IAPT: help or hindrance to general practice?

Abstract

Key messages

• IAPT needs to improve how it expresses itself to the outside world.

• Commissioning should be concerned with activities that develop and sustain trusting and therapeutic relationships as well as treat illnesses.

• Polyclinics should enable local people to collaborate and themselves improve their collective mental health.

• IAPT should enhance and not destabilise existing good practice.

Why this matters to me

For years I have been working to improve mental health provision in primary care. IAPT is potentially a powerful device to make a quantum leap forward, leaving behind poor primary care practice that medicalises appropriate distress and responses to life, and building from the best.

The Improving Access to Psychological Therapies (IAPT) Programme is tasked with delivering the NICE Guidelines on depression and anxiety following on from the analyses and work of Lord Richard Layard.^1–4 So what are the implications for general practice?

On the 16 September 2008, a consensus statement (Box 1) was signed at the Royal College of General Practitioners (RCGP) by a significant number of organisations, including the RCGP, Royal College of Psychiatrists and Primhe (Primary Care Mental Health and Education). This statement was presented to the Secretary of State for Health, who responded to it at the New Savoy Partnership Conference in London on 27 November 2008, by making four separate commitments in a Statement of Intent.^5,6

Box 1. Primary Care Consensus Statement 16 September 2008 (signed at RCGP).

Improving Access to Psychological Therapies

Psychological issues affect the physical and mental health of millions of people in England, yet few receive the psychological therapies that could help with recovery. Many with the courage to seek help have to wait for many months for treatment, or have to pay for it privately.

The Government has committed itself to turning this around and to implementing NICE Guidelines, so that everyone can have timely access to state of the art, evidence based therapies.

We welcome this initiative and call on the NHS to offer appropriate psychological therapies free at the point of delivery to all people who need them. We call for people to be given a choice of appropriate evidence based therapies available close to home, when they need them. We recognise that this could take up to six years to implement fully. So we urge the Government to invest in the further development and evaluation of psychological therapies to make England a world leader in this field. We commit to working together with the psychological therapy services and to ensure that the new services are safe, effective, and successful, and fully embedded in primary and community facilities.

In relation to primary care services this stated:

‘We will work with primary care services to achieve seamless, person-centred care for patients by:

• Ensuring that there is a GP in every multi-disciplinary IAPT team;

• Improving the skills of all primary care staff in recognising and managing the care of people with anxiety and depression;

• Supporting primary care clinicians to make evidencebased decisions when signing people off sick and to offer appropriate care while they are unable to work;

• Helping Practice Based Commissioning groups recognise and address how patients' physical and mental health needs impact on each other.’

An opportunity to reclaim the language of mental health

This commitment by the Secretary of State for Health challenges us to work hand-in-glove with IAPT. We must see IAPT as more than a service to refer to. We must work closely with IAPT to increase our skills at dealing with mental health problems and also at promoting good mental health for all. For too long primary care and mental health services have been overly separated. For too long the term ‘mental health’ has been used to merely mean mental illness or the absence of mental illness. Services have also become biased towards ‘severe and enduring mental illness’ (SMI), a term that is generally interpreted to exclude non-psychotic illness, for which the term ‘common mental health problems’ has been commonly used. Such terms are inaccurate and unhelpful. Common mental health problems, for example in the case of major depression or long-term phobias, can indeed be both severe and enduring, not only for the individuals concerned, but also for NHS workload and the financial consequences of dealing with the societal outfall. IAPT offers us the chance to reclaim the language of mental health as we encounter it in the generality of life – in general practice.

In the words of the 2005 RCGP Position Statement about Mental Health and Primary Care, reprinted in this edition of the London Journal of Primary Care, mental illness touches the lives of everyone and reflects a shift from mental balance to mental confusion. This can manifest as depression, anxiety and defensive behaviours. We encounter this kind of emotional fragility in a large proportion of our patients and recognise it to be a normal part of the human condition. For generalists, the diagnosis of mild-moderate anxiety or depression is not the end of our involvement, but the beginning of a conversation about the various contributing factors, and from this the negotiation of a personal action plan that uses the discomfort of the moment as a stimulus to become a wiser human being. Mental health, whether in an individual or a community, means being aware and having control over different strands of our lives, a sense of coherence that motivates us to act and is the source of energy and joy. This (generalist) interpretation of mental health and illness is far more contextual, fleeting and everyday than the highly focussed interpretation that is used by psychiatrists.

The take-home message is that front-line primary care professionals, amongst them general practitioners and their practice staff, are all front-line mental health practitioners. We all need mental health skills. The best way for practitioners and staff to develop the necessary skills is to have mental health professionals working closely with us – not merely co-located but collaborating. Such mental health professionals need to be an integral part of primary care teams, not a separate tagged-on service to which primary care simply ‘refers’.

From fragmentation to integration

The introduction of new and specialised (if welcome) workforces always need to be integrated into, or act as a further resource to, existing work. If this does not happen existing and excellent work and teams can be ignored or de-railed with a consequent loss of morale. Furthermore, if such introductions occur without the continuing training and up-skilling of existing practitioners, there is an opportunity for those practitioners to be become further deskilled as they simply pass their caseloads to others. We need to ask ‘will IAPT integrate, or further fragment, efforts for good mental health?’

IAPT has the potential to be a powerful device for leaving behind poor primary care practice that medicalises appropriate distress and responses to life (however uncomfortable or sickening they might feel), and build from the best (of which there is much). Primary care practitioners can learn how to help patients to bring into focus what it means to be a healthy, whole, citizen – a mentally strong, socially-aware, action-competent human being. IAPT is one of the best opportunities to come along in the history of the NHS to facilitate this, because until now all the initiatives and accompanying incentives have focussed on diagnosis and consequent referral to specialists.

The belief that mind and body are separate is at the root of our desire to so rigidly demarcate roles to deal with mental and physical health. This separation finds its historical origins in Descartes some 300 years ago.^7,8 Since that time we have continued to steer brain away from mind, mind from body and physical from mental in much of the health and social care curricula and the services that are designed and delivered as a consequence.

But the mind is ‘embodied’ and there can be ‘no health without mental health’.^9–13 The notion that the ‘brain-mind’ (as many authorities now refer to it) delivers its minding (mental) functions separate from the rest of a person, is simply not consistent with known facts.^14,15

Thankfully it is now recognised that dynamic interaction between functions, rather than rigid separation, is the natural state, even at the level of a single living cell.¹⁶ Neuro-endocrinology research reveals sophisticated feedback mechanisms mediated by neuropeptides that integrate body and mind.¹⁷ The paper by Ruprah-Shah in this edition of the London Journal of Primary Care emphasises that the practical task of integrating IAPT with both generalist primary care and specialist mental health care requires the hard slog of creating networks and negotiating shared vision and learning from doing things together. Is this not also a useful image of what happens in a mental healing process? In everyday general practice we help our patients with the hard slog of internally ‘net-working’ to bring into view the different parts of their life and memories whilst exploring ways to accommodate (‘re-story’) them, and from this to move forward with hope.

IAPT could feasibly catalyse and inform the debate about payment by results. Whose ‘results’ are under consideration? It is convenient for service providers to divvy up the body into its various compartments and for commissioners to fund activities that are often contingent upon the needs of those who provide the service and not those that use them. However, being mentally healthy means being enabled to function as whole beings; ‘results’ need to reflect the need to optimise peoples' quality of life and social functioning. IAPT could stimulate evaluation of quality of being as well as the cure of disease – this would be a welcome reframing of the notion of ‘health outcomes’.

IAPT needs to ensure that its own design and delivery is aligned to the expressed needs and experiences of those using its services. This is especially the case in relation to the management of key comorbidities and long-term conditions (such as diabetes, CHD, COPD, cancer), as well as medically unexplained symptoms.¹⁸ Here lies another potential opportunity – IAPT might give us pointers to the evaluation of services for chronic diseases so that positive health-giving aspects are counted, as well as disease-treating ones.

What to do now?

Traditionally, commissioning has been concerned with the direct effects of discrete activities. But it could be concerned with activities that develop and sustain trusting and therapeutic relationships.¹⁹ We need to develop better ways to evaluate the un-dramatic but empowering aspects of our role as GPs to ‘hold people’ – giving them permission to pause and reflect rather than merely hide away from pain or rush to quick-fix solutions.

At an organisational level, for example a polyclinic, the same need is apparent – how can commissioners evaluate the ability of multiple multidisciplinary teams to hold an umbrella over the communities they serve that enables local people to collaborate and themselves improve their collective mental health.

The IAPT Programme needs all the help it can get from existing excellent practitioners, many of whom work in GP practices. There are many excellent practice-based counsellors and psychotherapists who have been practising CBT and other evidence-based interventions for many years and routinely measuring their outcomes. There are also some excellent ‘common mental health problem’ direct-access psychology services in operation around the country. However, I am concerned that IAPT may destabilise some of this existing good practice, as PCTs decommission such services to reduce their costs. This is a traditional trick – to transfer activities into the budgets of others. Of course, we do also need to actively support IAPT and be a ‘critical friend’ – always encouraging but intolerant of poor quality – wherever it is found.

The English have become adept at claiming the labels of excellence before, or without, actually delivering the goods. We now have ‘World Class Commissioning’,²⁰ which is a bit like putting the label ‘turbo’ in front of the word ‘Lada’²¹ and expecting an enhanced experience through dint of hyperbole. We must acknowledge that mental illness service commissioning is still weak,^22,23 and mental health commissioning is even weaker. Commissioners also need to have psychological-mindedness training and long-term support in their work if they are to appreciate the subtle and interconnected actions that are required for good mental health and wellbeing, including their own. They need to commission for mentally healthy communities^24,25 and make sure that leaders of polyclinics know what this means.

In conclusion, the IAPT Programme might make the mistake of following the traditional NHS route of promoting a fragmented, illness-focused service that increases the divide between generalist primary care practitioners and mental health services. Conversely, the IAPT Programme might become a much-needed opportunity to unite all kinds of practitioners and managers to (re)discover ways of practicing and managing that enable whole people in whole communities to be become healthy and be cared for. So far the language sounds like they are aiming for the latter. I hope so. But it will take the efforts of a lot more than the IAPT workers to achieve this turn-around. Primary care practitioners and managers must become fully involved – and the sooner the better, if mindful and caring general practice is to become re-established in this country.

Appendix

A few tips about getting involved with IAPT

Visit the IAPT website to find out details of programme roll-out nationally and in your area www.iapt.nhs.uk/. If you are interested in commissioning for wellbeing and healthy communities, as well as the latest evidence for ‘creating mental wealth’ and going beyond short-term solutions to long-term embedded societal issues, read the Dowrick et al paper (Building Healthy Communities: a proposed model for commissioning for health and not just for illness. Adapted from the North Mersey Mental Health Improvement Programme Primary Mental Health Care Think Tank, July 2005. Available for download at: www.upstreamhealthcare.org/Building%20Healthy%20Communities.pdf) and resources on the IAPT website. These include the Foresight Report (www.foresight.gov.uk/OurWork/ActiveProjects/Mental%20Capital/Welcome.asp), the Wellbeing Institute of Cambridge University (www.cambridgewellbeing.org/index.html) and the Changing Minds Centre in Northampton (www.changingmindscentre.co.uk/).

If your PCT is an IAPT site; contact the SHA GP and IAPT Programme Leads as well as PCT identified Lead(s).

Becoming psychologically minded

The practitioner

• As part of your CPD and revalidation processes, reflect on your strengths and weaknesses in relation to mental health and mental illness issues.

• Consider training to acquire evidence-based skills and technologies that will support you in your day to day practice – e.g. CBT, solution-focussed, problem-based or family systemic therapies. NLP is also increasingly gaining in popularity. These will help you gain more job-satisfaction as well as enabling you to look after yourself and your patients optimally.

• Consider becoming a GP with a Special Interest in Mental Health and/or attending a Masters Course, to do so see www.primhe.org

• Register with your own GP and ensure you look after your own health; know how and where to contact national organisations that can offer help if you are getting into difficulties (sooner, rather than later) e.g. www.dsn.org.uk/ and www.bma.org.uk/doctors_health/index.jsp

• Join, or set up a local peer-peer support group, perhaps with some of your secondary care colleagues. Counsellors, psychotherapists, psychologists and psychiatrists are often prepared and available to run such groups e.g. www.balint.co.uk/

• Consider taking a sabbatical or doing a practice swap (at home or abroad), with someone you know, or someone you don't.

The practice

• Be sure to know about all your local and national voluntary sector organisations and programmes (e.g. books/exercise on prescription) that can offer help and support to your patients – whatever the diagnosis or predicament. Keep the list up to date (the PCT or Local Authority may already produce one).

• Consider employing a job retention counsellor for the practice, or as part of a collaborative. Be well linked to your local Citizens Advice Bureau and consider them providing a ‘surgery’ on a regular basis at your practice.

• Evaluate the outcomes of your treatments and interventions and those, such as counsellors, who may be working in the practice.

• Consider training in mental health and wellbeing for all partners and staff – self-care/dealing with distressed or angry members of the public.

• Start the practice day with Tai Chi or a period of 15 minutes of reflection together.

• Hold regular practice meetings that allow discussion of ‘difficult patients’ and the downloading of emotional ‘static’.

• Consider commissioning regular clinics at the surgery from your local secondary care psychiatrist(s) as well as teaching sessions.