BABCP Response - NICE Consultation January 2022

‘So sick of this IAPT game playing, it’s immoral!’

the comments of an IAPT worker when he was told by management to make sure that the client completed the PHQ9/GAD7 face to face at the 6th session. Normally the client completes the measures before each of the first 5 sessions at home. Face to face completion introduces a demand effect, politeness, wanting to please the therapist, lowering scores so that IAPT’s results look better. Matters are compounded for him by only being allowed to provide usually 6 sessions in high intensity. Where is the evidence base for 6 sessions doing anything?’

This behaviour echoes IAPT’s, misrepresentation of its’ own outcome data. A more realistic and independent picture has been painted by Barry McInnes

IAPT 2018: Why do less than 1 in 5 referrals reach recovery?

Clients are waiting less time than ever to access IAPT services, and recovery rates have reached their highest ever level at 50.8%. So why am I not throwing my hat in the air? In a nutshell, the astonishingly high levels of attrition. With less than one in five that are referred and one in four that enter therapy achieving recovery, what is the experience of those that IAPT is serving less well?

Below is a graphic which shows clients at key stages of their journey through the Improving Access to Psychological Therapies (IAPT) programme in the year 2017 – 18. It’s an update of the figures that I provided for 2016 – 17 in a previous blog. As was the case then some of the performance data for 2017 – 18 show an improvement over the previous year. I also said previously that some aspects of performance start from an already worryingly low baseline. Having looked at the latest data I see grounds only for modest optimism.

Once again, the main story behind the numbers is one of extraordinary levels of attrition at each stage of the journey. The detail follows in subsequent sections.

Key highlights

  • The recovery rate for 2017 – 18 was 50.8%
  • 30% of all referrals don’t enter therapy
  • 45% of clients that enter therapy don’t complete
  • Only 26% of clients that enter therapy achieve recovery
  • Almost as many (49%) don’t recover, as do
  • The best performing areas achieved a recovery rate roughly double that of the poorest

First, the headlines. In the year 2017 – 18, the report and supporting datafile show that:A

There was a total of 1,439,957 referrals

an increase of 54,293 on the previous yearA

Recovery rates were 50.8%

This is up one and a half percentage points on the previous year, and for the first time exceeding the target of 50%. (definitions for recovery and caseness are shown in the panel below).A

89.1% of referrals were seen within 6 weeks, and 98.8% within 18 weeks

exceeding their respective targets of 75% and 95%

The term used to describe a referral scoring highly enough on measures of depression and anxiety to be classed as a clinical case. If a patient’s score is above the clinical cut off on either anxiety, depression, or both, that are classed as a clinical case
A patient is ‘recovered’ if they finish treatment and move from caseness to non-caseness by the end of the referral. The patient needs to score below the caseness threshold on both anxiety and depression measures. Referrals that started treatment not at caseness are not included in recovery counts

Headlines aside, there’s a story behind the numbers which I’ve broken down into four chapters. They are:

The stages from referral:

30% of referrals don’t enter therapy.

The stages from entering therapy:

45% of clients that enter therapy don’t complete.

The outcome at therapy ending for all clients:

53% of clients don’t achieve recovery

The outcome at therapy ending for clients that were at case level at the start:

51% of clients achieve recovery. 49% do not.

In each chapter I’ll show data for 2015 – 16, 2016 – 17 and 2017- 18.

The journey from referral – 30% of referrals don’t enter treatment

The journey starts with all referrals for the three years. The table below shows those referrals as 100%. Subsequent stages in the process, and the proportion of clients referred that still remain are also shown. In 2017 – 18, 70% of those referred entered therapy. This is defined as having one or more sessions of therapy. The proportions in both of the previous two years were broadly the same.

As we progress through their journey we can see an emerging story of attrition. By the end of therapy, only 39% of clients that were referred now remain (down from 41% in 2016-17) Those that reach recovery represent just 18% of the total referred . That’s less than one in five clients.

Why did only seven in ten referrals enter therapy? I can only speculate, but in doing this it’s important to note that nearly nine in ten referrals were seen within six weeks. Hence length of wait may not be the most important factor. Otherwise, they may no longer have needed therapy, their referral may not have been appropriate, or they may simply not have liked what was offered to them.

Chapter 2: The journey from entering therapy – 45% of clients that enter therapy don’t complete

We begin this chapter with all clients that entered therapy. That is, all those that had one or more therapy sessions. In 2017 – 18, 55% of those entering therapy are recorded as ending it. This figure is down 4% from 2016 – 17. Whichever year we’re talking about, however, the fact that more than four in ten clients do not complete should be a concern.

Following the journey through, we can see that just 26% of those entering therapy achieved recovery. In other words, clients entering therapy appear to stand just over a one in four chance of recovering.

Why are only 55% of clients recorded as ending therapy? Again, it’s hard to know. In my experience, however, clients more commonly drop out because they feel that therapy isn’t working for them for some reason. Often, they simply disappear without the opportunity to explore this with their therapist, and make adjustments that may better serve their needs.

Chapter 3: The outcome at therapy ending for all clients – 53% of clients don’t achieve  recovery

Here we start with all the clients that are recorded as finishing a course of treatment. The first point to note is that not all clients were at a case level of symptoms or distress at the outset. No matter how much improvement they make, therefore, they cannot achieve recovery. In the 2017 – 18 population, 93% of clients were at case level, and could potentially recover. This is the same as in the previous year.

Those reaching recovery represent 47% of all those that finished treatment. For 2017 – 18, this is an increase of 1% over the previous year.

The outcome at therapy ending for clients that were at case level at the start – 51% of clients achieve recovery

The final leg of the journey, starting with clients who finished treatment that were at case level at the point they started. In this population we have all the clients who have the potential to achieve recovery.

In 2017 – 18, 51% of clients achieved recovery, of those that finished therapy and were at case level at the start. To be precise, the figure given in the IAPT report is 50.8% (against 49.3% for 2016-17).

The figure for those achieving recovery for 2016 – 17 is 1.5% higher than in the previous year. This is the first time that the recovery rate has exceeded the target of 50% that was established for the IAPT programme.

While this improvement is clearly welcome, however, it remains the case that almost as many clients do not recover as do. At nearly 51:49, the odds of recovering or not recovering are almost even.

Not all services perform equally

Using the tools that accompany the IAPT annual report, it’s possible to explore local and regional performance. Sadly, the datasheet which houses all of the raw data is now structured in such a way that it’s no longer possible to get a single improvement rate for each Clinical Commissioning Group (CCG) area and easily filter those to see the range of performance.

What I am loving, however, in this new reporting structure, is the IAPT Interactive Dashboard, which you’ll find at the foot of the Resources section of the summary page.  It’s the tool from which the image of the interactive map (main blog image at the top) is taken, and also the screenshot below.

The interactive tool allows you to filter performance data at a local level, either by hovering over the map or entering the CCG or commissioning region, for example. In the image above right, I’ve selected two CCG areas towards the lower and higher ends of the improvement range. If you’re interested in finding the performance for your local area I’d encourage you to go and have a play.

To summarise

In summary, then, there is some good news and some bad news. The good news is that clients are able to access services more rapidly than before and that for those that end therapy, their chances of recovery are more than one in two for the first time.

The bad news is that attrition is alive and well. 30% of referrals do not enter therapy. Only 39% of referrals reach the end of therapy, and only 18% achieve recovery. In that context, I find it hard to find too much to celebrate.

How do services improve?

I concluded the previous blog with a simple five-point plan that will assist any therapy service, IAPT included, to improve on its current performance. Rather than repeat myself here’s a link that will take you straight here.

I’d love to hear your thoughts on what you’ve read, whether you have a personal connection with IAPT or otherwise. Leave a comment below and please let us have your thoughts.

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Well done Barry

Dr Mike Scott

BABCP Response - NICE Consultation January 2022

‘I Have a Right to Know Whether Treatment Has Made A Real World Difference’

From a client’s point of view if they were considered ‘bad enough’, on the basis of a standardised diagnostic interview, to enter a controlled trial, the latter should also be the yardstick for judging whether their treatment was a success i.e they are ‘good enough’ not to be included in a further trial. Perhaps the researchers would like to explain to clients why there is an asymmetry between the assessment (standardised diagnostic interview) and outcome processes (the latter relying on self-report measures).  Arguably consent to treatment should only be given once the client feels this asymmetry has been properly explained! This is I think a matter for the National Institute of Health Research to consider when reviewing applicants for research funds, as a reviewer I have sometimes found submissions lacking this ‘real world’ feel.


Cuijpers et al meta analysis in 2016, [World Psychiatry, 15, 245-258 How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence] of 144 rcts for depression, panic disorder, generalised anxiety disorder and social anxiety disorder was restricted to studies that had used a standardised diagnostic interview for initial assessment, but the potency of the interventions were assessed only using psychometric tests. A standardised diagnostic interview is an independent reliable assessment, it is curious that outcome on this was not established and contrasted with the self-report data. It is not clear what proportion of the studies reviewed by Cuijpers reported on a re-administration of the standardised diagnostic interview. If a standardised diagnostic interview is the ‘gold standard’ for entry into an rct why is it relegated when it comes to assessing outcome. Is it that such an independent interview would be too high a bar for purported efficacious cbt treatments to clear or perhaps it is just cheaper to rely on self-report.


But the right to know whether treatment has made a real world difference  is not just a right to be exercised in the context of rcts, the right surely exists in routine practice. This right helps to ensure that the client is not just fodder for some numbers game. The realisation of this right forces a consideration about whether the customary sole self-report assessment and outcome measures are fit for purpose.

Dr Mike Scott