To the new health secretary, Andrew Lansley, target is a dirty word. He prefers outcome measures – actual results that show treatments are working.
 
In the first few months of the new government, he’s cut many of Labour’s target-led programmes, but one so far spared the axe is Improving Access to Psychological Therapies (IAPT), a £170 million mental health plan with lots of targets.
 
Launched in 2008, IAPT promised to treat 900,000 patients in the first three years (curing half of them), train 3,600 therapists to deliver the treatments, get 25,000 people off sick pay by 2010-11, and put thousands back into work. The Coalition Goverment has promised to maintain the programme by spending the remaining £70 million.
 
But in its first year, IAPT does not appear to have hit its targets or to have improved outcome measures very much. There is no evidence of anybody getting back to work, and only a 2 per cent drop in benefit dependency. Far too few sessions of treaament are being delivered to individual patients to have much chance of success.
 
Depression and anxiety are among the commonest problems seen by GPs, and the usual response is to prescribe antidepressants. But in 2004 the National Institute for Clinical Excellence (NICE) ruled that drugs should not be used for the first treatment of mild depression, because the risk-benefit ratio is poor.
 
That left GPs in a dilemma. The alternatives, including “talking therapies” such as cognitive behavioural therapy, which has a good evidence base, were not widely available. The reponse was to launch IAPT, following two successful pilots in Doncaster and Newham.
 
Roll-out began in in 2008, and in July the North East Public Health Observatory published a report on the first full year of operation for the 32 sites in the first wave. The report is optimistic, but it’s hard to see why.
 
The 32 sites provided 138,541 episodes of “clinical contact or near-contact” with would-be patients. How can you make a near-contact with a patient? That’s presumably when a patient is notified to the centre, usually by a GP, but never actually turns up. Of the 138,541, only 79,310 had even an initial assessment.
 
By the end of the period covered by the report, just over half of these people had been treated or had ended contact with the service: the rest were still in the system and their results could not be assessed. Of those who had finished their care, more than a third had attended only once, of whom almost 12 per cent left without being treated.  
 
That left 26,780 who had more than a single contact. NICE recommendations say that for mild depression treated by guided self-help, patients should have six to eight sessions of therapy. The average was actually only two. For more serious conditions requiring high-intensity treatment such as CBT, the guidelines recommend 16-20 sessions: the average was three. Only 1.4 per cent of patients needing high-intensity treatment met the NICE guidline.
 
The report concludes: “Overall, it seems that the pattern for treatments as reported by these data are, in most cases, some distance from NICE guidelines”. Less than half the sites used computerised CBT, even though it is recommended by NICE and is easier to prescribe because good programs already exist. “This seems surprising since these would be among the easier programme components to establish” the report says.
 
Outcomes were poorer than in the two pilot sites, though the report concludes that there was a 30 per cent fall in “caseness” – patients qualifying as cases by psychological measures at the start of treatment who no longer qualified as such by the end.
 
Getting people back to employment was admittedly a tough call when the UK was sinking into recession. In the pilot study in Doncaster, those in work and not claiming benefit rose by 4 percentage points; in Newham it was nearly ten percentage points. But in the 32 sites studied, it was only 2 percentage points.
 
In mitigation, some of the problems arose because the programme was new and people were still being trained as therapists. Last November, responmding to a critial article in The Observer, the DH said that 80 more sites would go live shortly. It admitted, however, that in future the money for IAPT would no longer be ring-fenced, raising doubts about how cash-strapped primary care trusts will go on paying for it.
 
Mariam Kemple, policy and campaigns officer for Mind, told Health Service Journal that the service had been rolled out very quickly and was overloaded, “Many of the therapists require high amounts of supervision, so there are not enough therapist hours. There may be a squeeze on resources so PCTs are offering fewer treatments” she said.
 
The DH said simply that the review had shown “a range of trends and in some areas excellent practice has been in place.” Hardly a ringing endorsement.
 
Declaration of interest: Nigel Hawkes is a member of the advisory board of Ultrasis, a company that develops and sells computerised CBT programmes for treating depression and anxiety.