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Thursday 27th October 2016

Break state monopoly over mental health counselling, urges major new report

25th May 2012

The NHS is failing to offer the mentally ill a full choice of psychological counselling and therapies, according to a major new report published by the Centre for Social Justice.


The report, ‘Commissioning Effective Talking Therapies,’ is highly critical of the NHS’s talking therapy service, and urges the NHS to slash its red tape and use therapists from the private and voluntary sector to allow people more choice, improved services and equal access.

At present, many therapies offered by specialists in the private and voluntary sector are not yet recommended by the National Institute for Health and Clinical Excellence (NICE), as it requires the same level of supporting evidence as treatments for chemotherapy or open heart surgery.

The report finds that the existing monoculture approach which favours the disproportionate use of cognitive behavioural therapy (CBT) is failing 84-87% of patients, while invalidating the broad range of other successful therapies available, and wasting millions of taxpayer’s money in the process.

The scale of mental illness is startling, with one in four adults experiencing mental illness at some point during their lifetime, and one in six experiencing symptoms at any one time – making mental illness the largest single cause of disability in our society.

The cost to the economy is estimated at £105 billion annually, with a loss of around £13 billion in earnings sustained by people of working age.

Yet the report finds that the NHS continues to choke the recovery of its patients by sticking to the stringent guidance and limited number of NICE approved therapies, which specify very narrow activities, rather than rewarding successful outcomes.

Currently 15% of NHS expenditure is spent on treatment for mental illness, but the report highlights how only a narrow range of therapies are made available by its main psychological therapy service IAPT (Improving Access to Psychological Therapies).

The Government has committed to spend a further £400 million over four years to 2014/15 on counselling but this is focused predominantly on CBT, and the seven other therapies approved by NICE guidelines, leaving no additional funds to spend on additional therapies so that they can undergo the research tests necessary to secure approval.

The success rate for current therapies is just 13-16%  of all clients referred to IAPT, at a time when there are at least 45 other types of therapy delivered by smaller NHS units, all of which are readily available on a national scale in the private sector.

As a result many people are denied a wider range of effective therapies through the NHS’s main delivery channel IAPT. If they request an alternative therapy, they usually have no other option than to try what is on offer. When this fails, there is no second option on the NHS.

Psychotherapists and counsellors who do not practice CBT, or the other therapies approved for delivery in rarer circumstances, are simply unable to treat patients who could benefit from an alternative approach.

At the same time, IAPT is spending around £10 million per year training up a parallel workforce within the state system specialising in CBT to meet its service goals, and continues to increase its training targets.

These practioners are usually trained for just one year, when there are 17,000 professionally qualified private sector therapists accredited at the highest level by registration bodies, which requires 4 years of training and supervision.

Many also have a decade or more of practical experience.

Despite claims by the Department of Health that it listens to the needs of the patients, the report finds that little has been done to break down the crippling bureaucracy and one-size-fit-all approach favoured by NICE.

In the Department for Health’s report ‘Liberating the NHS: greater choice and control,’ the majority of people said more choice was paramount to NHS reform, especially mental health services.

Yet only this month, the first service specification inviting public tender for any qualified provider (AQP) offered no development in providing additional therapies.

Published on 19 March 2012 by Dorset PCT, it specified its intention to ‘build firmly on the Improving Access to Psychological Therapies (IAPT) programme...[using] NICE approved/recommended psychological therapies in line with relevant clinical guidance.’

In reality, what began with a consultation with the public about additional choice, finished with a tender to the market that will deliver no additional choice in terms of available treatment.

This is despite patients and doctors wanting a choice of treatments, not simply a choice of providers of the same treatment.

Speaking at the launch of the CSJ report, Benjamin Fry, the co-author of the report and psychotherapist with his own private practice, said:

“The Department of Health’s own figures show that IAPT, doesn’t reach what the NHS defines as recovery for nearly 90% of the people referred to it, and costs the State about 50% more per recovery than voluntary sector services.

“The recent Dorset Primary Care Trust tender document highlights how out of touch the NHS is when it comes to psychological therapies and delivering what the patients need.

“Here was an opportunity to listen to the public and to allow a greater number of qualified providers to provide patients with real choice but nothing has changed. The number of therapies that have the potential to change people’s lives for the better are being squeezed out and only available to those who can afford them.”

“The needs of those who cannot afford to pay for treatment, but whose recovery will not be achieved through the limited range of therapies IAPT offers, are going unmet; some of them will die. It is a complete disgrace.

“Tight specifications and narrow guidelines have squeezed out countless other forms of therapies which have been proven to work and are what the patients ask for.

“The much smaller non-IAPT services in the NHS employ a far wider range of therapies than IAPT and still adhere to the patient safety aspects of NICE guidelines very strictly and successfully. There is no reason why the voluntary and private sectors cannot follow this lead.”

The report cites the Department of Work and Pensions as an example of how the NHS could adopt a payment by results commissioning approach whereby voluntary and private sector providers of talking therapy are commissioned by the NHS to work at their own financial risk until they have reached a proven effective outcome with each client.

The report calls on the Department of Health to adopt the approach of the Work Programme which rewards outcome in the opposite way to NICE guidelines which specify activities, regardless of outcomes.

Minimum safety standards would be essential but this approach would obviate the need for the higher barrier of NICE guidelines and result in an integrated system.

At present, if an individual on the Work Programme needs counselling, they can be sent to a therapist who is not following NICE guidelines, and receive a full range of therapies, but at the same time, a GP cannot send his employed neighbour with the same problem for identical treatment.

The report highlights how this results in a perverse inequality of access whereby someone who is out of work and on benefits is able to take advantage of a far greater choice of therapies to get well through the Work Programme than someone who remains at work.

Dr Samantha Callan, chairman-in-residence at the CSJ, who co-authored the report, advised the NHS to pull together more effectively with the aims of the Work Programme.

She said: “If therapists are paid on a consistent basis, budgets for therapy could be pooled for far greater effect.”

Dr Callan continued: “If the Department for Health used a similar approach to the DWP, they would create a range of safe, new choices without having to invest in a new workforce, and without wasting public money on unsuccessful treatments.”

“The current system has limited the number of experienced therapists available to supply the NHS at a time when the need for their effective contribution has never been more urgent.

“The patients have spoken and demand more choice. If the NHS genuinely allowed any qualified provider to provide therapy rather than the small number whose work is approved by National Institute for Health and Clinical Excellence (NICE) guidelines then patients would have greater choice and greater chance of recovery.”


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