Psychological Therapies

James Morris Excerpts

Wednesday 16th October 2013 Westminster Hall

[James Morris (Halesowen and Rowley Regis) (Con)]

It is a pleasure to open this very important debate under your chairmanship, Sir Edward. First, I want to talk about why this debate is important. Mental illness is one of the biggest health challenges that we face over the next 20 or 30 years. The NHS spends approximately £14 billion on support for people with mental health conditions, which amounts to about 13% of total health spending. However, mental ill health accounts for about 28% of morbidity and 23% of all GP appointments, and recent estimates show that the overall economic cost of mental illness in Britain is about £105 billion a year.

Those are the raw statistics, but behind them is a story of broken lives, isolation and mental suffering. Every week in my constituency, I see people suffering from a range of difficult mental health conditions as a result of personal circumstances, family breakdown and all kinds of different issues. I am sure that other hon. Members here today have had similar experiences in their constituencies. As a compassionate society, we have a duty to address the growing crisis of mental health in Britain, not only by seeking to control its symptoms, but by tackling its underlying causes.

Our approach to mental health has been dominated for too long by what I characterise as a medicalised model. A psychiatric approach has been dominant. I am not arguing that psychiatry does not have a role to play in mental health, but it has been a dominant model for the way in which we approach mental health care in Britain, and the national health service is very focused on drug-based solutions to mental health problems. The number of prescriptions for drugs to try to solve mental health problems has gone up exponentially over the past decade, and as a result, I believe that our approach to mental health in the national health service is very much focused on control, rather than on tackling the profound underlying causes of the growth of mental health problems in Britain.

That is why I want to discuss talking therapies today. It seems to me that talking therapies are a human and compassionate response to mental suffering, as our constituents, our fellow citizens, and we all come to terms with the pressures of modern life, the increase in family breakdown, and the sheer stresses of dealing with information overload and the complexity of living in the modern world. This issue is not confined to any one part of the population; it crosses the whole age range, from children and young people through to older people.

[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.

[Mr Gregory Campbell (East Londonderry) (DUP)]

I congratulate the hon. Gentleman on securing the debate. Earlier, he alluded, as my hon. Friend the Member for Upper Bann (David Simpson), did, to the problems in the younger age group, and now he is talking about the older age group. Given the significant increase of referrals in the past couple of years, does he agree that one of the overarching principles is that we will need significant additional resources to deal with the problem right across the age groups, from the young to the old?

--- Later in debate ---

[James Morris]

The hon. Gentleman makes an important point. The fundamental nature of my argument is that the current system, while it has made some progress, is not utilising the capacity that we should be able to develop in order to cope with the increasing problems that we face. IAPT needs to be tailored to older people and to be more flexible to meet their needs.

As I said, IAPT has made some progress, but we need to go further. Improving access is one thing; guaranteeing it is another. The NHS constitution provides a right to treatments recommended by NICE. The handbook to the constitution explains that that relates to any treatment that is

“recommended by a NICE technology appraisal.”

I am sorry to get a bit technical here, but I think the point is an important one. Technologies appraised by NICE include devices, medicines, diagnostic methodology, surgical procedures, health promotion activities and other therapeutic technologies. Regarding technologies, computerised CBT for depression and anxiety is the only NICE-approved psychological therapy, which, on the basis of the constitution, patients should have a right to. Psychological therapies have been excluded from the rights embedded in the NHS constitution, and we need to address that gap.

Also, there is no 28-week or any other waiting time target for psychological therapies. If I have a serious physical illness, for example cancer, I will be seen and treated within a particular time frame, and I will know my pathway of care, if that is the right way of describing it. However, if I have a mental illness, there is neither a guarantee nor a waiting time target.

[Dame Angela Watkinson (Hornchurch and Upminster) (Con)]

Does my hon. Friend agree that that is similar to what happens during the perinatal period? If a woman has a premature baby, thousands of pounds—if not hundreds of thousands—will be spent on neonatal intensive care; whereas if she has a full-term baby, but has a psychotic episode and requires in-patient mental health care, it is a complete postcode lottery as to whether she receives any help at all?

[James Morris]

I thank my hon. Friend for that intervention. She has done a tremendous amount of work in that area. I totally agree with her point; we need to shift our emphasis towards much more early intervention and ensure that the issue she identifies is addressed.

[Dr William McCrea (South Antrim) (DUP)]

The burden of the hon. Gentleman’s address today concerns the therapies necessary to deal with mental health difficulties, but surely, as my hon. Friend the Member for Upper Bann (David Simpson) identified a few moments ago, the problem for the under-10s age group is that more research is needed into how a person under 10 is taken down the dark path of mental illness. We must find out what the problem is, as well as identify some of the treatment.

[James Morris]

The hon. Gentleman makes a good point. The chief medical officer is producing recommendations about children and young people’s mental health care, which will specifically look at evidence on why the prevalence of such difficulties is increasing. She is becoming concerned about the growing problem.

A consequence of no guaranteed or set waiting time is that thousands of people are awaiting referral while suffering severe anguish. A constituent of mine who is suffering from a relatively severe mental health problem has received a referral, but is still waiting for treatment. That wait has been going on for a long time and he is in a state of severe anxiety and anguish. That is the direct human consequence of the situation. We need to move towards a waiting time target. I know people are wary of talking about targets, but such targets speak to a parity issue in the health service. If we have waiting time targets for severe physical illness, it is surely right that we move towards waiting time targets for access to appropriate psychological therapies. Appropriate access builds in choice, meets the needs of individual patients and moves us away from the monolithic approach I described earlier.

When responding to the debate, I ask the Minister to consider the following points. We urgently need further research into the efficacy of long-term psychological treatments. We need more holistic research combined with a more flexible NICE regime; as I said, Professor Haslam recently acknowledged that work is needed on the way that NICE approaches recommendations in that area. We need to give serious thought to a new commissioning model assisted by some of the reforms that have been brought into the NHS, such as commissioning groups, and building on the any qualified provider model, which brings choice and capacity into the NHS by allowing the highly professional cohort operating in the private sector to provide therapy on the NHS through IAPT.

Would the Minister seriously consider making or at least working towards a commitment to a 28-week waiting time target for access to psychological therapies? Too many people are in a state of anxiety about when they will get treatment and what that treatment will be. We need urgent action, as other hon. Members have said, to ensure that the IAPT programme is further developed for younger people and children and we need to commit to further research into what is causing the disturbing trend in mental illness among our young people. We also need urgent action to ensure that older people are not locked out of the IAPT programme. The debate is about more than the right policies; it is important because we must address the anguish and suffering of our fellow citizens whose voices desperately need to be heard and whose stories are often the key to their cure.

[Several hon. Members]

rose—