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Improving access to psychological therapies and long term conditions: what do the evaluations tell us?

New evaluations show that improving mental health treatment for people with long term conditions such as diabetes or cardiovascular disease leads to better outcomes for patients and reduced costs for the NHS. Professor David M Clark, one of the founders of the Improving Access to Psychological Therapies programme (IAPT), examines the findings.

Around 40% of people with depression and anxiety disorders also have a long term physical health condition (LTCs). Research studies show that the presence of depression or anxiety substantially increases the cost of managing the physical health problems. There is also evidence this excess cost can be considerably reduced by effective mental health treatment. Unfortunately, such treatment is not always available.

Data from NHS Digital show that people with LTCs have tended to be under-represented in the NHS’s Improving Access to Psychological Therapies (IAPT) services and hence have a reduced chance of receiving psychological therapy for their mental health problems. This is unfair and is probably partly due to NHS mental and physical healthcare being managed separately.

To overcome this problem, it is important that mental and physical health professionals work hand in hand. Since 2016, new integrated IAPT services which join up physical and mental healthcare were developed and tested in 22 early implementer sites, with a further 15 sites joining in 2017/18. The findings from the early implementers demonstrate that these integrated services are a very valuable development, both in terms of clinical outcomes and experience for patients and reduced costs to the wider healthcare system. For this reason, NHS England is now encouraging all areas to develop such services.

A national evaluation of IAPT for people with LTCs has been conducted by a team of researchers from Imperial College London, University College London and the London School of Economics. The main analysis focused on people who had an inpatient admission for chronic obstructive pulmonary disease (COPD), diabetes, or cardiovascular disease (CVD) and were subsequently treated in core IAPT.

Individuals who access mental health treatment in the next year were compared with individuals whose treatment was at a later date. Early IAPT treatment was associated with substantial savings in hospital costs (A&E and out-patient visits and inpatient admissions) during the subsequent year. The savings broadly covered the cost of IAPT treatment and ranged from over £400 for diabetes to over £800 for COPD and CVD.

Subsidiary analyses highlighted that new integrated IAPT services were more convenient for patients and achieved savings that were at least as large.

Many of the integrated IAPT early implementer sites have been conducting their own local evaluations. Although focusing on people with both physical and mental health problems, many of them have been able to obtain good outcomes that are in line with the overall national target for IAPT (at least 50% recovery). It seems likely that the additional training for working with people with LTCs that has been made available by Health Education England has helped therapists achieve these good outcomes with their patients. For this reason, the training will continue to be available to assist other areas that have yet to develop their integrated IAPT services.

Integrated IAPT is consistently associated with reductions in non-mental healthcare costs. In the short-term these are mainly in the region of £100 to £200 per patient but there are examples of considerably higher savings – over £300 in Thames Valley and North Staffordshire and an extraordinary figure of £2,000 in West Sussex. These savings apply to the full range of people with LTCs, not just those with previous hospital admissions.

I am confident, as are the IAPT national team, that integrated IAPT services will help right a wrong by ensuring that people with LTCs have the same access to psychological therapies as everyone else. The early implementer services have been widely welcomed by both physical health care professionals and service users. The evaluation by Imperial and colleagues will be published as an academic paper, as will several local evaluations. Commissioning of integrated IAPT-LTC services now needs to expand to the whole of England as detailed in the 2019/20 NHS England planning guidance. The early implementer results demonstrate this is a very valuable development, both in terms of reduced costs to the wider healthcare system and for the outcomes and experience of patients.

David Clark

Professor David M Clark holds the Chair of Experimental Psychology at University of Oxford and is the National Clinical and Informatics Advisor for the IAPT programme. Along with Lord Richard Layard and other colleagues, he is one of the original architects of the programme. He is well-known for his research on the understanding and treatment of anxiety disorders, especially panic disorder, social anxiety disorder and post-traumatic stress disorder. Recognition of his work includes Lifetime Achievement Awards from the British Psychological Society and the American Psychological Association.

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