According to the latest IAPT annual report for 2018 – 19, clients are, on average, accessing services well within target waiting times. The attrition that we’ve written about before, however, continues to undermine the claims that IAPT’s headline recovery rates represent a “remarkable achievement”. Using a format similar to previous blogs on IAPT, we explore the wider picture of IAPT clients’ recent journeys.
Above is a graphic which shows clients at key stages of their journey through the Improving Access to Psychological Therapies (IAPT) programme in the year 2018 – 19. It’s an update of the figures that we profiled for 2017 – 18 in a previous blog. Some of the performance data for 2018 – 19 show an improvement over the previous year. Otherwise there seem grounds only for modest optimism, and hardly the celebratory tone struck by Professor David Clark in his blog earlier this year.
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
Of all referrals that ended 2018 – 19:
- 29% do not enter therapy
- 29% of referrals have only one treatment appointment
- 43% of clients that enter therapy don’t complete
- Only 28% of clients that enter therapy achieve recovery
- Only marginally more clients recover (52.1%) than don’t
First, the headlines. For the year 2018 – 19, the report and supporting datafile show that:
There was a total of 1,495,680 referrals that ended in the year
An increase of 118,760 on the previous year
Of those referrals, 582,556 ended having finished a course of treatment
An increase of 27,847 on the previous year
Recovery rates were 52.1%
for those clients that started above case level and had two or more sessions of therapy. This is up 1.3% on the previous year (definitions for recovery and caseness are shown in the panel below).
89.4% of referrals were seen within 6 weeks, and 99.0% 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
To reach the point at which they can show recovery, clients that are referred must progress through a series of stages, as follows:
The stages from referral:
where 29.5% of referrals don’t enter therapy and 29.5% have one treatment appointment only.
The stages from entering therapy:
where 43% of clients that enter therapy don’t complete. The precise figure (drawn from the IAPT data) is 43.0%, slightly up from 41.6% in 2017 – 18.
The outcome at therapy ending for all clients that attend two or more sessions:
where 51% of clients don’t achieve recovery. The precise figure is 51.1%, slightly down from 52.5% in 2017 – 18
The outcome at therapy ending for clients that were at case level at the start:
where 52.1% of clients achieve recovery, a figure that is 1.3% higher than in the previous year.
Below I’ll elaborate on each stage and show data for the years 2015 – 19, from which the yearly trends can be seen.
The journey from referral – 29.5% of referrals don’t enter treatment, and less than four in ten end treatment
The journey starts with all referrals that ended in the year for the four years. The table below shows the total number of referrals as 100%. Subsequent stages in the process, and the proportion of clients referred that still remain are also shown. In 2018 – 19, 70.5% of those referred entered therapy. This is defined as having one or more sessions of therapy. This is slightly lower than in the previous year.
As we progress through their journey, we can see an emerging story of attrition. A further 29.5% of those referred only have one treatment appointment so that by the end of therapy, only 38.9% of clients that were referred now remain (1.4% lower than in the previous year). Those that reach recovery represent just 19.0% of the total referred. 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.
The journey from entering therapy – 43% of clients that enter therapy don’t complete
We begin this stage with all clients that entered therapy. That is, all those that had one or more therapy sessions. In 2018 – 19, 57% of those entering therapy are recorded as ending it. This figure has reduced in each of the past three years to the point now that more than four in ten clients do not complete.
Following the journey through, we can see that just 27.8% 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 58% 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.
Here it’s also worth noting the words of an anonymous IAPT staff member who posted the following comment on the blog Is IAPT too big to fail:
“Why are so many not finishing treatment? A growing game is to re-class those who don’t recover as ‘non-iapt’ during treatment so that you don’t have to include them at all in your recovery figures and they just drop off somewhere as discharged non-IAPT, having though served their purpose towards access rates and waiting times.”
The outcome at therapy ending for all clients – 51.1% 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 2018 – 19 population, 94% of clients were at case level and could potentially recover. This is just under 1% higher than the previous year, giving more clients that potentially could recover.
Those reaching recovery represent 48.9% of all those that finished treatment. For 2018 – 19, this is an increase of 1.4% over the previous year.
The outcome at therapy ending for clients that were at case level at the start – 52.1% 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 2018 – 19, 52.1% of clients achieved recovery, of those that finished therapy and were at case level at the start, an increase of 1.3% on the previous year.
The figure for those achieving recovery for 2018 – 19 is 1.3% higher than in the previous year. While this further improvement is welcome, however, we should remember that it is within the context of a slight reduction in the proportion of clients that enter treatment that are recorded as having ended it.
Here we should also note the concerning comments made by the same anonymous IAPT staff member mentioned above:
“Removal of Anxiety Disorder Specific measures from the system – many services now telling staff to not record the ADSMs in the main system as much easier to achieve recovery on PHQ and GAD only. Seems to be no checks and balances from NHS Digital to ensure ADSMs are used.”
“Where patients are entering measures remotely, a growing trend – ensuring that you talk through the measures with the patient in the last session, with pressure to edit them lower”
Finding data for your local area or service
Using the IAPT Interactive Dashboard that accompanies the IAPT annual report, it’s possible to explore local and regional performance. You’ll find this in the Key facts section of the summary page. It’s the tool from which the image of the interactive map below is taken.
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 , I’ve selected two CCG areas that include my own of Brighton. 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.
The bad news is that attrition is alive and well. Nearly one in three referrals do not enter therapy. Less than four in ten referrals reach the end of therapy, and less than one in five achieve recovery. As previously, I’m still finding 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.
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I’m curious to know if there is any data available regarding multiple referrals in to IAPT. It’s all well and good to say someone has “recovered” but given there is no follow up it is impossible to say whether treatment has had a lasting impact. If the data exists, is there any differentiation between clients who have completed treatment (either recovered or not), clients who failed to complete and clients who did not access therapy at all? I feel that this would be a very helpful piece of information in determining the effectiveness of the service.
Hi Laura and thanks for your comment. You make a very valid point. The level of detail in the IAPT annual reports has shrunk year on year and it’s getting increasingly difficult to extract much meaning from them. Unique referrals and re-referrals used to be included in reports but seem not to be now. Hence it’s hard to answer your question I’m afraid!
It is possible to follow up the details in the reports with a query as there’s always a contact point given. Should you happen to find out please do post again and let us know!
The problems with IAPT go right back to the start and to the training. Far too condensed, set up too quickly. Training those with increasingly less and less experience year on year once the stock of experienced secondary and primary care trained staff was depleted in year one and two. Courses losing 50% of money before they start to ‘central costs’, meaning only half or less left to actually deliver anything means quality suffers and increasingly inexperienced and unaware staff deliver them. I would never send my staff on them now, but IAPT have no choice. It’s a sown up deal. Accreditation does nothing to monitor standards as it’s the same people accrediting as delivering.
IAPT is now at best a painting by numbers model, a see one, do one, teach a hundred approach – delivered by the cheapest staff possible. Sadly, those staff don’t realise they are being used and far too inexperienced to be in that position. Personal ambition takes over. Over confident and under competent. A dangerous combination. A quick glance at some courses content, service models and materials and it can be seen that they are full of glaring mistakes and misunderstandings. It is a postcode lottery and not as compliant to guidelines as IAPT nationally would have people believe.
The services are also mainly now run at the top or worse, nationally led, by those with little if any experience of therapy or CBT prior to IAPT, no grounding in a suitable length of time in a appropriate core profession. I used to think key IAPT people had integrity. That’s proving not to be the case. Rather than solve the issues they plaster over the cracks and are too busy waiting for their own knighthoods and selling a story; or so it seems.
IAPT has many brilliant aspects. It is a shame we can not compare other mental health services with it, but unless they adopt outcome measurement in the same way it seems unfair to. I think until then it cannot defend itself fairly against its critics. Amongst all of this are patients in need and a further 70-75% of need not being seen even with IAPT, there are dedicated staff who really want to do the right thing, unaware of the background and politics involved in this monster, just trying to do their best, in virtually impossible circumstances. IAPT was badly set up from the start and sadly that will be it’s legacy. It is a shame as many of us still remember life pre IAPT and what we have now is better than the 2-3 year waiting lists we had then, but it isn’t good enough. I have the upmost respect for IAPT staff on the ground but little if any now for those leading it. I am just glad I am not amongst them.
Dear Anonymous
Thank you for the heartfelt post. As one of those who remembers well the time pre IAPT I feel intense sadness for much of what we lost. As you say, waiting lists could be frightful, but where we are now is frightful. We need an independent enquiry into IAPT but the chances of getting one seem pretty much zero.
Excellent blog. Can you just clarify for me:
Out of all clients referred, how many reach recovery?
Out of all clients who have at least one session, how many reach recovery?
Do the figures include people who are re-referred, and hence might be counted twice?
How long is recovery maintained? Do these figures exist?
How do IAPT recovery figures (at various points) compare to estimated natural recovery rates from anxiety and depression over the same period? How much advantage (if any) does IAPT confer over just waiting for time to pass?
What percentage of recovered IAPT clients take up employment if they weren’t working before? You will remember that the original justification for IAPT was that it would pay for itself in reduced benefits and increased productivity.
I suspect most of this information isn’t available…..
Excellent blog. Thanks Jane – I hope the following helps answer some of your questions!
Can you just clarify for me:
Out of all clients referred, how many reach recovery? A: Of all the referrals that were closed in 2018-19, 19% reached recovery
Out of all clients who have at least one session, how many reach recovery? A: In the blog these are clients from Stage 2: all clients that entered therapy. Of these, just 27.8% reached recovery.
Do the figures include people who are re-referred, and hence might be counted twice? A: Very likely some referrals are re-referred, and we should be asking ourselves what aspects of the whole system make this so? Figures used to be given for total referrals and unique individuals (obviously a smaller number). I don’t think that’s been the case for a couple of years so it’s really hard to know the true figures from the published data. Multiple re-referrals are an indicator of potential quality issues so they really need to be looked at.
How long is recovery maintained? Do these figures exist? A: I’ve not seen any and if any exist I imagine they would be from studies rather than routine follow up
How do IAPT recovery figures (at various points) compare to estimated natural recovery rates from anxiety and depression over the same period? How much advantage (if any) does IAPT confer over just waiting for time to pass? A: I’ve no idea on this one I’m afraid. What I can tell you is that from a 2001 study by Michael Barkham and colleagues of secondary care, there was no improvement for clients between referral and pre-therapy, and significant gains post therapy and at 6 month follow up. That was a different regime clearly so whether the same would apply to IAPT I don’t know.
What percentage of recovered IAPT clients take up employment if they weren’t working before? You will remember that the original justification for IAPT was that it would pay for itself in reduced benefits and increased productivity. A: Strangely that information isn’t in the routinely published data. I do recall that being one of the original justifications, but haven’t heard a peep about it for quite some time!
I suspect most of this information isn’t available….. You are right – over the past 4 – 5 years the length of the annual reports has shrunk from about 50 pages to about 15, and it’s much harder to get behind the headlines ☹
For many years I worked as a pharmacist in general practice, and the problems with NHS systems and quality, and also the legal framework within which pharmacy services were provided, were politically and commercially motivated, with little emphasis being placed on patient safety and corporate responsibility. The NHS solution was to enshrine in law that each dispensary should be run by a “responsible pharmacist” who was legally responsible for everything that occurred. If you look at that in the context of Ms Pharmacist complaining about her working conditions to any of the multiples who now run most pharmacies, you can see how unrealistic that was, but no action was ever taken to correct this issue and put the real responsible people in the firing line.
So what? – well, my experience indicates that it will be the individual therapists who are being hung out to dry. The real responsible agents will keep themselves well away from blame.
(and I wouldn’t get a prescription dispensed at a pharmacy that opens over lunchtime- the staff need a decent break, believe me)
Hi David
I’m sure you are right on the issue of accountability. I’m also sure the avoidance of responsibility will go up to the very highest levels, as it usually does.
Thanks for the advice about prescriptions too!