Improving access to psychological therapies (IAPT), the evidence base behind IAPT and why patients with diabetes will benefit from this programme.
IAPT services have transformed the treatment of depression and anxiety disorders in England. They are established in every clinical commissioning group (CCG), providing NICE recommended psychological therapies for people with common mental health disorders – anxiety and depression - in a model of stepped care.
In 2016, NHS England set out an ambition in the mental health implementation plan that, by 2020/21, 1.5m people a year will access psychological therapies through IAPT.
Around 40% of people with depression and anxiety disorders also have a long-term condition (LTC), such as Diabetes; however, mental health and physical health services are rarely coordinated, although the case for integrated care is overwhelming.
Rolling out IAPT - Long Term Conditions
The IAPT programme, in 2016/17 and 2017/18, worked with several IAPT services and CCGs across England to centrally fund the development of the first IAPT-LTC services. These services provide people with LTCs and medically unexplained symptoms (MUS) access to NICE recommended psychological therapies in pathways which are integrated with physical health, thus offering care that is coordinated, co-located, and modified to meet the needs of this population. Read the guidance for developing these integrated pathways.
The expansion of the IAPT workforce, to meet the expansion aims, was also a key driver. Sites were expected to take on trainees to replace the experienced staff who undertook top up training in LTC and MUS to deliver IAPT-LTC services.
Lessons from early implementers
Successful sites had a combination of disease specific pathways in acute hospitals and multi-morbidity models in primary care. This, within a single disease specific model, allowed greater depth of integration.
Implementing IAPT-LTC delivery for multiple pathways, was more successful in sites that had “phased roll-out”. Sites that focused on one or two specific pathways initially, found integration more successful and had higher referral rates.
The early implementer sites clearly demonstrated the need for collaborative working between physical health providers and IAPT-LTC teams. Reciprocal training arrangements between the IAPT-LTC service and the physical healthcare team led to improved relations, higher engagement and increased referrals. Sites highlighted the importance of continual engagement with health professionals to ensure that referrals were forthcoming, and pathways collaboratively agreed.
There will be a robust health utilisation evaluation published in early 2019, which has been commissioned nationally; however, several of the early implementer CCGs submitted initial local evaluations.
Although initial numbers are small, the indicators are positive. In Cambridgeshire and Peterborough the evaluation demonstrated a 72% decrease in use of healthcare services across the condition pathways. The healthcare services included GP, Specialist Nurse, Practice Nurse, and Consultant appointments, A&E attendances, ambulance usage, and inpatient admissions.
Coastal West Sussex, Horsham and Mid Sussex, and Crawley CCGs have shown a reduction in use of healthcare services of 51%.
Portsmouth CCG have demonstrated a 61% reduction of employment days lost in the first cohort of patients who had submitted 3 months post-treatment follow up.
The main driver for developing IAPT-LTC has been to improve the outcomes and experience for people with LTCs and co-morbid depression and anxiety. The national data has previously demonstrated that people with LTCs using core IAPT services currently achieve recovery rates on completing treatment that are approximately 3% lower than the national average for recovery rates. The data from the early implementer sites demonstrates improvements in recovery, bringing this in line with the IAPT service standard that at least 50% of people completing treatment should recover.
Combining the increased performance, service and staff satisfaction, patient experience and outcome improvements together with the potential for healthcare utilisation reductions, the programme has demonstrated great value.
National roll out and Diabetes’s opportunity
As the programme rolls out across the country from April 2018, in line with the NHS planning guidance, we would expect to see new pathways developing allowing greater numbers of patients to access this integrated model of psychological therapy.
To date the IAPT-LTC team have worked with many areas that have developed these services within the current pathways for people with Diabetes. They have worked with Diabetes teams locally to develop screening for depression and anxiety, collaborated with Diabetes education programmes, and developed reciprocal training between professionals. The Diabetes pathways have been one of the most successful to date, and if this is happening in your area we would be very keen to hear how it is working. Please contact us at England.MentalHealth@nhs.net. Local services struggling to deliver can also contact their Local NHS England mental health lead through their CCG, who can request national support from the IAPT-LTC team.