The IAPT story: a case for old fashioned working?

Access to psychological therapies for those with severe and enduring mental health problems has been much advocated for in mental health circles of late. Great strides have been made in recent years for those with common mental health problems through the Improving Access to Psychological Therapies (IAPT) programme. So, what has IAPT achieved, and how has it done it?

In terms of achievements the figures are impressive – going from two pilot sites in 2007 to a national service which should treat 900,000 patients each year by next March. It has the best data in mental health, perhaps the whole health service, and some services are now producing recovery rates of over 65% for those treated.

A large part of IAPT’s success is because it is fundamentally a good idea, providing new NICE-approved interventions for common mental health problems. The programme also benefited from being in the right place at the right time – results from pilots were ready to inform spending review discussions, policy announcements were needed, and the programme started in the days when money could still be found for new initiatives.

But the road to implementation hasn’t always been smooth – the transition to the new health system was a particular stumbling block – and the programme remains controversial. Challenges remain: meeting the current targets, providing choice and ensuring equality of access, and linking with employment support. 

Yet despite the difficulties, building an evidence-based service for a traditionally under-served group in seven years is a real step change in quality of care. So what really made a difference in getting there?  

Many things, of course, and in this mix three deeply unfashionable factors were significant: targets, a centrally controlled and directed implementation programme, and the close involvement of politicians.

Firstly, targets. Even in 2007, it is unlikely the injection of resource would have been agreed to without a clear commitment to visible results. The challenge of treating 15% of the 6.1m people with common mental health problems annually by 2015 meant that the programme was pushed from the beginning to deliver results quickly. Once set, ambition is hard to step back from – meaning the focus on IAPT has survived a change in administration and transition, where other areas have not been so fortunate.

Secondly, the central programme team has played a strong role. In the early days they defined what quality looked like, and provided impetus for change through tight project management. The programme team have provided a balance to the drive for results a target brings – strong clinical leadership making the case for services, a focus on quality, and providing capacity to do the development work needed to support a national programme. Crucially, they have been able to provide support locally and voice nationally for IAPT, needed over the last year to boost performance and deal with the inevitable political attention an unmet target brings.

And lastly, politics. The initial choice of IAPT as a national programme was after extensive political lobbying, with the rare combination of professional organisations, politicians and patient organisations pushing for the same thing. More recently, political interest in the scheme has allowed IAPT to enjoy a privileged status, taking an entire paragraph in the 14/15 mandate (cancer was namechecked but included no specific objective). Norman Lamb has both championed and held the programme to account for delivery (as I experienced first-hand working as the Department of Health policy lead). The sustained political interest, including monthly accountability meetings, has meant that delivering IAPT has never been far from senior officials’ minds.  

I know that there are good reasons why central programmes, targets and politics are viewed as a toxic combination. Quality of health services has suffered from punitive performance management regimes, unintended consequences, gaming and central directives riding roughshod over local context and need. IAPT has not been immune from these issues, but a combination of clinically justifiable targets, strong clinical leadership, a clear problem to be solved and passionate staff taking forward services locally has helped the benefit far outweigh the difficulties in the approach.

At the Health Foundation, we’re interested in how change can be achieved in health services. The IAPT experience suggests the ‘old methods’ are worth considering further and that, when well implemented, central programmes can drive change at impressive pace. Of course it’s not the answer to every problem, and greater localism will be the right thing for many situations. But rather than banishing the old methods to history, perhaps it is time for a more reasoned debate as to when and where the power of targets, politics and central initiatives can be harnessed to improve quality where improvement is desperately needed.

Felicity is a Senior Policy Fellow at the Health Foundation, www.twitter.com/FelicityTHF