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Access to psychological therapies almost non-existent
Special Report
Access to psychological therapies almost non-existent One in six people in the UK suffer from depression or anxiety, yet psychological services are almost non-existent. And, despite some Government investment, there has been little improvement in access to these talking therapies on the ground. Emma Wilkinson reports.
www.thelancet.com Vol 370 July 14, 2007
This woeful lack of access to psychological treatment is not down to a lack of evidence of effectiveness or even impetus. In December, 2004, the National Institute of Health and Clinical Excellence (NICE) issued guidance on the treatment of depression and anxiety, advocating the use of CBT instead of, or alongside, drug treatment. Andre Tylee, professor of primary care mental health at the Institute of Psychiatry, King’s College London, was on the NICE guideline development group and he says it was clear that the access to psychological therapies was dire. “We were conscious the guidelines would have to be used as a lever for people to get these services, as when we wrote it we knew full well most practices didn’t have that. Some of them have got hardly access at all. GPs are in a very difficult situation. We know a lot of people would like talking treatments and if you have not got it available it is very frustrating.” In the early 1990s, Tylee was a GP and due to fundholding—a scheme that gave GPs control of health budgets— he was able to provide counselling psychotherapies in his practice. He says once the fundholding scheme was abandoned, the psychological service they had built up was thinly spread across his primary care trust leaving them once again with little access. Last year, Labour peer and renowned economist Richard Layard from the London School of Economics produced a report on the state of depression services. He concluded the NICE guidelines could not be implemented because there were not enough therapists, resulting in waiting lists that were over 9 months, with no waiting lists at all in some places. His solution was a 7-year plan to provide
an additional 10 000 therapists in the UK, 8000 of those in England. From an economic point of view, the scheme could even be cost saving, he argued, as 1 million people currently receive incapacity benefit because of mental illness, at a cost of £750 per month per person, the same as one course of CBT. The Department of Health has been convinced by his calculations and have asked the Treasury for additional funding as part of the Comprehensive Spending Review due to report in October. Layard estimates that by 2010 the service would cost around £200 million per year growing to £400 million by 2013 when the service would be fully operational. In the meantime, two pilot sites were set up in Doncaster and Newham to offer psychological treatment to patients of working age. In May this year, the then health secretary Patricia Hewitt, announced an additional
See Editorial page 104 See Comment page 112
The printed journal includes an image merely for illustration
Getty images
A woman in her 30s has frequent panic attacks and anxiety. She has received advice and support from her general practitioner (GP), but to no avail. On one occasion a panic attack was so severe it warranted hospital admission. The gold standard treatment would be cognitive behaviour therapy (CBT) but there is a 6-month waiting list. She ends up leaving her job and becoming effectively housebound. This story is an all too familiar one for GPs in the UK. Ask almost any one of them about how they are able to treat their patients who present with depression and anxiety and you will hear a heavy sigh of frustration. Peter Swinyard is a GP in Swindon, in southwest England, where he has access to a primary-care mentalhealth service offering educational courses, computerised therapy, self-help materials, green therapy, and behavioural programmes. He is lucky, many GPs have nothing to offer their patients, but he does not feel particularly lucky. “It can be an absolute battle”, he says. “I have had one patient who got two sessions of CBT but that’s about it…We are meant to use our counsellors as the point of access to soft psychotherapies but there’s little service for the severely depressed or suicidal.” Swinyard says those who need more specialised help are referred through secondary care mental-health services but that system does not always work. He explains: “I had one patient—a 30-year-old man who has been housebound by his depression for 2 years—and they did not think that was severe enough to warrant intervention the first time. It was only when I pushed for a second time they offered him support.”
One in six people in the UK have depression or anxiety
121
Special Report
£2 million for ten pathfinder sites around the country to try out different ways of providing psychological therapies. “It’s not a lot of money but it will have the effect of identifying and boosting regional centres of excellence so it is a very good development and hopefully the pathfinder PCTs [primary care trusts] will put in their own money as well”, says Layard. Alan Cohen, primary care clinical adviser to the Government’s programme for improving access to psychological therapies and a GP in south London, said by and large NHS services had not generally prepared for dealing with this group of people. “We’re not trying to reinvent whether treating people with CBT makes people better or not. We’ve done the research but this is about taking that research and applying it in a practical way.” He added that they had 109 applications for the ten places on the pathfinder scheme, indicating the willingness of PCTs to improve their services. “When I was chair of the NICE anxiety guidelines at the first draft stage, I said every practice should have it’s own CBT therapist but for several reasons I had to take that out. However, every practice should have access to CBT.” “It was a manifesto commitment in 2005, and there’s lots of work going on to try and make it work. It’s the biggest improvement I have seen as a GP in access to talking therapies.” But despite the investment from the government there has yet to be much improvement on the ground.
Panel: A self-referral approach The Swindon Primary Care Mental Health Service in southwest England has offered a no-wait service for psychological treatment for well over a decade thanks to the adoption of a self-referral approach. A similar scheme has recently been set up in neighbouring Kennet and North Wiltshire. Patients can access psychological treatment through their GP or other health professionals but they can also self-refer from adverts on the scheme that are placed in the local area. A team of clinical psychologists, counselling psychologists, counsellors, and mentalhealth workers deal with problems such as anxiety, panic attacks, and stress. In addition to face-to-face appointments, the range of interventions on offer include psychoeducational courses, computerised CBT, behavioural programmes, and selfhelp materials, in the form of books, CDs, and DVDs—all as recommended by NICE. The onus is on the patients to book themselves into individual appointments or group sessions but they will be followed up if a GP or health professional is worried. The Swindon team deal with around 3000 individual appointments a year and nearly 3000 groups—at a cost of a little more than £100 per patient. In Kennet and North Wiltshire, the first 8 months of the service produced a sustained drop in referrals to secondary-care services of around 30%, enabling those services to focus their resources more appropriately.
David Kessler, a GP and senior research fellow at the University of Bristol, is evaluating other options. He is leading a randomised controlled trial of online psychotherapy and has also helped to start up a self-help service using primary-care mental-health workers in a similar way but on a much smaller scale to the Swindon model. “It is a way of broadening access to talking therapies but it must be said we’re not able, because of cost, to offer individual one-to-one CBT.” “In Bristol PCT about 50% of practices have access to some form of counselling. However, much of that counselling is not CBT, it’s generic counselling and they also have waiting lists.”
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The printed journal includes an image merely for illustration
122
“The NICE guidelines do not in themselves make psychological therapies more accessible but they do encourage people in the health-care system to think about making these therapies more available and we are going to have to be more creative about how we do that.” Kessler welcomed Lord Layard’s proposals but said the figures may be a bit optimistic. “I still think it is worth doing even if it costs money. But not everybody who starts CBT finishes CBT, it’s not a panacea, it can be quite a demanding form of therapy—it puts a lot of responsibility on the patients.” Tylee agreed the figures on the number of people who could get back to work with a course of CBT may not be realistic. “Once you have been signed off for 6 months you are less likely to go back to work. It’s probably more about getting people in the future rather than people who have been depressed for years. But he does concur with Layard’s view it needs ringfenced money. “Hopefully what we recommended in the NICE guidelines will come to fruition through this and we will have equity in availability.”
Emma Wilkinson www.thelancet.com Vol 370 July 14, 2007
Access to psychological therapies almost non-existent One in six people in the UK suffer from depression or anxiety, yet psychological services are almost non-existent. And, despite some Government investment, there has been little improvement in access to these talking therapies on the ground. Emma Wilkinson reports.
www.thelancet.com Vol 370 July 14, 2007
This woeful lack of access to psychological treatment is not down to a lack of evidence of effectiveness or even impetus. In December, 2004, the National Institute of Health and Clinical Excellence (NICE) issued guidance on the treatment of depression and anxiety, advocating the use of CBT instead of, or alongside, drug treatment. Andre Tylee, professor of primary care mental health at the Institute of Psychiatry, King’s College London, was on the NICE guideline development group and he says it was clear that the access to psychological therapies was dire. “We were conscious the guidelines would have to be used as a lever for people to get these services, as when we wrote it we knew full well most practices didn’t have that. Some of them have got hardly access at all. GPs are in a very difficult situation. We know a lot of people would like talking treatments and if you have not got it available it is very frustrating.” In the early 1990s, Tylee was a GP and due to fundholding—a scheme that gave GPs control of health budgets— he was able to provide counselling psychotherapies in his practice. He says once the fundholding scheme was abandoned, the psychological service they had built up was thinly spread across his primary care trust leaving them once again with little access. Last year, Labour peer and renowned economist Richard Layard from the London School of Economics produced a report on the state of depression services. He concluded the NICE guidelines could not be implemented because there were not enough therapists, resulting in waiting lists that were over 9 months, with no waiting lists at all in some places. His solution was a 7-year plan to provide
an additional 10 000 therapists in the UK, 8000 of those in England. From an economic point of view, the scheme could even be cost saving, he argued, as 1 million people currently receive incapacity benefit because of mental illness, at a cost of £750 per month per person, the same as one course of CBT. The Department of Health has been convinced by his calculations and have asked the Treasury for additional funding as part of the Comprehensive Spending Review due to report in October. Layard estimates that by 2010 the service would cost around £200 million per year growing to £400 million by 2013 when the service would be fully operational. In the meantime, two pilot sites were set up in Doncaster and Newham to offer psychological treatment to patients of working age. In May this year, the then health secretary Patricia Hewitt, announced an additional
See Editorial page 104 See Comment page 112
The printed journal includes an image merely for illustration
Getty images
A woman in her 30s has frequent panic attacks and anxiety. She has received advice and support from her general practitioner (GP), but to no avail. On one occasion a panic attack was so severe it warranted hospital admission. The gold standard treatment would be cognitive behaviour therapy (CBT) but there is a 6-month waiting list. She ends up leaving her job and becoming effectively housebound. This story is an all too familiar one for GPs in the UK. Ask almost any one of them about how they are able to treat their patients who present with depression and anxiety and you will hear a heavy sigh of frustration. Peter Swinyard is a GP in Swindon, in southwest England, where he has access to a primary-care mentalhealth service offering educational courses, computerised therapy, self-help materials, green therapy, and behavioural programmes. He is lucky, many GPs have nothing to offer their patients, but he does not feel particularly lucky. “It can be an absolute battle”, he says. “I have had one patient who got two sessions of CBT but that’s about it…We are meant to use our counsellors as the point of access to soft psychotherapies but there’s little service for the severely depressed or suicidal.” Swinyard says those who need more specialised help are referred through secondary care mental-health services but that system does not always work. He explains: “I had one patient—a 30-year-old man who has been housebound by his depression for 2 years—and they did not think that was severe enough to warrant intervention the first time. It was only when I pushed for a second time they offered him support.”
One in six people in the UK have depression or anxiety
121
Special Report
£2 million for ten pathfinder sites around the country to try out different ways of providing psychological therapies. “It’s not a lot of money but it will have the effect of identifying and boosting regional centres of excellence so it is a very good development and hopefully the pathfinder PCTs [primary care trusts] will put in their own money as well”, says Layard. Alan Cohen, primary care clinical adviser to the Government’s programme for improving access to psychological therapies and a GP in south London, said by and large NHS services had not generally prepared for dealing with this group of people. “We’re not trying to reinvent whether treating people with CBT makes people better or not. We’ve done the research but this is about taking that research and applying it in a practical way.” He added that they had 109 applications for the ten places on the pathfinder scheme, indicating the willingness of PCTs to improve their services. “When I was chair of the NICE anxiety guidelines at the first draft stage, I said every practice should have it’s own CBT therapist but for several reasons I had to take that out. However, every practice should have access to CBT.” “It was a manifesto commitment in 2005, and there’s lots of work going on to try and make it work. It’s the biggest improvement I have seen as a GP in access to talking therapies.” But despite the investment from the government there has yet to be much improvement on the ground.
Panel: A self-referral approach The Swindon Primary Care Mental Health Service in southwest England has offered a no-wait service for psychological treatment for well over a decade thanks to the adoption of a self-referral approach. A similar scheme has recently been set up in neighbouring Kennet and North Wiltshire. Patients can access psychological treatment through their GP or other health professionals but they can also self-refer from adverts on the scheme that are placed in the local area. A team of clinical psychologists, counselling psychologists, counsellors, and mentalhealth workers deal with problems such as anxiety, panic attacks, and stress. In addition to face-to-face appointments, the range of interventions on offer include psychoeducational courses, computerised CBT, behavioural programmes, and selfhelp materials, in the form of books, CDs, and DVDs—all as recommended by NICE. The onus is on the patients to book themselves into individual appointments or group sessions but they will be followed up if a GP or health professional is worried. The Swindon team deal with around 3000 individual appointments a year and nearly 3000 groups—at a cost of a little more than £100 per patient. In Kennet and North Wiltshire, the first 8 months of the service produced a sustained drop in referrals to secondary-care services of around 30%, enabling those services to focus their resources more appropriately.
David Kessler, a GP and senior research fellow at the University of Bristol, is evaluating other options. He is leading a randomised controlled trial of online psychotherapy and has also helped to start up a self-help service using primary-care mental-health workers in a similar way but on a much smaller scale to the Swindon model. “It is a way of broadening access to talking therapies but it must be said we’re not able, because of cost, to offer individual one-to-one CBT.” “In Bristol PCT about 50% of practices have access to some form of counselling. However, much of that counselling is not CBT, it’s generic counselling and they also have waiting lists.”
Getty Images
The printed journal includes an image merely for illustration
122
“The NICE guidelines do not in themselves make psychological therapies more accessible but they do encourage people in the health-care system to think about making these therapies more available and we are going to have to be more creative about how we do that.” Kessler welcomed Lord Layard’s proposals but said the figures may be a bit optimistic. “I still think it is worth doing even if it costs money. But not everybody who starts CBT finishes CBT, it’s not a panacea, it can be quite a demanding form of therapy—it puts a lot of responsibility on the patients.” Tylee agreed the figures on the number of people who could get back to work with a course of CBT may not be realistic. “Once you have been signed off for 6 months you are less likely to go back to work. It’s probably more about getting people in the future rather than people who have been depressed for years. But he does concur with Layard’s view it needs ringfenced money. “Hopefully what we recommended in the NICE guidelines will come to fruition through this and we will have equity in availability.”
Emma Wilkinson www.thelancet.com Vol 370 July 14, 2007