Used to be that the release of the annual IAPT performance date was accompanied by a fanfare. Not any longer. Looking at the trend data it’s easy to see why. In the space of five years the proportion of clients completing therapy has dropped from nearly two-thirds to slightly more than half. If this were a school it would have long ago been in ‘special measures’. How bad must it get?
In prepping this blog, I ran a search using the terms ‘iapt 2020 performance’. I was hoping to get some sense of the level of press coverage accompanying the release of the 2019 – 20 IAPT annual performance data published on 30 July 2020. I uncovered virtually none, but was momentarily distracted by a return on page 1 titled “Is Iapt any good?”
That return (see below) is linked to an NHS England blog by Professor David Clark which contains a paragraph which starts “Despite its successes, IAPT is still a work in progress.”
Nothwithstanding the fact that any initiative that still registers a pulse can be described as a ‘work in progress’, the burning question is “exactly how long do we have to wait?”
What do the latest data tell us?
In the year 2019 – 20 a total of 1,694,790 new referrals were received, and in the same period 1,647,716 referrals ended. The referrals ended number represents an increase of 10% from the previous year.
Other key data, which are also represented in the graphic below, are as follows:
Of the 1,647,716 that ended in the year, 521,312 (32%) ended without having been seen by the service.
A total of 1,126,404 referrals were seen, and were recorded as either ‘Ended having been seen but not treated by service’ (30,665), ‘Ended having only one treatment appointment’ (489,547) or ‘Ended having finished a course of treatment’ (606,192). In practice, ‘Ended having finished a course of treatment’ refers to clients that had two or more treatment sessions.
The number of referrals that actually entered therapy (i.e. had one or more sessions) was 1,095,739. This is the cohort on which the proportions of clients ending treatment and achieving recovery (represented in the header image of this blog) are based.
As shown in the header image, of the clients entering therapy, a total of 606,192 (55.3%) are recorded as ending therapy (i.e. having attended two or more sessions). As previously noted, 489,547 (44.7%) were recorded as ending having only one treatment appointment.
Of the 606,192 clients that had two or more sessions, 570,138 (94%) were at or above ‘caseness’ level and could potentially achieve recovery. (A client is ‘recovered’ if they finish treatment and move from caseness to non-caseness by the end of the referral. The client needs to score below the caseness threshold on both anxiety and depression measures. In practice this may only require a one-point reduction in the scores on one measure).
Of the 570,138 clients that were above the caseness threshold, 291,371 were recorded as having moved to recovery. This represents 51.1% of eligible referrals, and 26.6% of those that entered therapy.
Recovery has flatlined, therapy completion rates deteriorated. What next?
The national service standards for IAPT specify that at least 50% of people who complete treatment should recover. Quite why the bar should be set so low I’ve never been clear. Being told by a surgeon that your chances of an operation being successful is no more chance wouldn’t be tolerated, so why is it OK in psychological health?
Nevertheless, in the year 2019 – 20 IAPT met this target, with 51.1% of people who completed treatment achieving recovery. It will be interesting to see if this is maintained: the proportion of people recovering rose steadily from 46.3% in 2015 – 16 to a high of 52.1% in 2018 – 19, so the latest figures represent a slight drop from the previous year.
It is the data for the proportions of clients ending treatment, however, that is most disappointing. Since 2015 – 16, when I started monitoring this data in detail, this proportion has steadily declined from 62.5%, to 55.3% in the 2019 – 20 period. Now, not only do you stand little more than an even chance of recovery if you end therapy (two or more sessions is all that’s required), you also stand little better chance of actually ending therapy at all.
The tragedy is that we know a lot of what is required to improve outcomes. A study published in 2017 and profiled in an earlier blog highlighted the beneficial impact of active use of outcome feedback on outcomes and service efficiency in an IAPT service. David Clark himself, in a paper from 2018, highlighted a range of emerging factors that underpin variability in outcomes, including waiting times, therapeutic ‘dose’, and the quality of clinical leadership.
Despite what we know about what works, however, including what has been learned from IAPT services themselves, IAPT’s overall performance shows no sign of any further improvement. If anything, considering the declining proportion of clients ending treatment, it’s getting worse.
For the sake of the many people in need of high-quality psychological therapy services, as well as those who work in IAPT, it’s time this lumbering edifice was subjected to independent audit.
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