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BABCP Response - NICE Consultation January 2022

The Care Quality Commission and NHS Talking Therapies

I have today received the following response from the CQC, after seeking clarification from them of the position between the two. (Thanks to Michael Brazendale for raising the matter with me, in my previous blog).  

Dear Dr Scott,

 

Thank you for your email. I’ve liaised with our policy colleagues and the current position is set out below.

 

  • Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care.
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 schedule 1 defines what ‘regulated activities’ are and ‘Treatment of disease, disorder or injury’ (TDDI) is a regulated activity defined in schedule 1(4)
  • TDDI requires the activity to be provided by or under the supervision of a health care professional or social worker – whether psychological therapies is a regulated activity will depend on the person providing it or supervising it
  • CQC therefore regulates psychological therapies that are provided by or under the direct supervision of a doctor, nurse (‘health care professionals’ defined in the Regulations) or a social worker.

 

Does CQC regulate IAPT services?

  • In the IAPT services model, supervision is most likely led by senior therapists (not medical staff), so this would probably not include a nurse, medical practitioner or social worker therefore, CQC would not be able to regulate psychological therapies in IAPT services as they are usually led and supervised by therapists and not a nurse, medical practitioner or social worker.

 

What does future regulation of psychological therapies look like?

  • We are working with DHSC, trade associations and other key stakeholders to identify and understand how we may inspect and rate psychological therapies going forward and to make sure our legislative powers cover all which needs to be covered, which may include IAPT services.

 

I hope this response is helpful.

 

Many thanks

 

Mat

 

Matthew Hughes

Senior Parliamentary and Stakeholder Engagement Adviser

07384 525677

 

For information about CQC, including contact details, information about how we use and protect personal data, and how to request information from us, go to https://www.cqc.org.uk/contact-us

He responded very quickly to my e-mail and in depth, for which I  have thanked him. I would be very interested in any comments on this missive which I could take forward.

Regards

 

Dr Mike Scott

I responded today March 22nd as follows;

Hi Mat

Following on from your email of yesterday I note that the CQC believes that:

‘Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care’.

I gather from your e-mail that the CQC role is restricted to coverage of agencies, in which a Doctor, Nurse or Social Worker heads the Service Providing agency. How many Service Providers of Psychological Therapies has the CQC inspected? Are there publicly available reports on the inspections? What proportion of NHS Talking Therapies Providers fall under the orbit of the CQC?

It appears that the scope of the CQC has been limited by the ’The Health and Social Care Act 2008 (Regulated Activities)and there is no mention of psychologists. This may be because NHS Talking Therapies in the shape of IAPT did not come into being until 2008 and the Service has slipped under the radar of the CQC. In my experience it is usually a psychologist who is at the head of a local NHS Talking Therapies Service.

If the CQC is to discharge its’ role, it is difficult to see how this can be done without broadening its terms of reference. In terms of the protection of Service Users there can be no justification for the de facto exemption of the great majority of NHS Talking Therapy sites, from CQC inspection. I appreciate that at present the inspection framework has yet to be decided  but this is a separate matter from establishing the legitimacy of CQC inspection across all psychological therapies Service providers.

I would be grateful for your response to these matters.

Dr Mike Scott

 

 

 

 

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BABCP Response - NICE Consultation January 2022

What Mediates Treatment Outcome in NHS Talking Therapies?

 

 


A treatment must directly impinge on a mediator, and the change in the mediator must result in a change in outcome. The mediator and the outcome must be distinct. Thus for example, in the treatment of panic disorder, anxiety sensitivity (the belief that physical and emotional arousal is dangerous) is a mediator of outcome. The treatment, interoceptive exposure (deliberate induction of uncomfortable sensations) dovetails with anxiety sensitivity to affect outcome, the absence of panic attacks. But in                                   NHS Talking Therapies one searches in vain for a mediator – it is all CBT talk, without any substance.

In attempting to apply mediational analysis to NHS Talking Therapies one enters a minefield:

  1. There is no clarity about which disorder/ difficulty is the focus. It could be panic disorder/attacks but there is no reliable mechanism for ruling out disorders beyond the scope of NHS Talking Therapies, such as personality disorders.
  2. Potential mediators are legion, and might include variously post-traumatic cognitions, dysfunctional attitudes and anxiety sensitivity.
  3. There is no evidence that NHS Talking Therapies clinicians have targeted any specific mediator.
  4. In reality NHS Talking Therapy clinicians operate a ‘black box’. Those who have been allowed to penetrate its’ contents Drew et al’s (2021) and Faija et al (2022) have discovered a machine-like process were priority is given to client’s completion of psychometric tests, which do not inform treatment. There is no evidence of the application of mediational analysis.
  5. Outcome is not assessed in NHS Talking Therapies with any hard outcome measure, assessed independently.
  6. All that can be said of NHS Talking Therapies is that time (number of sessions) mediates outcome, but this could be said equally in any possible control group. Time as such is not a relevant theoretical mediator.

 

NHS Talking Therapies claim to provide cognitive behaviour therapy (CBT) is preposterous, as the hallmark of CBT is the highlighting of disorder specific mechanisms of change and corresponding treatment interventions. It is difficult to escape the conclusion that alleging the provision of CBT is simply a good marketing ploy, enhanced by claims to be able to treat over a million people a year.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

‘No Direct Evidence of The Effectiveness of NHS Talking Therapies’

If you disagree, please supply the evidence. The justification for NHS Talking Therapies rests solely on indirect evidence. Primarily the randomised controlled trials cited by the National Institute for Health and Care Excellence (NICE) for depression and anxiety disorders. But there is no assurance (fidelity checks) that these protocols have been accurately translated into routine practice. NHS Talking Therapies legitimate themselves by claiming NICE compliance. Whilst this might be excellent marketing, there is no evidence to substantiate it. Further the randomised controlled trials are themselves of variable quality. In a minority of trials there has been blind independent assessment. In principle the high-intensity NHS Talking Therapy Service could have the capacity to deliver these evidence-based treatments. But there is no evidence that this has actually happened – a gap between theory and practice. By comparison the low intensity NHS Talking Therapy Service has the reference base of relatively poor quality studies. Not only is there the problem of a dirth of evidence of compliance with a NICE approved protocol, but the foundations of the low intensity protocols are weak.

All manner of interventions can be made to appear great in theory. But the acid test is what happens in the real-world. Disinterest in this, paves the way for vested interests, whether they be Organisations or charlatans marketing their wares. Organisations readily adopt a volume approach, operational matters: numbers seen, waiting times, become the key performance indicators, with a blind eye turned to value. NHS Talking Therapies acts it seems in its’ own interest and the client does not get a look in. One might ask how matters have reach such an impasse? Professional bodies such as British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS) have advanced NHS Talking Therapies mission at every turn.They have totally failed to critically appraise NHS Talking Therapies.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies Both Judge and Jury On Recovery

Would you invest in a company simply on the basis of its proclaimed profits? But that is exactly what successive governments have done every year, for the past fifteen years. At a cost of £752 million in the year 2021 for adult Mental Health Services, £922 million on child and adolescent mental health (excluding funding for eating disorders £73 million). Making a grand total of £1.75 billion [Figures from the National Audit Office (NAO ) Report of February 2023] for 2021-2022. The NAO  re-iterates, uncritically, IAPT’s claim of a 50% recovery rate for the Adult mental health service, neglecting to say that there has been no independent verification of this. Further there is not even a claim to the effectiveness of Child and Adolescent Mental Health services!

The NAO  is unphazed by the haemorrhaging of clients from the NHS Talking therapies for Adults. It notes, without comment, that  46% of its clientele drop out before treatment, were treatment is  defined as attending 2 or more treatment sessions. So that the much vaunted 50% recovery rate, applies only to those who complete treatment! 

My own work Scott (2018) on 90 clients going through NHS Talking Therapies predecessor IAPT, was that only the tip of the iceberg recovered.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Does NHS Talking Therapies Alter The Course of Mental Health Symptoms?

After 15 years of the Service and £10 billion spent on it, we still do not know! If ever there was a matter for Health Ministers, the Office of Budget Responsibility and the Nation al Audit Office, this is it. To date NHS Talking Therapies have only ever taken their own snapshots of clients, discharging them as soon as their scores fall below ‘casenness’ on a psychometric test. But the natural course of anxiety and depression is a waxing and waning. A photo at any one point is next to meaningless, particularly if it is taken by a party with a vested interest in declaring recovery.

In a 2 year naturalistic study, of depressed, anxious and depressed plus anxious patients in the Netherlands,  Penninx et al (2011)  the criteria of recovery was at least 3 months free of symptoms as assessed by a diagnostic interview. This metric ensured that they were looking at how long it took to what could be taken as a real-world change. [A far cry NHS Talking Therapies studies]. With half of depressed patients recovering within 6 months. Half the anxious group recovered by 16 months and half the combined group by 24 months. Of those who remitted a quarter relapsed. Approximately half the population had psychological treatment and they fared no better than those who didn’t. There is no evidence that NHS Talking Therapies clients fare any better than those in the Netherlands or than those attending the Citizens Advice Bureaux.

In my capacity as an Expert Witness to the Court I reviewed 90 cases Scott (2018), some of whom had NHS Talking Therapies treatment before a personal injury and others who were treated afterwards, whichever was the case only the tip of the iceberg recovered. I called for a a publicly funded independent assessment of the Service, 5 years on, nothing, just a rebranding of IAPT earlier this year. 

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies Under a Cloud

SilverCloud is a computerised CBT programme, which according to the manufacturers supports ‘80%’ of the NHS services. A year ago, I complained to the Advertising Standards Authority (ASA) over its’ claim of, ‘up to 70% clinical recovery rates’, citing my independent evidence, Scott (2018), that only the tip of the iceberg recover.  The matter was passed to the Irish ASAI, under whose jurisdiction it actually falls, and they informed me  (April 27th 2023 ) that the advertised claim has since changed from “up to 70% clinical recovery” to “up to 65% users achieve clinically significant improvement”. For whatever reason there has been a watering down of SilverCloud’s claim. They no longer want to talk about recovery, a concept that most people can easily understand. The ASAI are continuing to address the matter. Unfortunately NHS Talking Therapies, are it seems answerable to no one and there is no indication that they are abandoning their absurd claim of a 50% recovery rate.

The claim that 65% achieve clinically significant improvement, has a scientific aura about it for a member of the public, but with no idea as to what it means in real world terms. They might consider that as ‘77% of volunteers agreed that volunteering improved their mental health and wellbeing’, National Council for Voluntary Organisations survey 2019, this was actually a better investment.  The implication of SilverCloud’s claim is that it is the use of their product that has brought about the ‘significant improvement’ but this has not been demonstrated. The said improvement could represent regression to the mean, patients presenting at their worst and becoming a bit better with time. Equally it could represent the client’s wish to please the therapist and/or to feel that they have not wasted their time. The claim of ‘significant improvement’ because of usage of the product is not evidence-based and is simply a marketing ploy.

NHS Talking Therapies have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. see SilverClouds Space for Depression programme   NICE Guidance ‘Space from depression for treating adults with depression’ Medtech innovation briefing published May 7th 2020. Strangely the NICE IAPT Expert Panel concluded that the case for adoption is ‘partially supported’ despite in the body of report noting lower depression scores, at the end of treatment for the clients of therapists who did not use the computer assisted CBT. An example of spin and conflict of interest.

Dr Mike Scott

 

 

 

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BABCP Response - NICE Consultation January 2022

Antidepressant Manufacturers Claim Independent Evidence of Effectiveness But From NHS Talking Therapies A Deafening Silence

This evening at 8.0pm, Panorama on BBC 1, looks at the debacle of antidepressants, with a quarter of people on them for 5 years. But the antidepressant manufacturer’s protest that there is independent evidence of the effectiveness of their product. However NHS Talking Therapies has ducked under the radar: they make no claim to independent scrutiny, they are not subject to Care Quality Commission inspection and there is not a single publicly funded, independent study of their effectiveness. The cost to the taxpayer of NHS Talking Therapies is over a £1billion a year. My own study of 90 clients going through the Service was that only the tip of the iceberg recover Scott (2018) I brought this to the attention of the BBC some years ago, but instead they chose to listen to the power holders in NHS Talking Therapies predecessor IAPT.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Formulation Nausea Revisited

Six years ago I blogged about Formulation Nausea, which is induced by a bewildering array of arrows, resulting in disorientation. A just published paper by Owen (2023) in Psychological Medicine notes the demise of Formulation amongst Psychiatrists. But it is still a staple of CBT training courses, based around the 4P’s of predisposing, precipitating, persisting and protective factors. This despite any evidence of its’ systematic usage in routine practice or effect on outcome. Yet it was meant to explain the client’s functioning. It is surely time for a re-formulation. 

The problem is that the 4P’s are in suspended animation with no specification of what kind of thing they are trying to explain. As Owen (2023) points out there is a need for a diagnostic anchor when it comes to formulation. Diagnosis is descriptive, with reliable agreement only occurring in the context of ‘gold standard’ diagnostic interviews. Without such an anchor Formulation is adrift on the high seas, clinicians suffer nausea and clients doubt their survival. Shorn of its’ moorings, Formulation becomes an exaggeration of the idiosyncracy of a client’s difficulties. There are evidence-based CBT protocols for depression and the anxiety disorders but their usage is dependent on ‘case-formulation’ not formulation.

Re-formulation needs to be added to re-framing and re-imagination

Matters have been compounded by psychological imperialism, assuming that there is only one axis needed to explain a clients functioning and subsuming  the social and biological under the first of the  4P’s, Kuyken et al (2009). A 3-D representation of a clients functioning, should arguably be represented by 3 axes at right angles to each other, psychological, social and biological with no primacy attached to the psychological per se. Each person has a score along each axis and their functioning represented by x, y, z coordinates. With this multi-axial classification (akin to DSM IV and not its successor DSM-5-TR) it is perfectly possible to ‘score’ much more highly on a non-psychological axis, making that the more relevant ‘intervention’ dimension. For example a client I saw recently was clearly depressed, with no previous psychological problems, but found himself living in terrible housing conditions that was seriously effecting the health of his children and all attempts to remedy this problem to date had failed. The social axis was clearly more pertinent in his case, but the presenting problem, as far as the way the local mental health services operate would be depression, albeit that moving in an intrapsychic direction flies in the face of common sense. Kuyken et al (2009) smuggle in an extra ‘P’ presenting problem to make 5P’s, but presenting problem is not part of an explanation, each of the 3 axes  has a predisposing, precipitating, persistence and protective explanatory framework, inclusion of ‘presenting problem’ is a category error. To take another example a patient may be judged non-compliant with physio after an operation, but a previous unrelated and unrecognised neurological condition was actually operating, resulting in a demoralised patient and frustrated physio’s. The appropriate axis here is a biological one not ‘stress management’ for the patient or physio. The failure to have a multi-axial approach means that psychological therapists take on everything, and their core skills get crowded out. Kuyken et al (2009) and CBT trainers and supervisors have unwittingly abandoned a biopsychosocial model adding to the stressors of would be clinicians. The failure to use a multi-axial system can be seen in NHS Talking Therapies practitioner’s struggle to provide therapy for those with long term physical conditions, carrying a sign ‘don’t ask me how far along the biological axis is this person located, because it is a mirage’, they are consigned to wander around the desert. Sufferers from FN are often stressed in silence, to reveal it to course leaders, supervisors may be taken as a sign of ‘weakness’. What is needed is a re-formulation.

Dr Mike Scott

 

 

 

 

 

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – A Sacred Cow

NHS Talking Therapies is the only NHS service that it is not independently assessed. Costing £2 billion a year for adult and child services, it has escaped the scrutiny of both the National Audit Office and the Care Quality Commission. It is also, it seems, the only NHS service were staff are not in a public pay dispute.  What is going on?

It deftly keeps below the radar, so that ‘value for money’ questions  are not asked. The other string to its’ bow is ‘gas-lighting’, the repeated repetition of a claim, absorbed by its familiarity. Its’ much vaunted ‘50% recovery rate’, has warmed the cockles of the hearts of politicians,  Integrated Care Boards and the media, who have all readily and willingly accepted the lie [see Scott (2018)] in the name of political correctness – to be seen to be on the side of mental health.  In Mental Awareness Week the powerholders need educating that functioning does not equal working. The Annual reports of IAPT (NHS Talking Therapies previous embodiment) portrays its functioning: numbers seen, waiting times and self-determined targets met. But with no evidence that it is working – no independent assessment of the proportion of clients who are back to their old self and remain so post treatment. There is no credible listening to the client by a Red Cross-like body.

The Citizens Advice Bureaux are a nationally recognised and valued body. Many of their clientele have mental health problems, but there is no evidence that they are any the less served than if they had attended NHS Talking Therapies.  The added value of this NHS service has not been demonstrated. Perhaps NHS Talking Therapies staff dare not consider strike action because they are afraid nobody would miss them. GPs may miss the brief respite that may come with off-loading to NHS Talking Therapies, some perhaps even believing or at least wanting to believe NHS Talking Therapies fairy tale. They may be complicit in marketing the tale to patients.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

The National Audit Office Confers With Mental Health Powerholders and Not Patients


Unsurprisingly the surveyed integrated care board (ICB) mental health leads and mental health trusts tell the NAO what a great job they are doing.  The NAO also interviewed mental health stakeholder organisations such as the BPS and BMA. On this basis, the NAO [“Progress in improving mental health services in England”] declared last month, that ‘the government has achieved value for money’. The yardstick used by the NAO was whether the surveyed bodies ‘met ambitions to increase access, capacity, workforce and funding for mental health services’. No attempt to access the voice of the people. 

Interestingly the NAO did not even attempt to make the claim of the prime movers in IAPT Layard and Clark (2015) that the Service costs nothing, due to savings on welfare benefits and physical healthcare costs!  The response of the great and the good in mental health (the NHS Confederation, SANE and Mind) has been, that the report highlights the need for increased funding, to recruit and retain more staff. No awareness that more of the same is unlikely to make any difference to patients.

 

The report reveals that £752 million was spent on NHS Talking Therapies predecessor, IAPT, in 2021-22. But when the NHS acquired IAPT earlier this year no audit of the latter was conducted. No business would behave in this way. Yet the NAO report re-iterates the target of ‘at least 50% achieve recovery across the adult age group’. No mention that there is no independent evidence that this has ever been achieved. With the best evidence Scott (2018) suggesting that only the tip of the iceberg recover. What sort of auditors are the NAO? Under their watch acquisitions can be made without credible scrutiny.

In 2018 the NAO jettisoned an enquiry into the Improving Access to Psychological Therapies (IAPT) Programme. In response to a Freedom of Information request, the NAO responded on February 17th 2020 ‘We commenced work on the IAPT programme in 2017-18. However, the work on this programme was curtailed in June 2018 by the Comptroller and Auditor General (C&AG) of the time in response to changing priorities. The alterations to the work programme were made so that the C&AG could respond quickly on important topical issues, such as work on the UK’s exit from the European Union, the government’s handling of the collapse of Carillion, and on significant NHS spending increases in 2017- 18 on generic medicines in primary care’.

Dr Mike Scott