Tag: NHS England

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IAPT’s Processes Contribute Towards Death or Injury

transcripts of tape recordings of client’s first contacts with the, UK Government funded, Improving Access to Psychological Therapies (IAPT) service, analysed by Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 reveal not only steadily increasing access,  but a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

‘We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’

Drew et al (2021) give an example of this surrounding risk assessment:

PWP: So just with regards to question nine, okay so we have a duty of care to yourself or others? .hhh.erm (.) > are we okay just to< have a bit of a chat around.hh what those thoughts might be for you at the moment. ‘Cos you’ve scored a one there haven’t you’ Pause 3 secs
 
PWP: Are you having current thoughts of wanting to hurt yourself or end your life? Pause 3.5 secs
 
Pat: No, may. hh Pause for 3.5 secs
 
Pat: It’s – It’s just feels like a really weird (.) week this week because –
(18 lines omitted in which the patient talks about the pressure they are under; only minimal responses and attempts to close from PWP)
 
Pat: I still feel like I – I’m not doing anything and not accompanying anything tearful/tremulous
 
PWP: Mm, mm, okay? .huh
 
Pat: MHHHH HHH [ and it’s tearful/tremulous]
 
PWP: Are you having any thoughts of wanting to be better off dead or off wanting to better off dead or hurting yourself
 
Dangerously The PWP is all at sea  – a disaster waiting to happen, there will be a death. The above exchange shows
 
the therapist unable to move beyond repeating question 9 on the PHQ9, like a broken record, without any reliable
 
exploration of suicide risk. But then the IAPT Manual provides no guidance in this respect, baldly stating risk
 
assessment is part of good assessment.
 
In the exchange above the PWP ignores the client’s story. Assessment and treatment are necessarily built on sand 
 
if the client’s narrative is not first distilled.  Making IAPT’s claim of a 50% recovery rate  beyond belief. [The average
 
session was 44mins for assessment and 33 mins for first treatment]. 

It is bad enough when a friend or relative will not listen to your troubles, but when a Government Agency does it routinely, that is unconscionable. Drew et al (2021) draw attention to the ubiquity of the problem which suggests that it is systemic. However Drew et al (2021) content themselves with recommending that IAPT’s assessors need to ask more open-ended questions at the start of their interviews. The authors claim no conflict of interest, but many of the authors have had previous privileged access to IAPT data, research data may not be so forthcoming if they take a more critical view of IAPT. In this respect they do not question IAPT’s recovery rate or cite data which may disconfirm it Scott (2018) https://doi.org/10.1177%2F1359105318755264.

 

Dr Mike Scott

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On What Basis Are Talking Therapies Out Of Bounds To The Care Quality Commission?

The Care Quality Commission (CQC) has just called the Government to task for blanket Do Not Resuscitates (DNRs) applied at the start of the pandemic. But the CQC is not allowed to investigate the quality of the Improving Access to Psychological Therapies (IAPT) services for those with mental health difficulties. Could there be a more glaring example of the disparity between physical and mental health services?

 

The IAPT service has had a decade of going under the radar of independent public scrutiny, despite Government expenditure of over £4billion. Strangely the National Audit Office (NAO) has no intention of mounting an audit (see recent post), citing preoccupation with Covid and its’ earlier preoccupations with the collapse of Carrillion and the provision of generic medicines. IAPT is responsible to NHS England but staff at the Department of Health also have key positions in IAPT. NHS England are likely to claim that they are ‘too busy’ to address trivial matters like conflicts of interest, reacting like the NAO. The Government will likewise claim preoccupation to avoid addressing sensitive matters.

The CQC can investigate whether the needs of those in Care Homes are being served and can champion the plight of residents, who is to champion the needs of those with mental health difficulties. Organisations such as Mind often have funding arrangements with IAPT. The  British Association for Behavioural and Cognitive Therapies (BABCP) and the British Psychological Society (BPS) regularly give pride of place to IAPT luminaries with rare opportunities for opposing views to be expressed.  The result is a groupthink within these organisations. 

Dr Mike Scott

 

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The IAPT Fiasco – A Failure of Governance Over Talking Therapies

no one is available to answer, why over £4billion has been spent on the Improving Access to Psychological Therapies (IAPT) service without independent evaluation. There should be a call to action when the best available evidence indicates that only the tip of the iceberg of IAPT client’s recover https://doi.org/10.1177/1359105318755264. Which Government Minister is responsible? Does responsibility lie with Public Health England or NHS England? Are Clinical Commissiong Groups (CCG’s) simply acting under orders?

It is not good enough for the architects of the IAPT service to blandly assert it is a ‘world beater’.  There is no transparency with regards to decision making and implementation in IAPT. In the 3 years of cbtwatch no public powerholder has deigned to answer the concerns raised.  Media pressure did however evoke a response by IAPT’s, public advocates, Professors Clark and Salkovskis, who are hardly disinterested commentators, albeit that they are persuaders par excellence. Ministers, Public Health England and NHS England have maintained a deafening silence.

Interestingly the failure in transparency over IAPT resembles that of the handling of the pandemic. It is it seems impossible to discover who postponed testing.  There has been a parallel failure, over the last decade to publicly and independently test out recovery rates in IAPT.  My own findings are that the tip of the iceberg of service users get back to their usual selves.

We seem destined to go from one fiasco to another, but all it needs to avoid this scenario is honesty and care, it is fundamentally an ethical matter. This could start by taking the time to listen to what IAPT client’s are saying and to IAPT front line workers.

Dr Mike Scott

 

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Declining IAPT – Clients Reject The Service

Rejection of the Improving Access to Psychological Treatments (IAPT) service continues to be the norm. Yet it has been funded to the tune of £4 billion without any independent demonstration that it has better recovery rates than its’ predecessors.

Nearly a decade ago, Richards and Borglin https://doi.org/10.1016/j.jad.2011.03.024 examined the pathway of over 7000 Improving access to Psychological Treatments (IAPT) clients – of those referred, 27.3% did not materialise for an assessment. Of those assessed 26.8% did not go further. Of those attending treatment 29.5% completed only one session. Of those initially referred  the rate of non completion of treatment was 62.5%. [Were ‘completion’ was defined by IAPT as attending 2 or more sessions]. This pattern of engagement is identical to that found in my 2018 study   https://doi.org/10.1177/1359105318755264    there are no signs of improvement, see the Table from my paper ‘IAPT – The Need For Radical Reform’

IAPT’s engagement and retention of clients (n=90).

page4image50356096

1. 23.6% of clients either did not initiate contact with IAPT (an opt-in arrangement) or IAPT were unable to contact them to arrange an assessment
2. 13.3% attended only an initial assessment
3. The mean number of treatment sessions attended was 5.5 with a median of 4.0 sessions, with missing data on one client

4. 39.3% attended 2 or less treatment sessions 5. 57.3% attended less than 6 treatment sessions 6. 23.6% attended 6–8 treatment sessions
7. 80.9% attended 8 treatment sessions or less 8. 4.5% attended 20 more treatment sessions

If such rates of ‘decline’ of treatment had been present in the randomised controlled trials  of the efficacy of CBT, then the latter would have been summarily dismissed.  There would have been no NICE guidance advocating CBT for depression and the anxiety disorders. In the IAPT service the average number sessions attended by those who engage in treatment is 6, this would be regarded as a sub-therapeutic dose of treatment in any of the rcts for CBT. No trial of CBT has ever been conducted with the average dosage delivered in IAPT. It strains all credibility to believe IAPT’s claim that it has achieved the 50% recovery rate that is common place in the rcts of CBT.

IAPT ignores the haemorrhaging and deftly switches the public focus to waiting times and numbers seen. The advantage of such key indicators is that it can always be claimed that with more funding waiting times will reduce and numbers seen increase and so the Titanic continues at speed. The crucial question that is avoided is ‘do waiting times matter in a context in which most decline to engage or complete treatment?’.

An unholy alliance between NHS England and IAPT has meant that the latter’s definition of the key indicators of success has been allowed to hold sway. The public are the victims of a failed duty of care.

 

Dr Mike Scott

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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

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BBC Chooses To Ignore Talking Therapies 10% Recovery Rate

this morning BBC Radio 4 focussed on the problems caused by the Improving Access To Psychological Therapies (IAPT) long waiting lists (half more than 28 days)  but reiterated IAPT’s claim of a 50% recovery rate. But IAPT has only ever marked its’ own homework on recovery rates. I spent hours explaining to Radio 4 reporters that the true recovery rate is more likely 10% as detailed in my paper published in the Journal of Health Psychology last year, but they totally ignored this – shortening waiting time for something, that is most likely to be ineffective approaches pointlessness:

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

billions of £s have been spent on IAPT over the last decade all without any publicly funded independent assessment of outcome, this would never have been permitted in evaluating a drug. NHS England claimed IAPT has exceeded expectations , but can cite no independent evidence. NHS England have failed the public in terms of accountability. There are so many vested interests in IAPT that the great majority of patients are likely to continue to be short changed. The yardstick has to be the proportion of people who get back to their old selves post-treatment, my study of 90 IAPT clients found that only the tip of the iceberg recover. NHS England need to commit to a publicly funded independent assessment of IAPT using real world outcome measures such as loss of diagnostic status for at least 8 weeks.

There is a troubling alliance of powerholders BBC, IAPT, BABCP and BPS that is ignoring the real needs of those with mental health problems.

 

Dr Mike Scott

  

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4 Out of 10 IAPT Workers Pressured to Alter Results

that is the finding of a survey of 550 current and past IAPT staff , https://survivingwork.org/5241-2/. The credibility of IAPT’s claims are in doubt, a referendum of its’ staff is needed.

NHS England is guilty of breathtaking naivety and laziness when it asserted on Radio 5 Live on Wednesday, November 13th, that 7 out of 10 IAPT clients move to recovery and 5 out of 10 recover. They did so without appeal to any independent audit. My own findings published in the Journal of Health Psychology last year suggested that actually the tip of the iceberg recover https://journals.sagepub.com/doi/10.1177/1359105318755264.

Clinical Commisioning Groups (CCG’s) should no longer see NHS England as a compelling source of persuasion in this matter, rather they need to listen to patients and the workers at the coalface. CCG’s should challenge IAPT to have a referendum of its staff at a local and national level, asking:

‘Do you want IAPT to move towards face to face assessment and treatment, as the norm?’ 

with simple ‘Yes’ or ‘No’ response options. The collective experience of IAPT workers has to be taken seriously. Judging by the stress levels reported by staff in the survey, IAPT cannot seriously maintain that it is  discharging its’ duty of care to its’ staff. 

Dr Mike Scott

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When IAPT Clients and Therapists Speak It Is Totally Different To The Powerholders

this morning Vicky, a victim of the Manchester bombing was interviewed on Radio 5 Live she managed to say live how crap she had found the IAPT service. But in the actual recordings she had said how the therapist wanted to persist with trauma focussed CBT/EMDR whilst she wanted to talk about how devastated her child, who accompanied her, was. Not content with this the therapist was constantly looking at the clock and door. On the same programme IAPT clinicians spoke incognito about pressure to fiddle results on the psychometric tests used to assess outcome.  Earlier in the day the public had their say, see link below:

https://mobile.twitter.com/bbc5live/status/1194542289663746048

for those directly involved the response was uniformly negative.

Contrast the above with the comments of Prof Paul Salkovskis, President of BABCP,  a prime mover in the genesis of IAPT, who described it as ‘marvellous’ but that ‘there are inevitably a few bad apples amongst the IAPT staff’.  NHS England waded in, in similar vein  and reiterated IAPT’s claim that 5 out of 10 recover and 7 out of 10 at least move to recovery. See Radio 5 Live podcast, the pertinent section is from 10.43 to 10.55am

https://www.bbc.co.uk/programmes/m000b5wk

I had recorded for the BBC an interview in which I said that it was criminal that over £3 billion had been spent on IAPT without independent audit. It has not been broadcast. I presented data on 90 consecutive clients going through IAPT, some before and others after a personal injury (PI) with a 10% recovery rate overall and no difference as to whether before or after. I had no axe to grind over IAPT, I simply discovered that it was failing people. This study was eventually published last year, together with 3 commentary papers and my rebuttal in a Special Issue of the Journal of Health Psychology https://doi.org/10.1177%2F1359105318781872.

Interestingly an earlier version of the paper was rejected by the Editor of Behavioural and Cognitive Psychotherapy, Prof Paul Salkovskis. To date the BBC seems to have preferred to broadcast his comments, which are without direct and systematic contact with IAPT clients rather than mine.

The powerholders have it, it seems, but I am not going to give up, earlier this week I saw a guy ( a non litigant), call him Dominic who, I discovered after a 1.5 hours assessment had been suffering from depression and generalised anxiety  disorder for 2 years. He had previously had a 15 minute telephone assessment with IAPT , had no more understanding of his condition than before but the assessor opined that he seemed anxious because he had listed a long list of problems.  Dominic was told that he would hear from them to attend a group, I asked him ‘a group for what?’ and he didn’t know.  He then asked me ‘how could I talk about all my problems in a group?’. Dominic said that he had got more out of our chat than in 2 years of seeing his GP and IAPT. Unfortunately most will not escape IAPT’s clutches.

Someone remind me why I am still a member of BABCP.

Dr Mike Scott

 

 

 

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IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott

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IAPT’s Clients – Vulnerable Adults With No Protection

Neither NHS England, Clinical Commissioning Groups or BABCP have taken any steps to ensure that there is independent monitoring of the welfare of IAPT’s clients. Such clients suffer a double whammy, not only do they experience the sense of helplessness often accompanying psychological debility, but they are also powerless to say anything about their experience.

The CONSORT guidelines ( see link below) state that randomised controlled trials should address outcomes that are meaningful to the patient. The same should apply to services delivered in routine practice. Changes in psychometric tests scores are not meaningful to clients, whereas no longer suffering from the disorder they were suffering from at the start of treatment is. But IAPT obfuscates its’ true performance by sleight of hand with psychometric test results. Clients are fodder for providing psychometric test data at each session, no matter that there is no certainty that the test is pertinent to what they are suffering, that repeated administration means that they can remember their last score and will want to convince themselves that they are getting better and that the results are interpreted by their therapist, creating a demand effect.

A major feature of the CONSORT guidelines is that treatment should be evaluated by those independent of service provision. There is no opportunity to protest about incompetence or the arbitrary number of session limit. IAPT violates this and every aspect of the guidelines that might be pertinent to routine practice.

Unfortunately Editors of Journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and the Lancet often ignore the CONSORT guidelines or any translation of them into routine practice. Consequently the evidence base for expansion of IAPT into areas such as psychosis in secondary care, is much less than understood by its’ workers.

https://www.dropbox.com/s/vj2hp1q43hz4lh8/CONSORT%202010%20Explanation%20and%20Elaboration%20Document-BMJ.pdf?dl=0

Dr Mike Scott