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Psychological therapies next steps towards parity of care September 2015 This report was prepared with funding from Ieso Digital Health. JMC Partners has retained full editorial control. contents FOREWORD.......................................................................................................................................................3 EXECUTIVE SUMMARY..................................................................................................................................4 RECOMMENDATIONS.....................................................................................................................................5 BACKGROUND: THE CASE FOR MENTAL HEALTH IMPROVEMENT..................................................7 Need for parity of esteem for mental health.......................................................................................7 Societal impact..........................................................................................................................................8 Economic impact.......................................................................................................................................8 Mental health service funding...............................................................................................................8 NHS spend..........................................................................................................................................8 Regional variation in mental health spend.................................................................................8 Approaches to mental health treatment..............................................................................................9 Medication: antidepressants...........................................................................................................9 Psychological therapies................................................................................................................ 10 IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES PROGRAMME........................................ 11 Programme overview and status update......................................................................................... 11 IAPT key improvement area one: clearer routes to treatment..................................................... 12 Referral:............................................................................................................................................. 12 Triage:................................................................................................................................................ 13 IAPT key improvement area two: tackling waiting lists................................................................. 14 IAPT key improvement area three: making better use of data.................................................... 15 Targets and regional variation:................................................................................................... 16 Data driven improvements........................................................................................................... 20 NEXT STEPS FOR PSYCHOLOGICAL THERAPIES: IAPT & BEYOND............................................... 21 Commissioning for Choice................................................................................................................... 21 Overarching suite of services..................................................................................................... 21 Signposting local therapy choices............................................................................................. 23 New models of care............................................................................................................................... 23 Digital solutions:.............................................................................................................................. 24 Populations with unmet need...................................................................................................... 26 Chronic physical illness and long-term conditions................................................................ 26 Extending IAPT................................................................................................................................ 27 APPENDICES.................................................................................................................................................. 28 REFERENCES................................................................................................................................................. 31 2 Psychological therapies next steps towards parity of care FOREWORD William Wragg MP Mental Health is an issue that is very important to me, both from a personal perspective and as a political priority. As a long standing member and supporter of Mind, it is an issue I am keen to champion in my new position as MP for the Hazel Grove Constituency. One of the important concrete steps on the way to better mental health services in the NHS is achieving parity of esteem, whereby mental health is given similar levels of research attention and treatment funding as physical health. Research shows that around one in three people in Britain will be affected by mental health issues in their lifetime; that’s almost as many as cancer, and many more than heart disease or diabetes. It is very important that these conditions receive world class treatment too, but it is not right that mental health comes far lower down the agenda - that is something I want to see change. We must give increased attention and esteem to mental health, and studies such as this provide a focus of attention, and give an opportunity to influence and improve NHS provision of mental health services at a national and local levels. The Government and NHS England are committed to delivering parity of esteem between mental health and physical health, and recognise that spending is one of the areas which must be addressed. As well as the financial settlement, a key element of achieving parity across mental and physical health care is in people having timely access to evidence-based and effective treatment. This study has taken a detailed look at all these issues and many more beside and I commend it for both its extensive scope and depth. This included wide-ranging consultation with mental health practitioners, commissioners, patient groups and campaigners, and a thorough interrogation of the data surrounding the effectiveness and outcomes of psychological therapy options, and how these vary across the country. The significant increases in recovery rates in patients who have benefited from improved access to psychological therapies, between 2009 and 2014, for example, is something surely to be welcomed. The report also lays out ways that this treatment path can be improved still further in the future. The report before us contains information which will be valuable to practitioners, policy makers and importantly patients in determining how to improve the structure of treatment and therapy options for the future. Its key findings and recommendations should prove to be of interests to those across the mental health sphere, and should receive appropriate consideration from decision makers at both national policy and local commissioning level alike. I welcome the commissioning of this report, and the contribution it is set to make to the ongoing and important policy debate and decision making as we work towards better mental health in Britain. Psychological therapies next steps towards parity of care 3 EXECUTIVE SUMMARY The current government and its predecessor have made welcome strides in raising the priority attached to mental health by putting it on a par with physical health. Words and deeds are not always easy to reconcile, especially at a time of economic constraint. This report looks at mental health in the round, before focusing more particularly on access to psychological therapies for adults. It does so in the knowledge that, as with most physical conditions, mental health problems need to be diagnosed and treated early to achieve the best outcomes. Unlike physical health, the continuing stigma attached to mental ill-health constitutes a considerable barrier to access. In that context, the Improving Access to Psychological Therapies (IAPT) programme represents a remarkable success story which is helping to re-shape the landscape for mental health for the individual and the NHS as a whole. Research conducted for this report, however, shows that much more remains to be done to improve access and to make the most of available resources. For example, 66 per cent of GPs cite waiting times for psychological therapy as the biggest barrier to treatment. The variation in IAPT performance between different CCGs around the country is also striking with the achievements of the best, combining short waiting times with recovery rates in excess of 50 per cent, demonstrating the magnitude of the opportunity. Drawing on the knowledge and expertise generously shared by a wide range of interviewees, this report makes a number of recommendations which have the potential to build on the initial success of IAPT without the need for massive levels of new investment. Perhaps most notably: n Effective triage, where it is offered, is critical in getting the right people to the right forms of treatment at the right time. Separating triage from provision seems essential in that regard; n Bearing in mind the continuing issue of stigma, scope for self-referral should be an integrated part of services throughout the country; n The ground-breaking database attached to IAPT should be used to identify what works best and to drive the improvement of performance nationwide; n In making informed decisions and exercising choice, healthcare professionals and patients need better information about the different types of psychological therapy, the evidencebase supporting them and for whom they are best suited; n This applies particularly to new models of care, which have real potential to improve access and efficiency but where the risk of comparing apples and pears is equally real; n The IAPT programme has the potential to address the mental consequences of physical ill-health more successfully and must be sensitive to smaller populations with unmet need. 4 Psychological therapies next steps towards parity of care RECOMMENDATIONS OWNER RECOMMENDATION 1 Clinical Commissioning Groups Ensure that their local IAPT services include an option for self-referral, which is actively promoted and supported with adequate information on the therapeutic options available 2 Clinical Commissioning Groups Ensure that triage is managed through a single point of entry, by an independent third party (rather than a service provider) 3 Government Ensure appropriate levels of funding for all steps of the psychological therapies care pathway to ensure patients can be triaged according to need 4 Clinical Commissioning Groups Ensure that triage is provided through a number of channels, including online 5 NHS England Develop a national service specification for triage 6 Clinical Commissioning Groups Work with triage services to ensure that waiting lists are managed in line with patient need 7 Department of Health Retain IAPT targets in its Mandate to NHS England, raising these as appropriate to reflect the Government’s ambition for parity of esteem 8 Health and Social Care Information Centre (HSCIC) Conduct regular and timely assessment of IAPT data that will support more granular benchmarking between CCGs and a better understanding of the services provided and for whom they are most effective 9 NHS England Work with HSCIC to ensure the IAPT annual report is published within 3 months of year-end and includes a greater degree of CCG benchmarking to provide timely impetus for improvement 10 Clinical Commissioning Groups Publish an annual report and plan for improving access for psychological therapies, setting out how they intend to improve performance over the coming year 11 NHS England Hold regional workshops to ensure stronger understanding of the IAPT data set and its implications for commissioning planning, with additional resource as required 12 Department of Health Bring together key psychological therapy stakeholders, including IAPT team and providers, to prepare an easy to understand guide for commissioners and patients on the types of psychological therapy that are available 13 NHS Choices Expand its psychological therapies database to include IAPT and non-IAPT services. The number of categories used to facilitate service comparison should also be expanded to enhance understanding 14 Clinical Commissioning Groups Commit to maintaining their entry on the NHS Choices psychological therapies database, including IAPT and non-IAPT services 15 NHS Choices Convene roundtable to consider the landscape for new digital models of care and how the market should be segmented to provide greater clarity to commissioners, health care professionals and patients 16 National Information Board Hold regular meetings with key representatives from the mental health community, including commissioners, patients and providers, to ensure that adequate consideration has been given to the specific considerations related to mental health 17 National Information Board Ensure that accreditation developed for digital apps provides a clear assessment of who an app is appropriate for and when it should be used, using digital services in mental health as an exemplar 18 Department of Health NHS England Assess which new models of care it would be appropriate to commission nationally and lead a work programme to implement national contracts as appropriate 19 National Institute of Health & Care Excellence Consider incorporating a range of measures in the next CCG Outcomes Indicator Set to ensure CCGs are seeking to improve access across a range of populations where unmet need exists 20 NHS England Work to develop national service specifications for psychological therapy access for people with a range of long term conditions 21 Department of Health Conduct a systematic assessment into how to achieve a more integrated approach to psychological therapies, giving consideration to the development of the IAPT brand and the feasibility of extending the programme’s remit Psychological therapies next steps towards parity of care 5 6 Psychological therapies next steps towards parity of care BACKGROUND: THE CASE FOR MENTAL HEALTH IMPROVEMENT Key points n Parity of esteem between mental and physical health is a national priority n With one in four people experiencing a mental illness each year, the cost of mental ill-health has significant social and economic implications n Y ears of low prioritisation mean that mental health budgets remain inadequate to support the Government’s ambitions for parity of esteem n A lthough this report focuses largely on what can be done to make better use of existing funding, parity of esteem will remain elusive until there is a clear move towards greater parity of funding between physical and mental health n T he Government’s planned increase to NHS funding should include ring-fenced funds for improving access to psychological therapies and wider mental health services Need for parity of esteem for mental health Despite being of central importance to our wellbeing, mental health has not been afforded the same priority as physical health within the NHS. People with mental health problems still do not have the same access to services and there remain issues around stigma which represent a key barrier to parity.1 In recent years there has been growing awareness of the gap that exists between physical and mental health services and the negative impact this has on individuals, society, the public purse and wider economy. This recognition of the need to drive change in mental health services is starting to be reflected in NHS policy. In 2015, NHS England introduced the first access and waiting time standards for psychological therapies and announced an additional £80 million in investment.5 While the introduction of these standards represents a step in the right direction, the additional funding is modest when seen within the context of overall mental health spending and the scale of the challenge in securing parity with physical health services. In keeping with the Health and Social Care Act 2012, the 2013-15 NHS Mandate2 instructed the NHS to put mental health on a par with physical health, and to close the health gap between people with mental health problems and the population as a whole. This commitment to improve the state of mental health services in the NHS also featured prominently in the Conservative Party’s 2015 manifesto: The Government has committed to increasing the NHS budget by £8billion by the end of this parliament in 2020.6 This is in line with the NHS Five Year Forward View, which projected a £30billion funding gap by 2020, with the balance of £22billion to be met by efficiency savings. It is not yet clear how the NHS budget increase will come into effect during the years ahead. “We have legislated to ensure that mental and physical health conditions are given equal priority. We will now go further, ensuring that there are therapists in every part of the country providing treatment for those who need it.”3 The Mental Health Policy Group has clearly stated that a key action for the current government is to ensure fair funding for mental health.7 Although this report focuses largely on what can be done to make better use of existing funds, parity of esteem will remain elusive until there is a clear move towards greater parity between physical and mental health spend. The government’s planned increase to NHS funding should include ring-fenced funds for improving access to psychological therapies and wider mental health services. Following the 2015 General Election, the new Minister with responsibility for mental health services, Alistair Burt, was quick to set out the new government’s stall: “I will continue the support and promotion of mental health services across the age spectrum, for expectant mothers suffering psychological distress, increased access to talking therapies for all, and enhanced education and counselling services in schools.”4 Psychological therapies next steps towards parity of care 7 Societal Impact One in four people will experience a mental health problem each year.8 Mental illness is generally more debilitating than most chronic physical conditions. On average, a person with depression is at least 50 per cent more disabled than someone with angina, arthritis, asthma or diabetes.9 Poor mental health has a significant impact on individuals and their families, reducing quality of life, educational attainment and life expectancy.10 For those people affected, and their friends and family, the most immediate impact of experiencing a mental health problem is the suffering caused. Living with a mental health problem also has a strong correlation with physical ill-health. For example, depression is linked with a 67 per cent increased risk of death from heart disease and a 50 per cent increased risk of death from cancer.11 Depression and anxiety disorders can also have a lifelong course of relapse and remission, meaning that they are more akin to long term conditions than discrete episodes of ill health. As with many long term conditions, this means that people who experience mental health disorders may need to access services repeatedly throughout their lives. Economic impact Notwithstanding the individual cost for those directly suffering from mental health conditions, the annual health, social and economic cost is estimated at £105 billion each year in England according to the Mental Health Foundation.12 The Department of Work and Pensions (DWP) has recognised mental health as a significant factor contributing to sustained unemployment levels in England.13 There is evidence that mental health problems are more common amongst people who are on benefits and out 20% 13% 67% Mental health Physical health Other Figure 2 2013/14 programme budgeting data spend on top ten categories, excluding other19 Mental health problems also add considerably to the costs of the education and criminal justice systems and homelessness services.18 Mental health service funding NHS SPEND Years of low prioritisation have seen mental health services funded more weakly than physical health services. As shown in Figure1, if spend on conditions related to physical health is grouped together and compared with spend on mental health, physical health expenditure is more than five times that on mental health. Such underfunding has tended to be obscured in policymaking owing to the way in which spending on mental health services is grouped together in comparison to disaggregated spend on different physical health services. NHS England collects programme budgeting data from CCGs, which groups a wide range of conditions including common mental health problems, psychosis, child & adolescent mental health services and dementia. This data is of variable quality but mental health spending forms the largest category of spend in 2013/14, as in Figure 2, with expenditure of about £14.5 million per 100,000 population across England.19 Regional variation in mental health spend There is also significant regional variation in mental health spend, ranging from under £8.5 million per 100,000 population to over £30 million per 100,000 population.20 Although some of the variation can be explained by looking at spend versus population need, the large degree of variation suggests an associated variation in the priority attached to mental health. 16,000,000 14,000,000 SPEND (£) PER 100,000 Figure 1 2013/14 programme budgeting data spend on physical vs mental health conditions19 of work than those in employment.14 While the prevalence of mental health problems amongst individuals in work is around 14 per cent,15 almost a quarter (23 per cent) of Jobseeker’s Allowance claimants have a mental health problem.16 According to DWP calculations, over 40 per cent of sickness claims record a mental or behavioural disorder as a primary condition.17 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 PROGRAMME BUDGETING CATEGORY 8 Psychological therapies next steps towards parity of care Maternity and reproductive health Cancers and tumors Neurological Problems due to trauma and injury Problems of the genito urinary system Problems of the respiratory system Problems of the gastro intestinal system Problems of circulation Problems of the musculoskeletal system Mental health disorders 0 Approaches to mental health treatment Key points n Mental health disorders encompass a wide range of different conditions, with an associated variety of appropriate treatments n The treatment landscape will inevitably continue to be a mixture of medications, psychological therapies and crisis care n In planning future improvements to mental health services, the increasing role of psychological therapies should be supported, with targeted improvements made Mental health disorders cover a wide range of symptoms and conditions ranging from schizophrenia and psychosis to depression and anxiety disorders. Treatments for these conditions vary accordingly and include: Medication: antidepressants n Medications including antidepressants 21 per cent of the England-based GPs surveyed for this report said that prescribing antidepressants was the most accessible treatment option for people with depression, whereas only 11 per cent of these GPs reported that referring the patient to local psychological therapy services including Improving Access to Psychological Therapies (IAPT) services was the most accessible treatment option. This compares favorably to Wales, Northern Ireland and Scotland, where there is no IAPT programme and a higher proportion of GPs stated that prescribing antidepressants was the most accessible treatment option for people with depression, as shown in Figure 4. n Psychological therapies n Other services such as crisis care The section below focuses on the treatment of common mental health disorders, which are estimated to affect up to 15 per cent of the population at any one time.21 Common mental health disorders are usually treated in primary care and, historically, the most common form of treatment has been psychotropic medication such as antidepressants.23 Common mental health disorder Number of people Depression 2.6 in 100 people Anxiety 4.7 in 100 people Mixed anxiety and depression 9.7 in 100 people Phobias 2.6 in 100 people OCD 1.3 in 100 people Panic disorder 1.2 in 100 people Post-traumatic stress disorder 3.0 in 100 people Eating disorders 1.6 in 100 people Figure 3 Overview of common mental health disorders22 Figure 4 Percentage of GPs identifying antidepressants as the most accessible treatment option in different parts of the UK 45% 40% PERCENTAGE OF GPS 35% 30% 25% 20% 15% 10% 5% 0% England Scotland Wales Northern Ireland PARTS OF THE UK Psychological therapies next steps towards parity of care 9 Recent figures published by the Health and Social Care Information Centre (HSCIC) reported that prescriptions for antidepressant medications rose from 53.3 million in 2013 to 57.1 million in 2014, an increase of 7.2 per cent. Of all prescription medicines, antidepressants saw the greatest increase in prescribing in 2014.24 However, a study by the University of Southampton showed that GPs are prescribing fewer antidepressants to patients with newly diagnosed depression than 10 years ago, and that the overall rise in antidepressant use is driven by recurrent cases and longer treatment regimens.25 The research showed GP prescribing of antidepressants in people with a first bout of depression fell by 12 per cent between 2003 and 2013, from around 73 per cent to 61 per cent, perhaps indicating increased use of psychological therapies as a first line intervention. Psychological therapies Since their introduction in the 1950s psychotropic drugs, including antidepressants, have been beneficial to millions of people experiencing mental health problems. However, there are limitations in their ability to help people recover from periods of ill health in the long run including risk of relapse. Some medications, especially those used for anxiety disorders, are also addictive and psychological therapies are thought to be more effective in achieving sustained recovery.26 In recent years there has been a focus on increasing the availability of psychological therapy as a treatment option for people with common mental health disorders. The government has recognised that in addition to being clinically effective,27,28 the provision of psychological therapies can provide significant economic benefits, by reducing healthcare usage, long-term repeat prescription costs, GP appointments, outpatient procedures and inpatient bed days.29 Further economic gains to the exchequer and employers through work retention, sick day reduction and welfare benefits have likewise been noted.30 NICE commissioning guidance recommends that psychological therapy services for people with common mental health disorders in England should be organised by a stepped care approach where patients are referred to the lowest appropriate treatment option for their condition and then moved up through the steps as deemed necessary.31 Figure 5 sets out examples of the type of conditions and the care that should be made available to people in each category. Each step represents increased complexity in the required intervention. This approach is also considered central to managing costs as lower level interventions are less expensive. However, in reality it can be complicated to move people between steps if the service is not well integrated. Psychological therapies is the collective term for a range of interventions including cognitive and behavioural therapies, psychoanalytical therapies and humanistic therapies. Further details can be found in Appendix 1. Figure 5 Stepped care approach to psychological therapies developed from NICE guidelines31 SERVICE LEVEL Step 4 Step 3 Step 2 Step 1 10 MENTAL HEALTH DISORDER TREATMENT OPTIONS For example: Severe and complex depression, risk to life, severe self neglect For example: Highly specialist treatment, crisis services, day hospiatl or inpatient care For example: Moderate to severe panic disorder, OCD and PTSD. General anxiety disorder, not responded to low-intensity treatment options For example: Mild to moderate anxiety disorder, panic disorder, OCD, PTSD, generalised anxiety disorder and depression For example: Suspected presentation of common mental health disorder Psychological therapies next steps towards parity of care For example: CBT, behavioural couples therapy, trauma focused CBT, self-help groups. For example: Individual facilitated self-help, self-help groups, computerised CBT, group based per support, individual or group based CBT Identification, assesment, psychoeducation, active monitoring, referral for other assessment IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES PROGRAMME Key points n IAPT is an important programme which has delivered significant improvements to mental health provision in England n Given its proven cost-effectiveness and impact on mental health outcomes, IAPT should be expanded and strengthened n Notwithstanding the successes of the programme to date, there is a range of targeted improvements which can help enhance psychological therapies, including IAPT, for the future Programme overview and status update In 2008, the Department of Health (DH) introduced the Improving Access to Psychological Therapies (IAPT) programme in an attempt to address low and variable access to evidence-based therapies across England, with improved delivery methods and outcomes for patients. The original justification for the IAPT programme was strongly based on the rationale that the service would pay for itself, and indeed make net gains in health spending and more broadly in relation to helping people stay or return to work:33 The initial ambitions for the IAPT programme were to secure access for at least 15% of the local adult population who needed psychological therapies and to achieve a 50% recovery rate among those completing treatment.34 The IAPT programme provides a model for delivering proven psychological therapies locally, based on a number of key principles such as data collection, assessment and triage of patients, the use of appropriately trained therapists and a stepped care approach to services. Common mental health disorder 2008/9 Since its establishment, IAPT has become the dominant model of psychological therapy provision outside secondary care, seeking to organise and deliver care locally in line with the principles set out above. It is important to note that not all psychological therapies available in England are provided through the IAPT programme. In national policy, however, the programme has been prioritised and in many respects become an umbrella term for locally delivered psychological therapies in their entirety. This dynamic is something that is given further consideration later in the report. In a short space of time psychological therapies have become an increasingly accessible, first line treatment for people experiencing common mental health disorders and the IAPT programme has been pivotal in achieving this success. The programme has dramatically raised the profile of psychological therapies and made significant strides to increase access. Over the five year period set out in Figure 6, during which the IAPT programme was accelerated, there has been an almost 28 fold increase in the number of people seen through the IAPT programme and an almost 71 fold increase in the number of people who have been treated each year. 2009/10 2010/11 2011/12 2012/13 2013/14 Numbers seen 40,000 180,000 380,000 530,000 600,000 1,119,000 Numbers treated 10,000 90,000 250,000 330,000 380,000 709,000 Figure 6 Numbers of people accessing IAPT services (2008/09 - 2013/14)26 Psychological therapies next steps towards parity of care 11 IAPT has also seen significant improvements to recovery rates, increasing from 37 per cent in 2009/2010 to 45 per cent in 2013/14.36 Moreover, in 2013/14, 32 CCGs reported a reliable recovery rate of over 50 per cent and 49 CCGs reported a recovery rate of over 50 per cent,37 meeting the government’s IAPT target.38 This suggests that as the IAPT programme has matured, it has also delivered better outcomes for patients. With access and patient outcomes improving as the programme has developed, IAPT has made a number of important strides towards its ultimate goal of significantly increasing the availability of Figure 7 IAPT annual recovery rates39 National Institute for Health and Clinical Excellence (NICE) recommended psychological treatments for depression and anxiety. As the government and NHS leaders seek to improve mental health provision during the course of this parliament, concerted action to continue to strengthen psychological therapies is essential. The following discussion identifies the key areas for improvements in future, with a view to maximising the value of investment in psychological therapies. Children and Young People’s IAPT is a complex area and beyond the scope of this report. 46% 45% RECOEVRY RATES 44% 43% 42% 41% 40% 39% 38% 37% 36% 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 YEAR IAPT key improvement area one: clearer routes to treatment Key points n Facilitating broader access to IAPT services must be a key component of future improvement work – this should include promotion of self-referral through numerous local channels n Well-informed triage needs to be conducted independently of local service providers to ensure patient need is the key consideration n Entry to IAPT services should be aligned with care pathways for other chronic conditions Getting treatment to the right patient at the right time is crucial for ensuring the best use of resources. The interviews conducted for this report identified a number of areas where more could be done to ensure the smoother and more effective delivery of psychological therapies to those patients who would benefit from them most. Referral: As the first port of call for most individuals suffering from mental health problems, GPs have an important role to play in the referral process. To ensure a standardised high level of care across the country, GPs should rely on an agreed diagnosis model to inform appropriate referrals. 12 Psychological therapies next steps towards parity of care Following an initial diagnosis, it is also essential that GPs are well informed about the treatment options available and can hold informed discussions with their patients should they wish for further information at this stage, particularly as selfreferral often follows an initial discussion with a GP. For more information on expanding knowledge of the services available in local areas, please see recommendations 13 and 14. Self-referral is recommended in IAPT guidance and is considered to be a core principle of the IAPT programme. One of the main reasons for this is that self-referral has been found to facilitate a higher number of referrals from those groups less likely to seek help via their GP, such as BME populations.40 42 per cent of referrals made to IAPT services in April 2015 were through self-referral.41 However, during interviews for this report, some commissioners noted they did not have self-referral in place. Furthermore, in its 2013 report, the Need to Talk Coalition reported that self-referral accounted for just 2.1 per cent or less of referrals in half of the IAPT sites.42 The configuration of local psychological therapies will depend on how local commissioners have organised these services. For example, a CCG may have multiple providers in the same area competing for patients, or providers may work in partnership or via a prime provider arrangement (see appendix 5). The provider of the triage service can also vary from area to area. As well as ensuring that a self-referral option is available, there is scope for commissioners to think more creatively about the way in which selfreferral can be used to address barriers to access. A commissioner from Newcastle described how they worked with local voluntary sector organisations who were in regular contact with specific groups, especially young people, to provide psychological therapies and also to sign-post patients to selfreferral options. One of the challenges voiced by a number of interviewees was that some of these models introduce the potential for conflict of interest for those carrying out the triage process. When a provider is responsible for triage, they may have a preference to refer into their own service. It is essential that triage offers unbiased advice to patients and facilitates their right to choose between clinically appropriate services available in the area. “Our CCG is currently undertaking work to try to make services more accessible to some of the hardest to reach populations. In doing so, we are looking into cultural issues that surround referrals in some communities and have self-referral options in place.” Chris Piercy, Executive Director of Nursing Patient Safety and Quality Newcastle Gateshead CCG Commissioners might also wish to consider offering a variety of channels for self-referral to facilitate access. For example, a number of areas in South London provide a range of self-referral options including online, over the phone and facilitated via a GP.43 RECOMMENDATION 1 Clinical commissioning groups should ensure that their local IAPT services include an option for self-referral, which is actively promoted and supported, with adequate information on the therapeutic options available. Triage: Once someone has been referred to an IAPT service, either by a GP or via self-referral, triage is the first point of contact that the patient will have with the service in areas where triage is a distinct part of the pathway. It is usual that they will be asked a number of questions in order to inform a provisional diagnosis, which is used to direct patients to the correct level of intervention, such as step 2 or step 3. Triage is vital for ensuring that patients are directed towards the most appropriate service for their needs. Report research indicated a number of challenges with IAPT triage processes. Effective triage also ensures that the resources within each treatment step are most efficiently allocated, which would also support swifter access. RECOMMENDATION 2 Clinical Commissioning Groups should ensure that triage is managed through a single point of entry, by an independent third party (rather than a service provider). Some reported that where parts of local IAPT services experience high demand and waiting times, triage can be used as a means to manage demand for different parts of the service. To ensure triage is based on the needs of the patients, rather than the current demands on the system, it is important to ensure that all parts of the system are adequately funded. Several interviewees noted challenges at the interface between step 3 and step 4 (acute) services, which tend to address more serious cases of mental illhealth, often requiring hospital care. The inadequate funding for step 4 skews behaviour and can lead to people being treated in step 2 or 3 when this is not appropriate. This inevitably leads to poor outcomes and inefficient resource allocation. “Our psychological therapies always push everything down to step 2. I panic every time I know a patient is in need of higher levels of care. They will enter the cycle of being referred down to a lower step due to insufficient resource for the acute psychological care they need.” GP, GP focus group RECOMMENDATION 3 The Government must ensure appropriate levels of funding for all steps of the psychological therapies care pathway to ensure patients can be triaged according to need. Psychological therapies next steps towards parity of care 13 Methods of triage tend to be limited to phone based assessments and there can often be a time lag between referral and triage. Diversifying the ways in which patients are triaged could help to minimise delays and make better use of existing resource. For example, the referral process could ask whether patients would prefer to speak to someone over the phone, or if they would be happy to be assessed online. The channels for triage should reflect the channels provided for therapy, allowing patients to choose the channel that best suits their circumstances. Triage best practice has not been properly assessed and there is subsequently significant variation in approaches taken across the country. Greater standardisation of triage services using best practice would help to ensure the most appropriate use of resource. RECOMMENDATION 5 NHS England should develop a national service specification for triage. RECOMMENDATION 4 Clinical Commissioning Groups should ensure that triage is provided through a number of channels, including online. IAPT key improvement area two: tackling waiting lists Key points n Lengthy waiting times for access to services are particularly detrimental for people with mental health difficulties n Waiting times for psychological therapies are a critical concern in England and often represent the main barrier to treatment access n Better management of waiting lists and broadening the psychological therapies available to patients will be important in addressing this There is evidence to suggest that longer waiting times have a detrimental impact on mental health and outcomes.44 In research conducted for this report, 66 per cent of the GPs surveyed in England reported that waiting times for psychological therapies were the biggest barrier to treatment for people with common mental health problems. As well as improving processes, waiting times could be addressed by ensuring availability of a range of services and ensuring the appropriate use of these interventions. If a local IAPT service consists of only face-to-face CBT it is likely to be more challenging to see the necessary number of people to keep waiting times down. GPs attending the focus group also indicated that longer waiting times for psychological therapies would make them more inclined to prescribe antidepressants as a stop-gap. “A key to addressing waiting times is helping the public understand the wide number of treatments out there. Classes or group sessions provide a good option for many individuals, but they are often resistant as these services don’t match their perceptions of therapy.” The reasons for long waiting times are likely to vary but there is now a significant impetus to reduce waiting lists in-line with the government target that by March 2016, 75 per cent of people referred to the IAPT programme begin treatment within 6 weeks of referral, and 95 per cent begin treatment within 18 weeks of referral.45 To support this ambition, £10million has been made available to CCGs who are struggling with waiting lists. £2million of this budget is available for process improvement and £6million is earmarked for non-recurrent funding to help clear backlogs. 14 Psychological therapies next steps towards parity of care Olive Fairbairn, Clinical Director for Mental Health/ Maternity and Children, NHS North East Hampshire and Farnham CCG In line with this need to provide a range of services, one commissioner mentioned that a team from NHS England had helped to conduct a review of its services and had recommended including an online offering in order to help reduce waiting times. Patients also need to be given the information to dispel any concerns that they might have about non-traditional forms of treatment. “In an ideal world, all people should have access to the information they need to manage their individual mental (and physical) health. That information is hard to come by now and it is certainly not integrated. A good place to start is by providing better information and signposting for the many people seeking help from the healthcare system.” Cynthia Joyce, Chief Executive Officer, MQ: Transforming Mental Health Commissioners should also explore whether more could be done to manage patients on the waiting list. A mechanism should be developed to identify any patients in urgent need of support who should be fast tracked or given additional support while on the waiting list. Commissioners should also consider whether offering an intervention with short wait times to patients with low-level problems would help clear waiting lists faster “We have been thinking about the waiting list experience. It might be possible to put something in place to support the individual while they are on the waiting list, for example, access to community support. This would allow some people with low-level problems to leave the waiting list because they’ve already received the necessary support. But because providers are incentivised by numbers of patients, they are less likely to want to remove people from the waiting list before they can be recorded as accessing their services.” Debra Lawson, Head of Commissioning for Mental Health, Knowsley CCG RECOMMENDATION 6 Clinical Commissioning Groups should work with triage services to ensure that waiting lists are managed in line with patient need. IAPT key improvement area three: making better use of data Key points n The data collected through the IAPT programme is ground-breaking n This data clearly demonstrates the overall success of the programme but also highlights significant regional variation, which will need to be addressed to put psychological therapies on a firmer footing for the future n Data benchmarking between CCGs and focused work with individual localities will be important measures to turn the tide of variation n Developing a clearer understanding of trends emerging in relation to treatment types will help to inform wider programme development Data is submitted directly by providers of NHSfunded IAPT services to the Health and Social Care Information Centre (HSCIC) to inform the IAPT Minimum Data Set (MDS).46 Monthly and quarterly recording of performance takes place and a more detailed analysis is published in an annual report. The existence of this data is crucial for assessing both the performance of IAPT and is an indicator of regional performance in relation to psychological therapies more generally. Despite the obvious successes achieved by IAPT to date, there have been significant challenges in implementing the programme consistently across the country, as demonstrated by the wide variation in performance, which is explored below. Psychological therapies next steps towards parity of care 15 Targets and regional variation: Targets have been introduced to drive consistency across the country, as shown in Figure 8, but there is still some way to go before the existing postcode lottery is fully addressed. Waiting times There is variation in waiting times across CCG IAPT services as set out in Figure 9. While 61 per cent of people in 2013/14 accessed services within 28 days of referral into treatment, 11 per cent of people Figure 8 Summary of IAPT targets47,48 accessing IAPT services waited for 90 days or more to access services. In 2013/14 more than 133,000 people waited more than 57 days to begin treatment after receiving a referral; and among this group, around 76,000 waited more than 90 days. Additional analysis of 2013/14 data shows that in the worst performing areas, more than 60 per cent of people waited over 90 days to receive treatment, but in the best performing areas, over 95 per cent of people waited less than 28 days. IAPT Targets In order to drive the next period of implementation and progress for the IAPT programme, the Department of Health recognised IAPT as a priority for NHS England in its refreshed 2015/16 NHS mandate and maintained the commitment that at least 15 per cent of adults with relevant disorders will have timely access to IAPT services, with a recovery rate of 50 per cent. In 2015/16 the first access and waiting time standards for mental health services were also introduced as follows: n 75 per cent of people referred to the Improved Access to Psychological Therapies programme will be treated within 6 weeks of referral n 95 per cent of people referred to the Improved Access to Psychological Therapies programme will be treated within 18 weeks of referral The Five Year Forward View, published in October 2014 also prioritised parity of esteem between physical and mental health and committed to a more ambitious target of 95 per cent Figure 9 Waiting times for accessing psychological therapies in 2013/14 37 % OF PEOPLE ACCESSING TREATMENT of people beginning treatment within 6 weeks. 70% 60% 50% 40% 30% 20% 10% 0% 28 days or fewer 29-56 days 57-90 days More than 90 days WAITING TIMES IN DAYS Access Access to IAPT services also presents a mixed picture across the country. In 2013/14 there was a 12 fold variation in referrals received per 1,000 population, ranging from 4.4 in North Hampshire CCG to 53.7 in West Cheshire CCG. The HSCIC report highlights that 350,450 referrals into IAPT services were made in the North of England Commissioning Region, representing 31 per cent of the national total but the London Commissioning Region received 162,890 referrals (15 per cent of the total).49 16 Psychological therapies next steps towards parity of care In 2013/14 there was also significant variation in the number of people receiving treatment once they had been referred into a local IAPT service, with an almost eight fold variation ranging between 95.8 per cent in Tameside and Glossop CCG and 12.2 per cent in Brighton and Hove CCG. Nationally, 63 per cent of people received treatment once they had been referred into IAPT services. Proportion of people accessing services within 28 days of referral Proportion of people accessing services more than 90 days after referral 61% 11% NHS Barking and Dagenham CCG 97% 1% NHS Chiltern CCG 95% 0% NHS Bracknell and Ascot CCG 95% No data returned NHS North Durham CCG 95% 0% NHS Windsor, Ascot and Maidenhead CCG 94% No data returned NHS Knowsley CCG 8% 58% NHS East Riding of Yorkshire CCG CCG 7% 59% NHS Lancashire North CCG 3% 69% NHS Vale of York CCG 3% 45% NHS Eastern Cheshire CCG 3% 63% England total Figure 10 Variation in IAPT waiting times by CCG* Best performing CCGs Worst performing CCGs Figure 11 People accessing IAPT treatments following referral 2013/14* NUMBER OF AREAS 120 100 80 60 40 20 0 Under 30% 30-45% 45-60% 60-75% 75% or more ACCESSING TREATMENT FOLLOWING REFERRAL According to the HSCIC figures, 1,118,990 referrals were received into IAPT services in England during 2013/14. Of these, 39.6 per cent of referrals resulted in a ‘finished course of treatment’ (having attended at least two treatment appointments). Within this figure, some people would have been referred more than once and the majority of people will have attended more than two treatment appointments.50 Almost 37 per cent of total referrals in 2013/14 did not enter treatment. This means that, of the people who had been referred into a local IAPT service, more people had left without being seen by the service than those that completed a course of treatment. Although there will be instances which will have a clear and valid explanation, such as a patient with a mild condition recovering prior to entering treatment; there are areas that require further explanation. For example, just 2.3 per cent of referrals resulted in a finished course of treatment and over 80 per cent of referrals ended prior to treatment in Brighton & Hove CCG. This compares to Eastbourne, Hailsham and Seaford CCG where 56.6 per cent of referrals resulted in a finished course of treatment and 31 percent of referrals ended prior to treatment. Psychological therapies next steps towards parity of care 17 This significant variation suggests that the CCGs may be taking markedly different approaches to IAPT referrals and appointments. Figure 12 below sets out the range in figures among CCGs that have a higher and lower proportion of finished treatment Figure 12: Variations in treatment completion by CCG* courses compared with referrals that ended prior to treatment. The data for South Gloucestershire CCG separately suggests that over 70 per cent of referrals may be resulting in a course of treatment that is not completed. Proportion of total referrals with a finished course of treatment Proportion of referrals which ended prior to treatment 32.6% 33.1% NHS Eastbourne, Hailsham and Seaford CCG 56.6% 31.0% NHS Wokingham CCG 56.1% 27.7% NHS Harrogate and Rural District CCG 56.0% 38.0% NHS South Tyneside CCG 54.2% 29.4% NHS High Weald Lewes Havens CCG 54.1% 28.0% NHS South Gloucestershire CCG 11.9% 19.2% NHS Bristol CCG 10.4% 19.2% NHS North Somerset CCG 4.3% 3.9% NHS North Hampshire CCG 3.7% 27.3% NHS Brighton & Hove CCG 2.8% 84.6% England total Best performing CCGs Worst performing CCGs “45.6% is the overall national recovery rate at the moment but it is clear that target of at least 50% overall is achievable as 70 (of 211) CCGs are already over 50% and some are over 60%.” Recovery rates As noted in Figure 7 above, there has been a steady improvement in recovery rates over time. However, Figure 13 below shows that there was significant variation between CCGs in recovery rates in 2013/14, with some CCGs reporting far below the 50 per cent target. Given the variation in access rates across the country, this is perhaps unsurprising. David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford Despite this variation, there is significant optimism among the mental health community about what is achievable. Figure 13 Variation in IAPT recovery rates across CCGs in 2013/14 51 As David Clark suggests, and Figure 13 confirms, some IAPT services are achieving recovery rates above the 50 per cent target, a standard that should be achievable by CCGs across the country. The key challenge is understanding how to encourage those areas that are performing badly to expedite their transition towards better practice. 70 NUMBER OF CCGs 60 50 40 30 20 10 0 Under 30% 30-35% 35-40% 40-45% 45-50% 50-55% RECOVERY RATES 18 Psychological therapies next steps towards parity of care 55-60% 60-65% 65% or more 6CCGs No data 6CCGs 20-30% 42CCGs 30-40% 112CCGs 40-50% 41CCGs 50-60% 4CCGs 60-80% Figure 14 Variation in recovery rates by CCG, 2013/14 37 London Figure 14 shows that there does not appear to be a geographical trend in the areas that are performing better and worse in relation to IAPT recovery rates. The top three performing CCGs have both a reliable recovery and recovery rate above 60 per cent and are spread across the country: NHS Knowsley CCG, NHS Swindon CCG and NHS North Hampshire CCG. The bottom three CCGs are: NHS Bristol CCG, NHS Bradford City CCG and NHS South Gloucestershire CCG. Some interviewees believed that an exclusive focus on recovery failed to capture the wider success of the programme. Reliable improvement was considered a better ambition for IAPT services than recovery, especially for those with more complex problems in step 3 services. “If we are focused on people’s experience in IAPT, we should look at reliable improvement. Some people may never hit the recovered target, but if they are consistently improving and content as they progress through the system, that should be measured.” More clearly needs to be done to reduce the levels of regional variation. However, the best performing CCGs demonstrate the possibilities in relation to improving access to psychological therapies. It is important that the programme maintains ambition and momentum. Targets should be reviewed annually to reflect this. In particular, it would seem sensible to raise the bar with regards to access targets and attach greater significance to the outcomes of treatment, encompassing both reliable recovery and improvement. RECOMMENDATION 7 Department of Health to retain IAPT targets in its Mandate to NHS England, raising these as appropriate to reflect the Government’s ambition for parity of esteem. Debra Lawson, Head of Commissioning for Mental Health, Knowsley CCG Psychological therapies next steps towards parity of care 19 Data driven improvements Additional analysis of IAPT data presents a number of opportunities for encouraging the more rapid uptake of best practice across the country and informing service development. Using better benchmarking to drive performance The annual HSCIC report provides a useful exploration of the national data and highlights some variations between the commissioning regions but it does not consider the reasons for variation or make recommendations for how CCGs might improve their performance. Exploring the reasons for good and poor performance may offer an opportunity to address problems and improve outcomes more quickly. The IAPT national team is in a unique position to maximise the impact of the data that is already collected in order to influence CCG performance and improve access and treatment completion rates. The IAPT website already provides resources for commissioners on models of care, commissioning and positive practice guides.52 This advice could be expanded to include data on the performance of CCGs and the success rates for different treatment approaches, setting out recommendations for improvement. Several CCGs noted the importance of more timely provision of data on IAPT to more accurately inform commissioner decision making. RECOMMENDATION 8 HSCIC to conduct regular and timely assessment of IAPT data that will support more granular benchmarking between CCGs and a better understanding of the services provided and for whom they are most effective. RECOMMENDATION 9 NHS England should work with HSCIC to ensure the IAPT annual report is published within three months of yearend and includes a greater degree of CCG benchmarking to provide timely impetus for improvement. CCGs should then be encouraged to reflect on the data findings and asked to set out plans for how they will address any issues in relation to access and outcomes. This could take the form of an annual plan for IAPT, or be incorporated into existing planning documents. Challenges in relation to prioritisation at CCG level are often caused by a lack of usable data.53 The availability of detailed data in IAPT should therefore act as a driver for improvements. 20 Psychological therapies next steps towards parity of care RECOMMENDATION 10 Clinical Commissioning Groups should be asked to publish an annual report and plan for improving access for psychological therapies, setting out how they intend to improve performance over the coming year. Promoting a better understanding of different interventions While there is a strong body of evidence supporting psychological therapies, the IAPT programme provides an opportunity to develop a far more nuanced understanding of which psychological therapies work for which diagnoses and how long it should take to achieve recovery. However, the current HSCIC data programme is yet to facilitate this level of understanding at a local level. “With regards to data we don’t know what we don’t know, but are working closely with other commissioners to see what types of other information we should be gathering.” Chris Piercy, Executive Director of Nursing Patient Safety and Quality Newcastle Gateshead CCG For example, at step 2, data could be used to understand whether people with generalised anxiety disorder recover as quickly (and with sustained results) from group-based CBT as with a self-guided online tool. In order to maximise the opportunity presented by IAPT’s data programme, it is essential that this granular data is analysed and reported in a way that can usefully inform IAPT service development at a local level. “Ultimately, a perfect scenario is that a patient is referred, receives a structured assessment, and their choice of treatment is assisted by an algorithm that indicates percentage of recovery etc based on their assessment.” Andy Blackwell, Chief Scientific Officer, Ieso Digital Health RECOMMENDATION 11 NHS England should hold regional workshops to ensure stronger understanding of the IAPT data set and its implications for commissioning planning, with additional resource as required. NEXT STEPS FOR PSYCHOLOGICAL THERAPIES: IAPT & BEYOND Patient choice was at the heart of the Health and Social Care Act 2012 yet a patient survey54 conducted by the Need to Talk Coalition, a group of mental health charities, professional organisations, Royal Colleges and service providers, found that 58 per cent of respondents were not offered choice in the type of therapies they received. It is reasonable to expect the range of services available to vary between CCGs, depending on the needs of the local population. However, research for the report has identified a number of challenges related to patient choice which need to be addressed. These challenges range from clarity on the psychological therapies that might be provided in any particular area, as well as extending choice through new models of care that support increased access and better use of resources. Commissioning for Choice Key points n Choice is important for people requiring psychological therapies. n CBT is an important part of the service landscape but should not crowd out other options which may better suit many patients n A holistic approach to psychological therapies that considers services that sit both within and alongside the IAPT programme is important n To guide more informed commissioning, a resource should be developed to clarify what interventions are available and to whom they are most suited n Once CCGs have decided what’s appropriate for their local area, they should keep a website updated to ensure up to date information is available for referrers and patients Overarching suite of services At a national level, more could be done to define the range of therapies that a commissioner should consider when assessing how to meet the needs of the local population. Several of those interviewed expressed concerns that the success of IAPT, of which cognitive behavioural therapy (CBT) is a core component, has had a detrimental effect on the availability of other services, particularly those smaller scale services delivered in the community. “What you get locally varies considerably in terms of evidencebased therapies. Most areas in the country refer to cognitive behavioural therapies – but for Interpersonal Psychotherapy (IPT), brief psychodynamic therapy (BPT) and other NICE-recommended therapies the offer is quite limited.” Stephen Freer, Clinical Affiliate CBT Therapist “IAPT has done very well indeed… but it is also taking away from all the other talking therapies – there is really a very limited choice. From individual psychotherapy to group therapy, the majority has been swallowed up by IAPT” Dr Clare Gerada, GP Partner Hurley Group and Medical Director of Practitioner Health Programme “It’s becoming increasingly hard for third sector organisations to offer services in an environment where local areas are not, in the main, commissioning community social prescribing, locally ‘linked-in’ models of delivery. This means that it has become difficult for some organisations to compete on an even playing field with Trusts offering a purely clinical, less socially connected model.” Mel Shad, Head of Business Development, Turning Point Psychological therapies next steps towards parity of care 21 The dominance of CBT is not surprising. CBT has been subject to a significant amount of evaluation and its effects have been established via hundreds of randomised control trials.55 A range of studies suggest that around 50 per cent of people treated for depression and anxiety using CBT recover during treatment, and more experience significant improvements to their conditions.56 Given that CBT has the widest indication in NICE guidelines and had the largest deficit in terms of availability,57 IAPT was right to focus on improving access to this important therapy, which itself encompasses a range of approaches to different conditions. CBT should be celebrated and efforts to improve access must continue. However, CBT is not the universal solution to common mental health problems and it is important that the full range of psychological therapies is recognised, alongside guidance on who the different interventions are most appropriate for. This will help to guide better commissioning decisions that ensure sufficient variety of services to meet the diversity of patient need within that area. Figure 15 St Mungo’s Lifeworks Psychotherapy Service “We have people who are not able to access IAPT services, because they are labelled ‘non-compatible’ with IAPT/CBT approach. This might be because of cannabis or alcohol use. Additionally if someone is being treated in secondary mental health care, we have historically not been able to simultaneously provide them with lower level care for anxiety and/or depression” Sarah Basham & Duncan Ambrose, Responsible Officer for Mental Health & Senior Responsible Officer for Mental Health, Brent CCG Failure to ensure greater breadth of services is likely to exacerbate health inequalities, particularly where services have developed to meet the needs of a particular segment of the population. Homelessness, for example, is an area where there is high unmet need in relation to psychological therapies but where therapy options provided through IAPT often not suitable (see figure 15). important therapy, which itself encompasses a range of approaches to different conditions. St Mungo’s Broadway is a homelessness charity and a housing association committed to every individual’s sustainable recovery. As part of their support, St Mungo’s Broadway provides psychological therapies outside of the IAPT service design, finding that IAPT services are often short-term and cannot provide the intensive and long-term support required by many homeless people with experience of complex trauma. Moreover, homeless people are often excluded from statutory mental health services because of their substance use problems. The charity’s Lifeworks psychotherapy service offers homeless people access to fully-qualified psychotherapists regardless of diagnosis or active substance use. The psychodynamic psychotherapy sessions are client led, with clients talking about emotional issues (such as relationship breakdown and bereavement), rather than ‘needs led’ (talking about substance use and non-engagement with services). Outcomes for clients have been very positive and have included a reduction in hospitalisations and emergency care, a reduction in drug and alcohol use, a positive change in housing circumstances and an increase in engagement in training and employment. To ensure that commissioners are basing their decisions on accurate information, there would be merit in the Department of Health working with psychological therapy providers and other key stakeholders to develop an inventory of the types of psychological therapy that should be considered for commissioning, clearly specifying those services that fall within and outside IAPT. 22 Psychological therapies next steps towards parity of care “A clear definition of mental health services would be helpful…at the moment we don’t have a directory of services, so service options are unclear.” Laura Carr, Lead Nurse and Clinical Director for Mental Health and Learning Disabilities, Cumbria CCG Such a resource should include information such as: existing evidence and guidance for each type of intervention, details of the patients most likely to respond to the specific interventions, guidance on the number of sessions required, and a summary of outcomes. For services delivered through IAPT, there is existing data that could be mined to provide helpful insights for commissioners. This analysis should be conducted at the earliest opportunity to ensure resources are directed efficiently to where they will deliver the best outcomes. RECOMMENDATION 12 Department of Health to bring together key psychological therapy stakeholders, including IAPT team and providers, to prepare an easy to understand guide for commissioners and patients on the types of psychological therapy that are available. Signposting local therapy choices This overarching suite of services should be used by local commissioners to guide their decision making about what makes sense for their local population. Work carried out at a national level should be available publicly and translated by commissioners to be relevant for the local situation. As the service landscape develops, it is important that local stakeholders are kept updated on the services available. GPs were quick to report that they were rarely well informed about what services were available for their patients. Without adequate information, there was also a tendency to dismiss newer models of care. It is essential that the evidence base and appropriateness of different interventions is made clear to those with a role in referral, including patients. “I know what is provided currently, but ask me again in a year…! Services are always changing.We provide a continuity of care for these patients, but there is no consistent provision, which is bad for individuals with mental health challenges.” GP focus group Commissioners could helpfully provide more reliable information on this front, accessible to patients and health care practitioners in a particular area. RECOMMENDATION 13 NHS Choices to expand its psychological therapies database to include IAPT and non-IAPT services. The number of categories used to facilitate service comparison should also be expanded to enhance understanding. RECOMMENDATION 14 Clinical Commissioning Groups to commit to maintaining their entry on the NHS Choices psychological therapies database, including IAPT and non-IAPT services. New models of care Key points n New models of care should be embraced in the quest to improve access to psychological therapies. n To make the most of the opportunity of digitally supported therapies, there needs to be greater clarity about the range of services available, the evidence base supporting these and details of for whom they are most appropriate n New models of care should also inform strategies for reaching populations with unmet needs and coordinating integrated approaches for individuals with chronic/long term conditions The IAPT programme has clearly demonstrated that the use of evidence based innovation can transform the landscape of service delivery in a relatively short timeframe, improving both access and outcomes. It is important to ensure that England continues to embrace an innovative approach to improving access to psychological therapies more broadly and makes a clear assessment of the expected benefits as it does so. As espoused by the Five Year Forward View, the NHS needs to dissolve traditional boundaries and explore how new models of care can help to meet the changing needs of patients, capitalise on the opportunities presented by new technologies and treatments, and unleash system efficiencies more widely.58 A number of new models of care are emerging in relation to psychological therapies, from new delivery platforms to innovative approaches to expanding access and encouraging integration. It is important that these are assessed and incorporated into the IAPT programme as appropriate. Psychological therapies next steps towards parity of care 23 Digital solutions: The development of digital technology has brought with it a number of opportunities for psychological therapies. An example is set out in the case study below (figure 16). Figure 16 Online consultation offering59 The Hurley Group has developed an online offering for GP practices, which it piloted across 20 London GP practices in 2013/14. The online offering is made up of five services including an online symptom checker, sign-posting to online counselling and eConsult, where patients complete a condition-based questionnaire on their GP practice website. This questionnaire is submitted and triggers a request for advice or treatment from their own GP. During the pilot, depression was the second most used eConsult document. Dr Arvind Madan, Chief Executive of the Hurley Group said during an interview that this represented patients’ appetite to consult remotely for these types of conditions, a phenomenon described as digital disinhibition. The Hurley Group’s report of the pilot also noted that particular problems, including mental health, seemed to surface sooner via eConsult. Need for clear segmentation of digital services In conversations conducted for this report, there was a tendency to group all digital innovations together, regardless of the fact that there is a variety of services offered within this bracket. Although digital services share certain characteristics, such as greater accessibility, there are important differences that need to be taken into account. Some of the therapies offered through digital platforms are most appropriate for patients at step two, whilst others deliver better value and outcomes at step three. Some services are courses for individuals to complete alone, some are guided self-help and others are therapist-led. The evidence base for each offering also varies. This lack of clarity is exacerbated by the fact that there does not yet appear to be a clearly defined vocabulary to describe the various digital services that are available, or where they sit in relation to other digital services that are provided. For example, NICE guidance often refers to ‘online CBT.’ Typically this would refer to interventions such as ‘Beating the Blues’, a computer based self-help course for people feeling anxious, stressed, depressed or down.60 However, additional options are now available, which a lay-person might also describe as online CBT. These formats might involve a therapy session conducted over Skype or via instant messaging. There is not a consistent term used for discussing these options and subsequently, no easily accessible discussion that can inform commissioning decision-making. 24 Psychological therapies next steps towards parity of care NHS Choices has a list of ‘online mental health services’ but the description of each service is fairly opaque and does not facilitate accurate comparison or understanding of what intervention would make most sense for an individual patient. The apparent lack of understanding of these distinctions leads directly to poor commissioning decisions being made and patients not being referred, or being referred to new models that may not be appropriate for their condition. Poor referrals lead to poor outcomes, which then exacerbate negative perceptions of new models of care. It is important to ensure that people are getting referred to the most appropriate service and the service that delivers the most value. RECOMMENDATION 15 NHS Choices to convene roundtable to consider the landscape for new digital models of care and how the market should be segmented to provide greater clarity to commissioners, health care professionals and patients. National policy support: digital strategy NHS England is well aware of the potential for new models of care to deliver efficiencies and make better use of existing resources. Tim Kelsey, NHS England’s National Director for Patients and Information, said that “technology has a hugely important role to play in delivering the health service’s productivity.”61 Personalised Health and Care 2020 is a government strategy being taken forward by the National Information Board (NIB). The strategy recognises that “better use of data and technology has the power to improve health, transforming the quality and reducing the cost of health and care services.”62 Although the strategy is broad ranging and encompasses the entire NHS approach to digital services, from online booking through to prescriptions management and patient record access; there are a number of element of particular relevance to the use of digital technologies in relation to psychological therapies. For example, workstream 1.2 is tasked with “providing citizens with access to an endorsed set of NHS and social care apps” and will look at the regulation, accreditation and kitemarking of technology and data enabled services, including apps, digital services and associated mobile devices. Given the opportunities and national priority now afforded to mental health, it is essential that the workstream leads engage adequately with the mental health community to ensure that the solution they develop is fit for purpose. The NIB has committed to support the development, diffusion and adoption of low-cost high-efficacy apps with a particular emphasis on mental health services, for example for cognitive behavioural therapy. It is likely that other elements of the strategy will have relevance for mental health and these should be fully exploited through close collaboration between the National Information Board and the psychological therapies community. RECOMMENDATION 16 National Information Board to hold regular meetings with key representatives from the mental health community, including commissioners, patients and providers, to ensure that adequate consideration has been given to the specific considerations related to mental health. RECOMMENDATION 17 National Information Board to ensure that accreditation developed for digital apps provides a clear assessment of who an app is appropriate for and when it should be used, using digital services in mental health as an exemplar. National policy support: opportunity for coordinated commissioning More could be done to make the most of the opportunity that technological developments have started to bring to psychological therapies. The commissioning environment is fragmented and providers of new models of care are required to approach different commissioners to discuss the merits of their particular product. “Fragmentation of services is costly to the system: joining up of services would make implementation and scaling possible and lead to a more coherent system and savings for the government. Right now we are answering to Test Beds, large tenders, Cabinet Office initiatives - all on the same idea of transformation and innovation and none of them connected together!” Ileana Welte, Global President, Big White Wall Where there is clear evidence to demonstrate that a novel intervention delivers cost-effective outcomes, national support should be provided. Some suggested that national commissioning for these services might be a sensible approach, particularly given the challenges of overcoming stigma related to digital therapies and the lack of geographical ties associated with these interventions. “NHS 111 is the same across the country.Why couldn’t online access to psychological therapies be organised in the same way. This would be more efficient for all involved. I find it more difficult to sell the benefits of therapy delivered on an online platform to those with less knowledge and experience of mental health and therapy delivery where cost is a significant driver.” Sven Law, IAPT Locality Manager, Leeds Partnerships NHS FT RECOMMENDATION 18 Department of Health and NHS England to assess which new models of care it would be appropriate to commission nationally and to lead a work programme to implement national contracts as appropriate. Psychological therapies next steps towards parity of care 25 Populations with unmet need A number of patient populations have been underserved by psychological therapies. Examples of those who have struggled to access appropriate psychological therapies. Older people,63 those from black and minority ethnic (BME) communities,64 people who don’t speak English65 and men66 are all cited as groups who are less likely to access these services. More also needs to be done to improve access for those living in rural populations.67 As shown below, many of the newer models of care are seeking to address this challenge but more needs to be done to ensure a more consistent national effort to reach these populations. Figure 17 Mind Harrow case study, reaching hard to reach populations “Males are massively underrepresented in traditional face to face services, we find double the number of women in such services. One of the online providers we use has a 50/50 split between men and women, when we’d see more like a 30/70 split for face to face therapies.” Sven Law, IAPT Locality Manager, Leeds Partnerships NHS FT Mind in Harrow (MiH) work in partnership with CNWL NHS Foundation Trust and Twiningsenterprise to deliver the Harrow Talking Therapies Service funded by NHS Harrow. Over the past year there has been a drive to engage community members from diverse backgrounds to access the service e.g. older people, Black & Minority Ethnic and Refugee communities (BMER). As part of this initiative, the MiH’s Step 2 Psychological Wellbeing Practitioners (PWP’s) team have adopted a proactive model to engage people from BMER communities. Firstly volunteers from BMER communities have been encouraged to become part of the team to help create a workforce that reflects the diverse population living in the Borough. Secondly PWP’s have worked with facilitators of BMER groups to develop tailored outreach sessions to their members. PWP’s tailored workshops/one off sessions were designed to engage their audience by introducing the concept of mental health and Talking Therapies in a light touch and non-stigmatising way. Key principles the PWP’s took into account when preparing tailored sessions for BMER communities included: n Workshop content:- cultural understanding of mental health n Location:- use of community settings n Language:- considering the use of translation To date PWP’s have successfully reached out to Afghan, Tamil and South Asian community members in various projects. This has contributed to increasing the awareness and likelihood of access to the service from BMER communities. It is positive to see that CCGs are measured through the 2015/16 CCG Outcomes Indicator Set on “access to psychological therapy services by people from BME groups.” However, more should be done to ensure that efforts are being taken to step up access across all under-served groups. RECOMMENDATION 19 NICE to consider incorporating a range of measures in the next CCG Outcomes Indicator Set to ensure CCGs are seeking to improve access across a range of populations where unmet need exists. 26 Psychological therapies next steps towards parity of care Chronic physical illness and long-term conditions A chronic physical health problem can both cause and exacerbate depression: pain, functional impairment and disability associated with chronic physical health problems can greatly increase the risk of depression in people with physical illness, and depression can also exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes, including shortening life expectancy.68 Depression is approximately two to three times more common in patients with a chronic physical health problem than in people who have good physical health and occurs in about 20 per cent of people with a chronic physical health problem.69 The model currently used by IAPT focuses on GP and self-referrals for common mental health problems. For those people who already use other NHS services, this referral route does not represent an integrated approach to care. “IAPT is a verb increasing access to psychological therapy. It is therefore important, going forward, that every mental health professional has training in psychological therapies as this is such a prominent treatment in almost all mental health NICE guidelines.” New models of care for the delivery of psychological therapies for patients with chronic conditions should be considered and a national approach standardised. It may not be necessary to use trained IAPT therapists to deliver these services. For example, it might be possible for diabetes nurses to be trained to deliver step 2 services to some patients.70 Making better use of existing clinical resource would help alleviate some of the demand for trained therapists, which is currently one of the major challenges facing the programme as it scales up. RECOMMENDATION 20 NHS England to work to develop national service specifications for psychological therapy access for people with a range of long term conditions. Geraldine Strathdee, National Clinical Director for Mental Health, NHS England Extending IAPT Key points n IAPT is a vital part of psychological therapy provision that has put England at the vanguard of improving access to psychological therapies. n Several services fall outside its remit and the national focus on IAPT is standing in the way of a truly integrated approach to psychological therapy provision. n Future work should consider whether the brand should be extended to encompass the full range of psychological therapies, given its success, or what further support should be given to those services outside the IAPT remit. The exceptional strides taken by the IAPT programme have put England in the vanguard of improving access to psychological therapies. The IAPT brand has gained increasing recognition at local, national and international levels. The IAPT programme was not intended to replace other psychological therapies but to complement them. Indeed, recently published data71 suggests that spend on IAPT is incremental to spend on nonIAPT services and has led to a larger overall spend on psychological therapies. However, the perception of many of those interviewed is that the impact of national ambitions and associated resource requirements has resulted in commissioners committing significant resource and attention to developing well performing IAPT services, to the detriment of other therapies. As England continues on its quest for improving access, it is important to consider the development of the IAPT brand, what it represents and what services it encompasses. To avoid confusion about how non-IAPT services should be commissioned and managed, consideration should be given to whether these services might be incorporated under the IAPT brand and asked to embrace the data collection requirements that are the hallmark of the IAPT approach. If IAPT was to extend its reach, the programme would obviously need to be adjusted to reflect the wider remit. For example, secondary care services could be managed through a separate workstream. However, the advantage of bringing all psychological therapies under the IAPT umbrella would provide a valuable opportunity for increased integration, greater consistency and ability to compare outcomes, as well as greater clarity for those looking for information on psychological therapies. RECOMMENDATION 21 Department of Health to conduct a systematic assessment into how to achieve a more integrated approach to psychological therapies, giving consideration to the development of the IAPT brand and the feasibility of extending the programme’s remit. Psychological therapies next steps towards parity of care 27 appendices Appendix 1 Summary of psychological therapies Psychological therapies can be broadly categorised as follows:72 Cognitive and behavioural therapies: these focus on cognitions and behaviours and recognise that it is possible to change, or recondition, our thoughts or behaviour to overcome specific problems such as anxiety. Psychoanalytical and psychodynamic therapies: these are based on an individual’s unconscious thoughts and perceptions that have developed throughout their childhood, and how these affect their current behaviour and thoughts. Humanistic therapies: these focus on selfdevelopment and help individuals recognise their strengths in the ‘here and now’. Other common forms of psychological therapies include couples therapy and art therapy. Appendix 2 Methodology GP focus group from across England (x1): this was organised to seek insight into diagnosing and treating mental health problems in local populations, with a view to identifying barriers to referral and access. Interviews (x24) interviews were conducted with a wide range of experts with an interest in mental health, these included individuals from patient organisations, commissioning bodies, professional organisations and GPs. For a full list of interviewees please refer to appendix 3 Survey: following interviews with service providers and commissioners, a survey was circulated through doctors.net. The survey garnered 1000 GP responses from GPs across England, Scotland, Northern Ireland and Wales. Informed by the previous GP focus group, the survey questions more deeply explored key considerations with regards to referrals and access. Questions from the survey can be found below: nWhat proportion of your time do you spend assessing people with common mental health problems such as anxiety and depression? (Please enter a percentage) nFor your patients with common mental health problems, such as anxiety and depression, please indicate which is the most accessible treatment option. (Please select one option) • To provide support to the patient myself • To prescribe antidepressants • To refer the patient to local psychological therapy services including IAPT services • A combination of the above • Other (please specify) • There are no accessible treatment options nWithin your CCG, what is the biggest barrier to treatment for people with common mental health problems such as anxiety and depression? (Please select one option) • Waiting times for psychological therapies • Availability of appropriate services for their condition • Stigma • Ease of access to services • Other (please specify) • There are no barriers nOf those patients you have signed off from work because of sickness in the past year, what proportion would you estimate is due to common mental health conditions like anxiety and depression? (Please enter a percentage) 28 Psychological therapies next steps towards parity of care Appendix 3 Interviewees overview NAME ROLE Organisation 1 Ileana Welte Global President Big White Wall 2 Arvind Madan Chief Executive Officer Hurley Group 3 Clare Gerada GP Partner Hurley Group and Medical Director of Practitioner Health Programme Hurley Group 4 Andy Blackwell Chief Scientific Officer Ieso Digital Health 5 Barnaby Perks Chief Executive Officer Ieso Digital Health 6 Sven Law IAPT Locality Manager Leeds Partnerships NHS Foundation Trust 7 Jon Higgs Local Services Strategy and Development Manager Mind 8 Geoff Heyes Policy and Campaigns Manager Mind 9 Cynthia Joyce Chief Executive Officer MQ - Transforming mental health 10 Chris Piercy Executive Director of Nursing Patient Safety and Quality Newcastle Gateshead CCG 11 Dawn Scott Principal Consultant in Public Health Newcastle Local Authority 12 Sarah Basham Responsible Officer for Mental Health NHS Brent CCG 13 Duncan Ambrose Senior Responsible Officer for Mental Health NHS Brent CCG 14 Laura Carr Lead Nurse and Clinical Director for Mental Health and Learning Disabilities NHS Cumbria CCG 15 Geraldine Strathdee National Clinical Director for Mental Health NHS England 16 Debra Lawson Head of Commissioning for Mental Health NHS Knowsley CCG 17 Olive Fairbairn Clinical Director for Mental Health / Maternity and Children NHS North East Hampshire and Farnham CCG 18 James de Pury Mental Health Commissioning Manager NHS West Kent CCG 19 Rebecca Eadie Senior Commissioning Manager Mental Health (Process Lead) North of England CSU 20 Stephen Freer Clinical Affiliate CBT Therapist 21 Dominic Williamson Executive Director of Strategy and Policy St Mungo’s Broadway 22 Mel Shad Head of Business Development Turning Point 23 David M. Clark Professor and Chair of Experimental Psychology University of Oxford 24 Christopher Leaman Policy and Public Relations Manager Young Minds Psychological therapies next steps towards parity of care 29 Appendix 4 List of NICE recommendations/ TAs/ Guidance on common mental health disorders and CBT/ other psychological therapies NICE Guidelines • Antenatal and postnatal mental health: clinical management and service guidance (CG192) December 2014 • Antenatal and postnatal mental health: Clinical management and service guidance (CG45) February 2007 • Occupational therapy and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care (PH16) October 2008 • Promoting mental wellbeing at work (PH22) November 2009 • Social and emotional wellbeing in primary education (PH12) March 2008 • Social and emotional wellbeing in secondary education (PH20) September 2009 • Social and emotional wellbeing: early years (PH40) October 2012 • Workplace policy and management practices to improve the health and wellbeing of employees (NG13) June 2015 NICE Quality Standard • Mental wellbeing of older people in care homes (QS50) December 2013 • Service user experience in adult mental health (QS14) December 2011 • The health and wellbeing of looked-after children and young people (QS31) April 2013 NICE Documents in Development • Mental health of adults in contact with the criminal justice system (NICE guidelines) November 2016 • Transition between inpatient mental health settings and community and care home settings (NICE guidelines) August 2016 • Antenatal and postnatal mental health (Quality standards) October 2015 • Social and emotional wellbeing in primary and secondary education (update) (NICE guidelines) TBC • Older people – independence and mental wellbeing (NICE guidelines) November 2015 NICE Pathways • Antenatal and postnatal mental health • Mental wellbeing and older people • Promoting mental wellbeing at work • Social and emotional wellbeing for children and young people • Workplace health: policy and management practices 30 Psychological therapies next steps towards parity of care Appendix 5 Examples of different contracting arrangements Prime contractor/prime provider model: a single provider assumes all clinical and financial responsibility for delivering defined patient outcomes. Commissioners hold a single contract with the prime contractor/ prime provider. The prime contractor may be an existing provider (such as a mental health trust), a broker or an integrating organisation. Lead accountable provider: a single provider is accountable for providing a whole care pathway or pathways, or achieving defined outcomes for a defined patient population. Commissioners hold a single contract with this provider, who may subcontract some parts of the pathway or some services. Alliance: typically led by commissioners, this contracting mechanism aims to incentivise a number of providers to co-operate to deliver a particular service or an interrelated set of services. Any qualified provider (AQP) contracts are an example of this arrangement. Joint venture/partnership: providers jointly create a new vehicle to facilitate provision of integrated care, but each provider remains independent. Commissioners contract with the joint venture (rather than individual providers) for the delivery of services. REFERENCES 1 ouses of Parliament: Parliamentary Office of Science and Technology: Parity of Esteem H for Mental Health POST NOTE, 2015 46 Improving Access to Psychological Therapies: Improving Access to Psychological Therapies Data set v1.5: Summary of Changes, 2014 2 epartment of Health: A mandate from the Government to the NHS Commissioning Board: D April 2013 to March 2015, 2013 47 epartment of Health: The Mandate: A mandate from the Government to NHS England: D April 2015 to March 2016, 2014 3 onservative Party: Manifesto: Strong Leadership, A Clear Economic Plan, A Brighter, C More Secure Future, 2015 48 NHS England: Five Year Forward View, 2015 49 ealth & Social Care Information Centre: Psychological Therapies, Annual Report on the H use of IAPT services 2013/14, 2014 50 Ibid. 51 Ibid. 4 he Guardian: “Alistair Burt: We must treat a broken mind with same urgency as a broken T leg”, 2015 5 epartment of Health, NHS England: Achieving Better Access to Mental Health Services D by 2020, 2014 6 HM Treasury: Summer Budget 2015, 2015 7 ental Health Foundation: National organisations call on new government to make mental M health a priority in emergency budget, 2015 8 Mind: How many people have mental health problems?, accessed August 2015 9 ondon School of Economics and Political Science: How mental illness loses out in the L NHS, 2012 10 HM Government: No Health Without Mental Health, 2011 11 Mental Health Foundation: Physical Health and Mental Health, accessed August 2015 12 ental Health Foundation: Economic burden of mental illness cannot be tackled without M research investment, 2010 13 Department of Health, Department for Work & Pensions: Psychological Wellbeing and Work, 2014 14 15 16 17 18 Ibid. NHS Information Centre for health and social care: Adult Psychiatric Morbidity Survey, 2007 isability and Health Journal: Physical ill health, disability, dependence and depression: D results from the 2007 national survey of psychiatric morbidity among adults in England, Vol 5 No 2, 2012 DWP calculations based on 5% sample of administrative data and the Work and Pensions Longitudinal Study, available from the DWP tabulation tool: http://83.244.183.180/5pc/ tabtool.html. IB, SDA and ESA claimants are included HM Government: No Health Without Mental Health, 2011 19 NHS England, Programme budgeting: benchmarking tool, accessed August 2015 20 Ibid. 21 ational Institute for Health and Care Excellence: Common mental health disorders: N Identification and pathways to care, 2011 22 Ibid. 23 Ibid. 24 ealth and Social Care Information Centre available here, Prescriptions Dispensed in the H Community: England 2004-2014, 2015 25 Pulse: GPs cut back on antidepressant prescribing in recent years, study shows, Accessed August 2015 52 Improving Access to Psychological Therapies: Commissioning, 2015 53 ssociation of British Pharmaceutical Industry Rheumatology Initiative: RAising the A game: translating national policy into local action for rheumatoid arthritis services, 2014 54 Need to Talk Coalition: We still need to talk A report on access to talking therapies, 2013 55 linical Psychology Review: Psychological treatment of generalized anxiety disorder: a C meta-analysis, Vol 34 No 2, 2014; Journal of Affective Disorders: Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups, Vol 136 No 3, 2011; Fonagy, P, Roth, A: What works for whom (2nd Edition): A critical review of psychotherapy research, 2005; Family Practice: Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis, 2014 56 Clark, D, Layard, R: Thrive: The Power of Psychological Therapy, 2015 57 Improving Access to Psychological Therapies: IAPT three-year report: The first million patients, 2012 58 NHS England: Five Year Forward View, 2015 59 WebGP: Pilot Report, 2014 60 NHS Choices: Online mental health services, accessed August 2015 61 NHS England: Use of technology and data can help plug NHS funding gap, 2015 62 HM Government: Personalised Health and Care 2020, 2014 63 Improving Access to Psychological Therapies: Older People, accessed August 2015 64 Improving Access to Psychological Therapies: Black and Minority Ethnic (BME) Communities, accessed August 2015 65 Ibid. 66 Interview with Sven Law, IAPT Locality Manager, 2015 67 The Five Year Forward View Mental Health Taskforce: Public Engagement Findings, 2015 68 ational Institute for Health and Care Excellence: Depression in adults with a chronic N physical health problem: Treatment and management, 2009 69 Ibid. 70 J ournal of Diabetes Nursing: The role of psychological interventions for people with diabetes and mental health issues, Volume 17 No 8, 2013 71 Clark, D, Layard, R: Thrive: The Power of Psychological Therapy, 2015 72 Counselling Directory: Types of therapy, accessed August 2015 * Figures based on data provided by the Health & Social Care Information Centre 26 Clark, D, Layard, R: Thrive: The Power of Psychological Therapy, 2015 27 ational Institute for Health and Care Excellence: Depression in adults: The treatment N and management of depression in adults, 2009 28 National Institute for Health and Care Excellence: Anxiety disorders, 2014 29 Improving Access to Psychological Therapies: IAPT three-year report: The first million patients, 2012 30 Ibid. 31 ational Institute for Health and Care Excellence: Commissioning stepped care for N people with common mental health disorders, 2011 32 Ibid. 33 Improving Access to Psychological Therapies: IAPT three-year report: The first million patients, 2012 34 Ibid. 35 Clark, D, Layard, R: Thrive: The Power of Psychological Therapy, 2015 36 IAPT uses patient completed questionnaires to measure change in a person’s condition. Moving to recovery counts the number of people that were above the clinical cut-off before treatment but below following treatment. Recovery occurs if that person subsequently scores below the clinical threshold on depression and anxiety. If an individual’s score changes by an amount that exceeds the measurement of reliable change, they are thought to have shown reliable change. 37 ealth & Social Care Information Centre: Psychological Therapies, Annual Report on the H use of IAPT services 2013/14, 2014 38 Ibid. 39 Ibid. 40 Improving Access to Psychological Therapies: A review of the progress made by sites in the first roll out year, 2010 (2010) 41 Improving Access to Psychological Therapies: Improving Access to Psychological Therapies, Executive Summary, 2015 42 Need to Talk Coalition: We still need to talk A report on access to talking therapies, 2013 43 LaM: Improving Access to Psychological Therapies in Croydon, Lambeth, Lewisham S and Southwark: Self-referral, accessed August 2015 44 eed to Talk Coalition: We still need to talk A report on access to talking therapies, 2013; N National Audit of Psychological therapies for anxiety and depression: National Report 2011, 2011; Department of Health: ‘Access and waiting time standards for 2015-2016 in mental health services’ Impact Assessment, 2014 45 epartment of Health: The Mandate: A mandate from the Government to NHS England: D April 2015 to March 2016, 2014 Psychological therapies next steps towards parity of care 31 For further information about this report, please contact: JMC Partners Hudson House, 8 Tavistock Street London WC2E 7PP Telephone 0203 178 7571 Email [email protected] This report was prepared with funding from Ieso Digital Health. JMC Partners has retained full editorial control. JMC Partners is an award-winning communications consultancy, with a particular expertise in healthcare. Ieso Digital Health provides digitally enhanced mental health services to health providers, including the NHS. The Ieso online talking therapy service provides clinically-led treatment for patients with moderate to severe anxiety and depression. For further information, please visit: www.iesohealth.com
