BABCP Response - NICE Consultation January 2022

How Do NHS Talking Therapies Clients’ Fare Downriver?

The Improving Access to Psychological Therapies River began flowing 15 years ago, rebranded NHS Talking Therapies last year. Yet we still don’t know how clients fare, downstream long-term. Quite why we don’t know is an interesting question. One doesn’t have to be a conspiracy theorist to suggest that there may be an unholy alliance of Service Providers and politicians/media at work. The former fearing independent public audit, the latter wanting to be seen championing the side of the ‘good’.

Clients invariably enter the river destabilised. Some may quickly regain their balance and be part of the 40% of people who do not go on to engage in treatment (defined by the service as engaging in 2 or more treatment sessions). But what proportion of those who have had treatment go on to return to how they were before entering the river? Or to put it another way, what proportion reach the promised land? What proportion  continue to thrash about at sea? Despite the much vaunted and extensive NHS Talking Therapies database it is impossible to answer these simple questions. There is clearly something amiss here. The answer cannot be to spend £2billion a year on child and adult services in NHS Talking Therapies. Just throwing money at a problem cannot be an answer to anything. 

The best guess from an independent review [Scott (2018)] is that only the tip of iceberg recover. The burden of proof is on those who would claim otherwise, simply reiterating NHS Talking Therapies mantra of a 50% recovery rate is not evidence.  

The NHS has proposed that interventions are evaluated using the mnemonic PICOTS. P requires a specification of the population being addressed and presupposes a reliable diagnosis. But NHS Talking Therapies therapists are not trained to make diagnoses. The Service therefore fails at the first hurdle. I stands for intervention and requires the specification of the intervention used so that it could be replicated and evaluated by other clinicians. But there have been no fidelity checks to establish whether a particular protocol has been followed. Rather there is a cacophony of voices claiming to deliver ‘CBT’. The service falls at the 2nd hurdle. C pits the service against a control condition, but there has been no such evaluation of NHS Talking Therapies. There is no reason to believe that its clients fare any better than if they had attended the Citizen’s Advice Bureaux. O refers to outcome, but there has never been a blind independent assessment of NHS Talking Therapies Clients instead there has been entire reliance on self-report measures which are subject to both demand characteristics (wanting to please the therapist and not think you have wasted your time) and regression to the mean (people invariably come at their worst and there is some improvement with time whatever. Finally there is T, which is about the duration of gains (time),  never has there been a real world assessment of recovery e.g lasting at least 8 weeks. NHS Talking Therapies fails all the NHS hurdles.

Dr mike Scott 

7 replies on “How Do NHS Talking Therapies Clients’ Fare Downriver?”

Any news on CQC looking at inspection and rating ?
“Improving access to psychological therapies (IAPT)
“Therefore, CQC is not able to
regulate psychological therapies in IAPT services and we hold no data relevant to the inquiry.
However, we are currently working with the Department for Health and Social Care, trade
associations and other key stakeholders to identify and understand how we may inspect and
rate psychological therapies going forward. Progress on this matter has been delayed due to the
Covid-19 pandemic”

Hi Michael
Very interesting, the short answer is that I don’t know. So have just e-mailed CQC to find out the current position. Will let you know if I hear anything.
Take care

This comes from 2020 Forgive my ignorance it might not be of value or apropos this link — 2020 Specification for Patient-level information and costing systems (PLICS) IAPT data set

It seems like there was a suggestion pre-pandemic to do costing in a different way, but no indication that this materialised and nothing to suggest regulation in a way a member of public would understand.
Take care Liz

Is “costing” a development of the Payment by results system, that was linked to clustering and care pathways. Evaluating the “care pathway” could be beneficial, costing seems to simply rely on IAPTs own KPI data being provided.
I’m not aware of care clustering being officially scrapped.

I also thought there may have been some benefits in people being able to identify their care cluster and then asking/demanding appropriate treatment eg. for cluster 3

“Moderate problems involving depressed mood, anxiety or other disorder (not including psychosis).”
– Care is usually provided by Primary Care or IAPT Services
– The problem is likely to be short term when treated
– The care package will contain high intensity psychological interventions, including individual therapy, possible medication and lifestyle and physical health advice.
– Clinical review will be carried out at a maximum of 6 months from commencement of treatment
– Treatment may be provided for up to 6 months”

So rather than being dependent on services making the decision and simply refusing or passing on to PWPs, people could hold the service to account.

Care Clustering appears to be used in IAPT, training course 2021

Mental Health Clustering Tool (MHCT)
Welcome to your Mental Heath Clustering Tool (MHCT) IAPT course

I’d be fascinated to see how this is being used by PWPs who have the majority of first contacts, along side “problem descriptors”. Personally I don’t think it’s used.
Another flaw in the IAPT/TT system?

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