Psychological Therapies

Debate between James Morris and Gregory Campbell

Wednesday 16th October 2013 Westminster Hall

[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?