that is the finding of a survey of 550 current and past IAPT staff , https://survivingwork.org/5241-2/. The credibility of IAPT’s claims are in doubt, a referendum of its’ staff is needed.
NHS England is guilty of breathtaking naivety and laziness when it asserted on Radio 5 Live on Wednesday, November 13th, that 7 out of 10 IAPT clients move to recovery and 5 out of 10 recover. They did so without appeal to any independent audit. My own findings published in the Journal of Health Psychology last year suggested that actually the tip of the iceberg recover https://journals.sagepub.com/doi/10.1177/1359105318755264.
Clinical Commisioning Groups (CCG’s) should no longer see NHS England as a compelling source of persuasion in this matter, rather they need to listen to patients and the workers at the coalface. CCG’s should challenge IAPT to have a referendum of its staff at a local and national level, asking:
‘Do you want IAPT to move towards face to face assessment and treatment, as the norm?’
with simple ‘Yes’ or ‘No’ response options. The collective experience of IAPT workers has to be taken seriously. Judging by the stress levels reported by staff in the survey, IAPT cannot seriously maintain that it is discharging its’ duty of care to its’ staff.
bestowing their munificence without any audit by GPs of local benefit, at a cost nationally of billions of pounds. Yet it should be a simple matter for any GP to interrogate the practice database of IAPT ‘beneficiaries’ and ask the patient the basic question ‘are you back to your usual self since seeing IAPT’? and to further determine whether recovery is stable and reliable by asking ‘for how long have you been back to your usual self?’ Then to integrate the responses with any recent record of functioning in the record of Consultations. Such data can then be presented to the local GP reps on the CCG’s to decide whether the local IAPT is value for money.
CCG’s need to move beyond simple operational matters of numbers of patients seen and waiting times, to a determination of the percentage of people recovering. The randomised controlled trials of cognitive behaviour therapy for depression and the anxiety disorders have suggested a 50% recovery rate when there has been blind assesment of patients. This was the original justification for IAPT. The suspicion is from my independent analysis of 90 IAPT cases that in routine practice the recovery rate is about 10% see link below
However when IAPT marks its’ own homework it miraculously comes up with a 50% recovery rate and has seduced CCGs with its own data. The response of most GPs to this is ‘give us a break, but I am nevertheless grateful for a respite from the patient if they are seeing someone else, so I can get on with my core tasks’. We need to move on to a point where GPs are to a degree advocates for their patients, if they don’t do it no one else will. Without such advocacy mental health patients become not just Cinderellas compared to patients with physical problems but confined to their own personal asylum.
It is perfectly possible transform IAPT so that it properly translates the findings of rcts into routine practice, see my trio of Simply Effective Cognitive Behaviour Therapy books published by Routledge and my last book Towards a Mental Health System that Works (2017) London; Routledge. But we need to wake up and smell the coffee.
Clinical Commissioning Groups (CCG’s) should consider why other parts of the UK have not followed England’s lead on IAPT, after more than a decade. Wales, Scotland and Northern Ireland have remained unimpressed by IAPT’s groundbreaking claims and have not followed suit. In Wales almost 40% of people surveyed said ‘yes’ or ‘mostly’ when asked had the services they accessed led to improved mental health and wellbeing [Gofal (2016) Peoples experiences of primary mental health services in Wales Three Years On]. The results show that the largest proportion of respondents (79%) were offered prescription medication. The proportion of people who felt that they has been offered advice and information was 77%. 21.5% were offered Cognitive Behavioural Therapy, while 32% were offered another form of psychological therapy. 36% were offered a further mental health assessment. 26% were referred to another service and 17% were signposted to another service. Just 12% were offered physical exercise, 10% were offered books on prescription and 3% were offered befriending. If you have a mental health problem in Wales it is not obviously worth the trip across the border to an English IAPT service.
There are undoubtedly serious problems with mental health services across the UK, but these are no less in England despite IAPT. .
Clinical Commissioning Groups (CCG’s) fund IAPT (Improving Access to Psychological Therapy Services), but have failed to ensure that mental health sufferers are not given the cheapest option, guided self-help (GSH), without being informed of its poor performance compared to regular therapy. GSH is the most commonly proferred service by IAPT and its’ usage has breached informed consent. As Pim Cuijpers https://doi.org/10.1111/cpsp.12238 has observed ‘A self-help intervention cannot replace more usual forms of psychological treatment and this should be made clear from the beginning’. CCG’s are risking legal action from patients given the cheapest treatment option without explanation of alternative treatments, risks and benefits. There is a pressing need for CCG’s to seriously appraise IAPT and not blindly fund it because ‘it is the only show in Town’.
The response of CCG’s to any criticism of IAPT is typified by the letter below that I received from the
Liverpool CCG, published as an appendix in ‘Transforming IAPT’
CCG’s are rubber stamping the funding of IAPT services, without questioning the alleged 50% recovery rate for depression and the anxiety disorders. But CCG’s would never give approval to the dissemination of a psychotropic drug based solely on the manufacturer’s claim. It seems that GP’s on CCG’s are too busy to critically appraise IAPT’s claim. CCG members need to ask why £1bn has been spent on IAPT services that have never been independently evaluated using a rigorous methodology. My own, by no means definitive study of 90 consecutive attenders at IAPT suggests a 10% recovery rate [ the paper ‘IAPT The Need for Radical Reform’ can be accessed by selecting below and right clicking https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/]. CCG’s are like the Titanic, heading towards an iceberg, on board are not only depressed and anxiety disorders passengers but a recent cohort of those with long term physical health conditions and medically unexplained symptoms:
Via my MP, Maria Eagle I put the following questions to the Liverpool CCG, (one of the CCGs covering the IAPT clients I examined in the North West) and their response dated March 6th 2018 was as follows:
Are the CCG aware that the recovery rate in the IAPT Service they fund is just 10% (far short of the 50% recovery rate targeted by Alan Johnson, then Labour Minister in 2007 when the service was set up).
Latest local data indicates that the current recovery rate for the service stands at 50%, targets for access and recovery are under regular review with performance reported to NHS England and published nationally and through LCCG Governing Body papers.
What, if any independent data do the CCG use in assessing the IAPT Service? Response 2.
All IAPT services must assess their performance using nationally mandated measures contained within the IAPT Minimum Data Set (v1.5). Information on these measures and the outcomes achieved by IAPT services can be obtained from NHS Digital.
Why have the CCG never asked IAPT service users their opinion of the service? Response 3.
All IAPT services routinely ask every IAPT service user their opinion of the services using 2 measures, the Patient Experience Questionnaire (Assessment) and the Patient Experience Questionnaire (Treatment). Information on these measures and the patient satisfaction levels achieved by IAPT services can be obtained from NHS Digital.
Why do the CCG consider it acceptable to continue to fund a service, were assessments are conducted by telephone by the least experienced and qualified staff? Are they supporting a double standard for physical and mental health?
LCCG has commissioned a service in line with NICE guidance both in terms of accessibility and responsiveness, but also the required skills of staff employed by the service.
What steps will the CCG take to ensure that evidence based treatment takes place in IAPT? Response 5.
All treatment provided by Talk Liverpool conforms to the following NICE Guidelines which lay out the evidence based therapies that should be offered for disorders of anxiety and depression:
NICE Guidance for depression in Adults (CG90)
NICE Guidance for Depression in adults with a chronic physical health problem (CG91) NICE Guidance for Common Mental Health Problems (CG123)
NICE Guidance for Generalised Anxiety Disorder and Panic Disorder in Adults (CG113) NICE Guidance for Obsessive Compulsive Disorder and Body Dysmorphic Disorder in Adults (CG31)
NICE Guidance for Post-Traumatic Stress Disorder (CG26) All the above can be accessed through;
How will the CCG ensure that GPs are given comprehensive data on the functioning of their patients? Currently data is supplied to GPs on less than half of patents and purely in the form of psychometric test results, there are no ‘gold standard’ diagnostic assessments conducted at all. How will the CCG remedy that IAPT workers do not know what they are treating?
GPs are informed of the outcome of all their patients’ therapy episodes with Talk Liverpool. This includes both psychometric scores and clinical information. With regard to “gold standard diagnostic assessments”, the IAPT service is a treatment service and not a formal diagnostic service. Talk Liverpool provide problem descriptors (and not formal diagnoses) as mandated by the IAPT Dataset V1.5 set out by NHS England, using the nationally mandated psychometric tests (details of which can be found in the IAPT Data Handbook published by NHS England).
Further information relating to IAPT nationally can be obtained through the National Collaborating Centre for Mental Health and NHS England who have recently published the IAPT Manual which outlines the model that all IAPT services should follow (including some of the procedures implemented by Talk Liverpool including some outlined in the responses given above).