IAPT – Achieving the vision of Improving Access to Psychological Therapies
Webinar Blog and Q&A summary, 2 Dec 12:30-1:45
Connect Health “Change” brings you the sixth in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
In 2014, NHS England laid down an ambitious vision to put health care for people with mental health problems on an equal footing with care for people with physical health problems. People of all ages and from all groups should receive the equivalent level of timely, evidence-based, clinically effective, recovery focused, safe and personalised care as people with a physical health condition.
This session discussed a number of key themes and issues that reflected on progress towards the 2020 vision. These included how integrated approaches between physical health and mental health in IAPT is still under developed, that longstanding disparities exist in mental health support for BAME individuals, indirect COVID-generated demand on mental health services will be significant and how COVID has offered the opportunity to transform services.
- “Charlotte’s answer about improving population resilience was truly insightful and inspirational.”
- “Mini’s session really explained how to address health inequalities.”
Watch the Webinar in Full
Charlotte Augst, Chief Executive, National Voices discussed the true impact mental health has on patients.
Question 1: is there one key thing that you could suggest that came out of all the discussions you had? One fundamental error that we are making that the patients continually feedback about?
Answer: If I had to zoom right out and say just do this one thing, I would say be honest with your patient about what’s possible and what’s not possible by way of health care right now, and then open up a conversation about what the patient themselves thinks would be helpful.
In the meantime, whilst we wait for whatever it is that can’t happen right now, be that face-to-face support, be that a medical procedure and so on. And I think in that, acknowledge the hardship. And I think there’s something about trauma informed approaches, and I don’t want to get too carried away with that. But I think just even acknowledging that lockdown has been really hard for people, and that people who normally would use health and care services very regularly and were very much cut off from all the support, some of those people have experienced really terrible situations.
Even just acknowledging that, I think, will take the pressure off and we need to do everything we can to take the pressure off people’s mental health.
Question 2: Can some of the I statements help improve people’s internal resilience? And if so, how can we do this on a population basis?
Answer: I think that’s a question of leadership.
It’s like the clinician sits with one patient at a time, and can only talk to one patient at a time. But System Leaders talk to a lot of people. So that’s System Leaders in the health system, if you run the outpatient departments of so-and-so, if you run the physiotherapy department or the psychological therapist department of so-and-so trust, you talk to a lot of people. So I think that’s an opportunity to say some of these things that help people cope, like acknowledging trauma and making it clear who’s in charge, and making it clear how you can get hold of this person, making it clear when you will reach out again and those bits of information.
I also think there is a level above that, which is the sort of political and social leadership we have. And I think, the thing that I regret the most really about how we got through the first wave and how we arrived at where we are now is that, I feel we’ve had a real absence of that very clear values-based leadership that would have helped us to stay united in facing this massive challenge, and that we have allowed this initial moment of unity that happened early on in the first lockdown in a way to disintegrate, and to start a very tribal response to what’s going on. ‘It’s the old people who are dying not the young people, why do we care about them?’ ‘It’s the young people who are causing it, we need to stop them’ ‘It’s the Asians who live in large households, they’re to blame’.
I think it’s become really very fragmented and that, I think, will decrease our resilience in dealing with the challenges that next year will still very much hold. And I would have a real longing for a different kind of leadership that speaks to all of us in a different way and taps into our good will for each other.
Question 3: How can we get patients and practitioners together over the next four to five years?
Answer: I think we have to have conversations about what matters to people, and then take our lead from that, and that will force the integration agenda. Because what matters to people tends to straddle all the silos. And therefore, rather than thinking ‘who do I have to integrate with?’ The question should be what is the person or the community I’m here to support says matters to them? And if it then transpires that it straddles health and care, or straddles mental and physical health, or straddles housing and health, then that’s the integration agenda isn’t it? It needs to follow the conversation with the patient in front of you, or the community you’ve been tasked with supporting.
Question 4: We recently held a pain seminar, and Connect Health launched a public health literacy campaign called Flippin’ Pain™, which has been incredibly successful. And it’s very much run by patients, for patients. Is that an area that we need to concentrate on in mental health? Rather than trying to go through individual consultations and GPs, actually get out to the public and get a better understanding of mental health and what is available?
Answer: I wouldn’t want to argue against good mental health services for people who have quite substantial needs, or at points of view traumatic transition, clearly we do need those. But we also need the other thing. We need a more grown-up conversation about health and well-being and we need to take the whole self-management agenda much more seriously.
Just thinking through the COVID situation again, as far as I know, not a single piece of information has been produced by NICE or the NHS or the government, on how you look after someone who’s got COVID at home. Or how you look after yourself when you have COVID. Which I think just tells you everything about where self-management is on the agenda, nowhere.
The vast majority of COVID care has taken place in people’s bedrooms and living rooms. A very small proportion of COVID care is taking place in hospital. And we have not supported the people who do all that COVID care at home. There’s no, as far as I can tell, support with how do you support people who’ve got a high temperature? What does breathlessness look like? What are worrying signs and symptoms? Nothing.
And I think that’s just an example of how we still have a complete blank when it comes to realising that most health care happens in people’s houses. And we need to just get much better. We need to tackle the quality improvement there. How can we make that care better? More sustainable, and more evidence-based on what actually helps and supports people and that clearly applies to mental health.
Question 5: Moving into 2021, do you think we need to reset our targets because of COVID? Or is it reasonable to push on to 25% and accessing long term conditions across the board?
Answer: I’m not close enough to the data to know whether 25% is realistic or not. I think what I see makes me think existing service models won’t hack it. We need to complement or redesign them, with real community based, volunteer-based, peer support based, socially embedded models. Because the wave of need around mental health is just enormous.
Marie Chellingsworth, Group Clinical Director, Concern Group, discussed the challenges in taking IAPT services from where they were, to where they need to be.
Question 1: Where do you think the biggest resistance is going to be to long-term conditions? Is it the physical health providers who are going to provide the most resistance to this as they are very busy? Or is it from the mental health services themselves?
Answer: I think it’s an unintentional barrier or blockage that probably nobody recognises because everybody’s so busy, as you say, just dealing with the front of house and the back of house within their own organisations.
In terms of resistance, I think you need to break down the barriers that you either go to somebody for your mental health, or you go to somebody for your physical health, and we actually have this joint service, or this joint umbrella that’s commissioned if we can. Certainly from the clinicians I speak to, they really want to attend the long-term conditions training that’s being commissioned every year, in fact getting places for the increased expansion, we could fill those twice over I’m absolutely sure.
And I’ve done quite a lot of integrated work with digestive disorders units. I’ve just finished co-authoring an IBS app with Melissa Hunt from Penn University, around psychological support for Irritable Bowel Syndrome that follows NICE guidelines. And actually, we found no resistance on either side. Sometimes there can be some challenges on the patient side, because they either see their problem as integrated and get frustrated by the number of hoops they need to jump through before they get to either of us, rather than just having that unified sharing of information and approach.
But in the main I think it is just the business and that’s probably what we need to do is put a system in place.
Question 2: You’ve got a vast experience of IAPT services, how are we going to get anywhere near 25%?
Answer: I think one of the first things we need to do is probably change the way that we market services, in terms of doing much more partnership working, in terms of reaching out and doing much more integrated work with physical healthcare services.
Now, a lot of that does go on at the moment, but I think we just need to get some brand awareness of IAPT out to those areas who quite often, you know, I’ve done a lot of our integrated physical health care services locally and nationally, who often say ‘wow yeah we’d heard about it but we didn’t really think to draw the dots, so oh actually, we’ve never looked at it from that perspective that’d be really helpful!’ So I think if we can make sure that it’s on their radar, when they go into people’s homes, when they’re seeing patients, when they’re spotting signs, it will start to join those dots up.
I think the other thing we need to do is much more collaborative training. So, yes, we’ve got the integrated IAPT training, but that’s for IAPT staff. And I think we’re missing a trick there in terms of getting people together in the room for more training around, actually this is what each other’s services can offer each other at a local and national level. And I think that would be really, really beneficial as well, because I think that would help to bring people together in a way that hasn’t been done before through the current commissioning and instruction models that we’ve got.
Question 3: Moving into 2021, do you think we need to reset our targets because of COVID? Or is it reasonable to push on to 25% and accessing long term conditions across the board?
Answer: I don’t think it’s an either or. I think we need to focus across all.
IAPT put out, with the BACPE, a fantastic IAPT positive practice guide to increasing access to BAME groups. That has an auditing that all services are being encouraged to undertake, both in terms of people accessing the services and staff profiles.
With COVID I think we need to wait for the long-term guidance to come out to know exactly what to deliver to make sure we’re doing the right things, for the right people, at the right time. But I do think we need to be monitoring, as is happening at national level, in terms of access rates because we had a dip at the start of COVID. And we’re starting to see referrals increase across the board. But we’re not yet seeing the high rise that’s kind of predicted so it’s hard to know where we’ll be in six months or 12 years and there’s some capacity in demand modelling taking place within IAPT nationally for that, which is going to be really helpful.
So I don’t think we can separate those things out. I think we need to be having a unified approach across all of those things, which obviously means lots of work and lots of people and lots of resources needed, probably more than went into the original plan this year for expansion.
Dr Ollie Hart – GP and PCN Clinical Director, NHS Sheffield, debated MSK and mental health. Success and innovation in the integration of mental health in primary care and future gazing.
Question 1: When are PCN’s going to be ready to link with IAPT services?
Answer: I think they’re maturing all the time, and you’re right it’s tricky, COVID has set us back a bit because we’ve all been focused a lot on delivering vaccines and protecting services and so on.
But the real benefit Primary Care Networks is going to encourage localised integrated solutions with new roles emerging. I think over the next 18 months to two years is a realistic time scale where you’ll see PCNs really upping their game in terms of how they lead integration, health and social mental health and physical health coming together. But it will take a bit of time but over that time scale it will happen.
Question 2: Where is the funding going to come from to address needs? What are we going to see with the new requirements, post COVID?
Answer: Yeah money’s always a thing isn’t it?
I think what we always forget, though, is that there’s already a huge amount of money in the health system. And sometimes it’s just about reattributing it and repurposing how we do things. So this proactive approach to engage people around an integrated agenda, if anything requires a mindset shift more than it requires finance.
It always helps to have new roles and there isn’t lots of money coming to PCNs for these additional roles, I think my network’s going to get about 20 increase in workforce. But what will really multiply that effect will be the mindset shift of the rest of the profession.
Claire Forkes – Service Manager, Central Region, Occupational Health Services, Connect Health highlighted issues with employment and mental health – the link to longer term health outcomes, biopsychosocial approaches and the social impact on work.
Question 1: Clearly, things were challenging before COVID, there’s lots of different aspects on how COVID is going to impact us, one of these aspects being unemployment. How is that going to be in the mix when it comes to IAPT services trying to help people back into work?
Answer: I think it’s just going to strengthen the policy drivers that are already in play, to be honest. It’s going to bring it to the top of the agenda, I expect.
I think everyone’s anticipating an upsurge in referrals to IAPT and other mental health services, and possibly other physical health services. So I don’t think anything new particularly is on the horizon, it’s just going to strengthen the stuff that’s out there already and Marie might be in a better position to answer that in terms of what’s coming. But that would be my thought.
We already have a strong focus on employment and employability and improving that within the mental health arena. COVID is just going to increase that problem. So therefore, we need to put more emphasis on it.
Mini Mangat – Head of Patient Engagement, Connect Health, uncovered learning in ensuring a patient centred approach when developing services
Question 1: How can we engage the community to access mental health services? From a BAME point of view, what are the two key things that we should do that get them in front of practitioners?
Answer: What I’d say to that is it’s about getting our practitioners in front of those people, I think that’s the first thing, not the other way around.
So it’s reaching out and building relationships with communities. Because there’s a huge stigma in BAME communities about accessing mental health services. And sometimes, it’s about how we frame it, how we frame our services and the language that we use. But for me, it’s definitely about making that access easier, by going to the community, working with the community, and delivering culturally adaptive services, right from the point of where they access.
So it might already be in a community group that where they go to, we need to almost anchor onto things to make sure that we are there and spreading the word around about education of IAPT services.
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