Advice to the National Audit Office, ‘Gardening Is Cheaper Than Inept IAPT’

My independent audit of IAPT suggests a 10% recovery rate https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0.

A year ago the National Audit Office invited submissions for its investigation into IAPT, and has to date decided not to make its’ conclusions public. Whither transparency and the use of public funds? They failed to advise that gardening might be a better use of the public purse, then at least we would get tomatoes.

 

Dr Mike Scott

House of Lords – Expansion of IAPT into ME Despite Not Knowing How Such Clients Have Already Fared In The Service!

Chronic Fatigue Syndrome: Written question – HL7468

Asked by The Countess of Mar
Asked on: 01 May 2018

Department of Health and Social Care
Chronic Fatigue Syndrome

HL7468
To ask Her Majesty’s Government what are the recovery rates of patients with myalgic encephalomyelitis who have received treatment under the Improving Access to Psychological Therapies programme.

Answered by: Lord O’Shaughnessy
Answered on: 15 May 2018

This information is not available

 

 

Whatever happened to evidence based CBT?

 

Dr Mike Scott

National Audit Office IAPT Investigation ‘progress..slipped substantially….

We have not yet made a firm decision about whether or not we will publish a short report on IAPT in due course…We may choose to simply write a management report’, my communication received from the NAO today. I have made a Freedom of Information request re: the decision making and communications, which legally I should have in the next 10 days.

 

 

Given that £1bn has been spent on IAPT not to have an independent audit/assessment  seems scandalous. Claims of competing pressures is not terribly convincing.

Dr Mike Scott

 

Without A Written Aid To Remembering Session Content Little Chance Of Real World Change

Most client’s are highly anxious, the chances of them remembering session content accurately, much less applying it, are therefore slim. But review of therapy records usually provides no evidence of session summary or detailed specification of homework. At most therapists may write ‘activity scheduling’, ‘thought records’ or ‘continue exposure’. Compare this vaguenness with the specificity of a medical prescription “take ‘x’ 3 times a day after meals’.  I remember a client with Multiple Sclerosis who was in agony with his symptoms for a couple of weeks before it was discovered he had inadvertently been prescribed a sub-therapeutic dose of medication. The lack of specificity about CBT homework means that it cannot be easily corrected and in essence there is no accountability as there is in medicine. Below replace ‘students’ with ‘clients’:

If CBT is primarily educational then we have to teach properly. But training does not equip therapists to teach, even worse therapeutic interventions are often not modelled by tutors first!

Despite therapists endeavours clients lose out because of poor therapist training, psychological therapists often come off CBT courses less confident than when they began.

Dr Mike Scott

IAPT and The Absence of Treatment Markers

IAPT purportedly offers NICE –indicated treatments for depression and anxiety at Steps 1-3.  But the NICE guidelines do not offer guidance on the treatment of specific phobias or adjustment disorder.   So that in practice Psychological Therapists fail to adequately distinguish between these excluded categories and the included ones such as PTSD, OCD etc.  The result is that there is a serious mismatch between disorder and treatment, for example I’ve just seen a person treated with 10 sessions of trauma focussed CBT, I knew him to have simply a specific phobia about driving and travelling as a passenger in a car and he was still suffering from just this after IAPT treatment. The treatment records referred to ‘likely PTSD’,   such statements are not only unreliable but dangerous. There is a need for a

In practice IAPT treatment is determined by therapists rules of thumb, such as ‘if the trauma was extreme and there are disturbing intrusions go for PTSD treatment’, ‘if there was prolonged abuse go for complex PTSD’, ‘ a high score on the Impact of Events Scale means PTSD is likely’,  but there is no scientific basis for such rules.  The NICE guidance makes no mention of treatment being determined by the therapists ‘formulation’, but many therapists are perfectly happy with this supposed magical insight into the way forward, which they see as a product of their clinical experience and acumen.  In practice lip service is paid to the NICE guidelines, for the most part therapists do their own thing, with perhaps a psychometric test such as the IES thrown in to appease management and a concern to use keywords like habituation, trauma focussed CBT and exposure. Training courses do not it seems help students critique the validity of the IAPT treatment approach.

Wither true accountability?

Dr Mike Scott

Mis-selling of the Cognitive Therapy Rating Scale

If your performance has been evaluated using the cognitive therapy rating scale (or the revised version) you may have a claim for ‘damages’. Curiously the cognitive therapy rating scale has a shaky foundation:

  1. The CTRS has only been evaluated in a sample of depressed clients undergoing cognitive therapy [Shaw et al (1999)] , therapists scores on this did not  predict outcome on self-report measures the Beck Depression Inventory or the SCL-90 (a more general measure of psychological  distress) however it did predict outcome on the clinician administered Hamilton Depression Scale predicting just 19% of the variance in outcome, but it was the structure parts of the scale (setting of an agenda, pacing, homework) that accounted for this 19% not items measuring socratic dialogue etc. The authors concluded: ‘The results are, however, not as strong or consistent as expected’
  2. There is no evidence that the CTRS is applicable to disorders other than depression. Some aspects of the CTRS such as socratic dialogue may be particularly inappropriate with some clients e.g OCD and PTSD sufferers.
  3. The CTRS does not make it clear that the clinician cannot have set an appropriate agenda without reliably determining what the person is suffering from.
  4. In practice raters appear to pay more attention to the socratic dialogue item as opposed to interpersonal effectivenes (e.g non-verbal behaviour). There is a poor intra class correlation of the order 0.1, ratings of least competent therapists are more in agreement with those of supervisors than the more competent therapists! [McManus et al (2012)]
  5. The Hamilton Scale used in the Shaw et al (1999) study was developed before the development of DSM criteria and it is questionable about whether any correlation would be found between DSM diagnostic status and score on the CTRS for depression or indeed any disorder.

 

Dr Mike Scott

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 – Supervision

As I mentioned in my first post last week I was working in IAPT in Bury in 2015. Clinical Supervision was delivered in the group setting and was not compulsory to attend.  Often the supervision had to be postponed for several weeks if the supervisor was either not available or was on holiday or had casework at a higher step which took precedence over the needs of the group.  Personal supervision was a similarly structured affair, with pressure and time constraints eating into very short sessions.

 

It was incumbent upon the supervisee to ensure that “risky cases” were discussed in a timely manner, since it was the supervisee’s responsibility to “raise the alarm”.  In many cases, the supervisee was not aware that any alarm needed to be raised, since they were inexperienced with either the identification or managing of risk with regard to mental health patients.  Please do not take this as a criticism of my colleagues; it is a criticism of the system’s failure to provide them with the knowledge they needed to understand the risks.

Anonymity protected Dr Mike Scott