In 2015 – 16 nearly 1.3 million referrals were made to IAPT services. Less than half of those finished a course of treatment, and, of those, less than half achieved recovery. This blog explores whether IAPT, as it is currently delivered, is capable of providing quality therapy at the scale which is required
Take a moment to look at the graphic below. It illustrates, nationally, the number of clients at key stages of the journey through the Improving Access to Psychological Therapies (IAPT) programme during 2015 – 16.
The number at the top represents the number of clients (1,299,525) whose referrals ended in the year April 2015 – March 2016. Halfway down are the number of referrals (537,131) that finished a course of treatment. That number represents just 41% of the total referrals. At the bottom is the number of referrals (226,850) who completed treatment and achieved recovery. The number achieving recovery represents 17.5% of all referrals that ended in the year.
In what follows I explore whether IAPT is meeting its stated aims, and later, what happened to the more than three quarters of a million referrals whose journeys did not result in a completed treatment.
To conclude, I speculate on whether the current IAPT model is capable of delivering high quality therapy at scale.
One the face of it, the IAPT programme in England is not far short of meeting its targets. For the period 2015 – 16, the data show that:
There was a total of 1,399,088 new referrals
a more than 10% rise on the previous year
Recovery rates were 46.3%
up one and a half percentage points on the previous year, and edging towards the target of 50% (definitions for recovery and caseness are shown in the panel below).
81.3% of referrals were seen within 6 weeks, and 96.2% within 18 weeks
both exceeding their respective targets of 75% and 95%.
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
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
The numbers involved, in total, and by their now historic Strategic Health Authority (SHA) area, are shown in the table below.
Source: IAPT three-year report: The first million patients (Department of Health, 2012)
In summary, by March 2015, services were to treat 15% (i.e. 900,000) of the over six million people in England with common mental health disorders. Of those, 600,000 should complete treatment, and of those, 300,000 should recover.
Is IAPT meeting its targets?
The IAPT programme targets are a combination of the big picture objectives set out above, in addition to more recent targets for key performance indicators such as waiting times. I’ll address four key questions in the paragraphs that follow.
Is IAPT reaching the target of treating 15% of people with common mental health disorders?
Are two-thirds of clients that enter treatment completing it?
To what extent is IAPT meeting the target of 50% of clients completing treating achieving recovery?
Are waiting time targets being met?
Is IAPT reaching the target of treating 15% of people with common mental health disorders?
There are two ways we can consider this. Unfortunately, each gives a different answer.
The first is by looking at the number of new referrals that are received in a specific period, and the second by the number of referrals that ended in that period. The numbers for each will not be the same as some referrals that start in one year may not complete until the following year, and some referrals that end in one year may have started in the previous year.
In 2014 – 15, a total of 1,267,193 new referrals were received, of which 815,665 (64.4%) are recorded as entering treatment. In 2015 – 16 the number entering treatment rose. 953,522 (68.2%) of the 1,399,088 new referrals entered treatment. Based on the number of new referrals entering treatment, therefore, the target of 900,000 patients entering treatment was not met in 2014 – 15, but was comfortably achieved in 2015 – 16.
Of referrals that ended in those periods, for 2014 – 15, 706,638 of the 1,123,002 referrals entered treatment. In 2015 – 16, of the 1,299,525 referrals ending in the period, a total of 858,896 entered treatment. In neither year, therefore, was the target of 900,000 patients entering treatment met.
The table below shows which of the targets for treatment access, completion and recovery have been met for each year. Note that completion and recovery figures are based only on the referrals ending in each year.
While the number of people entering treatment, based on referrals ending in each year, has so far fallen short of the 900,000 target, the overall level of new referrals is rising steadily year on year.
For the period 2015 – 16, the number of new referrals entering treatment has exceeded 900,000 for the first time. This trend will certainly continue, especially given the Government’s plans to expand the programme over the next five years.
Planned expansion of IAPT
IAPT is set to expand further over the coming years. NHS England has been tasked with increasing access to evidence-based psychological therapies to reach 25 per cent of those in need by 2020/21. For now, however, the targets are as set out above.
Are two-thirds of clients entering treatment completing it?
To answer this question, we need to look at referrals that ended in each period, then work out what proportion of clients that entered treatment also completed it. Figures are shown in the table below.
In 2014 – 15, of the 706,638 clients recorded as entering treatment, 468,881 (66.4%) completed. In this year, therefore, the target was met. In 2015 – 16, however, it was not, as only 62.5% completed treatment (537,131 completing of 858,896 entering treatment).
There is, however, a twist to this. The two-thirds target, as originally conceived, was based on a projected 900,000 entering treatment, giving a numerical target of 600,000. Using this figure leaves the number completing treatment well short in both years.
To what extent is IAPT meeting the recovery target of 50%?
The answer to this question is simple. It is not. Overall, the recovery rates for 2014 – 15 and 2015 – 16 were 44.8% and 46.3% respectively.
Behind those averages lies a startling range of recovery rates across CCG (Clinical Commissioning Group) areas. The lowest recovery rate achieved is 21.4% and the highest 63.2%. In other words, clients in the best performing area stood a three times greater chance of achieving recovery than those in the lowest. Only 70 of the 211 CCG’s achieved a recovery rate that was better than the 50% target.
Are waiting time targets being met?
Under the terms of the Government’s mandate to NHS England, 75% of new referrals to IAPT should enter treatment within 6 weeks, and 95% within 18 weeks.
In 2015-16, 81.3% of referrals were seen within 6 weeks, and 96.2% were seen within 18 weeks – both above the targets. Both the 6 and 18 week targets were therefore comfortably achieved. The average waiting time to enter treatment was 29.4 days.
While this figure appears to represent a relatively modest wait in terms of access to NHS services, it does disguise another enormous range of waiting times. The shortest average wait was 5.9 days (NHS South Tyneside CCG) and the longest was 139.3 days (NHS Wirral CCG).
So, what’s the overall verdict on IAPT so far?
First, we should celebrate the fact that waiting time targets are being broadly met. On average, most referrals are seen within 6 weeks, and that is a notable achievement. That said, the range of waiting times is a major concern and represents a significant challenge for CCG’s and providers.
Looking beyond waiting times to other IAPT targets, it’s hard to conclude anything other than IAPT is failing to meet most targets. The only target that has unequivocally been met is new referrals entering treatment for 2015 – 16, where the 900,000 target was exceeded by 53,522. The target of two-thirds clients completing treatment was technically achieved in 2014 – 15, but the actual number completing was short of the numerical target of 600,000.
In outcome terms, the overall IAPT recovery rate, which still rising slightly, continues to be stubbornly short of the 50% target, and disguises a range of across CCG areas that is of real concern.
Client attrition through the IAPT pathway
The graphic below shows the flow of referrals through IAPT in 2015 – 16 for referrals that ended in the period, and highlights the points at which they either disengaged or progressed no further in their journey.
A total of 440,629 referrals were either not seen at all, or were seen but did not enter treatment. This represents 34% of all referrals ending in the period. Of the 858,896 that received one more treatment appointments, 321,765 or 37.4% ended having had just one treatment appointment.
Taken together, referrals that were not seen at all, or were seen but not treated or had only one treatment appointment, gives the total of 762,394 I highlighted earlier. Put another way, 58.6% of referrals that ended either did not start or did not complete treatment.
Clearly, we would not expect that all referrals would attend an initial appointment if it were offered, nor that those attending an assessment would progress into therapy. Neither would we expect that all clients that enter therapy will complete it. Such expectations would be unrealistic, and a degree of attrition at each stage is inevitable. As a former service manager and as a consultant, however, I’ve seen what ‘good’ looks like, and this is not it.
In my final year (2004 – 5) at my former service, the Royal College of Nursing Counselling Service, 83% of referrals progressed into therapy. Of those, 84% completed and of those, 85% achieved clinical and/or reliable improvement (the CORE equivalent of IAPT’s reliable improvement).
Over the years of its existence, IAPT has largely either replaced or absorbed the primary care counselling services that existed previously. Patchy and imperfect though these were, it is illuminating to reflect on those services’ outcomes. In 2006, 32 services helped compile recovery and improvement benchmarks for NHS primary care counselling [i] which showed that an average of 72.2% clients achieved clinical and/or reliable change. By contrast, in 2015 – 16, IAPT services averaged 62.2% reliable improvement), performance which would place IAPT in the bottom performing 25% range of services.
I’ve spoken with many IAPT practitioners over the years, and my over-riding sense is of a heroic group of people giving of their best in a system struggling under the weight of political expectations, increasing constraints on service delivery, and a vast level of unmet need. Despite this, there are many shining examples of service provision within IAPT, delivering remarkable outcomes for the people they serve. If they were the norm I wouldn’t be writing this blog, but sadly, they are not.
Building on shaky foundations?
The NHS Operational Planning and Contracting Guidance for 2017/19 [ii] has tasked CCG’s with commissioning additional IAPT services so that by 2020/21 services are reaching 25% of those in need. In other words, at least 600,000 more adults will access treatment, with at least 350,000 (58.3%) completing treatment (note this is less than the previous target of two-thirds completing treatment).
I would feel more enthusiastic about the extension of IAPT if I had seen solid and consistent evidence that the overall trajectory was an improving one. Having followed IAPT from the early days, however, I see very limited signs that is the case. The proportions of clients that reach recovery as a proportion of those that enter treatment has remained static over 2013/14, 2014/15 and 2015/16, at 26.2%, 26.8% and 26.4% respectively. In other words, if you enter treatment you have a one in four chance of recovering, and your chances don’t appear to be improving over time.
I’ve been on the improvement journey in my own service, and I’ve helped others in their own journeys too, and I think I’ve earned the right to say I know what good looks like. I refuse to believe this is as good as it gets, but at present I see few signs that IAPT as a meta-system is one that is capable of continuous improvement. Until I do I will continue to have concerns about simply investing ever greater sums to build on the current structure.
The key data sources for this blog, unless specifically referenced, are Psychological Therapies; Annual Report on the use of IAPT services: England 2014/15 and Psychological Therapies: Annual report on the use of IAPT services England, 2015-16. Both are available from NHS Digital at http://content.digital.nhs.uk/iaptreports along with monthly, quarterly and annual performance reports.
[i] Mullin T, Barkham M, Mothersole G, Bewick BM, Kinder A. (2006). Recovery and improvement benchmarks in routine primary care mental health settings. Counselling & Psychotherapy Research, 6, 68-80