Better access to talking therapies: what are the options?

If something in health improves outcomes and saves money for health services, should local areas have a choice over whether it is provided? Or should it be compulsory for them?

Talking therapies are one such example. Currently they are recommended by NICE for treating a range of mental health problems, and service users and organisations representing them campaign for better access to them. 

There is also an impressive cost effectiveness case for talking therapies. Cognitive-behaviour therapy (CBT) for someone with psychosis makes a net saving to health and care services of £998. If everyone recorded on the payment system as ‘high need psychosis’ accessed this treatment it would save £160m a year – not to mention health gain and broader societal benefits.

And yet access is mixed. For people with common mental health problems progress has been made – the Improving Access to Psychological Therapies (IAPT) programme has meant that around 13% of all people with anxiety and depression can access talking therapies over the course of a year. Others in need of talking therapies are not so lucky – for adults with severe mental illness and for children and young people, rates are much lower.

There are a range of policy responses to encourage organisations to provide interventions, ranging from the mandatory (‘you must do this otherwise you will be fired’), to the recommended (‘you may face some difficult conversations if you don’t do this’), to the discretionary (‘please do this, it’s for the greater good’). Which is the correct approach for talking therapies?

The NHS Constitution is being altered (after much campaigning) to make explicit that psychological therapies are part of the set of NICE recommended treatments people have a right to. However, this change is mostly symbolic, and I think is unlikely to make a difference. The difficulty is that providing the full suite of NICE recommended treatments across health care is unaffordable. So the right in the Constitution was unaffordable as written, and the amended right is still unaffordable, in addition to being unmeasurable.

Some have called for mandating access to talking therapies through NICE, in the same way as medications. This is theoretically possible: NICE can do technology assessments (where they assess the evidence and then make mandatory recommendations) on interventions rather than medications, and commissioners must provide them if recommended.

Technology assessments make no assessment of affordability: if treatments are cost-effective they must be funded. They are not quick, and the commitment to review all significant new drugs fills up the programme. A strong case for prioritising talking therapies over other drugs and interventions would need to be made. Support would be needed from national bodies, commissioners, clinicians and patients. With talking therapies already in NICE guidance the case may be difficult to make, and people will have concerns about implementing recommendations within three months with no central support. Also, can we justify singling out talking therapies from other much needed interventions such as radiology, or weight management programmes?

A target would be an alternative direct approach. Waiting times standards are being planned for all of mental health, so a logical step might be to commit to a waiting times target, for example to take effect in 2018, for anyone with a mental health problem to access talking therapies.

Or a prevalence target could be set, say for 20% of people with relevant mental health problems to access treatment each year. This has worked well for IAPT – and has the advantage of addressing our best estimate of need, rather than just demand.

A well-designed target is a clear statement of priority, and could make the other aspects needed for delivery more likely. However, targets detract from local autonomy, local improvement priorities, and have unintended consequences. I also doubt an incoming government will have appetite for challenging new targets, particularly given the precarious NHS finances.

If a target isn’t possible, a transformation programme could be considered, with investment and support to local areas, and national coordination where needed. Support for local areas could include facilitating sharing knowledge, training, and resource for transformation. Nationally, a real-time data system providing outcomes and activity would be a leap forward in transparency, research to show substantiated cost savings would be incredibly valuable, and advocacy to include the goal in national thinking and actions worthwhile.

But, returning to where we started, if talking therapies make therapeutic and financial sense, and are popular with people who use services, why aren’t they happening in our clinically led commissioning system?

There are of course many reasons but, fundamentally, the clinical case is not widely accepted and championed – otherwise commissioners and providers would make talking therapy provision happen.

To date, campaigning has focused on central levers for change – persuading NHS England, NICE or the Department of Health of the importance of talking therapies. This is important, but needs to be matched by making and winning the clinical argument – not just with the choir of those who work in mental health already, but with the broader clinical community, and particularly GPs as referrers and commissioners.

The new NHS England mental health taskforce has an interesting decision to make – do they focus on the centre, or on building a broader clinical coalition for change?   

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