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

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

 

£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

IAPT’s Training Fails But CBT Can Make a Real World Difference

three papers just published in the journal Cognitive Therapy and Research, tell contrasting stories: two are by leading lights in IAPT assessing the competence of trainees, in neither study did they demonstrate any real world outcome. By contrast in a study by Perrin et al (2019) of individual CBT for children (aged 10 to 18) suffering from generalised anxiety disorder 80% no longer had GAD by the end of 10 sessions of treatment compared to 0% in the waiting list.   These impressive results were maintained at 3 month follow up.

IAPT could learn from the Perrin et al (2019) study in that client’s diagnostic status was assessed using  a standardised diagnostic interview  and again at the end of treatment using blind assessors, further therapists followed an evidence based protocol for the identified disorder. Whilst it is costly to make such rigorous assessments and IAPT might fear having to explain to Clinical Commissioning Groups the necessary change in modus operandi, IAPT might then at last make a socially significant difference.

IAPT has been provisionally scheduled to be the focus of presentations on BBC TV and Radio on Wednesday, November 13th. 

Perrin et al (2019) Cognitive Therapy and Research (2019) 43:1051–1064
https://doi.org/10.1007/s10608-019-10020-3

Liness et al (2019) Cognitive Therapy and Research (2019) 43:959–970
https://doi.org/10.1007/s10608-019-10024-z

Liness et al (2019) Cognitive Therapy and Research (2019) 43:631–641
https://doi.org/10.1007/s10608-018-9987-5

Dr Mike Scott

National Audit Office Failed To Audit Improving Access To Psychological Therapies Service

 

because it was ‘too busy’. In response to a freedom of information request, from Liverpool, Consultant Psychologist, Dr Mike Scott, the NAO said on November 1st 2019 that amongst its’ reasons for curtailment of its’ investigation were Brexit, the collapse of Carillion and spending increases on generic medicines.  Further the cost of its’ incomplete investigation in 2017-2018 was £74,000. But Dr Scott comments that the reasons that prompted the investigation still remain. He adds that the IAPT service has cost the taxpayer over £3 billion in the last decade with no independent audit of outcome. Clinical Commissioning Groups have simply taken at face value IAPT’s marking of its’ own homework – whither accountability? The NAO response is a yet further illustration that despite official assurances mental health is at the bottom of the agenda. Is it beyond the political parties to go beyond the rhetoric on mental health at the forthcoming general election and commit to an independent inquiry as to how IAPT client’s actually fare? 

In his submission to the NAO Dr Scott pointed out that IAPT had never been subjected to independent audit using the ‘gold standard’ methodology that has been used to assess the effectiveness of a drug. His own published research see link https://journals.sagepub.com/doi/10.1177/1359105318755264 has suggested that only the tip of the iceberg of IAPT client’s recover much less than the 50% claimed by the Organisation. The Journal of Health Psychology also published 3  commentary papers and a rebuttal paper by Dr Scott.  He suggests  that Clinical Commissioning Groups should in the short term refuse to fund the low intensity interventions (guided self- help, computerised cognitive behaviour therapy and educational classes)  that the majority of IAPT clients receive and for which the evidence base is particularly weak, in favour of funding the face to face psychological therapies and for the long term insist that they will be guided by an appropriate independent audit.

Dr Mike Scott

 

 

 

 

 

Expansion Into Long Term Conditions By IAPT Is Quackery

so challenge Clinical Commissioning Groups on the value for money – no better than homeopathy. Studies of CBT  for long term conditions (LTCs) show either no effect, see Serfaty et al study (2019) on cancer https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/effectiveness-of-cognitivebehavioural-therapy-for-depression-in-advanced-cancer-cantalk-randomised-controlled-trial/E9264C516634EC7BC3FF9E80B551A8C5

and/or rely on a self report measure of questionable real world significance, see the Everitt et al  (2019) study of irritable bowel syndrome https://www.thelancet.com/journals/langas/article/PIIS2468-1253(19)30243-2/fulltext In the Everitt et al (2019) study outcome was assessed primarily by the patient’s completion of a 5 item measure of the severity of IBS (IBS-SSS) rather than a clinician independent of the study asking the IBS-Adequate Relief  question ‘ since… have you had adequate relief of your IBS’. Usually the IBS-AR uses the time frame of the past seven days but in the context of assessing CBT it could be since entering the study for a control group or since cbt for those having cbt.  The correlation between the IBS-AR and IBS-SSS though significant is small see Passos et al (2009) http://nrs.harvard.edu/urn-3:HUL.InstRepos:35859644

The authors of the Everitt et al (2019) study appear not to realise  that use of a self-report measure as the primary outcome measure introduces a demand effect for clients undergoing cbt, they don’t want to feel that they have wasted their time. Further the Passos et al (2009) study showed that the IBS-AR is much less subject to fluctuation than the IBS-SSS. Arguably the IBS-AR is of much greater social significance, addressing whether an intervention makes a real world difference. 

It is worrying that Everitt et al (2019) opine:

‘Offering both web-CBT and telephone-CBT in NHS services such as Improving Access to Psychological Therapy could allow many patients to gain substantial benefits with web-CBT with minimal therapist input while allowing a step-up approach to telephone-CBT for those needing additional
support’

IAPT will surely jump on this to justify empire building and likely ignore the caution of Serfaty et al (2019) 

‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these  findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’

If as seems likely Clinical Commisioning Groups fund IAPT’s expansion into LTCs they should be asked to justify this expenditure in the abscence of any empirical base.  

Dr Mike Scott

Only The Client Knows Whether Psychological Treatment Has Made a Clinically Relevant Difference

trouble is nobody asks them! When was the last time you remember a client being asked ‘are you back to your usual self with the treatment you have had’? Organisations, such as IAPT have their own metric, a decrease on a psychometric test and in secondary care psychiatrists will opine ‘seems a bit brighter to day, increase…’. These ‘metrics’ ensure the survival of the Organisation, but have no demonstrated relationship to loss of diagnostic status as assessed by a clinician independent of the service provider.

In a study by Stegenga et al (2012) see link below depressed patients were followed up over 3 years whether there depression took a chronic (17%), fluctuating (40%) or remitting course (43%) course they all showed decreases in PHQ9 scores throughout the study and without any psychological intervention. The only exception was a worsening of PHQ9 score at 6 months for the chronic subgroup. Similarly a 12 year study of anxious patients Bruce et al (2005) showed they were only suffering from their anxiety disorder 80% of the time. Thus finding a decreased psychometric test score per se does not mean anything.

Bruce et al (2005) linkhttps://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

Stegenga et al (2012) linkhttps://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

Organisations and Clinical Commissioning Groups much prefer to talk about operational matters, numbers and waiting lists and show no interest or expertise in reliably assessing clinically relevant outcomes. But it is not just these bodies, the leading journals have for the past decade predominantly published papers on the efficacy of psychological interventions with no insistence that there should have been blind independent assessment. Instead self-report measures have ruled with little awareness that their completion is subject to demand effects and the measures often bear no obvious relationship to the construct under examination.

It is difficult to escape the conclusion that clients are largely fodder for the Organisations. A problem that will not be resolved by increased funding for mental health services albeit that this is clearly needed or by atypical clients as tokens on mental health bodies. The fundamental problem is a lack of respect/reverence for clients.

Dr Mike Scott

Clinical Commissioning Groups Need To Know What Actually Happens Behind IAPT’s Closed Doors

this can be achieved by asking local GPs to ask patients about their experience and crucially to determine what proportion of patients returned to normal functioning after referral to IAPT.

Most IAPT clients receive low intensity CBT, with only 20% recovering, half of whom relapse in a year [ Ali et al (2017)]. Only 10% of LICBT patients are stepped up to high intensity. Independent assessment suggests the overall recovery rate in IAPT is just 15%.[ Scott (2018)] https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Results Show IAPT To Be No Better Than Pre-existing Services

A study from 2006 profiled the improvement rates of 32 primary care counselling services using the CORE Outcome Measure. (CORE-OM). The mean level of reliable improvement (including clients that also recovered)  was 72%. Across IAPT, the reliable improvement figure was 66%. But services can be re-organised to transform IAPT Scott (2018)

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

The Failure To Inspect

CCG’s and the National Audit Office show a conspicuous lack of interest in what is happening behind the closed doors of IAPT, preferring to take the Organisations marketing at face value. IAPT appears not to be accountable to the Care Quality Commission. But the CQC’s failure to effectively monitor institutions catering for those with learning difficulties and autism has unearthed a scandal, and instils little confidence in a critical appraisal of IAPT anytime soon.

An Illustration Of The Travails of a Low Intensity IAPT Recipient

Ted’s case illustrates the dire quality of service, he met IAPT in 2014, the records stated that he had been a worrier all his life, but no diagnosis was made. He was no better after 18 months of low intensity cbt. A lost soul:

Initially Ted was directed to a Psychological Wellbeing Practitioner and computerised CBT, Beating the Blues. Ted is recorded as finding the sessions helpful. At the end of LICBT it is recorded that

‘he would prefer not to access cbt again as good understanding of how his negative thoughts impact his behaviour regularly reads his previous cbt notes but implementation does not improve mood’ his psychometric test results are shown below, ‘his billboard’:

    PHQ9GAD7  
Feb 14   10   14  
 March 14 8   7
  May 14 5   9
  July 16 21 15
  August 16 20   18
     
     

At the end of his low intensity journey, there was again no assessment of his diagnostic status and he was understandably not enthusiastic about further CBT. It seems likely that few people are stepped up from low intensity to high intensity because cbt is at best seen as having limited utility.

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Dr Mike Scott

Clinical Commissioning Groups, IAPT’s Fairy Godmother

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

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

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.

Image result for clinical commissioning groups

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.

Dr Mike Scott