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.
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%
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
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.
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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