Psychological Therapies

David Simpson Excerpts

Wednesday 16th October 2013 Westminster Hall

[David Simpson (Upper Bann) (DUP)]

I congratulate the hon. Gentleman on securing this very important debate. An alarming thing that I have discovered recently is that 80,000 young people across the United Kingdom suffer from severe depression, and 8,000 of those are under the age of 10. It is alarming, and it is running out of control. As the hon. Gentleman has said, personal counselling is an avenue that we can go down. An organisation in my area called Yellow Ribbon does exactly that, and it has had some fantastic results.

[James Morris]

The hon. Gentleman makes a good point; there are major issues with children and young people’s mental health, and I will come on to that later in my speech.

I want to talk today about improving access to psychological therapies. That is a big area on which I have been focused on in my role as chairman of the all-party parliamentary group on mental health. The improving access to psychological therapies programme was established under the previous Government in 2006, following work by Lord Layard, who looked at the economic benefits of a widespread programme of access to psychological therapies across the country. IAPT was initially launched with small pilot areas and then was formally launched in 2008. I do not think anyone here would deny that the IAPT service has made progress. We have seen 1 million people entering treatment and 680,000 people completing treatment, and we have seen recovery rates of about 45%, with 65% significantly improved. The IAPT programme has led to 45,000 coming off sick pay and benefits, and we have seen 4,000 new practitioners trained in the national health service.

The programme was started by the previous Government, and in February 2011, the current Government published their “No health without mental health” strategy, which committed them to investing more than £400 million over four years into the IAPT programme. At the same time as the publication of that strategy, the Department of Health also published its “Talking therapies: A four-year plan of action”, which had the objective that by March 2015, 15% of the adult population would have access to evidence-based psychological therapies that are capable of delivering rates of recovery of 50% or more. Therefore, some progress has been made, but I want to raise serious questions today about how we should take the IAPT programme forward, about the scale of our ambition, and about the extent to which real choice is embedded in the system. I believe that those questions need to be addressed urgently.

The Department of Health, in its assessment of IAPT—its very comprehensive report was published in November 2012—was clear about challenges that the IAPT programme faced in the future. In particular, its report talked about the challenge of waiting times, stating that one of the challenges is

“building adequate service provision (including number of services, and size and efficiency of workforce) to ensure access for all who need treatment within 28 days of first contact.”

The report discusses the challenge of:

“Unmet need—addressing issues concerning equitable access to services where access is lower than expected among some population groups.”

It also refers to the challenge of “Patient choice”, which goes to the heart of the questions that I am raising today, and

“increasing information on treatment options and ensuring that treatment plans are agreed by both patient and therapist.”

Another challenge is the:

“Funding distribution process—ensuring that appropriate investments continue to be made in local IAPT services, to continue to expand capacity and assure quality in line with the overall financial expectations set out in the Spending Review.”

The Department of Health is clear, therefore, about the challenges faced by the further roll-out of the IAPT programme. In order to meet the challenges that come out of the Department’s assessment, we need radical thinking. We need to build on the strength of the existing IAPT programme, but we also need to address some of its fundamental weaknesses, which I believe are holding the programme back.

A central issue that we need to have an honest debate about is the fact that the IAPT programme is still dominated by the use of one therapy—cognitive behavioural therapy, or CBT. The National Institute for Health and Care Excellence guidelines that were drawn up in 2005 made the recommendation that CBT should be the default treatment option for the NHS, because it had the most random-controlled-trial supporting evidence for its effectiveness. In 2010, the guidelines were modified slightly to allow five other therapies into the NICE recommended mix. The reality, however, is that IAPT is still dominated by CBT. Again, I am not arguing that, in many circumstances, for patients with particular forms of anxiety and depression, CBT is not an appropriate form of treatment. However, it is a short-term, highly manualised approach to mental health treatment.

There is an interesting quote from NICE’s recommendations on psychological therapies:

“In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness.”

That is a wonderful little quote from NICE.

One of the consequences of our approach to research into the efficacy of particular forms of mental health treatment, and of NICE’s approach to the formulation of its guidelines, is that long-term therapies such as psychotherapy and psychoanalysis, to name just two, which require long-term commitment from the patient and from the analyst, have effectively been locked out of IAPT. In Britain, we have a mature and highly professionalised cohort of therapists in psychotherapy and psychoanalysis. They have, over the past five years, found themselves unable to provide the sort of capacity that we need in IAPT. One of the consequences of that, and of the dominance of CBT, with a focus on training up therapists to concentrate on CBT, is that we have a monolithic model.

Within IAPT, we have access, but no effective choice for the patient—choice that is focused on the individual needs of the patients and on an assessment of the patient’s particular requirements. We have a professional cohort of highly trained therapists in long-term therapies who are unable to assist the NHS in extending capacity for the provision of psychological therapies and who are unable to become part of the conversation to address the programme challenges identified by the Department of Health’s assessment of the three-year IAPT programme in 2012.

We need to recognise those weaknesses in the existing IAPT programme, because there are still 50% of people who have been through the programme who have not responded well to CBT. Some 85% of people who are currently suffering from severe mental anguish cannot gain access to any appropriate psychological therapy on the NHS. We urgently need a review of the existing NICE guidelines, and I know that Professor David Haslam, the chair of NICE, has recognised the issue and has agreed to initiate a review.

We also need to look again at how we formulate evidence on the efficacy of mental health treatment. For certain long-term therapies, it might not be appropriate for research to be totally focused on randomised control trials, which are also costly to undertake. We therefore need to look at new types of evidence base. We also need to think about developing a new commissioning model for psychological services to create real choice. I will come on to talk about how that might work.

We also need to consider other groups who may benefit from greater choice and access to psychological therapies. The hon. Member for Upper Bann (David Simpson) talked about children and young people. He is right to be concerned about them; it is a major issue that we face in Britain today. Some 850,000 children between the ages of five and 16 are known to have mental health problems. There is a children and young people’s IAPT, which provides a broad range of interventions —parenting therapy, interpersonal psychotherapy and family therapy.

I think we all know and agree that early intervention for children and young people is crucial to prevent problems from becoming more serious. Lots of evidence shows that early intervention at the onset of psychosis in children and young people and suitable psychological therapy treatment can prevent that from blowing up into something much more serious later on. Perhaps we can learn some lessons from the children and young people’s IAPT for adult services, while recognising that the children and young people’s IAPT needs to be developed further.

Also, we must not exclude or not think about the needs of people aged over 65. As we all know, we have an ageing population, meaning that mental health in older people is an increasing problem. The Department’s “Talking Therapies” action plan committed the Department to address the underrepresentation of older people using IAPT. A quarter of people over the age of 65 have symptoms of depression that require intervention, but only one in six will consult their general practitioner. Therefore, IAPT needs to be tailored to meet the needs of older people. Those needs are not just one, single need; the needs of a 65-year-old may be different from those of a 90-year-old.

--- Later in debate ---

[Jim Shannon]

I thank my hon. Friend for raising that matter. That is exactly the problem; if I wanted to sum it up in one phrase, that is the phrase I would use. There was a taboo around mental ill health in the past, but hopefully we can discuss it now. I hate the word “mental”, because it almost puts the thought in one’s mind of someone to be kept at bay. We must be able to find another word in the English language that is more sympathetic. I am not sure what it would be, but we should give the matter consideration.

Psychological therapies are defined as an interpersonal process designed to bring about modification of feelings, cognitions, attitudes and behaviour—all issues the hon. Member for Halesowen and Rowley Regis mentioned—that have proved troublesome to the person seeking help from a trained professional. That is what we want to achieve.

The psychological therapies in the NHS 2013 event marked the halfway point of the coalition Government’s mental health strategy. Psychological therapies generally fall into three categories: behavioural therapies, which focus on cognitions and behaviours; psychoanalytical and psychodynamic therapies, which focus on the unconscious relationship patterns that evolved from childhood, which are important; and humanistic therapies, which focus on self-development in the here and now. We need to focus on those three categories.

I presume that most Members catch up on the news on BBC or Sky before they come here. A story today covered the role of carers and what they do for elderly people, but it also mentioned their role for those with mental health issues and focused in particular on the time that carers have to deliver care to people in those two categories. It underlined where we are in the debate about those who suffer from psychological imbalance and emotional issues.

The improving access to psychological therapies programme was built on evidence, produced in 2004 by the then National Institute for Health and Clinical Excellence, on treating people with depression and anxiety disorders. It was created to offer patients a realistic and routine first-line treatment, combined, where appropriate, with medication, which traditionally had been the only treatment available.

Things have changed. The Minister, whom I respect greatly, will outline the issues when he responds. The IAPT programme was dedicated to spending more than £700 million on psychological therapies between 2008 and 2014. It was first targeted at people of working age, but in 2010 was opened to adults of all ages. There has been success—it would be wrong to say that there has not.

In the first three years, 900,000 people were treated for depression and anxiety; 450,000 patients are in recovery, with another 200,000 moving towards recovery; 25,000 fewer people with mental health problems are on benefits; and the average waiting time has reduced from 18 months to a few weeks. In terms of what has been done so far, that is good news, but it is fair to say that there is a lot more to do. There has been a significant increase in the number of people with such issues, and all statistics indicate that that number will continue to grow.

People require psychological therapy for many reasons. Members have spoken about the things that lead to the position we are in today and why society and Government must respond. Reasons for therapy can be to do with home life and bereavement. On many occasions in my constituency office, we deal with bereavement and how it affects not only the partner, but the young people in the house. The hon. Member for Halesowen and Rowley Regis referred to that in his introduction. I regularly see it in my office—the frailty of life, the suddenness of death and how that affects people.

Unemployment, when young people who cannot get the jobs they need or the discipline that a job brings, and trouble in the workplace are other reasons for therapy. Another reason is childhood trauma, as we can see from the sexual abuse cases of the past few years. Many people were not aware of such trauma, but it existed. Social deprivation is another one, and all those issues contribute to where we are.

[David Simpson]

My hon. Friend mentioned young people again. Surely our schools, whether primary or secondary, need to focus on our teachers being trained to identify when a child has difficulties—the hon. Member for Halesowen and Rowley Regis (James Morris) mentioned early intervention—so that treatment can be introduced at an early stage, which could solve the problem for a lifetime.

[Jim Shannon]

As my hon. Friend and colleague mentioned, education is one of the areas in which Government can play a role, as can, I would say, Departments responsible for health, social services and welfare. They all need to come together.

Among many other factors, one comes to mind to do with young carers who look after their mum, dad, brothers or sisters. In my constituency, there are about 230 young carers, which is a massive number. They are making a contribution to society, but they are also the main carers for their adults or siblings. Again, that is a real issue.

In Northern Ireland, unemployment, too, causes problems because, among the regions of the United Kingdom, it has the highest percentage of working-age population not in paid employment—the figure is 30% higher than the UK average, which is 19% of individuals receiving a form of out-of-work benefit. The highest rates are recorded in Londonderry with 29%, Strabane with 29% and Belfast with 26%. Some 9% of the working-age population receive disability living allowance, including the 3% who receive DLA for mental health reasons. That proportion has risen by 25% since 1998, and is more than the UK average, while 70% of those registered with a disability are not in paid work.

Incidentally, am I the only elected representative to have had an increase in referrals for those who have served in the forces suffering from post-traumatic stress disorder? I know the answer: no, I am not. In all my years as an elected representative, I cannot recall having so many referrals of soldiers, male and female, for emotional, mental-health trauma suffered as a result of their service.

The Prince’s Trust, which many of us have knowledge of and great faith in, has found that one in four young people at work are down or depressed “always” or “often”—for people of that age to be downhearted or depressed is incredible. Unfortunately, that leads to an increase in the suicide rate among young people. In parts of our Province, suicide is at frightening levels. A few years ago in my constituency, there was a spate of suicides by young people, which was saddening for the people of our area, because we knew most of them—young people who did not feel that there was much for them in the future. We must address that issue.

The figure for young people who are down or depressed always or often, but are unemployed, is 50%. That is a massive figure. Clearly, a large section of people are at risk and, in my opinion, early intervention can and will make a difference. However, to establish it, there must be funding. My hon. Friend the Member for Upper Bann (David Simpson) referred to those in education diagnosing cases early, and that is one thing we can do. Our own Health Minister in the Northern Ireland Assembly, Edwin Poots, has taken steps to address the issue, but a UK-wide strategy would be useful and must be considered. I am keen to hear what the Minister will say.

Improving access to psychological therapies in all areas such as health and employment for individuals, families and carers in Northern Ireland could relieve anxiety, depression and distress. The long-term benefits would be more than worth any initial cost. The funding has to be in order, but it has to be there to discharge effectively what has to be done.

In addition, improving mental and social well-being can help to prevent antisocial behaviour and family breakdown for children and young people—again, in my constituency, we regularly witness the effect on people of family breakdowns. It also might make a positive input into the rehabilitation of offenders and assist in the maintenance of independence, reducing reliance on residential and hospital care. The benefits are numerous and clear.

Due to the years of suffering through the troubles, many people in Northern Ireland have poor physical, emotional, behavioural and/or mental health conditions. Dr Nichola Rooney, chair of the division of clinical psychology in Northern Ireland, said that there is

“historical underinvestment in psychological therapy services for people suffering from mental health difficulties in Northern Ireland”.

I am sure that is replicated UK-wide.

Clearly, we must continue to invest and see the rewards of such therapy, not simply as a method of cutting the costs of help in the future, but because it changes the quality of people’s lives and—a knock-on effect— the lives of the people around them. Everyone benefits.