Impact case study database

The English Improving Access to Psychological Therapies (IAPT) has greatly increased public access to effectively delivered, NICE recommended psychological therapies for anxiety disorders and depression [A]. From small beginnings in 2008 (when less than 80,000 patients were seen) it now sees around 1,200,000 people per year (NHS Digital, 2020) [B] and the NHS Long-Term Plan (2019) [C(iii)] commits to a further expansion with the programme seeing 1.9 million people per year by 2024. During the impact period the IAPT programme has tripled in size (from 434,247 in 2012/13 to 1,165,653 in 2019/20) [B]. The England-wide clinical recovery rate for individuals who receive a course of psychological treatment has improved from 43% to 52% [B] on the same timescale and is now in line with expectation from randomised controlled trials. Furthermore, nearly 7 in every 10 treated patients (68%) show reliable improvement [B]. New integrated IAPT services that bring together mental health and physical health care have been created and are achieving substantial savings in physical health care costs [D]. Clark has been the National Clinical and Informatics Advisor for IAPT since the programme started and is widely considered to be its principal architect. The work of his research group at the University of Oxford has underpinned substantial parts of the impact of IAPT, as outlined below.

Collecting Outcome data on everyone who has a course of treatment (two or more sessions before discharge). When Alan Johnson MP, announced the IAPT programme on 10^th October 2007, he stated that, once it was established, 50% of treated patients will recover “as expected by NICE guidelines”. In order to assess whether this ambitious target was met, it was necessary to devise a system for collecting outcome data from everyone who was treated. The existing NHS outcome monitoring system, which involved giving patients a symptom questionnaire to compete at the first and last session of treatment, was not up to the job. A national audit of counselling services showed that this system only collected outcome data on 38% of treated patients [A]. To get around this problem, IAPT adopted the session-by-session monitoring system pioneered by Clark and Hackmann [1] in their Omagh community treatment project [E]. On advice from Clark, the programme also decided that the nationally reported outcome metrics for IAPT (recovery rate and reliable improvement rate) would remove any incentive for services to fail to collect data as they would assume that anyone without a post-treatment (last available session) score would have failed to recover/improve. Together, these two decisions have enabled IAPT to achieve an unprecedented pre-post treatment data completeness rate of 99% for everyone who is seen at least twice (NHS Digital) [B]. This is better than in most randomized controlled trials and means that IAPT can accurately assess the outcomes that it achieves.

Improving clinical outcomes. The initial clinical outcomes achieved in IAPT (recovery = 40%) were well-below target. Clark & colleagues’ patient level analysis [2] of outcomes during the first year of the programme showed that better outcomes were associated with giving the NICE recommended treatment, and with services that had higher average numbers of therapy sessions and higher step-up rates. Their subsequent service level analysis [3] of data from 2014 confirmed the importance of an adequate number of sessions and higher step-up rates. It also showed the services that had shorter waiting times, lower DNA rates, and consistently identified the problems they were treating using ICD-10 codes, had better outcomes. Clark fed these findings back to services in an extensive series of regional and national workshops between 2013 and 2018 and they were incorporated into NHS England’s IAPT Manual (2018) [C(iv)], advance draft copies of which were available from late 2016. IAPT activity and outcomes have improved dramatically (recovery from 43% to 52%), during the REF2021 Impact period, meaning that 230,000 more people a year recover and 314,000 more a year improve than in 2013. Regional variation in outcomes has also halved. Longitudinal analyses show that improvements in services’ outcomes are strongly related to adoption of the quality standards identified in the Oxford analyses. Using the full national dataset, Clark et al [3] showed that the between-year improvements they identified in the service organization features (2014/15 to 2015/16) predicted service-level improvement in outcome. Subsequently, Clark reported that services continued to improve on these variables and that the degree of these improvements between 2015/16 and 2018/19 predicted over half the variance in service improvements in the proportion of people who have recovered by the end of treatment (R²=.54) [F(i)]. These findings were independently confirmed using data collected from London IAPT services between 2013 and 2019 [F(ii)].

Providing the combined clinical and economic arguments for further expansion and development of IAPT . On 14^th July 2014 the arguments outlined in Layard and Clark’s 2014 book entitled Thrive: the power of psychological therapies were presented at a major public event [G] in London, chaired by Andrew Marr and attended by senior politicians of all persuasions (including Alan Johnson MP for Labour and Norman Lamb MP for the Coalition). This event, and multiple private meetings with politicians and treasury officials, helped ensure that Labour, the Liberal Democrats and the Conservatives all included a commitment to expand IAPT in their manifestos for the 2015 General election [H]. The government and the NHS subsequently confirmed major expansions of IAPT in the NHS Five Year Forward View (February 2016, page 15) [C(ii)] and the NHS Long-Term Plan (January 2019, page 68) [C(iii)]. Thrive (page 209) also argued for the creation of integrated IAPT services that provide co-located mental and physical healthcare for people with anxiety/depression and a long-term physical health condition. In March 2015, NHS England asked David Clark and the President of the Royal College of Psychiatrists to co-chair a working group to define the operational principles that would underpin integrated IAPT [H]. The working group’s recommendations were confirmed by the British Psychological Society, and the Royal Colleges of Psychiatry, General Practice and Physicians in a joint statement issued in November 2015 [C(i)]. Clark was then asked by NHS England to Chair the Education and Training Group that would develop curricula for training the psychological therapists who would work in the new integrated IAPT services and to also join the group that elaborated the clinical model, selected CCGs to receive early adopter funding, and set-up national and local evaluations [H]. 37 CCGs were funded to develop integrated IAPT services in 2016-2018. The official NHS England Blog (10^th July 2019) [C(vi)] confirmed that these services were achieving excellent clinical outcomes while savings physical healthcare costs as predicted in Thrive. NHS England has confirmed that 75% of all CCGs in England are now developing integrated IAPT services.

Take-Up of NICE recommended treatment for social anxiety disorder. The specialised cognitive therapy for social anxiety disorder (CT-SAD) that Clark and colleagues developed and initially tested in Oxford [5] had been recommended as the first line treatment for social anxiety disorder in the NICE Clinical Guideline (CG159, May 2013) that was published just before the start of the Impact period. This recommendation has since facilitated its widespread adoption. CT-SAD is in the national training curriculum for IAPT CBT therapists (latest edition January 2019 [C(v)]), has been taught to over 4,800 English IAPT therapists and has been used to treat 64,000 patients during the Impact period. During COVID all the IAPT therapists moved to delivering treatment remotely (by video link). NHS England asked Clark and colleagues to provide detailed guidance on how to do this and the resulting webinar was viewed by 2,613 NHS therapists up to 22/07/20. The Canadian Province of Ontario has recently started its own IAPT programme (called “Structured Psychotherapy”) and has adopted CT-SAD as the social anxiety treatment to be included in its therapist training programme [I]. To assist with such the training initiatives, the Oxford team created a free therapist resources website [J] that includes the therapist manual, specialized measures to guide treatment, and stream-able videos of a full-day clinical workshop by Clark plus 45 short videos illustrating key techniques. As well as being extensively used by IAPT training courses, the website had over 16,500 registered clinical users in 144 countries. Together they visited the site 268,459 times during 2020.

International Impact of IAPT. The success of IAPT has attracted considerable international attention during the REF impact period. As the NHS’s Clinical and Informatics Advisor for IAPT and the author of Thrive, Clark has been invited to advise health commissioners and ministers in multiple countries [I]. Many of these countries have subsequently started IAPT-like services and others are considering doing so. The most advanced is Norway, which now has over 50 IAPT services (termed “Prompt Mental Health Care”) that use the same outcome monitoring system to England and report similarly good outcomes [I(i)]. The Ontario [I(ii),(iii)], Israel [I(iv)] and Australia initiatives are also all adopting the outcome monitoring system and other IAPT features that derive from Clark’s research. International press coverage includes a feature length article in the New York Times (24^th July, 2017) [K] described it as “ the world’s most ambitious effort to treat depression, anxiety and other common mental illnesses”, and a December 2018 article that discussed IAPT in the Canadian Globe and Mail [K] was simply entitled, “ For better mental health care in Canada: look to Britain”. An independent report in 2018 [L], commissioned by the Ontario (Canada) Department of Health, concluded that IAPT was the world’s most successful attempt to increase public access to evidence-based psychological therapies for mental health problems. Finally, IAPT was selected for presentation as an outstanding example of UK innovation in mental health at the First Global Ministerial Mental Health Summit Government in London on 10^th October 2018 and in the main plenary session of the World Government Summit in Dubai on 10^th February 2019.