1. Kevin Mullins National IAPT Director
Improving Access to Psychological Therapies
The First Million Patients
10th April 2014

2. Conflicts of Interest
None to Declare

4. The IAPT Argument (Depression Report 2006)
Much current service provision focuses on psychosis which deserves attention but affects 1% of population at any one time.
Many more people suffer from anxiety and depression (approx.15% at any one time. 6 million people).
Economic cost is huge (lost output £17 billion pa, of which £9 billion is a direct cost to the Exchequer).
Effective psychological treatments exist. NICE Guidance recommends CBT for depression and ALL anxiety disorders plus some other treatments for individual conditions (EMDR for PTSD, Interpersonal Psychotherapy, Couples therapy, Counselling & Brief Dynamic Therapy for some levels of depression).
Less than 5% of people with anxiety disorders or depression receive an evidence based psychological treatment. Patients show a 2:1 preference for psychological therapies versus medication
Increased provision would largely pay for itself 4

5. The Original Economic Case Layard, Clark, Knapp & Mayraz (2007) National Institute Economic Review, 202, 1-9.
Cost (per patient)
Benefits to Society
Extra output 1,100
Medical costs saved
Extra QALYs 3,300
Total ,700
Benefits to Exchequer
Benefits & taxes
Healthcare utilisation reductions
Total ,200

6. Which Psychological Treatments are recommended by NICE?
Problem
NICE Recommended Treatments
Anxiety Disorders (all six)
CBT only
Depression (moderate-severe)
CBT or IPT (with meds)
Depression (mild-moderate)
Low intensity CBT based interventions
CBT (including group)
Behavioural Activation
IPT
Behavioural Couples Therapy
If patient declines above, consider:
Counselling
Short-term psychodynamic treatment

7. Demonstration Sites:Newham & Doncaster.
Awarded £1.5- £2 million per annum to increase access to psychological treatments (includes special set-up)
Stepped care
* Least burden principle
* Psychological Well-Being Practitioners, HI intensity
therapists & employment advisers
Session by session outcome monitoring
Experiment with self-referral 7

8. Demonstration Sites: First Year Results (see Clark, Layard,Smithies, Richards et al. (2009) Behav. Res & Ther)
Excellent data completeness (99% in Doncaster, 88% Newham).
Large numbers treated (approx 3,500 in first year). Use of Low intensity important.
Outcomes broadly in line with NICE Guidance for those who engaged with treatment (52% recover). Employment benefits. Maintenance of gains.
When compared with GP referrals, self- referrals were as severe, tended to have had their anxiety disorder or depression for longer, and had BME rates that were more representative of the community. Ditto social phobia & PTSD.
Outcome does not differ by ethnic status or referral route
White 50%
Black 54%
Asian 67% 8

9. The National Programme
First 3 years ( ) funded in 2007 CSR (£300 million above baseline).
Train at least 6,000 new therapists and employ them in new clinical services for depression & anxiety disorders. Initial focus on CBT. Now being expanded to other NICE approved therapies
Services follow NICE Guidelines (including stepped care).
National Training Curricula (high and low intensity practitioners: PWPs)
Published set of competencies for all therapies (Roth, Pilling et al)
Success to be judged by clinical outcomes (50% recovery target, with many others showing some benefit)
Self-referral & Session by session outcomes measurement 9

11. Talking Therapies: four – year plan of action (2011-15) funded in 2011 (£400m)
Complete roll-out of services for adults
Improve access to psychological therapies for people with Psychosis, Bipolar Disorder, Personality Disorder
Talking Therapies
Initiate stand – alone programme for children and young people
Improve access for older people and BME communities
Develop models of care for:
Long Term Conditions
Medically Unexplained Symptoms

12. Resources Available Policy 2011/12 2012/13 2013/14 2014/15
Completing roll out 43 88
133
Children & Young People Pilots 8 20 14
MUS/LTC Pilots 2
Total 51
110
149
147

13. Start Point & Planning Assumptions

14. At End of Q2 2013/14 IAPT services established in 100% of health areas
Approx 5,000 new High & low intensity therapists trained
At December 2014 programme is on target
Over 2.2 million people seen in services
Over 75,000 moved off sick pay & benefits
46% recovery rate
Current access rate pa c700,000
Initiation of a major CAMHS transformation using IAPT quality markers 14

15. IAPT for Adults – Quality Standards

19. Public Transparency: A Revolution for English Mental Health Services
Originally
IAPT services submit to government quarterly data on number of people seen and average recovery rates for the service.
Public access (
Now
IAPT services required to submit 50 data items per patient covering demographics, diagnosis, type of treatment and pre & post treatment scores.

20. Key Performance Indicators
Pathway data ie referrals, waits, access, completers
Patient demographics (age, gender, sexual orientation, ethnicity, disabilities, etc)
ICD-10 provisional diagnoses, problem duration, medication, benefits,
Outcome measures at pre and post (PHQ, GAD, Anxiety Disorder Specific Measures, WSAS)
Post July 1st 2014
Measure of need, mental health cluster
Patient experience questionnaire (pre and post).
Type of treatment, number of sessions, step-up/down

21. Performance Management
NHS Operating Framework for 12/13
Access – full roll out by 2014/15 (BME & Older People)
Recovery – 50% in fully established services
Scope – SMI (inc PD) & LTCs
NHS Mandate 2013/15 & 2014/15
Access 15 % by 2015
Recovery Rate 50%
Prepare for full roll out of Children & Young People IAPT

22. Map showing PCT with IAPT Services & Projects
KEY
No IAPT Service
IAPT Service
IAPT Service + PBR
IAPT Service + LTC/MUS
IAPT Service + CYP
IAPT Service + SMI
IAPT Service + PBR + CYP
IAPT Service + PBR + SMI
IAPT Service + CYP + SMI
IAPT Service + CYP + LTC/MUS
IAPT Service + PBR + LTC/MUS + CYP
IAPT Service + LTC/MUS + CYP + SMI

23. National Training Summary Table
Total Commissions
Replacement
Commissions
Additional
Cumulative
Additional commissions
2012/13
226
4,995
2013/14 (filled)
973
206
767
5,762
2014/15 (Planned )
756
200
556
6,318

24. Access Performance to Q4 12/13

25. Recovery Performance to Q4 12/13

26. Performance to Q4 12/13

27. Performance to Q2 13/14

28. Challenges & Opportunities
Winning the economic argument for investment
Winning & maintaining political support
Programme design & consistent delivery of NICE compliant services
Quality Standard development, alignment and compliance
Training curricula – practitioners/supervisors
Data set development, implementation & reporting

29. What Next? Extending scope & transforming services for:
Children & Young People
People with Severe Mental Illness
People with Long Term Conditions
Increasing scale to reach 25% of those in need
Sustainability through development and system wide adoption of an outcomes based currency and tariff
International adoption
Norway - Demark
Sweden - Canada
Iceland

30. Kevin.mullins@nhs.net Tel +44207 972 5917 Mob +447789 876 546
Questions?
Tel
Mob