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Richard Layard
What is the future for state funded psychotherapy services?
TRANSCRIPT Excerpted from British Psychoanalytical Council Recording Part 5

I think the most useful thing I can do this morning is to describe where I think we are with the initiative, and what has to happen if we are really to get adequate access to evidence-based therapy for everybody who needs it.

So first, and this is the right way we should think about any problem, first let me describe where we think we need to get to. What's a description of an adequate system? And then come to the question of how are we going to get there and what is going to happen over the next three years.

The basic concept is that we need adequate teams of therapists in every PCT area, and we've estimated that for a typical population of say a quarter of a million people, a London borough or equivalent, we need a team of some 40 therapists. Which if you multiply it up, means something between 7500-8000 for the whole of England. These numbers are very similar to the ones that the Sainsbury Centre came up with independently, and I believe they are rather similar to the ones that NICE is coming to for its commissioning guidelines, using actually a completely different dataset. So I think these are numbers we should take rather seriously and have in our heads.

What would these therapists be doing? The majority of them would be delivering regular, sustained, one-to-one therapy recommended in the NICE guidelines for citizens needing step-through care. So that is the standard thing which most of you know very well and that is the centerpiece of this initiative, and those would be the Step Three - people doing Step three type work would be 60% or so of all the therapists. There would also be therapists giving Step Two care, brief interactions, as also recommended in the guidelines, again mainly one-to-one. And these would be the other 40% of the therapists, so we are talking about something like 60% what you might call high intensity therapists, doing high intensity work and something like 40% doing low intensity work.

In addition as we know, many of the citizens we are talking about have got all kinds of social problems and employment problems, housing problems, benefit problems, the team would need to include experts who can help them with that closely on the employment front, perhaps the largest number.

The team would operate on a hub and spoke basis. Meaning that it would have a central location where there was supervision, training, and record keeping, administration and so on, but much of the therapy would happen nearer to people's homes, in GP premises, or elsewhere. How would people get there? Probably the largest number would be referred by a GP or occupational health or job centres but there would also be self-referral, this is a really important principal that's now been accepted, partly on the basis of one of the pilot sites. Which has shown that the people who self refer are not the 'worried well'. But actually sicker than the people on average who are referred through the GPs.

So what we are talking about is a specialist service for depression and anxiety separate from general practice, to which general practitioners can refer people. But not part of the secondary care system which will continue to focus mainly on people who are even more severely distressed.

The service would be run and directed by therapists, this is also very important and of course it would be funded in the normal way through commissioning by PCTs, with some qualifications in the immediate future that I'll come to.

The range of therapies, would be whatever is recommended by NICE at the time, and that may change over time, and within that range, patient choice should be a major factor. All outcomes will be systematically monitored, typically by asking the patient to complete a PHD9 or GMD7 or both, sheet before each session.

That's a picture of what would be an adequate system. How do we get there and how quickly can we get there? Well one obvious feature of the present situation is the shortage of people trained in CBT relative to the numbers needed there. I think anyone can see that there is a greater imbalance in the supply and demand of people trained in CBT than in any of the other therapies. So there will have to be a major training in CBT, which doesn't mean that CBT is the only therapy that will be used in the service, far from it. It will be the case that the major training effort is in CBT. And there will be again the two types of training corresponding to the higher and lower intensity work. With the high intensity therapist being recruited from people with considerable prior experience of working with mentally ill people, either as clinical psychologists, practitioners of other therapies, therapists, counsellors, nurses and so on. The training will be two days a week, off the job in the training centre, normally the university, and three days of supervised work in cases, and it will last a year.

The training for the low intensity work will be available to a wider range of candidates and will involve a one day a week off the job element and also last a year.

At the same time of course, we must take the proper advantage of all the well qualified therapists who are already out there. And of course it would be impossible to make any progress if they weren't there, because who could do the supervision and training, provide the example and so on, to people who are being trained. The therapists are needed for the existing and future service users and they are needed to help with the trainees.

So if you take the stock of people that we already have, available, and obviously we can't drain the whole of the rest of the mental health service for this purpose, we can get some people, either from within the rest of the NHS, or the private practice in to help get this launched on the scale needed. We take the stock we already have, plus the accumulated stock of newly trained people.

We think that it would not be possible to cover the whole country with the adequate service that I described at the beginning, in less than six years. But we must be committed to doing it within that period. And the plan that was put forward in the proposals to the Health Secretary? was to get half way in the three years, that was how we calculated the money needed and as you know we got everything that we asked for.


So what's going to happen with this money? In the first year there will be, in each of the ten strategic health authority regions, one training centre for high intensity workers, and one training centre for low intensity workers, which might be separate, or they might be in the same place. So there's going to be ten training efforts, one in each region, set up over the coming months and there will be a big discussion involving obviously the centre and the health authorities about who those will be.The order of magnitude of the training effort would be something like 500 trainees in the nation the first year. And something like double that in the following years.

So that's the training. Now obviously the delivery, obviously the pattern of development has got to be uneven in order to provide some centres of excellence which are beacons to the rest of the country as to what a service should look like, and also provide an adequate environment in which people can be trained and properly supported. So there would be a limited number of teams that receive special funding in the first year, something like between 20 and 40 teams would be receiving special funding in the first year, and they would be providing most of the job placement for the trainees.

In the first year, the money will be centrally held and distributed, in agreement with the strategic health authorities. In the second and third years there will have to be more teams and the aim would be to use this money that we have, to increase the coverage of high quality services, funded from this money, over half the country half way to where we need to get to.

And the whole process will be strongly performance managed from the centre and I would like to mention, if you want to know how secure all this is, that this whole programme has got the personal support and commitment of the head of the NHS, David Nicholson, and the Head of Commissioning Martin Bricknell. I think this is very important because they stay longer than politicians and it's really important to know that this is embedded, really now embedded into the top priorities in the NHS.

Now that is how the money will be spent but of course there's something else that goes on, which affects the whole country from the first year, and that is the instructions which are given to PCTs, to all PCTs, through what is called the NHS Operating Framework. And there will be pressure through that on every PCT to up its provision of psychological therapies out of their own money.

One of the really important things that we secured, was that out of only 13 targets, so-called PSA targets, the Treasury targets for the Health Service only 3? covered the psychological therapies and that of course will be devolved right down to the PCT level. Each PCT will have to come up with a three year plan for how they intend to provide increased access to psychological therapy, together with quantitative commitments to improved access numerically, which they will be held to by the strategic health authorities. So there is a mechanism there, a really important mechanism, for putting pressure on the PCTs… but probably even more important from the GPs and citizens side, lets keep up that pressure as well. Also important pressure is going to be coming from NICE, through the commissioning guidelines that they are going to issue, and of course there will be pressure from the Health Care Commission. So we are altogether in quite a good situation, but this is something that will require absolutely continuous and relentless pressure for it to happen and it is also difficult, a difficult thing to do. But we have to do it and that's what we owe to the millions of people who haven't had what they need and deserve to have.

The Savoy Conference: The Psychological Therapies in the NHS Science, Practice and Policy, November 2007
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