who completed treatment, unsurprisingly therefore the Liverpool CCG has increased its funding by 25% to 10 million in the coming financial year. My own research published in 2018 suggests an actual 10% recovery rate.

It is time that the Government and Dominic Cummings got to grips with this.

The dropbox link to the FOI  response is below:

https://www.dropbox.com/s/x5kza6e6bpft2b3/Scott%20Internal%20Review%20Decision%20Letter%2020.01.2020.pdf?dl=0

My own findings are in the dropbox link below;

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

more about these matters anon

Dr Mike Scott

A Critical Transatlantic Take on IAPT

Dr David Tuller from the University of Berkeley, California has penned a very critical blog on IAPT  http://www.virology.ws/2020/01/15/trial-by-error-cbt-provides-no-benefits-to-advanced-cancer-patients-study-finds/

two years ago he was one of the authors of a reanalysis of the PACE trial data on the efficacy of CBT for chronic fatigue syndrome and essentially found the data had been fudged.

Dr Mike Scott

Rely Solely On A Self-Report Measure To Hike Up Funding and Fudge Outcomes

the routine audit of mental health services such as IAPT, is based on client self-report measures such as the PHQ9.  This carries the implicit assumption that the cut offs by themselves meaningfully distinguish cases from non-cases.   Correspondence in this months British Journal of Psychiatry highlights how misleading reliance on a single self-report measure can be. One study using this methodology claimed two fifths of 11-15 year olds had mental health problems  but when in another study assessment was conducted using standardised diagnostic interviews and diagnostic criteria the figure was just 13.6%!. doi:10.1192/bjp.2019.225

Whilst claims of high prevalence rates might be good for funding purposes and placing mental health on the public agenda there is no real world change for clients, the powerholders are the only beneficiaries.

In October 2019 my local IAPT claimed 87% (Talk Liverpool Performance Data) of those who completed treatment recovered in the previous 12 months, making Talk Liverpool outperform all other IAPT services (a national claim of a 50% recovery)! I can only think that Talk Liverpool have looked with envy at how Liverpool FC outperforms  all other teams and has gone into delusional mode! My own    study of 90 IAPT clients that I assessed independently using a standardised diagnostic interview showed that only the tip of the iceberg recover, see link below:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Rogers and Bender have written about ‘the myth of the laser accuracy of cut offs’ in their seminal work ‘The Clinical Assessment of Malingering and Deception’ (2018) Guilford Press.  Clinical Commissioning Groups could do with lessons in all these issues when interacting with IAPT and stop displaying such breathtaking naivety. 

Dr Mike Scott

 

Groups An Attractive Option…. But?

Last month I gave a days workshop ‘Better Together’ at the Maudsley Hospital for an IAPT Service, I did think it was going into the lion’s den but the hospitality was superb.  The link to my presentation is below:

https://www.dropbox.com/s/4i2tw7l2t4rxnfr/Better%20Together.pptx?dl=0

I presented  for the  first time the DAGger for groups, a questionnaire containing the dysfuntional attitudes that will often have to  be circumnavigated to successfully engage someone in a group. I also spelt out how to engage in a debate about the ‘DAG’s using the vectors of validity, utility and authority. But such dialogues are not easily possible with IAPT’s standard triage, there is a need  for reform to make groups properly viable. One of the problems with groups is that those most likely to benefit from groups are those least likely to agree to attend!

Groups are not the same as classes and I was struck at the Workshop by the lack of understanding that there is a strong evidence base for the former       for depression and most  anxiety disorders but the evidence base for the latter is extremely weak by comparison. There was also near universal acceptance that a stepped care model was intrinsically better and that not having an extended face to face conversation with a client initially was in any way problematic. Near the end I did mention my  findings of a 10% recovery rate in IAPT see link below:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

but by then attendees were either too tired/polite/fearful to say anything. But I must thank Marion Cuddy the organiser for a great day.

Dr Mike Scott

£3 Billion Spent On Talking Therapies For No Clear Benefit

when will the Government insist on an independent evaluation of the Improving Access to Psychological Therapies Service? These are the concerns raised in my just published paper ‘Ensuring IAPT Makes A Real-World Difference’ see link http://mhfmjournal.com/Inpress.html

The Key Messages are:

  • Over the last decade over £3billion has been spent on the UK
    Government’s Improving Access to Psychological Treatment
    programme, without any independent assessment of outcome.
    • IAPT claims a 50% recovery rate but other evidence suggests
    that only the tip of the iceberg recover.
    • Expansion of IAPT beyond its remit of depression and anxiety
    disorders should be halted, until it has been demonstrated
    that it adequately performs its’ core task.

Clinical Commissioning Groups are being defrauded by IAPT’s claimed recovery rates

Dr Mike Scott

Mental Health – Propaganda For IAPT and Antidepressants Far Outstrips Evidence of Effectiveness

a just published editorial in Psychological Medicine 1–10. https://doi.org/10.1017/S0033291719003295 indicates that it is  doubtful that antidepressants exert a clinically significant effect compared to being on a waiting list for depressed patients. Strangely the editorial goes on to recommend IAPT as an addition to antidepressants. But there are major problems with this a) the effect of IAPT has never been compared to a waiting list b) IAPT clinicians do not make a diagnosis, so that it is unknown whether IAPT makes a difference for depression c) there has never been an independent evaluation of IAPT. In fairness to the writers of the editorial they do suggest halting the embrace of IAPT until the Service demonstrates that it has a long term effect.  NHS England and Clinical Commissioning Groups should at least heed this latter point. 

here is my 5 minute interview with BBC TV, https://vimeo.com/316124732

and a link to the waiting list  investigation by BBC Radio 4 last week:

https://www.bbc.com/news/health-50658007

the main points of my interview are:

  • only the tip of the iceberg of those attending IAPT fully recover https://journals.sagepub.com/doi/10.1177/1359105318755264 this contrasts with the Organisations claim of a 50% recovery rate
  • IAPT has only ever marked its’ own homework, despite over £3 billion being spent on it in the last decade. There has been no independent assessment of outcome, of the quality that would be expected were the effectiveness of a drug was being evaluated
  • IAPT fails to effectively engage and treat people. The IAPT Annual Report (2018)/2019] see link below, reveals that a third (31.2%) of new referrals drop out before treatment and approximately two thirds (61.1%) do not complete a course of treatment (using IAPT’s liberal definition of treatment as attending 2 or more session) with almost a third (29.54 %)  attending only one treatment session.

    https://www.dropbox.com/s/hwn9ncuuyds8qfa/IAPT%20Annual%20Report%202018-2019.pdf?dl=0

  • the most common gateway into IAPT is via a 20-30 minute telephone assessment with the most junior members of staff who are trained to signpost people via problem descriptors they do not make diagnoses
  • most IAPT clients do not get psychological therapy rather they are given either guided self help, computerised cbt or invited to attend a class/group i.e they receive low intensity interventions which are without the evidence base of the psychological therapies (high intensity)

Dr Mike Scott

BBC Chooses To Ignore Talking Therapies 10% Recovery Rate

this morning BBC Radio 4 focussed on the problems caused by the Improving Access To Psychological Therapies (IAPT) long waiting lists (half more than 28 days)  but reiterated IAPT’s claim of a 50% recovery rate. But IAPT has only ever marked its’ own homework on recovery rates. I spent hours explaining to Radio 4 reporters that the true recovery rate is more likely 10% as detailed in my paper published in the Journal of Health Psychology last year, but they totally ignored this – shortening waiting time for something, that is most likely to be ineffective approaches pointlessness:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

billions of £s have been spent on IAPT over the last decade all without any publicly funded independent assessment of outcome, this would never have been permitted in evaluating a drug. NHS England claimed IAPT has exceeded expectations , but can cite no independent evidence. NHS England have failed the public in terms of accountability. There are so many vested interests in IAPT that the great majority of patients are likely to continue to be short changed. The yardstick has to be the proportion of people who get back to their old selves post-treatment, my study of 90 IAPT clients found that only the tip of the iceberg recover. NHS England need to commit to a publicly funded independent assessment of IAPT using real world outcome measures such as loss of diagnostic status for at least 8 weeks.

There is a troubling alliance of powerholders BBC, IAPT, BABCP and BPS that is ignoring the real needs of those with mental health problems.

 

Dr Mike Scott

  

Only The Powerholders Believe In IAPT

politicians of all political parties and the media believe in IAPT, that should make one immediately suspicious! A decade on there is no evidence of:

  • economic saving – see this link https://www.academia.edu/39289068/Comparative_public_policy_-_the_economic_policy_failure_of_IAPT_in_the_NHS_improving_access_to_psychological_therapies_ either in terms of a) a reduction in work absenteeism b) number of people helped into work or c) reduction in benefit payments
  • psychological recovery – there is no evidence that IAPT clients lose their diagnostic status with treatment, much less that any changes are enduring. When IAPT marks its’ own homework it claims a 50% recovery rate (but without claiming how long this lasts!) but independent assessment suggests only the tip of the iceberg recover

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Worryingly the iceberg may be melting with the high stress levels amongst IAPT frontline staff. Its much vaunted ‘low threshold’ for access means that therapists are ‘treating’ clients for problems in living e.g a stressed client forced to commute a long distance for financial reasons  complaining of insomnia and tiredness but being treated for depression because of her PHQ9 result! The therapist is stressed by her recovery target, that is unlikely to be met with this client, the client is stressed by the hoops she has had to go through to accommodate appointments in her busy schedule and all to no avail. 

No politician wants to admit the wasting of a £1 billion on IAPT in the last decade. The media and politicians are desperate for a good news story, claiming the success of IAPT and the moral highground of being anti stigma and for mental health gives a warm glow in the winter of our discontent.

But if treatment services began with the hospitality that traditionally marks the Christmas season, then actually they would not go far wrong, it’s not that complicated. 

Dr Mike Scott

IAPT Revolving Door Data Casts Doubt on Recovery Rate

following a Freedom of Information Request from Dr Elisabeth Cotton last year, it appears that 1.5 million people were referred to IAPT between 2 and 10 or more occasions in a 6 year period (2012-2018), with 3.2 million people referred just once. A re-referral indicates that treatment had no enduring effect. Further IAPTs claim is for a 50% recovery rate,  thus at face value 1.6 million would have recovered, but this is only a third (34.5%) of those referred, not a half! Thus even within IAPT’s own terms its’ claims are dubious. 

The staff of my local coffee shop always say ‘see you soon’ as I depart, perhaps this is what IAPT ought to say to clients albeit that in low intensity they won’t actually ‘see’ them, such hospitality. 

IAPT Defrauding A Local Clinical Commissioning Group?

on November 20th I wrote to the Chief Officer, (see link below), of  the Liverpool Clinical Commissioning Group, about Talk Liverpool’s claim that it has had an 87% recovery rate in the last 12 months [see Talk Liverpool’s Performance Data]. A Freedom of Information Response that I received on November 19th from the Liverpool CCG revealed that this financial year it expected to increase its’ funding by £2.5 million to £10.6 million. IAPT’s local claims are eye-brow raising as nationally IAPT claim one in two recover [see IAPT Manual (2018)]  – Talk Liverpool have clearly discovered some therapeutic secret that is being kept very secret!   Liverpool CCG has spent £60.6 million on IAPT since 2013-2014 all without any independent assessment. The CCG has simply taken Talk Liverpool’s word and focussed entirely on operational matters such as numbers seen and waiting times. 

https://www.dropbox.com/s/7ch5uka6yq8pukd/CCG%20letter.docx?dl=0

But the issue is not confined to Liverpool, Mental Health Commissioners nationally need to be critical of IAPT. Unfortunately the focus of Mental Health   Commissioners Network Forum is simply on building liason between Commissioners and Providers. The IAPT National Networking Forum  meeting on January 21st  is to be addressed by the Forum’s Deputy Chair. The day is titled ‘Building and developing your service to meet IAPT LTC expansion’ the advertising blurb  for the meeting reads ‘With access rates going up, is your service trying to do things you don’t have the capacity to do? IAPT staff are invited to bring along a Commissioner free of charge. There is a pressing need for Mental Health Commissioners Network Forum to address the question of the reliability of the evidence that IAPT is value f or money.