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Falling Mental Health Waiting Lists "Skewed" By Drop-Outs

There is mounting pressure for the NHS to meet targets for mental health services across the country (Alamy)

7 min read

Therapists have accused NHS England of presenting misrepresentative data that includes hundreds of thousands of people who drop out of mental health treatment without any follow up, in order to meet waiting list and recovery rate targets.

NHS England has recently recorded success in meeting mental health service waiting list and recovery rate targets relating to Talking Therapies, previously known as Improving Access to Psychological Therapies (IAPT) before it was rebranded in January. The programme is used by the NHS to treat people for common mental health problems such as anxiety and depression, with cognitive behavioural therapy (CBT) as the favoured method.

In 2021/22, 1.81 million people were referred to IAPT, 1.24 million entered treatment, and 688,000 finished a course of treatment, according to NHS England data. Therefore only 38 per cent of those referred actually completed treatment, which is defined as attending two or more treatment care contacts between referral and end of treatment.

The government target is that 50 per cent of eligible referrals to IAPT services should move to recovery; a target which was met by a hair’s breadth in 2021/22 with 50.2 per cent of those finishing a course of IAPT treatment moved to recovery and no longer classed as having a clinical mental health problem.

Some mental health professionals believe the official figures are “disguising” failings in the system, which in reality sees many patients drop out of treatment. They say that while the average number of people receiving a first talking therapy appointment within the targeted time is exceeding expectations, the number of those who go on to complete the course is significantly lower. 

Referrals to IAPT have been increasing year on year – reaching a record high in 2021/22 – and while NHS England reports that it has met government national targets to improve waiting list times and recovery rates, the system remains under immense pressure, with some people, including children and young people, still waiting more than a year for treatment.

Dr Elizabeth Cotton, a senior researcher at Cardiff Metropolitan University and a qualified psychotherapist, said that the discrepancy between therapy referrals and completion was “the worst kept secret in IAPT”.

Cotton has carried out a range of academic research and surveys over the last few years, the findings of which she believes show that complex NHS data is not as representative as it should be when it comes to tracking IAPT outcomes. She told PoliticsHome this problem had not gone away, with even more pressure to reach government targets after Prime Minister Rishi Sunak announced cutting NHS waiting lists as one of five key pledges for 2023.

“Within the sector there is a very serious problem but it's not part of the public debates, partly because no-one can manage the complexity of the discussion,” Cotton said.

“The IAPT model has introduced a standardised model of metrics and no-one's questioning that on a political level.”

Cotton argued that not acknowledging patients who drop out when calculating recovery rates allows NHS England to present a picture of a service that has better outcomes than it actually does.

To collect recovery data, NHS Trusts often ask patients to score themselves at the end of a session. Psychotherapist and co-founder of the Free Psychotherapist Network Paul Atkinson argued this is not an effective way of measuring recovery and disguises the fact that many people do not return to therapy despite not completing treatment.

Atkinson, who delivers free therapy to people on low incomes in east London, believes that despite a strong correlation between social deprivation and mental health problems, NHS England “ignores” long term recovery rates and does not sufficiently investigate the living conditions of patients. He said that while plenty of patients may see short term improvements after CBT offered on IAPT services, there is no data on whether long term recovery is achieved.

“I think that's why [the NHS] don't do follow up reviews, because I think they would just get pretty awful results after six months,” he claimed.

“Who knows? Because they don't do the research, there's no evidence base for it, so it can be ignored."

There is no obligation for NHS Trusts to carry out follow-up reviews of IAPT patients once they have completed a course of treatment. Published responses to FOI requests show multiple NHS Trusts do not carry out follow-ups and therefore do not record any data on long term recovery rates.

Camden and Islington NHS Trust said it does not routinely offer six-month follow-up appointments to individuals who have completed therapy and that clients are "discharged to the care of their GP following completion of a course of therapy".

On a webpage offering advice for people participating in talking therapies, NHS Berkshire said that sometimes it "may be appropriate" to arrange a follow-up, and that they might "recommend other services that can help you maintain the progress you have made in therapy or give you further support for your emotional wellbeing".

The government sets the national waiting time standard for NHS England that 75 per cent of patients finishing a course of IAPT treatment should wait less than six weeks for their first treatment.

In 2021/22, this target was reached with 91.1 per cent of patients waiting less than 6 weeks to access initial treatment. However, average waiting times for first treatment vary substantially across England, and while the average waiting time for a first treatment was 21 days, the average waiting time between first and second treatment was 50 days.

“The IAPT model has introduced a standardised model of metrics and no-one's questioning that on a political level.”

Ruth Jones, a psychoanalytic psychotherapist and regional representative of the Psychotherapy and Counselling Union (PCU) for the South West and Wales Region, told PoliticsHome she believed that the fact that services in her region are “desperately overloaded” has been “disguised” by the average 90 per cent rate for people getting an initial assessment.

She said many patients then need to wait for treatment to actually start beyond just an initial assessment, with their mental health deteriorating as they wait.

Conservative MP James Morris has called on the government to implement a review of Talking Therapies and “redouble its efforts” to properly research and prioritise NHS mental health treatment as part of the new Major Conditions Strategy. Morris said a review should also look at improving data collection on the effectiveness of the service.

The Labour Party has pledged to massively cut NHS mental health waiting lists if they get into government at the next general election, with the aim of guaranteeing mental health treatment within a month for all patients, not just initial assessments. The opposition party has also promised to recruit 8,500 new mental health staff by the end of their first term in office and to put an open access mental health hub for children and young people in every community.

Shadow Mental Health Minister Dr Rosena Allin-Khan agreed that issues with reporting around talk therapies was disguising shortfalls in the system.

“Far too often patients drop off waiting lists for mental health treatment despite referral," she told PoliticsHome.

“It is vital to have accurate reporting mechanisms in order for the scale of the crisis in mental healthcare to be grasped.

“The Tory government is failing patients. The scrapping of the 10-year mental health plan shows that yet again, the government is kicking long-term planning for mental health services into the long grass."

An NHS spokesperson said: “The NHS remains committed to increasing support through its world-leading talking therapy services and has helped record numbers of people struggling with their mental health.

“NHS Talking Therapies was the first part of the national mental health programme to implement a referral to treatment waiting time standard, and the routine collection of clinical outcome measures is a key characteristic of the programme.”

National data standards and the collection of high-quality data are used by the NHS to identify areas for improvement and reduce inequalities, although the NHS has recognised that more work needs to be done in address regional inequalities.

According to the NHS, most people who do not complete a course of treatment have more serious mental health problems, and it is hoped that the rebrand of Talking Therapies will clarify that these services are only designed to treat depression and anxiety, therefore ensuring referrals are appropriate for the service and reducing drop out rates.

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