Mental Health Matters: The recovery position

The latest annual report on sector’s IAPT services, published last week, revealed performance on recovery standards has dropped for the first time since 2015-16.

Improving Access to Psychological Therapies was a flagship service under the Five Year Forward View and is one of few for which performance standards have been set.

Under one standard at least 50 per cent of patients starting an IAPT course must “recover”.

Data for 2019-20 showed 51 per cent of patients who started therapy “recovered”, compared to 53 per cent in 2018-19. Although the standard was still met, it was the first time performance decreased year on year since at least 2015-16.

This deterioration, although slight, is important to note in the current climate when the NHS is gearing up for a surge in mental health need, as IAPT will be central to NHS England and Improvement’s mitigation plan.

Performance in March and April will also be of particular concern as rates dropped significantly to 46 and 47 per cent.

This may be explained, in part, by changes to IAPT services during the pandemic. Some, for example, will have gone to digital-only options.

HSJ understands when some services switched to digital, the patients who declined this mode of therapy would have been discharged before they finished their sessions – hence would not be recorded as having recovered.

Some people may also have chosen not to attend sessions during covid-19.

It is unlikely services will be following up with either set of patients and so this could lead to more acute illness later down the line.

Inequalities within IAPT

It has been well known that IAPT services have produced poorer outcomes for BAME populations compared to white, although there was some slight improvement last year.

Performance across other areas of IAPT, such as the number of referrals or the number completing treatment, are also worst for BAME users.

There are numerous reasons for this disparity and as the NHS prepares to tackle inequalities, commissioners should be asking if IAPT services are really adapted to fit the communities and cultures they serve.

Another important area to note is outcomes by deprivation. If you compare areas categorised as “most deprived” nationally the recovery standard was missed by eight per cent, while for those in the “least deprived” it was exceeded by seven.

Again, in the last three years the gap has barely been addressed.

As with BAME groups there really should be no reason talking therapies do not work as well for those who are more deprived, so it must come down to the way in which the service is provided.

Phase three planning

On Friday NHS England and Improvement published its guidance on phase three of the NHS’ restoration.

The focus was on acute, elective, cancer and community services, but there was also a small section directed to mental health, learning disability and autism providers.

As mentioned above IAPT is likely to be one of the main pillars on which the sector prepares for any impending surge in mental health need.

The guidance told systems IAPT services must fully resume. Despite efforts to maintain mental health services throughout the pandemic, it will have been inevitable that changes meant for some this service will have stopped.

It is interesting to note NHSE/I does not say how IAPT should resume – could systems interpret this as purely digital? This could lead to problems if so.

Ambitions for IAPT to be widened out to offer bereavement and PTSD in response to covid-19 were previously floated, however, experts remain sceptical as to whether this would be possible with the current state of services.

Crisis services and children and young people are the second two focusses of the restoration - but nothing very specific has been demanded for the latter.

For crisis and emergency care trusts were told to maintain their 24/7 crisis lines. It is worth noting there was no mention of the mental health assessment units set up during covid-19 as an alternative. This is perhaps because local service leaders are unsure whether they were worth the cost.

More interesting is the direction for trusts to review patients on community mental health teams’ caseloads with the view to “increase” therapies and interventions across those with serious mental illness.

This is a group of service users who until the long term plan were forgotten and it is telling that NHSE/I have chosen to highlight their needs post pandemic - is there a worry this group has been particularly impacted?

Another core concern during the pandemic was how difficult infection prevention control was made by the poor condition of the mental health estate. This will create the perfect storm for the sector should there be a significant rise in people needing inpatient admission.

Dormitory wards were of particular concern when it came to containing covid-19 and the government has since promised £250m to help eliminate them.

However, if trusts don’t want to decrease their bed base the projects could be considerable as some require the building of completely new units.

In any case the elimination of all dormitory wards is unlikely to happen before a second wave of covid-19.

If you have a tip or would like to share feedback direct message on Twitter or email me on rebecca.thomas@wilmingtonhealthcare.com.