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

IAPT – Improving Access to Placebo Therapies

There is no evidence that IAPT’s psychological interventions are better than placebo and the organisation ought to be renamed Improving Access to Placebo Therapies. This calls into question the unswerving devotion of Clinical Commissioning Groups (CCG’s) and the British Association of Behavioural and Cognitive Psychotherapy (BABCP) towards IAPT.

Expectations exert a powerful influence on any psychological therapy, yet in no IAPT study or analysis of its’ own data, has there been a comparison of the IAPT intervention, with that of a group who expected to get better with a particular intervention. There is no reason to believe that IAPT’s results exceed that of a placebo.

IAPT claims to follow NICE Guidelines in delivering evidence-based treatments (ebts) for psychological disorders. But as it takes no steps to reliably identify disorder/s thus there can be no certainty that an ebt is being used that matches the debility.

GPs’ Cognitive Dispositions To Respond Promotes IAPT

Seeing a GP is a common first step along the IAPT pathway, this of itself is likely to increase expectations that something can be done about the presenting problem. The patient then invests time and energy in the said IAPT intervention, at the end of that period he/she does not want to think they have wasted their efforts. Particularly so if the therapist has been ‘nice’, there is a desire to please him/her but this does not mean that they have met criteria for recovery as defined by NICE, i.e they would no longer be eligible to enter a randomised controlled trial for the disorder from which they were originally suffering.

GP’s might be glad of the placebo effect in that it gives them a brief respite from the patient. But because a placebo does not address the mechanism involved in the generation of a disorder, difficulties are ongoing.

It is easy for GP’s to convince themselves that the IAPT interventions are making a difference because in fact, at least for the anxiety disorders, patients naturally only suffer from a condition for 80% of the time.

Thus a GP can doubtless see a post IAPT client in a good state, the vividnes of this experience (availability heuristic) then gives a mistaken impression of how likely this sequence of events is likely to be and the improvement is attributed to IAPT’s efforts (mis-attribution bias), unfortunately the next time a post IAPT patient is encountered in a good state this is seen as confirmation of their believe (confirmatory bias) in the value of the service. Such GPs may unfortunately play a major part in the CCG’s leading to the perpetuation of a failed service.

Resources

  1. Placebo response, Boot et al (2013) click link below: https://www.dropbox.com/s/fnmuv4t6imdcsug/Placebos%20Boot%20et%20al%202013.pdf?dl=0
  2. Not always got a disorder Bruce et al (2005) click link below

https://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

3. Information processing biases see link below

https://www.dropbox.com/sh/66o4qo8ru8sairz/AABxU_IeXeEcaNOqeEYBgGNOa?dl=0

Dr Mike Scott

IAPT – The Need For A Product Recall

In response to David Clark’s blog ‘IAPT at 10’ on the NHS England website, I wrote: ‘If NHS England invited the manufacturer of a pharmaceutical to review the growth and successes of its’ drug over the last decade eyebrows would be raised. Yet this is precisely what has happened in asking David Clark to comment on his baby (IAPT) with whom he has an ongoing commitment and financial arrangement. In terms of publication bias his piece is off the scale.

No Independent Replication

There has never been independent replication of IAPT’s claim to 50% recovery. My own work, which is wholly independent of IAPT and was published in the Journal of Health Psychology   last year (see link below)  suggests a 10% recovery rate.

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

Questionnaires Rather Than An Independently Administered Standardised Diagnostic Interview

IAPT relies on questionnaires completed by clients with the full knowledge of the treating clinician, introducing a ‘demand’ element into the proceedings. Further there is in IAPT’s procedures no way of knowing that the questionnaire/s are tapping the disorder/s that are germane to the client. 

No Evidence of An Added Value To IAPT When Compared With Findings Before Its’ Inception

The changes in questionnaire scores observed in IAPT clients are no different to those observed on self-report measures administered to clients going through counselling before the advent of IAPT. The Mullin (2006) findings (see link below) are the appropriate counterfactual and indicate no added value to IAPT.

https://www.dropbox.com/s/8a4qv5r13rotkyy/Appropriate%20Counterfactual%20Mullin%202006.pdf?dl=0

Clients present for therapy at their worst and some improvement with time would inevitably be visible on a questionnaire, IAPT has provided no evidence that clients given simply attention would not have shown the same changes to those observed.

The Jettisoning of Evaluation Guidelines

Entry into Pharmaceutical/Psychological Studies is governed by the administration of a standardised diagnostic interview. Outcome is determined by blind re-administration of the interview at the end of treatment and follow up. In line with this, an international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions. All IAPT generated studies have breached these guidelines.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

Countries that do not look at psychological interventions through the lens of such evaluation guidelines will be taken in by IAPT’s marketing prowess. Unfortunately many such countries have shown such gullibility in the last decade.

Failure to Engage and Treat Clients

IAPT loudly proclaims the very large number of clients that it makes contact with but this is meaningless when their trajectory is considered. Half of those referred to or referring themselves to IAPT   have less than 2 treatment sessions.  The mean number of sessions attended for those who have 2 or more sessions is 6, there is no NICE approved treatment for a psychological disorder that requires just 6 sessions.  It is scarcely credible that IAPT is providing an evidence based treatment on any scale. There is an an independent re-analysis of the IAPT data in the link below

http://therapymeetsnumbers.com/is-iapt-too-big-to-fail/

A Failure of Governance

IAPT is essentially a QUANGO dependent on NHS England, and committed to expansion but without any observance of evaluation guidelines.  NHS England has taken IAPT’s claims at face value, as a consequence Clinical Commissioning Groups focus only on operational matter, numbers, waiting times etc with no focus on clinical matters in their interactions with IAPT. The National Audit Office conducted an inquiry into IAPT but has failed to publish its’ results. There has been a gross failure of governance by public bodies and their representatives.

Only The Voice Of IAPT’s Hierarchy Is Listened To

There has been no attempt by public bodies to independently seek the views of consumers of IAPT services. However an IAPT teacher, Jason Roscoe has publicly made a blistering attack on the service, see link below

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’ and adds ‘The result? A revolving door where patients return in quick succession for multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’.

The views of the 90 IAPT clients I examined were almost wholly negative and indicated the need to transform IAPT see link below

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

IAPT The Need For Product Recall

There are such serious doubts about what IAPT has delivered over the last decade, that if it were a piece of machinery the product would have been recalled. A decade ago I wrote a book on how CBT can be delivered, with fidelity to evidence based treatment protocols, [Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge], there is a pressing need to review such provision. In private communication with David Clark I have acknowledged that my approach would make the assessment process more costly. However the evidence of the past decade is that it is not possible to make a real world difference to client’s lives without closely following the procedures involved in randomised controlled trials of CBT. Departure from reliable assessment, diagnosis, advice/treatment results in a failure to translate efficacious treatments to routine practice’.

Unfortunately NHS England only permits upto 1000 character comments on their invited blogs, so essentially only the 1st paragraph of this blog will likely appear.

Dr Mike Scott

Where IAPT Has Never Happened, No Evidence Of Worse Outcome

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. .

Dr Mike Scott

BBC Investigates IAPT – A Stepping Stone To Accountability

On Friday the BBC TV broadcast an interview with me in which I said IAPT’s recovery rate was just 15%, this contrasts with IAPT’s claim of a 50% recovery rate, arrived at by marking their own  homework. Further I noted that using IAPT’s own data there is a threefold  difference in recovery rate by geographic area, if there were such differences in outcome with heart bypass surgery it would be thought that something was seriously amiss.  It is great that the subject of IAPT has finally come under public scrutiny but Clinical Commissioning Groups, MPs, and professional bodies have to put IAPT in the dock and question whether the £1bn expenditure on it has been justified. That there has been no funded independent assessment is an ongoing scandal.

The BBC Investigation  can be accessed using the  following link

http://www.bbc.co.uk/news/health-45895541

interestingly IAPT focussed the BBC’s attention on the 1 in 7 geographic areas that fail to reach its’ 50% yardstick, rather than that only 1 in 7 of its’ clients overall recover.

 

Dr Mike Scott

The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

Dr Mike Scott

Clinical Commissioning Groups Fail To Check Compliance With Informed Consent – Have You Been Affected?

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’

https://www.dropbox.com/s/ie4yg6hgmt5fybw/EDITED%20Transforming%20IAPT.docx?dl=0https://doi.org/10.1177/1359105318781873

in the August issue of the Journal of Health Psychology

 

Footnote: In earlier work Cuijpers

https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0

has noted that the effect size for GSH  for depression is small 0.28 compared to 0.6 or more (large to moderate) for the regular face to face therapy.

 

Dr Mike Scott

Transforming Improving Access to Psychological Therapies

The three commentaries on my paper ‘IAPT – The Need for Radical Reform’ are agreed that Improving Access to Psychological Therapies cannot be regarded as the ‘gold standard’ for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its ‘own homework’ and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation. What is interesting is that nocommentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government’s National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.

Dr Mike Scott

Clinical Commissioning Groups (CCG’s) Incredibly Naive Re: 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:

Question 1.

 

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).

 

Response 1.

 

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.

 

Question 2.

 

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.

 

Question 3.

 

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.

 

Question 4.

 

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?

 

Response 4.

 

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.

 

Question 5.

 

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;

https://www.nice.org.uk Question 6.

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?

 

Response 6.

 

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).

 

Links:

 

http://content.digital.nhs.uk/iapt

 

http://ipnosis .postle.net/PDFS/iaptoutcomestoolkit2008november(2).pdf

 

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).

 

Links:

 

http://www.rcpsych.ac.uk/workinpsychiatry/nccmh/mentalhealthcarepathways/improvingac cess.aspx

 

https://www.york.ac.uk/healthsciences/pc-mis/newsarticles/lAPT%20Manual 30OCT17.pdf

 

 

I hope that you and Dr Scott this information helpful.

Yours sincerely

 

Ian Davies

Chief Operating Officer

 

Liverpool CCG show no evidence of having bothered to read my analysis of 90 cases, and have not answered my questions, they have simply acted as the mouthpiece for IAPT.

 

Dr Mike Scott

Is It OK That Only The Tip of The Iceberg Recover?

If only 1 in 10 people recovered from heart disease and cancer there would be uproar, but it seems to scarcely raise a professional eyebrow when independent assessment suggests that is the recovery rate for common disorders in IAPT. The blog post on ‘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/. One can only guess at the reasons behind the deafening silence. Perhaps it has to get as dramatic as yesterday’s BBC Panorama programme which announced a 50% increase in mental health deaths in the last 3 years.

There may be a need to move beyond professional interests to discussions with MPs, Clinical Commissioning Groups, Patient groups, Media etc

Dr Mike Scott