The Rock in the Hard Place: the IAPT standards

Following James was always going to be tough; so this is probably a good moment to slip in the blog about the IAPT standards. I know, I know, it’s dry; but on the plus side it’ll be shorter than most of my posts. The rest of IAPT doesn’t really make any sense until you understand the targets, so it’s got to be done. I promise to be as ranty about it as I can.

Most services scrape through the targets, but the fit is so tight that they end up bleeding.

Before I start I want to be clear that in principle I agree with targets and standards; there’s got to be a way of measuring if a publicly funded service is fulfilling its purpose. We should have accountability. That being understood; a system that is imposed from the outside in, based on numbers, and not responsive to the needs of the people involved is dangerous and harmful to patients and practitioners.

The threefold standards

There are three IAPT targets that services are expected to meet: access, waiting times and recovery.

1) Access Every IAPT team is expected to see a percentage of the local population who have got depression and anxiety (targets are set as a percentage of ‘prevalence’). So, for example, you live in a biggish city Pop. 200,000. Statistics tell you that a quarter of that population have got depression or anxiety so the IAPT service in that area might have a target of, say 15% of that 50,000 to see every year. That’s 7,500 people that that team has got to offer treatment to.

The access target is being increased every year because of the IAPT “expansion”; lots of new LITs and HI Therapists are being trained so that we can meet the goals of the five year forward view. Except it’s not really an expansion if you’re training barely enough new people to replace the LITs that you burn out and discard with your meat grinder of a system is it? Or if you recruit people who never had any intention of staying in post for more than a year or two. In about two years we’re going to have access targets that are about double our current targets, and our teams wont be any bigger. That isn’t going to be brilliant for the quality of the service that we can provide. There will also be a knock on to target number two…

2) Waiting times Once someone has got into contact with an IAPT team they then stop being part of the access target and become part of the waiting time target. The waiting time target is that from referral 75% of people should start treatment within 6 weeks. There’s 25% leeway to start treatment within 18 weeks.

This is how you end up with hidden waiting lists and headlines like the recent article by Andy Gregory in the Independent that did the rounds. This target is based on an assumption that the access targets are being met by an adequately staffed team with enough of an estates budget to have rooms to see people. Nope.

3) Recovery Once you’ve had more than one appointment with an IAPT team you become eligible to count towards their recovery target. The recovery target is pretty straightforward (hah!): 50% of people who have more than one appointment with an IAPT team should finish treatment with their scores on the PHQ-9 (depression measure) and GAD-7 (generalised anxiety measure) “below caseness”. This means that according to the numbers you haven’t got depression and anxiety anymore. If you’re being treated for a specific type of anxiety like PTSD, OCD or Health Anxiety, then the questionnaire for that can replace the GAD-7. This is why we’re so obsessed with questionnaires. This one is based on an assumption that most of the people who come to see us will be able to benefit from the treatments that we can provide. See my previous and future posts for what I think about that.

Numbers crunch

What happens when you get a clash of targets? When the waiting time and recovery targets just arent compatable? What if you can meet your access target but a lot of the people who you assess require a High Intensity intervention? You have to choose between waiting times and recovery. Do you prioritise the waiting time target and offer a step 2 treatment that can be accessed quickly? Or the recovery target which means you put someone on a waiting list for an intervention with a higher chance of success? Hint: If a step 3 treatment is indicated, that is what should be offered; don’t, for example, try Behavioural Activation at Step 2 with someone who needs treatment at Step 3 for PTSD, that person usually drops out of treatment without getting the therapy they should have been offered.

There have been a few times in my working life when I’ve number crunched my caseload beyond what our computer generated reports will tell me (I’m a raging geek, so sue me). So here’s some data from 4 years of my clinics. We have ironed out some of the issues in our service since this period and are under new leadership etc so don’t freak out. People only appeared on that report if I had seen them more than once and they had been discharged without seeing anyone else; To keep things brief today I’ll just look at PHQ-9 outcomes, this report doesn’t let me track recovery on both measures easily. Years ago when I first looked at these I did the same with the reports of two of my supervisees (with permission) and found very similar results.

• The people who had mild-moderate symptoms of depression (44% of my caseload) at their first appointment with me had an 84% chance of being below caseness when they had their last appointment.
• 45% of the people with moderate-severe symptoms (26% of my caseload) moved below caseness.
• People in the severe range (30% of my caseload) had a 15% chance that Step 2 treatment for depression would work.

‘But NaG’, I hear you cry, ‘why would you offer Low Intensity interventions to someone with severe depression? There’s no evidence for that’. You are correct, there isn’t. What there is, is a 6 week to treatment standard. In clinics where a high proportion of people access IAPT with severe symptoms and complex circumstances the waiting list for CBT and counselling becomes months long very quickly. When the waiting list starts getting longer you start to be nudged by your manager and the CBT therapist (oddly, counsellors have never done this) to ‘have a go’ at something with someone. No one wants someone sat on a waiting list with no treatment for up to a year. And there is a 15% chance that it’ll work, don’t forget.

There’s the potential to find solutions to a lot of problems with resources and passion like this in the role. Unfortunately these people have got their eye on the door…

You also have the LIT in a room with a person who is really struggling. The LIT has to look them in the eye and explain that there isn’t any way of guessing when an appointment will be available, but they can see their GP if they need urgent attention while they’re waiting. There’s only so many times that you can do that before your heart breaks and you can’t resist the urge to just try, especially if your rapport with the person is particularly strong.

Time is ticking away…

IAPT services are built with these numbers and targets in mind; the decisions about how staff time is used are all about hitting these. I’ve heard lots of very exciting ideas recently about how the LIT role could develop; what we could be doing to make IAPT services truly inclusive for different groups of people who currently struggle to access what we offer. You know what the problem is with all of these ideas? They take time.

As an example: At the BABCP conference in 2019 the Chair of the Equality and Culture SIG, Saiqa Naz, proposed that LITs are well placed to build relationships with their local BAME communities, and adapt IAPT treatments to meet the cultural norms and unique needs of these communities. Saiqa would like to see LITs have half to one day to do outreach work, on top of their admin time, to enable them to develop relationships with local communities. Really exciting idea and potentially very effective. But building relationships and co-working with community groups takes months and years, not hours and days. IAPT managers will be looking at the capacity in their teams and measuring that against their access and waiting time targets, and they wont be able to reduce LIT clinics (or any other clinics) by half a day indefinitely in order for these essential relational foundations to be laid and maintained. Even if that could potentially improve recovery rates.

Saiqa also co-authored the IAPT BAME Positive Practice Guide – if you haven’t looked at this yet please do! There’s a link to it right there.

Creativity or bust

The targets impose what feels like a false economy. We’ve got a huge resource of intelligence and creativity in IAPT at step 2. There are a few LITs in my team who are pretty typical of the people I’ve worked with over the years; their minds are like supernovas, and they’ve all got a huge depth of compassion to go with that intelligence. With resources and passion like this in the role there’s the potential to find solutions to a lot of problems . Unfortunately they’ve all got their eye on the door because there isn’t any time in their working week for them to think about and respond to the difficulties that they are confronted with every day. Their work isn’t adequately rewarded or respected either, but that’s another issue.

IAPT is a system that is built top down from numbers. Every LIT I know bends over backwards to soften this. They work with compassion, offer real empathy, they’re creative in how they offer the interventions and warm and genuine in their personal manner. But very often it feels like you’re doing that in opposition to the system. So you end up with people, often young people, who have got a rigid system behind them and desperate need in front of them and it’s very difficult, as the person who’s got to find a way to connect the two, not to be torn apart by the pressures. We hemorrhage LITs, there’s a national shortage of qualified low intensity workers, and that’s not just because they came into the job as a stepping stone to something else. There’s enough to learn and get excited about to last most people for at least a couple of years. We lose a lot of people because the job just isn’t sustainable.

You also have the LIT in a room with a person who is really struggling. The LIT has to look them in the eye and explain that there isn’t any way of guessing when an appointment will be available…There’s only so many times that you can do that before your heart breaks and you can’t resist the urge to just try,

LITs are often natural problem solvers, in a role that doesn’t allow them to use these skills effectively. We need LITS to have more time to think, and the time, resources and authority to put their ideas into action. Unfortunately, because of many factors, we don’t retain people in the job long enough for them to grasp it’s potential. Most services scrape through the targets, but the fit is so tight that they end up bleeding. We don’t retain teams that are big enough to meet the targets and to put down roots in their local community and innovate to improve access and retention in treatment. There aren’t any quick fixes here, but you really can’t understand IAPT without a grasp of the standards.

On a personal note: I’m doing a happy dance because I’ve finally managed to stick to my self-imposed 1500 word limit for a blog! (Edit: So close, went 200 over in the end)We’ll see if I can repeat that next week with a post that welcomes the Trainees who are joining IAPT this month.

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