Decrypting the Improving Access to Psychological Therapies (IAPT) Code

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024.  To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’. The silent assumptions are that:

a) there would be reliable agreement (reliability) between clinicians about what would constitute a clients main problem and

b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility.

But there is no empirical evidence for either a) the reliability or b) the clinical utility. 

IAPT operates its’ own coding device, akin to the Enigma machine used by the Germans in World War 2, and it has as a result ill-served millions. NHS England and CCG’s have totally failed to recognise its’ operation, believing instead IAPT’s public broadcasts e.g a 50% recovery rate, when independent assessment indicates a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Dr Mike Scott

Problem Descriptors – A Confusing IAPT Signpost Leading to Crashes

‘ I think it is social anxiety disorder, from my problem description my manager thinks its’ generalised anxiety disorder’  should treatment be determined by the power holder or should they just spin a coin with a ?50% chance of the client getting the right treatment. Such is the soap opera acted out in IAPT.

IAPT uses problem descriptors to determine what treatment to give to whom. But problem descriptors are a rule of thumb to determine treatment. In randomised controlled trials treatment was based on a reliable diagnosis, which would typically take an hour or more to determine. IAPT has come up with a problem descriptor shortcut of undetermined reliability and which it seeks to legitimate by asking therapist to provide an ICD-10 code.

The IAPT Manual considers it best practice if a service provides an ICD-10 code for at least 80% of cases. Can it be acceptable for up to 1 in 5 people to have rudderless treatment? When clients are assigned an ICD-10 code it is usually a single code and a Manager may advise that a another code is appropriate rather than the one the clinician selects.  Whilst the IAPT Manual advises that more than one code can be appropriate, it also advises that treatment should be dictated by the principle problem, this likely has the effect of making for single awards of ICD-10 codes.

The IAPT Manual claims that ICD-10 codes are the basis of the NICE recommended treatments, but they are not. Most of the mental health trials considered by NICE are based on the more reliable and stricter DSM criteria. Notwithstanding this ICD-10 provide diagnostic criteria for each disorder, but IAPT also contends that it does not make diagnosis. It is therefore difficult to escape the conclusion that IAPT pays lip service to ICD-10 codes for its’ own credibility.  Despite this the IAPT Manual insists that the treatment protocol should follow the identified problem but the protocols have never been matched to problems but to disorders!

Dr Mike Scott

 

IAPT’s Eventual Implosion

there are no limits to IAPT’s ambitions, making failure inevitable. IAPT’s target in practice is, “whatever the client complains of” and treatment is operationalised as “whatever its’ therapists do”, Both focii are so loose that it cannot fulfill it’s promise, like a totalitarian revolution that runs out of steam.

The IAPT Manual published a year ago leaves both targets and treatment ‘fuzzy’, whilst proclaiming a commitment to NICE Guidelines. A target of ‘client complaints’ makes no distinction between ‘ disorder’ and everyday unhappiness/stresses. Yet the treatments advocated by NICE are quite specific to disorders.

At most IAPT staff ask about some symptoms of a disorder, but without coverage of all the symptoms of a disorder. But they are not taught to ask whether a symptom is present at a clinically significant level, i.e whether it is making a real world difference to a client’s life. Only clinically significant symptoms count in DSM. As a result IAPT client’s are typically treated for disorders they don ‘t have, without any fidelity check on compliance with a protocol.

There is tremendous vested interest, financially, emotionally and intellectually in IAPT continuing as it is, marking its’ own homework with applause from BABCP and the BPS.

Dr Mike Scott