older psychiatryIntroducing competition to the provision of psychological therapies has resulted in a funding system that encourages providers to reject some patients because they are not easy to treat, and puts pressure on therapists to claim patients are recovering – or they won’t get paid, a report has claimed.  

Research by the University of Chester’s Centre for Psychological Therapies in Primary Care found that the government’s Any Qualified Provider (AQP) policy, which includes Payment by Results (PbR), was destabilising mental health provision and there is widespread dissatisfaction with the system.

The report, Mental Health's Market Experiment: Commissioning Psychological Therapies Through Any Qualified Provider, found that: 

  • Low tariffs and PbR – meaning some providers don’t get paid for treating patients who don’t recover – are a factor in the decision to take patients on, and the type of treatment to offer
  • The introduction of ‘patient choice’ between multiple service providers, and zero value contracts for organisations and therapists, has resulted in destabilisation of mental health provision 
  • The new market system uses scales to measure the progress patients are making, that determine whether payment should be made to the provider – but they weren’t designed for this purpose; and according to a respondent in the research report can result in ‘perverse’ incentives
  • There is widespread unhappiness with a PbR system that means patients may be pushed through as fast as possible in order to get paid, with a risk of relapse.     

Indeed, one provider in the report said: “As for patient needs, the tariff doesn’t fund the service spec, which has undermined a good IAPT [Improving Access to Psychological Therapies] service. In terms of best practice, this has forced us in to a strict recovery-driven model to financially survive. As for patient choice, this has forced us into rejecting those unlikely to fit in to a recovery model.”

But the report did find some positives, with real movement seen in the fall in patient waiting lists. However, the AQP policy coincided with a big increase in investment in psychological therapies, so that improvement may be simply due to more services being available. It also found some examples of more flexibility and diversity of service provision reaching less well-off communities that have not in the past had access to psychological therapies.

Serious flaws in delivery of psychological therapies

The Centre’s director, Professor Patrick Pietroni, said: “This is the first comprehensive study of the Government’s Any Qualified Provider policy in which contracts are governed by payment by results.  This part of the NHS reorganisation was intended to extend patient choice, and raise service quality and efficiency through competition between providers. The implementation of such a complex policy is bound to have teething problems. However, the researchers were surprised at the consistency of the themes that emerged in the responses, which were often critical.  

“It appears that there are some serious flaws in the way psychological therapies are being delivered, in particular a highly competitive environment which has been poorly thought through. We have learned a great deal from the study, and we need now to get together with providers, commissioners, GPs and others to review the IAPT programme and redesign its methodology in order to minimise the weaknesses and build on the strengths identified by the report. We need to develop a model of service delivery that is integrated with general practice and other partners in order to address the wider determinants of poor mental health.”  

To view the full report, click here