Clients are waiting less time than ever to access IAPT services, and recovery rates have reached their highest ever level at 50.8%. So why am I not throwing my hat in the air? In a nutshell, the astonishingly high levels of attrition. With less than one in five that are referred and one in four that enter therapy achieving recovery, what is the experience of those that IAPT is serving less well?

Below is a graphic which shows clients at key stages of their journey through the Improving Access to Psychological Therapies (IAPT) programme in the year 2017 – 18. It’s an update of the figures that I provided for 2016 – 17 in a previous blog. As was the case then some of the performance data for 2017 – 18 show an improvement over the previous year. I also said previously that some aspects of performance start from an already worryingly low baseline. Having looked at the latest data I see grounds only for modest optimism.

Once again, the main story behind the numbers is one of extraordinary levels of attrition at each stage of the journey. The detail follows in subsequent sections.

Key highlights

  • The recovery rate for 2017 – 18 was 50.8%
  • 30% of all referrals don’t enter therapy
  • 45% of clients that enter therapy don’t complete
  • Only 26% of clients that enter therapy achieve recovery
  • Almost as many (49%) don’t recover, as do
  • The best performing areas achieved a recovery rate roughly double that of the poorest

First, the headlines. In the year 2017 – 18, the report and supporting datafile show that:

A
There was a total of 1,439,957 referrals

an increase of 54,293 on the previous year

A
Recovery rates were 50.8%

This is up one and a half percentage points on the previous year, and for the first time exceeding the target of 50%. (definitions for recovery and caseness are shown in the panel below).

A
89.1% of referrals were seen within 6 weeks, and 98.8% within 18 weeks

exceeding their respective targets of 75% and 95%

CASENESS
The term used to describe a referral scoring highly enough on measures of depression and anxiety to be classed as a clinical case. If a patient’s score is above the clinical cut off on either anxiety, depression, or both, that are classed as a clinical case
RECOVERY
A patient is ‘recovered’ if they finish treatment and move from caseness to non-caseness by the end of the referral. The patient needs to score below the caseness threshold on both anxiety and depression measures. Referrals that started treatment not at caseness are not included in recovery counts

Headlines aside, there’s a story behind the numbers which I’ve broken down into four chapters. They are:

The stages from referral:

30% of referrals don’t enter therapy.

The stages from entering therapy:

45% of clients that enter therapy don’t complete.

The outcome at therapy ending for all clients:

53% of clients don’t achieve recovery

The outcome at therapy ending for clients that were at case level at the start:

51% of clients achieve recovery. 49% do not.

In each chapter I’ll show data for 2015 – 16, 2016 – 17 and 2017- 18.

The journey from referral – 30% of referrals don’t enter treatment

The journey starts with all referrals for the three years. The table below shows those referrals as 100%. Subsequent stages in the process, and the proportion of clients referred that still remain are also shown. In 2017 – 18, 70% of those referred entered therapy. This is defined as having one or more sessions of therapy. The proportions in both of the previous two years were broadly the same.

As we progress through their journey we can see an emerging story of attrition. By the end of therapy, only 39% of clients that were referred now remain (down from 41% in 2016-17) Those that reach recovery represent just 18% of the total referred . That’s less than one in five clients.

Why did only seven in ten referrals enter therapy? I can only speculate, but in doing this it’s important to note that nearly nine in ten referrals were seen within six weeks. Hence length of wait may not be the most important factor. Otherwise, they may no longer have needed therapy, their referral may not have been appropriate, or they may simply not have liked what was offered to them.

Chapter 2: The journey from entering therapy – 45% of clients that enter therapy don’t complete

We begin this chapter with all clients that entered therapy. That is, all those that had one or more therapy sessions. In 2017 – 18, 55% of those entering therapy are recorded as ending it. This figure is down 4% from 2016 – 17. Whichever year we’re talking about, however, the fact that more than four in ten clients do not complete should be a concern.

Following the journey through, we can see that just 26% of those entering therapy achieved recovery. In other words, clients entering therapy appear to stand just over a one in four chance of recovering.

 

Why are only 55% of clients recorded as ending therapy? Again, it’s hard to know. In my experience, however, clients more commonly drop out because they feel that therapy isn’t working for them for some reason. Often, they simply disappear without the opportunity to explore this with their therapist, and make adjustments that may better serve their needs.

 Chapter 3: The outcome at therapy ending for all clients – 53% of clients don’t achieve  recovery

Here we start with all the clients that are recorded as finishing a course of treatment. The first point to note is that not all clients were at a case level of symptoms or distress at the outset. No matter how much improvement they make, therefore, they cannot achieve recovery. In the 2017 – 18 population, 93% of clients were at case level, and could potentially recover. This is the same as in the previous year.

 

 

Those reaching recovery represent 47% of all those that finished treatment. For 2017 – 18, this is an increase of 1% over the previous year.

The outcome at therapy ending for clients that were at case level at the start – 51% of clients achieve recovery

The final leg of the journey, starting with clients who finished treatment that were at case level at the point they started. In this population we have all the clients who have the potential to achieve recovery.

In 2017 – 18, 51% of clients achieved recovery, of those that finished therapy and were at case level at the start. To be precise, the figure given in the IAPT report is 50.8% (against 49.3% for 2016-17).

The figure for those achieving recovery for 2016 – 17 is 1.5% higher than in the previous year. This is the first time that the recovery rate has exceeded the target of 50% that was established for the IAPT programme.

While this improvement is clearly welcome, however, it remains the case that almost as many clients do not recover as do. At nearly 51:49, the odds of recovering or not recovering are almost even.

Not all services perform equally

Using the tools that accompany the IAPT annual report, it’s possible to explore local and regional performance. Sadly, the datasheet which houses all of the raw data is now structured in such a way that it’s no longer possible to get a single improvement rate for each Clinical Commissioning Group (CCG) area and easily filter those to see the range of performance.

What I am loving, however, in this new reporting structure, is the IAPT Interactive Dashboard, which you’ll find at the foot of the Resources section of the summary page.  It’s the tool from which the image of the interactive map (main blog image at the top) is taken, and also the screenshot below.

The interactive tool allows you to filter performance data at a local level, either by hovering over the map or entering the CCG or commissioning region, for example. In the image above right, I’ve selected two CCG areas towards the lower and higher ends of the improvement range. If you’re interested in finding the performance for your local area I’d encourage you to go and have a play.

To summarise

In summary, then, there is some good news and some bad news. The good news is that clients are able to access services more rapidly than before and that for those that end therapy, their chances of recovery are more than one in two for the first time.

The bad news is that attrition is alive and well. 30% of referrals do not enter therapy. Only 39% of referrals reach the end of therapy, and only 18% achieve recovery. In that context, I find it hard to find too much to celebrate.

How do services improve?

I concluded the previous blog with a simple five-point plan that will assist any therapy service, IAPT included, to improve on its current performance. Rather than repeat myself here’s a link that will take you straight here.

I’d love to hear your thoughts on what you’ve read, whether you have a personal connection with IAPT or otherwise. Leave a comment below and please let us have your thoughts.

We thrive on feedback, so please let us know what you think about what you’ve read in the comment section below. Only the name you use to identify yourself will be shown publicly. Thank you!

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Posted by:Barry McInnes

6 replies on “IAPT 2018: Why do less than 1 in 5 referrals reach recovery?

  1. Appreciate the work you put in to ‘lift the veil’ on this stuff!

    I also wondered about the referral numbers and attrition, and was interested whether this was an IAPT referral that made it through to step 3 (ie those allocated to step1/2 and groups would count as attrition), or whether it was genuine attrition from step 3 alone?

    Does that make sense?

    1. Hi Justin and thanks for your post. I’m not sure if I can fully answer your question, but historically the reporting seems to have distinguished between referrals and people.

      The revised 2016-17 report clarifies what this means:

      In 2016-17 there were:
      • 1,385,664 new referrals to IAPT care providers, and
      • 1,198,952 people12 referred to IAPT care providers.
      There are several reasons for there being more referrals than people:
      • A patient may have finished a referral to IAPT services, but been
      referred again later in the year;
      • A patient may make multiple service requests across different
      providers;
      • A patient may be ‘stepped up’ to high intensity treatment, or
      ‘stepped down’ to low intensity treatment and this may need to be
      referred to a new provider
      https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-annual-reports-on-the-use-of-iapt-services/annual-report-2016-17-further-analyses

      That clarification is missing from the 2017-18 report – I can see the figure for referrals but not people. So my best guess is that the report includes all referrals into all steps, and classes a step up or down as the closing of one case and the opening of another. From step 3 alone? I’m afraid the report just doesn’t go into that level of detail, but it would be very interesting to know.

      You can by the way make enquiries as I have done in the past, to enquiries@nhsdigital.nhs.uk Let me know if you do!

  2. Hi Barry,
    I am really happy that I found your article on LinkedIn. Last summer IAPT was heavily plugged in the Netherlands, up to government levels, under the name Therapiewinst (‘Therapy Profit’).
    I was suspicious of the claims that were made by the British researchers, but couldn’t get a complete picture. The facts you present are really helpful for the discussion in the Netherlands, hopefully we can learn from the mistakes made by IAPT.

    1. Hi Peter
      Thank you so much for your comments. I hope that we too can learn from the mistakes made by IAPT! It’s important to acknowledge that there are some excellent local services, but overall we have more to learn than we have to teach. Feel free to contact me if I can help further.

  3. I’ve worked in Mental (ill) Health services for decades and have been IN IAPT from the start. The use of the word ‘recovery’ to describe how someone scores on a tick box self assessment is ludicrous and I wonder how did it ever come to this.

    Service funding, micro management and the mass burnout of staff are all linked to these two measures its like the twilight zone.

    IAPT is more akin to a production line of suffering that is harming staff and doing very little for the people its meant to help – how can it? 6-10 x 50 minute sessions with a stressed out therapist that at worst ignores the toxic context/culture of people lives and at best reduces it to a mere trigger for some internal issue. Of course some people feel comforted and helped by therapy but this is not surprising given the alienation, fear, and stress people are living with – if we had more time for each other, more time to listen, connect and be – to live in mentally healthy cultures then these services would vanish and I for one would much rather change my career than help to maintain a toxic culture while encouraging people to be responsible to adjust to it rather than change it.

    1. Dave – thank you so much for your comments and the passionate way you’ve expressed them. I think your concerns are echoed by many others and your personal experience is telling.

      In some ways I think what we’re seeing now was perhaps inevitable, given the political imperatives behind IAPT as well as the way it’s been set up. Services before IAPT were far from perfect, especially in terms of geographical spread. But I worked with some stunningly good services from which we could alllearn. Many of those were swept aside to make way for IAPT sadly.

      I think the reality of life in many IAPT services today and the pressures on staff show up clearly in the data. All predictable and all avoidable.

      May I wish you well in finding a good fit for your passions!

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