IAPT Is a Car Crash – Transforming IAPT

IAPT (Improving Access to Psychological Therapies) is a car crash, funded by the taxpayer to the tune of £1bn, but without any insurance for the public. Staff are stressed out and there is a 10% recovery rate for clients. The National Audit Office (NAO) recently investigated IAPT but have chosen not to make its’ findings  public. I pursued a Freedom of Information Request but the NAO’s response has shed no light on their decision making. These findings are contained in my just published paper ‘Transforming IAPT’ in the Journal of Health Psychology:

 

 

the abstract reads:

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 no commentary 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

Supervision Of Most IAPT Workers Is Not Supervision – Monumental Waste

Alexandra Painter was for 2 years a Psychological Wellbeing Practitioner, in her doctoral thesis *, she reviews her experience and that of other PWP’s.  She notes that in the so called ‘Case Management Supervision’ that PWP’s are subjected to, a core component of supervision, the opportunity to reflect on practice and talk about how you feel about cases is routinely absent. Alexandra calculates that approximately 2.5 minutes is allowed to discuss each case! It seems that the PWPs, who are the most numerous of IAPT workers, are at the ‘front line’, most commonly they have been health care assistants in the past,   unlike the high intensity therapist’s in the rear with often clinical or counselling psychology backgrounds. In this war against mental ill health it is more likely that the troops at the front will bear the brunt.

Leaving the troops fearful of going over the top and disobeying commands from on high. The PWP’s plight resembles resembles the Charge of the Life Brigade, in that the powers that be refuse to accept that they are not on solid ground intent on reaching their target at all costs. There are no evidence based techniques, only evidence based treatments and all the so called EBT’s in low intensity treatment fail to meet criteria for evidence based treatment [ Scott (2017) Towards a Mental Health System that Works London Routledge].

  • At least two randomised controlled trials, on a clearly specified population, with independent assessment by a blind rater using a standardised interview
  • At least one of the rcts conducted by researchers independent of the developers of the treatment
  • Replication in routine practice using non-expert clinicians

How long will it be before there is a national outcry about such waste. Unfortunately the National Audit Office is still undecided about whether to publish its’ investigation into IAPT. People including myself and BACP made a submission to the NAO fully expecting the latter’s findings would be made public, if they and I knew that this was not necessarily the case, we would have wondered whether it was worth the effort! At the moment they appear to be countenancing a letter to NHS England, inspection of their website shows the latter’s wholesale support for and funding of IAPT! The NAO, to date, seems no better than Carillion’s Auditors!

Dr Mike Scott

* Painter, A. (2018) Processing people! The purpose and pitfalls of case
management supervision provided for psychological wellbeing practitioners,
working within Improving Access to Psychological Therapies
(IAPT) Services: A thematic analysis. DCounsPsych, University of
theWest of England. Available from: http://eprints.uwe.ac.uk/33351

National Audit Office IAPT Investigation ‘progress..slipped substantially….

We have not yet made a firm decision about whether or not we will publish a short report on IAPT in due course…We may choose to simply write a management report’, my communication received from the NAO today. I have made a Freedom of Information request re: the decision making and communications, which legally I should have in the next 10 days.

 

 

Given that £1bn has been spent on IAPT not to have an independent audit/assessment  seems scandalous. Claims of competing pressures is not terribly convincing.

Dr Mike Scott

 

National Audit Office Not Publishing Its’ IAPT Investigation?

Whatever happened to transparency and accountability! Last year the NAO invited the public to make submissions for its’ IAPT investigation, but it seems a letter from the NAO dated February 14th 2018  obtained under Freedom of Information (FOI) by a Dr Elizabeth Cotton states ‘you requested information …. that relates to the decision not to make the report publicly available  … correspondence and any documents sent by the NAO to the UK health bodies involved that outline the key findings of the inquiry…. The NAO is still drafting its findings and these have not been communicated to any of the health bodies’.

 

 

Under the FOI there is an exchange of e-mails between NAO and NHS England, one from the NAO dated June 28th 2017 is titled ‘NAO investigation into the integrity of IAPT performance data’ and strangely states ‘we have not yet decided for definite whether we will publish a report’.  I made a submission to the NAO on July 25th 2017 and I, like all those submitting evidence which ran to Autumn 2017, would have assumed a report would be published, otherwise they might have considered it a waste of energy!

I have e-mailed the NAO and await a reply.

 

Dr Mike Scott

National Audit Office Listening Over Critique of IAPT

On September 21st I received an e-mail response from the National Audit Office which said: ‘The clarification you have provided regarding the usefulness of the tests used to assess patients, and the fact that, in IAPT, a link is not consistently being made between diagnosis and treatment, is very useful in helping us to understand more about the points you previously raised with us about recovery rates’

See earlier post on National Audit Office, extract below:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.

It will be very interesting to see the final report of National Audit Office.

 

Dr Mike Scott

Discussion With National Audit Office Re: IAPT

On Monday I received a thoughtful, considered and detailed response from the National Audit Office with regards to my submission re: the IAPT investigation. I’ve just penned the following response:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.
  1. I am unsure whether the National Audit Office are aware of the paper by Griffith’s and Steen (2013) [Improving Access to Psychological Therapies (IAPT) Programme: Scrutinising IAPT Cost Estimates To Support Effective Commissioning, The Journal of Psychological Therapies in Primary Care, 2, 142-156]. that suggest that the cost of IAPT therapy sessions is 3 times more than the Department of Health Impact Assessment estimates and this may lead to very different conclusions about the cost-effectiveness of IAPT. For ease of reference I attach a copy of this paper.
  2. How has the IAPT data set demonstrated that it offers added value over a) services as they existed before IAPT b) non-IAPT services in Wales, Scotland and Northern Ireland? In the absence of such a demonstration it can be questioned whether IAPT overs value for money.
  1. It may be that one part of IAPT say high intensity therapy, is value for money but say low intensity (the most common modality) is not but no such analysis has been proferred. Why?

 

Dr Mike Scott

Mental Health Services Expansion Before Completion of Investigation!

On July 31st 2017, the Health Secretary, Jeremy Hunt announced funding for an extra 2,900  new therapists in Adult Mental Health talking therapy services. A week earlier the National Audit Office invited submissions for its’ investigation into IAPT, with a closing date of this Autumn. It is clearly the time of the year for the Mad Hatter’s Tea Party:

 

be careful that you don’t mutter under your breath at such gatherings that ‘evidence should precede action’, if heard it could be ‘off with your head’.

But beware, the historian High Trevor Roper wrote in the Last Days of Hitler ‘mythopoeia is a far more common characteristic of the human race than veracity’. The wholesale endorsement of IAPT by BABCP and to a lesser extent by BPS reflects mythopoeia:

 

IAPT with its low intensity modality has attempted to make therapy ‘simpler’ than simple, resulting in ineffective treatment.  When it comes to the high intensity modality it has made matters ‘simpler’ than simple, by abandoning reliable diagnosis/high specification of problem/s as a Sat Nav for treatment again often resulting in ineffective treatment.

 

Dr Mike Scott

 

National Audit Office IAPT Investigation, Whistleblowers

Below is the National Audit Office’s request for evidence re: IAPT, I note they have a whistleblower’s policy. It may be possible to ask for anonymity. I would hope that BABCP and BPS would make a submission to the National Audit Office, but to my knowledge this is not on the agenda of either, why not?

Investigation: Improving Access to

Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to

National Institute for Health and Care Excellence approved treatment for depression and

anxiety disorders. In October 2014, the Department of Health and NHS England

jointly published Achieving Better Access to Mental Health Services by 2020. This set new

standards for the time people should wait for mental health treatment and the care they should

be able to access. In the case of IAPT services, the standards are that 75% of people referred

should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of

those who complete treatment will recover. NHS Digital publishes monthly statistics

that report performance against these standards. This investigation will establish the facts

around how the national statistics are prepared.

If you would like to provide evidence for our study please email the study team on

enquiries@nao.gsi.gov.uk, putting the study title in the subject line. The team will consider the

evidence you provide; however, please note that due to the volume of information we receive we

may not respond to you directly. If you need to raise a concern please use our contact form.

IAPT Performance Investigation – National Audit Office Request

‘The National Audit Office is currently carrying out an investigation into the performance data of IAPT services. The investigation is focussing on waiting times, but also refers to the reported 50% recovery rates and can accept information about the collection and measurement of data across IAPT outcomes.  

This is a genuine opportunity for us to challenge the data on which mental health service targets are being set.

Many of you have important experience of what is happening in IAPT services that is crucial for the NAO in building an accurate picture of what is going on.

Please submit your evidence to Jenny George Jenny.George@nao.gsi.gov.uk and David Rarity David.Raraty@nao.gsi.gov.uk  who will be writing the report during August. It’s a tight deadline so please submit what you can as soon as possible.

The NAO website is HERE and below is the information provided about the inquiry.

Improving Access to Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to National Institute for Health and Care Excellence approved treatment for depression and anxiety disorders. In October 2014, the Department of Health and NHS England jointly published Achieving Better Access to Mental Health Services by 2020. This set new standards for the time people should wait for mental health treatment and the care they should be able to access. In the case of IAPT services, the standards are that 75% of people referred should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of those who complete treatment will recover. NHS Digital publishes monthly statistics that report performance against these standards. This investigation will establish the facts around how the national statistics are prepared.

This is a really significant opportunity for us to share our experiences of what is going wrong in performance management of services. Please, take the time to contribute to the report’. 

 Thanks to Steve Flatt for alerting me to the above from the ‘Surviving Work’ website
Dr Mike Scott

 

Copyright © 2013 The Resilience Space, All rights reserved. www.theresiliencespace.com

Evidence Based CBT Joins the ‘Endangered Species’ List

‘The good news is we have successfully amputated your right leg, the bad news is we operated on the wrong leg’.  The moral is that there can be no evidence based CBT treatment without an evidence based assessment (EBA). But EBA’s are increasingly absent in order to ease the research burden, ‘just rely on a psychometric test’, and reduce ‘treatment’ costs.

Emergency medicine operates on the 7 P’s, ‘Proper Pre-planning Prevents Piss-Poor Performance’. Is it seriously proper-pre-planning to operate as IAPT do, with a  typically 15-20 minute telephone conversation, conducted by the most junior member of staff, to be then placed on waiting list of upto 6 months for a treatment of indeterminate appropriateness? The reliability of this ‘pre-planning’ has never been assessed by anyone independent of IAPT. But this has not stopped Clinical Commissioning Groups often ring fencing IAPT monies at the expense of other mental health service providers.   The CCG’s need to be reminded that they ought to be working in an evidence based framework were the results of randomised controlled trials with independent assessment of outcomes hold sway (the top of the pyramid below). 60% of IAPT clients receive low intensity treatment, this is way down at the bottom of the evidence pyramid below, with a high potential for bias, reflected in powerful marketing.

It is time that CCG’s told IAPT that their pre-planning is simply unacceptable, there has to be an evidence based assessment. It is time the National Audit Office asked why are we continuing to fund a Service that has not been independently evaluated using ‘gold standard’, diagnostic assessment procedure. But most of all it is time to listen to those subjected to an inhospitable and unhelpful service. MP’s have to insist they are listened to.

Dr Mike Scott