It’s A Myth That The Improving Access to Psychological Therapies (IAPT) Service Pays for Itself

IAPT has flourished over the last decade by proclaiming that it pays for itself [see Layard and Clark’s book Thrive  (2014)]. It has been music to the ears of politicians, NHS England and Clinical Commissioning Groups  but none, including the National Audit Office, has bothered to question it. Despite the £1bn price tag this year, see footnote 1. Anyone with the temerity to raise doubts, risks being accused of lacking a commitment to mental health, a pre-requisite of being considered progressive, whatever one’s political hue. 

 

When will the funding and professional bodies such as the British Psychological Society (BPS) and British Association for Behavioural and Cognitive Psychotherapy (BABCP) see that the ‘Emperor Has No Clothes’? IAPT claims the service pays for itself by getting people off unemployment benefit (16.8% of IAPT clients) Davis et al (2020) http://dx.doi.org/10.1136  and/or long term sick or disabled benefit (6.9% of IAPT clients).   It is therefore a change in the employment status of minority of IAPT clients that may justify the belief that the service pays for itself. But further elaboration of this population shows that the proportion of clients who could make an economic difference is smaller still. Further when the psychological mechanism by which a change of occupational status may operate is considered, it is improbable that the service pays for itself.  

 IAPT could in principle get 20-25% of clients off benefits. Assuming the target clientele this year is 20%, i.e 0.3 million people, how would the service pay for itself?  Well 40% of IAPT clients do not attend their 1st treatment appointment, so only 0.18 million will be exposed to an IAPT treatment therapist. Of these 42% attend just one treatment appointment, thus 0.1044 million have exposure  to IAPTs treatments and are in the categories of unemployed or long term sick, and potentially might have their employment status changed by the Service i.e 104,440. Those undergoing IAPT treatment ( defined by the Service as attending 2 or more treatment sessions) have an average of 8 treatment sessions in 2018-2019 Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 but the unemployed and those on long term sickness benefit are less likely to attend a treatment session, Davis et al (2020)http://dx.doi.org/10.1136, as are those who have been referred previously. Thus one might expect this 104,440 to attend a mean of 6 sessions and treatment typically spans 12 weeks according to Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 . But the population who may return to employment is smaller still because of the following considerations:

  1. There will be a sub-population of the ‘unemployed’ whose unemployment is  related to a work related negative life event, e.g now being physically unable to do the manual work they were employed to do or maltreatment at work. It is difficult to see how 6 sessions of psychological therapy  delivered over 12 weeks would change the diagnostic status of this sub population. There is absence of evidence that such a dosage of psychological therapy can change the employment status of this sub-population. If the sub-population of clients for whom work has been an iatrogenic factor in their debility, are excluded from the analysis, then the population that IAPT’s ministrations could conceivably address is much less than 100,000.
  2.  There will be a further ‘sub-population’ of the unemployed for whom work within their training is simply not available e.g a redundant fisherman. IAPT does not have the resources to conjure up new opportunities, albeit it might direct a client towards re-training.  

Thus the range of action of IAPT with regards to employment status is very limited and even more so when one considers by what mechanism could the typical 6 sessions change employment status over the 12 week span? To return a person to occupational functioning means addressing three key areas a) persistence – the ability to persist with a task b) pace – the ability to complete a task in a timely manner and c) adaptation – the ability to handle the inevitable hassles of the workplace. There is no evidence that IAPT specifically targets these difficulties or has provided training in tackling them. Neither has it been demonstrated that 6 sessions of psychological therapy can resolve such difficulties in 12 weeks and even less evidence as to whether such treatment is enduring.

IAPT lacks the potency to make a real world difference to the unemployed and those on long term sick. Layard and Clark (2014) muddy the distinction between the power of evidence-based psychological therapies and the power of their offspring, IAPT. It can be objected that IAPT pays for itself by increasing the productivity of those already employed, rather than by changing occupational status. But there is no evidence that it does so anymore than the pre-IAPT counselling services.

IAPT’s claim that it changes the employment status of its’ clients is akin to a Dickensian Government’s claim that Workhouses resolve employment issues.

Footnote and reference

 

  1. According to The IAPT Manual 2021 the target for 2021 is 1.5 million clients at a cost of £680 per client [data from Clark (2018) https://doi.org/10.1146/annurev-clinpsy-050817-084833] making the anticipated cost of the service this year, £1.02 billion.
  2. Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited

Dr Mike Scott

 

The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

Dr Mike Scott