Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

‘Attempts to Justify The Cost-Effectiveness of IAPT…Severely Lacking’

this is the conclusion of a recently published study in the Journal of Health Psychology

https://doi.org/10.1177%2F1359105318803751

Scott Steen, the author of the the new cost-benefit analysis, comments ‘The first limitation concerns the high proportion of early disengagement which, according to the latest annual report, around 40 per cent of those entering treatment attend one session only (IAPT, 2018). Within the same annual report, approximately 43 per cent of assessed-only referrals were deemed suitable but declined treatment, while
23 per cent were deemed not suitable, and only 9 per cent were discharged by mutual agreement following advice and support (IAPT, 2018). The second limitation concerns the heavy reliance on brief, self-report measures and lack of long-term outcomes which, when using more in-depth and longitudinal techniques, have found intervention effects to be diminished or even temporary (Ali et al., 2017; Cairns, 2013; Hepgul et al., 2016; Marks, 2018; Scott, 2018)’.

Steen continues ‘research used to justify the economic benefits of the IAPT programme has little relevance for how it delivers and evaluates interventions. For instance, Layard and Clark (2014) cite a study conducted by Fournier et al. (2015) to justify the potential rate at which individuals move from incapacity benefits into employment. However, this specific study focuses only on patients who had recovered from severe depression, were assessed using structured clinical interviews and diagnostic criteria, and were treated by highly trained practitioners, the majority of whom had PhDs. Similarly, research into the long-term effects of interventions appears to have been selectively chosen, omitting the generally limited to mixed findings in this area (Marks, 2018)’.

In summary Steen opines:

Taken as a whole, the IAPT programme seems to be delivering treatment at an inefficient cost. Although outcome targets are being reached, this appears to be due to an increased emphasis on low-intensity styled provision which not only drives up costs-per-IAPT outcome but also potentially reduces the appropriateness of treatment allocation and sustainability of these outcomes’.

All CCGs should be asked to consider this study.

 

Dr Mike Scott

Clinical Commissioning Groups Not Listening To GP’s on IAPT – The Chaos of Liverpool

Earlier this month Pulse reported ‘In Liverpool, Dr Barnett (GP) says services last year ‘couldn’t have been much worse’ and ‘GPs did not bother to refer patients [to IAPT] because nothing would happen’. Yet the Liverpool Clinical Commisioning Group in its report ‘Talk Liverpool Contract’ dated July 10th 2018 talked of a steady improvement of IAPT’s performance such that it fell just short of the target 50% recovery rate!  Via my MP Maria Eagle I complained that my own independent study of 90 former IAPT clients showed an overall 9.2% recovery rate. https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

The Chief Operating Officer,  for Liverpool CCG, Mr Ian Davies replied simply re-iterating IAPT’s national claims.

It is clear that when CCGs talk to IAPT Managers the discussion is about operational matters e.g number of client’s seen, waiting times etc and never about whether the Service makes a real world difference to patient’s lives. CCG’s have blindly taken on board IAPT’s own metric of recovery and its’ assessment of meeting targets, there would never be such incredulity about a drug. NHS Foundation Trusts ought to be challenging this naivety.

Dr Mike Scott