Psychological Therapies

Andrew Selous Excerpts

Wednesday 16th October 2013 Westminster Hall

[Andrew Selous (South West Bedfordshire) (Con)]

Like my colleagues, I congratulate my hon. Friend the Member for Halesowen and Rowley Regis (James Morris) on bringing this important debate before the House. We know from this morning’s radio bulletins that the discussion is topical and timely, and I am pleased to have the opportunity to contribute to it.

My focus will be on the need to broaden the scope of what is offered under IAPT, particularly in relation to couple relationships. I strongly believe that it is hugely in the interests of the NHS and the Department of Health to realise the significance of strong couple relationships to good health, which is essential to protecting the NHS budget. That point is really important—[Interruption].

[Sir Edward Leigh (in the Chair)]

Order. Officials should not talk to a Member of Parliament while the debate is continuing.

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[Andrew Selous]

As colleagues have already stated, data on the type of therapies available under IAPT show that couple therapy is available in less than a quarter of cases. The data came from the “National Audit of Psychological Therapies for Anxiety and Depression, National Report 2011”, so they are official. The figure for couple therapy is only 24.6%, while interpersonal therapy is available in under half, or 48.3%, of the settings in which provision is made. For psychodynamic and psychoanalytic therapy, the figure is under 40%, at 39.8%, whereas cognitive behavioural therapy is available in 94.9%—just under 95%—of cases.

Those figures demonstrate the significance of CBT, which for some people with mental health issues is absolutely the right treatment, but it is important to realise that CBT is clearly not the appropriate treatment for all those with mental health conditions. We should also remember that all those therapies are approved and recommended by NICE, and the evidence shows that all such treatments are effective for the right patients.

I am particularly concerned that the benefits of a relational approach to the treatment of depression are not being realised and that, in many cases, individual CBT counselling is given where it is not appropriate. I want to tell a true story of one young couple’s experience of interacting with the IAPT programme. Figures and sums of money give the broad picture—they are our stock in trade as Members of Parliament—but they are a bit high-level and do not capture the essence of mental health provision on the front line.

Let me tell the story of Polly and Mark—to protect their anonymity, those are not their real names—who experienced considerable challenges in having two children, with several miscarriages and a stillbirth. Polly became very low and left her successful career. The hon. Member for Feltham and Heston (Seema Malhotra) has already pointed out the cost to the economy when people have mental health issues. Polly’s husband, Mark, had a very difficult childhood, and he was badly affected by his parents’ violent and stormy relationship.

When Polly and Mark’s youngest child was two, Polly confessed that she had had an affair seven years earlier, which left her feeling guilt and shame long after it ended. On learning that, Mark was utterly devastated by the revelation and fell into a deep depression, with unmanageable rages during which he threatened to kill the other man. Polly developed severe headaches, so she went to her GP and was sent for tests. On finding nothing wrong, the GP recommended that Polly have individual counselling focusing on the stillbirth four years previously. After being unable to work and having three weeks of sleepless nights, Mark also visited his GP. Mark was referred to a psychiatrist, who diagnosed him as suffering from acute depression and prescribed him antidepressants.

The couple were acutely conscious that their relationship was about to break down. Not having been offered any form of couple therapy by IAPT, they approached a voluntary sector service, and for six months, they went to weekly couple therapy. At the same time, they were offered cognitive behavioural therapy through IAPT. They believed that the problem was their relationship, but health professionals clearly thought that the depression needed treatment. In couple therapy, Polly was able to share her anxieties about her parents’ divorce and about how she did not want her children to suffer as she had. As the couple therapy progressed, Mark and Polly became more open with each other and began to understand how their relationship problems were a product of both recent and past difficulties.

An important point is that that couple therapy—it was not provided through IAPT; Mark and Polly had to go to the voluntary sector for it, because IAPT had offered them CBT that they did not need—was voluntary help that lasted for six months. My concern is that IAPT provision, whether of CBT or other measures, is often given for only a short period, which is not always appropriate or likely to be successful in such cases.

That true story illustrates powerfully why we need to look again at the IAPT programme, excellent though much of it is, and to take a relational approach to many of the issues where appropriate. I hope that it has been helpful to Members to put that real-life case study on the record.

Academic studies show why what I have said is important and matters. Evidence reveals links between relationship quality, depression and re-employability. For example, a meta-analysis conducted by McKee in 2005 concluded that lack of social support by partners in a relationship has negative impacts on the physical and psychological health of the unemployed person and is especially associated with more frequent development of psychosomatic symptoms, stress and depression.

The all-party parliamentary group on strengthening couple relationships, which I chair, and the newly formed Relationships Alliance published only last week a report that said that relationships were the missing link in public health. That report showed that relationship quality is often a key determinant of health and well-being, and that it has strong links with the ability to deal well with cardiovascular disease, obesity, alcohol misuse and mental health issues. All those issues link up, and strengthening the health of couple relationships is often right at the heart of them.

If we look at what has happened since the IAPT programme began—I understand that it receives funding of about £400 million a year—we can see that the investment has been very much towards cognitive behavioural therapy, with interpersonal psychotherapy, counselling for depression, brief dynamic therapy and couple therapy the poor relations in the area.

In a written parliamentary question, answered on 8 January 2013 and printed in volume 556, column 258, of the Official Report, we learn that of 1,225 sessions in 2012-13 only 99 were for couple therapy, whereas 459 were for CBT low-intensity therapy and 322 for CBT high-intensity therapy. If we look at the period from 2008-09 all the way through to the projections for 2013-14, we will see that of nearly 8,000 different sessions—7,958 to be precise—only 297 were for couple therapy. The story that I have just given of Polly and Mark shows that such sessions are needed up and down are country and can indeed make a significant difference.

[Seema Malhotra]

The hon. Gentleman is making a powerful speech on the importance of having a relational base to services. In my own constituency of Feltham and Heston, I visited a service that was started a year ago by the National Society for the Prevention of Cruelty to Children. It works with children who have parents with drug and alcohol problems. I am struck by what the hon. Gentleman is saying. Is he able to talk a bit more about, or perhaps give a comment on, how having such a focus in a service can help children who are the victim of the illness of their parents?

[Andrew Selous]

I am grateful to the hon. Lady for her comments. May I extend to her a very warm invitation to come to the next meeting of the all-party parliamentary group on 6 November when we will consider such issues further? She is absolutely right that these issues are intergenerational. If she was following the example of Mark and Polly, she would have learned that it was their own parents’ stormy relationships that had affected them. Of course their children were suffering deeply from the problems that they were having in their own relationship or marriage. Such issues are deeply related, and she is completely right to say that the children suffer hugely when there are relationship problems between the parents. It is vital that we get this matter right for the children, and I would welcome her support on a cross-party basis on these important issues; they are just too important to be bipartisan about. I would love to have cross-party agreement on the importance of relational issues in public health, because I feel so passionately about the matter.

Another concern is the geographic differences in the ability to get couple therapy through IAPT at the moment. Ruth Sutherland, the chief executive officer of Relate, told me only yesterday that the programme is very geographically bound. Provision is better in the north of England—I note that there are not many colleagues from the north of England in the Chamber today—than in the south, so there is an inequality of access geographically, as well as there being fewer of these sessions available across the UK as a whole.

Let me make one further point to the Minister about why one part of IAPT provision is an incredibly serious matter for the whole NHS. As a clinician, he will know about the huge importance of long-term conditions, which are faced by so many of our constituents. He will be well aware of the significant demands that they will make on the NHS in years to come. I am talking about strokes and dementia and all sorts of other long-term ailments that many of our constituents will live with for a very long time.

I heard a moving story a couple of weeks ago from a gentleman who was visiting his elderly parents in Manchester. He said that between them as a couple they could function. Between the two of them, they had one pair of eyes, ears and legs that worked. They were both sick in different ways. They could cope and look after each other, but what would have happened if they had split in younger years? They might have been like Polly and Mark and had difficulties and not been able to receive the type of help that I have outlined. Let us say that they did sadly split up, like so many couples do today. They would be in two different flats in different parts of Manchester needing far more help from their GP and far more adult care, and that would fall on the clinicians for whom the Minister is responsible and on adult social services. Yes, it would have an impact on their families, and we would all be paying more through our taxes and there would greater burdens on business as well from having to look after that couple in two different settings. The importance of strong couple relationships in older age, in later life, is critical not least to deal with the increase in long-term conditions, which are becoming more and more prevalent and which many of our constituents will be coping with for many years to come. That is my final pitch to the Minister.

We are talking specifically about mental health and IAPT. I understand that a lot of good work is being done under IAPT and that it is an excellent programme, but I ask the Minister, when he goes back to his Department and talks to his colleagues and the Secretary of State, to take back with him the absolute centrality of strong relational health up and down are country as far as public health, the burdens on the NHS and his Department are concerned.

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[Dr Poulter]

The hon. Gentleman is right. We UK Health Ministers work collaboratively on many issues. However, on veterans, we have to recognise that, although we have UK-wide armed forces, health is a devolved responsibility. We need to share different initiatives better between the devolved Administrations. Some remote areas of Wales, in particular, could learn from best practice in the NHS about how we are using, to good effect, specialist mental health teams for veterans. I should be happy to share that and meet my counterpart in Wales to talk that through in greater detail.

I will focus in particular on the important contribution of my hon. Friend the Member for Halesowen and Rowley Regis. He addressed a number of issues that are central to the provision of good mental health care, and he threw down some challenges on how we could make things better. In particular, he praised the scale of the Government’s ambition to have genuine parity between physical and mental health, which has to be right; it is at the centre of everything that we are looking towards in the good commissioning of services locally.

I reassure the hon. Member for Liverpool, Wavertree that, with the addition of IAPT, there has been a substantial increase in the NHS’s total investment in psychological therapies. As she will be aware, however, it is down to local commissioners to prioritise their resources to meet local need, based on the local population that they serve. In the past, the challenge has been that good commissioning has too often been seen purely through the framework of physical health. Through the NHS Commissioning Board’s mandate, we are now ensuring that there is parity between mental and physical health. That journey is already well under way to ensure that good commissioning is no longer just about commissioning for acute services, such as stroke and heart attack, but about looking at the whole patient and considering the importance of upstream interventions, which are central to IAPT’s role in looking after patients.

My hon. Friend the Member for Halesowen and Rowley Regis also talked about the need to consider CBT and its evidence base. As he knows, it is not the role of Ministers to question the integrity of NICE, but NICE keeps its criteria under review, and there is a very strong evidence base to support CBT. The evidence base for IAPT is continually being developed and adapted, and a number of pilots are already in place to consider the potential to extend the scope of therapies, including to older people. I hope that that is reassuring. NICE will be listening to this debate, and it continues to evaluate the evidence. With mental health, there has always been controversy on how evidence is collated, because mental health is different from physical health, and NICE will keep that under review when it adapts and introduces future guidelines.

The debate has been called because all hon. Members in the room believe that, for too long, there has been too much focus on crisis management and acute response when patients with mental health conditions become very unwell. We would all like to see much more focus on upstream intervention, which is what IAPT is all about. We need to move the focus away from SSRIs—selective serotonin reuptake inhibitors—and drug-based therapy towards upstream, proactive intervention for what is sometimes a very vulnerable patient group.

The benefits of early intervention have been outlined by many hon. Members. There are clear health benefits, but there are also economic benefits, benefits to the family and benefits from getting people back to work, education and training, and from supporting people to have more productive and happier lives. That is why we will continue to ensure parity of esteem in commissioning for physical and mental health, and it is why we will continue to support upstream interventions in the early years—I will address early-years IAPT later. We will also ensure that we continually drive good commissioning to encompass mental health as well as physical health. That holistic approach to health care, by prioritising mental health, is good for people’s health care, good for families and good for the economy. That is why we will ensure that it remains a priority.

As hon. Members will be aware, the mandate set by the Government for NHS England last year establishes a holistic approach as a priority for the whole NHS for the first time. Improving access to psychological therapies is fundamental to the success of improving mental health. The mandate makes it clear that everyone who needs them should have timely access to evidence-based services. That is particularly important for mental health. By the end of March 2015, IAPT services will be available to at least 15% of those who could benefit—an estimated 900,000 people a year. We are also increasing the availability of services to cover children and young people with long-term physical health problems and those with severe mental illness to ensure that everyone can access therapies. There is an emphasis on those who are out of work, the black and minority ethnic populations and older people and their carers.

IAPT is being made available throughout the country. The programme was started by the previous Government in 2008, and we now have an IAPT service in every clinical commissioning group. There are more than 4,000 trained practitioners, and more than 1 million people are entering and completing treatment. Recovery rates have consistently been in excess of 45%, and they are much greater in many areas. The programme already has a clear track record of evidence-based success, and it is helping to reach some of the most disadvantaged and marginalised people in our society, which we would all say is a good thing.

[Andrew Selous]

My hon. Friend is absolutely right about the evidence. Although this is a little premature, he might be aware that the Department for Education has just commissioned evidence on the efficacy and cost-benefits of couple counselling. I have sometimes heard it said that there is no evidence for anything other than CBT, so will he say a little about the range of provision available under IAPT, specifically in relation to couple counselling?

[Dr Poulter]

My hon. Friend is absolutely right. I will address children’s IAPT in a moment, because the hon. Member for Upper Bann (David Simpson) made an important point on that.

My hon. Friend is right that, through not only IAPT but other programmes that consider health care more holistically—particularly the family nurse programme, which is aimed at vulnerable teenage mums—upstream intervention supporting those vulnerable groups helps to keep couples together and helps reduce rates of domestic violence. The programmes also support a stronger bond between mum and baby, so the child does better at school and mum and dad are supported to get back into education, training and work. So it is a win-win situation for the economy, and it helps vulnerable younger parents to have a better start in their own lives and provides a better start in life for their children. That is not exclusive to family nurses; we are also considering how the approach may be developed with IAPT, so that we can have a more joined-up approach both to children’s health generally and to families.

Earlier this year, I launched a system-wide pledge across education, local authorities, the voluntary sector and the NHS to do everything we can to give each and every child the best start in life. Part of the pledge is to do exactly what my hon. Friend outlines, which is to focus on getting early and upstream interventions right to support children in having the best start in life. We are also seeing the benefits of supporting families and reducing rates of domestic violence. I hope that is reassuring, and we will continue to develop and press those policies.

Briefly, our children’s IAPT programme is no less ambitious in its aim to transform services. In 2011, we announced funding for children and young people’s IAPT of £8 million a year for four years, and in 2012, we agreed significant additional investment of up to £22 million over the next three years, which is a total of £54 million up to 2015. That additional funding will be used to extend the range of evidence-based therapies to include systematic family therapies and interpersonal psychotherapy, to extend the range, reach and number of collaborators within the project and to develop interactive e-learning programmes to extend the skills and knowledge of professionals such as teachers, social workers and counsellors. Again, there is a multi-agency approach to improving the support and care available to children, because this is not just about the NHS, but about local authorities and education working together to get it right for young people. Behind those facts and figures are the people whose lives and services have been transformed by IAPT.

To conclude, it might be worth outlining a recent conversation that I had with a GP. When talking about IAPTs in West Sussex, he said, “I hear from GP colleagues that this is the single most positive change to their medical practice in the last 20 years, and I echo this. Our local service reaches out to the community, and it is always looking at ways to improve. It is continually developing new evidence-based interventions for people with anxiety and depression, delivered one-on-one and in groups in a flexible way that means patients have real choice. They have filled a huge gap in need and are a force for good.” That is absolutely right, and it is why we will continue to develop parity between mental and physical health and continue to expand the IAPT programme.