Sunday, 23 September 2012

Can IAPT ever really look after PD properly?

Sometimes I get into interesting email conversations with people I have never met, or from a long time ago. Here’s one from a medical psychotherapy colleague wanting some background on the National PD Programme for a talk. To save any embarrassment, I have redacted any identifying details. For me, it reminded me of how sad it was to lose a government programme that was really trying to introduce the idea of relationships - at group and society level as well as for individuals - being more important than ‘therapy products’. With a little more time and nurture, it could have introduced some truly radical thinking into mental health services for some of the most dispossessed. But perhaps this conversation shows that I may be feeling more bleak about it than I need be…

Remember me?  Its been a few years. I wonder if I could pick your brains about services for BPD and IAPT. I’ve been asked to step in and give a talk about IAPT for SMI and BPD, and I am going to talk about relational therapies. I just wanted some info about the wider picture, and how IAPT could improve access to services for people with BPD.
Hope you are well!

Of course I remember you – those research conferences were one of the most formative experiences of my career! Good to hear from you.
But you do ask the most sensitive questions…

My personal view is that IAPT does not have, in its leadership at least, a good enough understanding of the ‘complexity agenda’  that was the defining feature of the DH’s National PD Development Programme until its effective demise in 2011. This was specifically defined as cross-agency working, service user partnership at all levels, no exclusion criteria if diagnosable as PD, multiplicity of suitable therapeutic approaches often arranged in complex group programmes, whole-system interventions, staff attitude change, and a research agenda including the social sciences.

The programme had £6.9m annually (2002-11), and set up 11 Imperial-researched pilot sites across England (using different models) as well as the ‘Knowledge and Understanding Framework’ online awareness training plus a BSc and an MSc. What was the national PD programme has now effectively moved to the Ministry of Justice (where excellent work is being done, for example, on setting up therapeutic environments in prisons and training custodial staff in ‘relational security’) and DCLG (where there are similar champions for the housing and homeless sectors).
I suppose the underlying conflict - laid bare by the recession and thus the need to shoehorn any future PD work into IAPT - is that the DH’s PD programme was trying to do innovation and exploratory work in a very messy field that crosses almost all sectors and government agencies, and IAPT was ‘rolling out’ a precise delivery and measurement model for treatments that had already been through the ‘evidence mill’. And those of us in the PD programme were left feeling that IAPT was an entirely different type of thing, that would not well serve the needs of our service users - particularly the angry BPD people who were (I believe justifiably) outraged at the scandal of the poor treatment they have always had in the NHS, except in very few places.

But when we (the ‘PD exiles’) are feeling less aggrieved and more philosophical, we hope it is simply a matter of time scale. BPD treatment is so much less researched than anxiety, depression and all the common mental disorders, that we will need years to catch up. And - fundamentally - it is not yet possible, and may never be, to prescribe a simple suitable evidence based treatment programme for people diagnosable with PD, and all the relationship (dare I say transference) problems they bring…
Do get back if you want more info, or a phone chat, etc.

Hi. That's great. Glad I asked you!!!
I'm basically standing in at a talk which was going to be on CBT and personality disorders, and the need to adapt it. I'm going to review relational therapies instead.
The latest I've picked up from IAPT is the view it's about increasing access rather than recreating the wheel. But I'll summarise what you've told me.
Is essentially money being taken out of existing services? And diverted to IAPT or prisons?
Best wishes

What an interesting conversation!
In answer to your questions, the money that is being taken out of exisiting services is the pilot funding (£6.9m) which was always DSPD money, and meant to be picked up by PCTs (and now CCGs) once the pilots had shown their worth. Some of them have been taken on by local commissioners (often with substantial cost savings imposed, or requirements to ‘income generate’), but others are still needing the central funding to prevent closure. The idea is to reduce the central funding to zero over the next 3 years or so (although that is the message they have been given for several years now).

The bigger problem, in my book, is that only 12% of the English population was ever covered by the pilots - so 88% never had a bean (for local specialist non-residential PD services - what is called Tier 3. Tier 2 is as part of existing mainstream services - such as a small DBT clinic - which is more widespread, I think). Obviously in areas with powerful champions like Anthony Bateman, or commissioners with a particular understanding, Tier 3 services have developed - but most of the country is still a desert for people with BPD. Reading (where Jane and I set up Winterbourne TC in the 90s) was rather reluctantly incorporated into the big 'Thames Valley Initiative' pilot, and still struggles on quite successfully (clinically) in an unsympathetic milieu and hard-nosed health economy .

Back in the early days of the PD Programme (2004-5-6) the expectation was for more funding to roll out the successful models across the country, with a continuing  R&D programme to support it: but it never happened. Maybe it was the recession and inevitability of hard times, by my feeling is that there was a deeper resistance - maybe denying the size of the PD problem, or the diagnosis itself, or the messy uncertainty and chaos that goes with the territory, or (my favourite) that people with PD challenge authority and the established order in a way that is just not tolerated. Many stories to tell there, over a beer or two, if we ever get the chance!

Another interesting piece of the jigsaw is ‘Tier 4’ provision - which has been grumbling on as an unresolved issue since the Henderson and its replicates were shut down. The commissioners involved did recognise that there is a severe unmet need - particularly for those people uncontainable in non-residential services, who tend to cause chaos in acute wards and often end up in expensive and un-therapeutic long-term forensic care. So that has now re-emerged as a workstream of the National Commissioning Board, and last I heard they were looking at something like £33m revenue for 500 people in treatment at any one time in up to 10 regional centres - but they will be very different from the Henderson model - with a lot of emphasis on outreach, forensic liaison, consultation and training, and – under ‘Any Qualified Provider’ – are likelier to be run by independent, non-NHS, providers. And - even more important maybe - to exert leverage on CCGs to provide better Tier 3 services in the localities (our experience in Thames Valley is that the need for BPD referral to a residential out-of-area unit is rare when good local services are in place).

As you might gather - PD services have been my main preoccupation (and headache) for the last few years!

Thanks again for all your thoughts. Amazingly helpful! Not sure how it will end up but the people involved with PD at IAPT seem very aware of the complexity issues. And IAPT seems to be the only bus in town at the moment.
I think it's a big ask  ....... but I think it depends on the evaluation from the demo sites. If some show  clear savings... better chance of leverage with CCGs.
A beer would be great some time. You need to run for president of the college. We haven't had a psychotherapist since Fiona Caldicott. 
You've got my vote! 

And then, after the meeting, to several of us who had helped.
This is just to say thanks to you all for your helpful comments, thoughts, data etc.
I thought I'd just give some feedback:
Their remit appears to be to implement IAPT for SMI including PD, and are keen to get away from the idea that IAPT services will deliver treatment as they have done for the adult primary care initiative. But they appear to recognise the complexity of the problem and also that there are therapists and resources out there who have trainings that could be utilised to treat people with BPD.
The meeting was attended by a mix of people but mainly heads of psychology services and senior managers.
The main issue was about how commissioning and resources could be both protected and strengthened for people with BPD. No clear answers ! 
I suggested a strong case could be made for funding on the back of potential cost savings and there was evidence in relation to this both from RCTs  and comparative and before and after studies. Presumably when Imperial report their findings re the 11 pilot sites there may be some additional evidence.
I also made the point that the relational therapies did not need to be 'adapted' for treatment for BPD as they were either initially designed or developed for people with BPD or were tailored for use with BPD many years ago. I also suggested that there is a wealth of experience re treatment of BPD within CAT, PIT and MBT therapists, and that CAT in particular had an established training and system of accreditation which was popular and accessible to a wide range of psychological practitioners. 
People are grappling with how services can be organised and how any therapists undertaking work with people with BPD can be supported and assimilated into current support and treatment networks. Clearly the current IAPT stand alone model won't work.
It's quite interesting standing outside the psychotherapy system and seeing and hearing people's concerns. RAID had a transformational effect on liaison services, together with  a variety of policy and strategy documents. So if there are significant savings demonstrated from some of the 11 pilot services and these can independently verified, that's likely to have most effect with GP commissioners.

Cross references:
- Has CBT killed the human spirit? (June 2012)
- CBT rules in the House of Lords (October 2012)
- Alphabetti spaghetti therapies (June 2008)