London Journal of Primary Care 2009;2:50–1
# 2009 Royal College of General Practitioners
Commentary – Improving Access to Psychological Therapies
Improving access to psychological therapies: the intention Rod Holland IAPT Clinical Advisor, London, UK
Rod Holland is a member of the national board for the IAPT Programme. LJPC asked him to explain where IAPT came from and what it aims to do.
From an idea into national policy The Improving Access to Psychological Therapies (IAPT) programme became a reality in November 2007, following the Secretary of State for Health’s announcement that £173 million would be made available from the comprehensive spending review to fund the first three years of the six year programme. This decision meant that work could begin to bring about a real increase in the provision of psychological therapies in England along the lines envisaged when Lord Richard Layard from the London School of Economics facilitated a seminar entitled ‘Mental Health: Britain’s Biggest Social Problem’ in the Prime Minister’s Strategy Unit in December 2004. At the 2004 seminar Lord Layard highlighted the benefits that could come from improving access to evidence-based psychological therapies. Fifteen percent of people experience treatable anxiety and depression at some point in their lives but less than 5% get treatment. Psychological therapies had been shown to be effective across a wide range of psychological problems, and people are increasingly requesting them from their general practitioners. As a social economist Lord Layard was conscious of both the cost that untreatable mental health problems place on the country in terms of incapacity benefits, and also the damaging effect on wellbeing – mental distress often prevents people from remaining in, or returning to, employment. In addition, there are damaging knock-on consequences for families, friends and the wider society. Layard’s arguments were so persuasive that expansion of psychological therapies appeared as a commitment in the 2005 Labour Party election manifesto.
The IAPT programme turns this political commitment into practical reality. IAPT was tasked with setting up a network of specialist treatment services and training therapists to deliver a variety of evidencebased psychological therapies.
What IAPT services will contribute IAPT seeks to tackle those mental health problems that from a psychiatrist’s point of view might be termed ‘mild to moderate’ mental health problems. But from the perspective of an individual the experience can be severe and disabling. Such people feel vulnerable so it is important that entry into IAPT is made as easy and available as possible. The early IAPT pilot sites show how to do this in a way that is emotionally acceptable and hassle-free. IAPT services offer ‘stepped care’, which means providing the appropriate level of help delivered by the right person at the right time. For many people, a ‘low intensity’ intervention is best – for example guided self-help, computerised cognitive behaviour therapy (CCBT) using programmes such as ‘Beating the Blues’ and ‘Living Life to the Full’. When symptoms are more severe or problems complex, a longer course of ‘high intensity’ therapy will be required as indicated in NICE Guidelines. IAPT mainly treats mild–moderate anxiety and depression, but also other conditions – panic and
Improving access to psychological therapies
obsessive compulsive disorders, social phobia, post traumatic stress and severe depression. Ongoing evaluation will help to establish what conditions are most appropriate to be treated by IAPT services. IAPT services will see many clients who were previously treated in primary care, some who were treated in secondary care, and many who would not have been treated at all. IAPT is therefore blurring the boundaries between primary care and secondary mental health care – a form of intermediate care. To be effective, IAPT services cannot be isolated but must work in partnerships with both primary and secondary care practitioners and also with those services provided by voluntary and independent organisations. If clients are to receive the right help at the right time then good communication and local agreements are essential between all of these agencies. Ongoing evaluation will examine ways that these are effective. IAPT will contribute to the reversal of inequalities by being particularly responsive to people from disadvantaged communities, ethnic minority groups, people over the age of 65, single parents, people with unexplained medical symptoms and other marginalised groups. Ongoing evaluation of the profile of clients seen will inform future strategy about addressing inequalities. IAPT is not just about delivering CBT although this is currently recognised as the psychological therapy with the clearest evidence base. It is about delivering and making accessible all evidence based therapies that are recognised in the NICE Guidelines. In 2009 both Interpersonal Psychotherapy (IPT) and couples counselling will be included alongside CBT. Ongoing evaluation of the clinical impact of the therapy will inform how these services should evolve.
The programme so far IAPT funding was approved in November 2007 and the programme started in October 2008. The first wave of 35 primary care trusts (PCT’s) across England have been selected and are now up and running and the training of the first group of 3600 new therapists has started. Learning from the IAPT pilot site in
51
Newham helped inform the development of the programme and in 2008 NHS London funded Ealing, Camden, and City & Hackney PCT’s to become full IAPT services, with smaller transition sites in Southwark and Haringey. These sites now train both high and low intensity therapists, in collaboration with the Institute of Psychiatry, Royal Holloway, University of London and University College London. In 2009 the number of IAPT sites in England will more than double. In London, an additional ten PCTs will develop an IAPT service and over 250 more trainees will be enrolled. The national target of 50% coverage of PCT’s in England within three years is likely to be achieved ahead of schedule with the likelihood of 60– 70% having an IAPT service by 2011.
The future The changes in the economic climate since IAPT was proposed make the need for the programme and full coverage of all PCT’s even more urgent than it was back in 2004 – anxiety and depression will inevitably increase. It represents a unique opportunity to make a real impact on the psychological wellbeing of the population and move psychological therapies from a service that few people could take advantage of to one that can be delivered when and where it is needed most. It also has the potential to provide a mechanism to achieve better partnerships for good mental health than have ever been achieved before, in which generalist and specialist practitioners are able to use their skills in the most appropriate ways.
ADDRESS FOR CORRESPONDENCE
Rod Holland Department of Clinical Psychology Lakeside Mental Health Unit West Middlesex Hospital Twickenham Road, Isleworth Middlesex TW6 8AF UK Email: [email protected]
# 2009 Royal College of General Practitioners
Commentary – Improving Access to Psychological Therapies
Improving access to psychological therapies: the intention Rod Holland IAPT Clinical Advisor, London, UK
Rod Holland is a member of the national board for the IAPT Programme. LJPC asked him to explain where IAPT came from and what it aims to do.
From an idea into national policy The Improving Access to Psychological Therapies (IAPT) programme became a reality in November 2007, following the Secretary of State for Health’s announcement that £173 million would be made available from the comprehensive spending review to fund the first three years of the six year programme. This decision meant that work could begin to bring about a real increase in the provision of psychological therapies in England along the lines envisaged when Lord Richard Layard from the London School of Economics facilitated a seminar entitled ‘Mental Health: Britain’s Biggest Social Problem’ in the Prime Minister’s Strategy Unit in December 2004. At the 2004 seminar Lord Layard highlighted the benefits that could come from improving access to evidence-based psychological therapies. Fifteen percent of people experience treatable anxiety and depression at some point in their lives but less than 5% get treatment. Psychological therapies had been shown to be effective across a wide range of psychological problems, and people are increasingly requesting them from their general practitioners. As a social economist Lord Layard was conscious of both the cost that untreatable mental health problems place on the country in terms of incapacity benefits, and also the damaging effect on wellbeing – mental distress often prevents people from remaining in, or returning to, employment. In addition, there are damaging knock-on consequences for families, friends and the wider society. Layard’s arguments were so persuasive that expansion of psychological therapies appeared as a commitment in the 2005 Labour Party election manifesto.
The IAPT programme turns this political commitment into practical reality. IAPT was tasked with setting up a network of specialist treatment services and training therapists to deliver a variety of evidencebased psychological therapies.
What IAPT services will contribute IAPT seeks to tackle those mental health problems that from a psychiatrist’s point of view might be termed ‘mild to moderate’ mental health problems. But from the perspective of an individual the experience can be severe and disabling. Such people feel vulnerable so it is important that entry into IAPT is made as easy and available as possible. The early IAPT pilot sites show how to do this in a way that is emotionally acceptable and hassle-free. IAPT services offer ‘stepped care’, which means providing the appropriate level of help delivered by the right person at the right time. For many people, a ‘low intensity’ intervention is best – for example guided self-help, computerised cognitive behaviour therapy (CCBT) using programmes such as ‘Beating the Blues’ and ‘Living Life to the Full’. When symptoms are more severe or problems complex, a longer course of ‘high intensity’ therapy will be required as indicated in NICE Guidelines. IAPT mainly treats mild–moderate anxiety and depression, but also other conditions – panic and
Improving access to psychological therapies
obsessive compulsive disorders, social phobia, post traumatic stress and severe depression. Ongoing evaluation will help to establish what conditions are most appropriate to be treated by IAPT services. IAPT services will see many clients who were previously treated in primary care, some who were treated in secondary care, and many who would not have been treated at all. IAPT is therefore blurring the boundaries between primary care and secondary mental health care – a form of intermediate care. To be effective, IAPT services cannot be isolated but must work in partnerships with both primary and secondary care practitioners and also with those services provided by voluntary and independent organisations. If clients are to receive the right help at the right time then good communication and local agreements are essential between all of these agencies. Ongoing evaluation will examine ways that these are effective. IAPT will contribute to the reversal of inequalities by being particularly responsive to people from disadvantaged communities, ethnic minority groups, people over the age of 65, single parents, people with unexplained medical symptoms and other marginalised groups. Ongoing evaluation of the profile of clients seen will inform future strategy about addressing inequalities. IAPT is not just about delivering CBT although this is currently recognised as the psychological therapy with the clearest evidence base. It is about delivering and making accessible all evidence based therapies that are recognised in the NICE Guidelines. In 2009 both Interpersonal Psychotherapy (IPT) and couples counselling will be included alongside CBT. Ongoing evaluation of the clinical impact of the therapy will inform how these services should evolve.
The programme so far IAPT funding was approved in November 2007 and the programme started in October 2008. The first wave of 35 primary care trusts (PCT’s) across England have been selected and are now up and running and the training of the first group of 3600 new therapists has started. Learning from the IAPT pilot site in
51
Newham helped inform the development of the programme and in 2008 NHS London funded Ealing, Camden, and City & Hackney PCT’s to become full IAPT services, with smaller transition sites in Southwark and Haringey. These sites now train both high and low intensity therapists, in collaboration with the Institute of Psychiatry, Royal Holloway, University of London and University College London. In 2009 the number of IAPT sites in England will more than double. In London, an additional ten PCTs will develop an IAPT service and over 250 more trainees will be enrolled. The national target of 50% coverage of PCT’s in England within three years is likely to be achieved ahead of schedule with the likelihood of 60– 70% having an IAPT service by 2011.
The future The changes in the economic climate since IAPT was proposed make the need for the programme and full coverage of all PCT’s even more urgent than it was back in 2004 – anxiety and depression will inevitably increase. It represents a unique opportunity to make a real impact on the psychological wellbeing of the population and move psychological therapies from a service that few people could take advantage of to one that can be delivered when and where it is needed most. It also has the potential to provide a mechanism to achieve better partnerships for good mental health than have ever been achieved before, in which generalist and specialist practitioners are able to use their skills in the most appropriate ways.
ADDRESS FOR CORRESPONDENCE
Rod Holland Department of Clinical Psychology Lakeside Mental Health Unit West Middlesex Hospital Twickenham Road, Isleworth Middlesex TW6 8AF UK Email: [email protected]
