In the seven years since Improving Access to Psychological Therapies was launched the scheme has had some successes, but problems in some areas remain, as Emma Dent explains.
When the Improving Access to Psychological Therapies (IAPT) programme was launched in 2008, it finally gave recognition to the effectiveness of psychological, or talking, therapies. Evidence had been growing for some years for this – indeed, the Department for Health (DH) said in its IAPT implementation document that psychological therapies were “as effective as anti-depressants in the short-term and more effective at preventing relapse” (DH, 2008).
Since then, IAPT, which was initially intended to provide talking therapies for people with mild to moderate anxiety and depression in primary care, has helped hundreds of thousands of people in their recovery, yet there remains a feeling that it could do more.
When the programme was assessed by the Department of Health (DH) in March 2012, more than one million people had accessed the service and 680,000 had completed a course of treatment, with recovery rates of more than 45%.
Three years on, by March 2015 – following a promised £400 million further investment outlined in the ‘No health without mental health’ strategy – the DH predicted access would be at 100%, up from 60% in 2011. By this deadline DH said a further 3.2 million people would have accessed the service, of which 2.6 million would have completed a course of treatment, with half experiencing measurable rates of recovery.
The DH also predicted that about 6,000 workers trained in cognitive behavioural therapy (CBT) – the therapy most commonly provided by the programme – would be delivering services and one employment support worker for every eight therapists would be helping IAPT users back into work. In addition, older people would be properly represented among those receiving treatment, having been significantly underrepresented in services to date.
Long-term conditions and medically unexplained symptoms were also outlined in 2011 as areas needing further policy work to ensure mental health problems were routinely included in personalised care planning.
March 2015 has come and gone but by the time of going to press NHS England would not confirm the extent of the service’s coverage, nor the number of service users accessing the IAPT programme although it is known to be increasing year-on-year.
However, while it is widely acknowledged that IAPT has enjoyed some considerable successes, it is still deficient in some areas.
“You don’t often see a programme like that being set up from scratch and at that scale,” says King’s Fund fellow in health policy Helen Gilburt. “But there are limits to what it can do. A 2012 report [‘How mental illness loses out in the NHS’] found that around a quarter of all people with a mental health diagnosis were accessing IAPT – so it’s missing a lot of people.
“There is under-referring, with a propensity for certain groups to have it underestimated about how much they would benefit from psychological therapies. In some areas capacity building may not have been sufficient and in others the investment may have been cut altogether.”
Choice of treatment is also highlighted as one of IAPT’s limitations; a common complaint has been its reliance on CBT. Though NHS England says training for other National Institute for Health and Care Excellence (NICE)-approved ways to treat depression including interpersonal psychotherapy, counselling and couple therapy for depression has also been funded through the programme it is believed to not be as extensively provided as CBT is.
Geoff Heyes, policy and campaigns manager at mental health charity Mind, adds there are still problems when it comes to access for certain groups; such as people with serious mental illness (SMI), older people and people from black and minority ethnic groups.
There have though been targeted services for people with SMI, albeit on a demonstration site rather than national basis. Two years after a report in 2010 by what was then Rethink – now Rethink Mental Illness – said that 80% of trusts had found IAPT had not freed up resources for secondary care, funding was announced for an SMI IAPT scheme.
“When IAPT was set up it was hoped psychological therapies would still be commissioned from secondary care,” says Rethink Mental Illness’ head of policy and development, Antonia Borneo. “But what quite quickly happened instead is that secondary care funding was diverted to help set up IAPT services and the workforce got pulled out of secondary care.”
SMI IAPT clinical lead Dr Alison Brabban, a consultant clinical psychologist at Tees, Esk and Wear Valleys NHS Foundation Trust, adds that rather than try to create a service from scratch, the six pilot sites – three for personality disorder, one for people experiencing psychosis (plus an academic centre) and two for people with a bipolar disorder diagnosis – have taken a ‘transformational’ approach.
“We are not creating a new service with a new workforce, rather it is about ensuring staff have the skills to deliver psychological therapies,” says Dr Brabban.
A similar approach has been adopted by IAPT services for children and young people (see box below). “We want to enhance the service we already have,” adds Dr Brabban. “Psychological therapies are still seen by many as something of a luxury. So when therapy is currently provided in secondary care it is likely to be done by a care co-ordinator trying to do it as part of their job, not in a defined role.
“We hope that with this type of targeted care, within three to five years, service users will have the chance to recover and get back into primary care and get on with their lives.”
Dr Brabban believes the success of the demonstration sites contributed to the then coalition government’s pledge to introduce waiting times and access targets, including 50% of those experiencing a first episode of psychosis to get access to NICE-approved treatment within two weeks and 95% of people referred to IAPT to be treated within 18 weeks of referral.
But though welcome, Mind’s Heyes cautions that significant investment will be needed to make these targets achievable, particularly in the light of current waiting times and issues around access.
Mind’s 2014 report ‘We still need to talk’ found one in 10 service users waiting for up to a year and more than half waiting three months to receive treatment. More than half said they were not offered a choice of therapy and 10% resorted to paying for their own therapy when what they wanted was not available on the NHS.
Borneo agrees that work is still needed to solve these problems: “Access standards will help enormously but work is now needed to address the significant gaps in the workforce,” she says. “There just aren’t enough practitioners to do IAPT in primary and secondary care.”
Department of Health (2008) Improving Access to Psychological Therapies Implementation Plan: National guidelines for regional delivery. London: DH
Department of Health (2012) No health without mental health. London: DH
The Centre for Economic Performance’s Mental Health Policy Group (2012) How mental illness loses out in the NHS. London: LSE.
About the author
Emma Dent is a freelance journalist
Children and young people IAPT services – a ‘transformational’ approach
A three-year children and young people (CYP) project that began in 2013 has established 24 pilot sites covering about 68% of the country.
With £30 million funding to deliver a curriculum and training for staff rather than creating a new service, CYP IAPT aims to treat a range of conditions such as anxiety and depression, eating disorders, obsessive compulsive disorder, post-traumatic stress disorder and conduct disorder in three to 10 years.
“It is going well in terms of the number of people being trained although there is an issue with the number of staff being employed on short-term contracts,” says Sarah Brennan, chief executive of mental health charity YoungMinds. “But the fact that it is not a separate service is one of its strengths. Otherwise if you lose the funding, you lose the service, which is something we see happen again and again. But that was not an issue, as there just isn’t enough funding to provide a whole service.”
CYP IAPT national clinical lead Professor Peter Fonagy says he is pleased with the progress of the programme so far, particularly at a “challenging” time for children and adolescent mental health services.
“The adult IAPT programme had to establish an infrastructure; we have been able to use all the resources available to make the existing system more effective at delivering NICE-recommended interventions,” he says. “The involvement of the families of the children and young people in setting up and delivering this care and making care decisions has been particularly valuable. They have been at the heart of their own care and in this we feel we have delivered irreversible culture change.”
Professor Fonagy thinks achieving 100% nationwide coverage for CYP IAPT is achievable within the next few years, although much work is needed to do this. “The gap so far is geographic; there are areas without these services. Also we have so far focused on common conditions, but we have neglected some areas, for example pervasive development disorders such as autism, CYP with learning difficulties and with hearing problems, all of whom require specialist interventions.”