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Psychological Therapies in the NHS 2017

An Open Letter to the Profession, its Leaders & the Government

On behalf of psychological practitioners and their patients who depend on them to work together

In 2017, it will be 10 years since we came together to agree the New Savoy Declaration. It was a moment of optimism and collective goodwill to seize the opportunity for radical reform. Mental health charities and professional bodies had called for universal access to evidence-based psychological therapies and the government heard them. IAPT was born.

Two recent reports reveal the scale both of the IAPT achievement and some sobering facts about the remaining challenge. IAPT’s 4th annual report shows access has increased dramatically. Almost 1M patients entered and over 0.5M completed treatment in 2015-16 of whom 226, 850 recovered. Over 80%, we are told, waited less than 6 weeks from referral to treatment. Impressive though this is (if we believe the wait times) it still means in plain language that around 80% don’t recover. Year on year that is a lot of misery. When we look at what the Adult Psychiatric Morbidity Survey reveals we see that IAPT’s access figures are dwarfed by numbers on anti-depressants. Over three times as many. GPs used to say it was long waiting times for talking therapies, which patients prefer, that meant their default first-line treatment was anti-depressants. But if IAPT has really made long waits a thing of the past why have GPs not changed their behavior?

Both reports point us to another causal factor: economic recession. The recovery rates in IAPT for those in the most deprived areas are 20% lower than for those in better off parts. More worryingly, the Adult Psychiatric Morbidity Survey shows an alarming increase in self-harm amongst young women since 2007, who are the single largest IAPT user group. Shockingly, it tells us almost half of welfare claimants on ESA benefit (many of whom have chronic depression that prevents them working) have attempted suicide. Men aged 55 to 64 are now identified a high risk group for suicide if they become unemployed. But weren’t they the very people we promised to help when we set out on the IAPT journey? If reports like these are not persuasive (or you think this is me having a bash at IAPT) can I recommend you see Ken Loach’s film I, Daniel Blake for a dose of the sad human truth.

Our 10th anniversary conference is an open letter to the profession, its leadership and the government, therefore, to face these truths. The BBC’s Mark Easton will jojn us to put your questions to the politicians. Paul Farmer CBE, who has taken on the task of holding the system to account for making sure its promises are delivered, will join us on day 2.

Our opening keynote is addressed to a profession yet to engage fully with evidence-based practice. Why is this? Professor Bruce Wampold calls for us to forget brand names. In fact, his argument is based on a radical new paradigm for evidence-based practice that eschews the medical model and forces us to question what we have been doing in IAPT: namely, treating a disease entity called depression and anxiety whose psychological targets are meant to take up an analogous place to the long promised biological markers that psycho-pharmacologists told us previously were the ‘real’ causes of mental illness. But if this model is wrong and if, as Wampold has shown, the evidence from RCTs that it relies upon for its justification often does not tell us “what works for whom”, what then? Not everyone will agree with Wampold’s alternative but all who are committed to evidence-based practice will need to engage with his sophisticated and powerful analysis. Moreover, whilst the jury remains out it behoves us to allow a more pluralist discipline.

Our call to the leadership of our profession to focus on staff wellbeing comes also with an invitation. We want to create an honest conversation between IAPT clinical leads and local commissioners about the negative impact of increased targets and decreased resources. We are making available a limited number of free places for this discussion. Our Charter (see page 6) has gained wide support and the results of our annual BPS/NSP staff wellbeing survey are the barometer for whether it has had any impact in 2016. Please take the survey and pass on our invitation to your IAPT lead or commissioner. After a decade of ‘command and control’ we need a different kind of leadership. We will hear from Professor West, at the highly respected Kings Fund, what this might look like.

We return to the plight of Ken Loach’s Daniel Blake on day 2. Last year we heard for the first time of a more hopeful approach towards helping the long-term unemployed who have chronic depression. Theresa Grant inspired delegates with Greater Manchester’s plans for its pilot: Working Well. Another sign that policy makers have listened comes with the Green Paper out for consultation Improving Lives. The influence of Greater Manchester’s integrated, personalized support offer is evident and, unusually, a truthful admission is made that for mental health support “the system provides too little too late”.

Our opening keynote on day 2 features the two foremost experts whose work has been influential in the areas of behavioral change theory and in measuring states of health and wellbeing, respectively, Dr. David Halpern and Professor John Brazier. It is unavoidable, in my view, that psychological therapists must be central to implementation of any new policy approach that genuinely seeks to improve quality of lives because the unmet needs of welfare claimants for emotional and psychological support are so significant. But this places us equally unavoidably on the frontline of what Loach’s film portrays as a heartless, dehumanizing bureaucracy, which is how many clients experience Job Centers. Our profession must find out how to instill a context of compassion in its wellbeing work. In Halpern and Brazier, we have excellent guides for navigating our way towards this.

Another report - the first outcomes report on children and young people’s mental health services - asserts: "Achieving parity of esteem between physical and mental health requires parity of data”. Well, yes. But all the effort and burden involved can only be justified if it leads to improved responsiveness. Not against a backdrop of cuts. The report tells us that for just under 100,000 children and young people accessing CYP-IAPT services from 2011-2015 the main issues were: family problems, depression, anxiety and relationships with peers. Significantly, over half the cases assessed did not map directly onto a NICE guideline. Encouragingly, though, in 9 out of 10 cases where the child or young person had both set and assessed their own goal for therapy there was clear improvement. We will hear from the report’s authors about its key findings and their implications. Across both days, in addition, we will be fielding a range of important workshops where the aim is to re-set the balance - using hard-won data and evidence - around a more honest conversation between clinicians and their patients with managers and commissioners setting targets.

If, like me, you believe that evidence based NHS practitioners can still aspire to tell the truth about ‘what works for whom’ then I look forward to offering you a warm welcome.

For further information about the Psychological Therapies in the NHS 2017 conference visit http://www.healthcareconferencesuk.co.uk/psychological-therapies-2017


18 November 2016

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