Lord Richard Layard - mental health: from rhetoric to reality?

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Lord Richard Layard

Lord Richard Layard, Professor Emeritus at the London School of Economics and founder of Action for Happiness, speaks at our event on moving conversations on mental health from rhetoric to reality, part of our breakfast series on the big election questions.

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Transcript

The key concept of course is parity of esteem. And I think it is really important that we have a very clear definition of that, because people love saying ‘oh we don’t know what that means’. I think the definition is very clear, it is that if you are mentally ill you have the same access to NICE recommended treatments as you would if you were physically ill. That is a very precise definition that you should, I would have thought, be able to use with commissioners and whoever else. And of course the obvious feature of NICE recommended treatments, which is not being carried out is that there should be psychological therapy offered to everybody with mental illness and at present we are miles from there. And therefore a major part of the transformation of mental health in the coming parliament has to be a much wider access to psychological therapy. So I am just going to focus on that and on the future of IAPT and tell you what I and some others have been trying to persuade the political parties to include in their manifestos about psychological therapy.

So there are four issues. One is access, one is quality, one is outcomes and measurement and the last is finance and commissioning. So starting with access, the access target has been crucial. Without the 15 per cent of need target that we have had for adult IAPT it would have basically wilted. And it is quite amazing to see how this target which we managed to get into the NHS mandate has caused such alarm and despondency right up to the desk of the Prime Minister. He worries about it. Can you imagine? It is extraordinary really. This 15 per cent has been one of the weirdest levers that I have ever heard of in the political process, and a huge amount of activity in Whitehall to try and achieve this target.

So what have we got? We have got 6 million people, adults, with depression and anxiety in the country. And the target has been that 15 per cent of them should be seen by IAPT with a view to psychological therapy which of course is an incredibly low proportion. We picked it because it was the most we thought was feasible in terms of training and quality, but it is incredibly low. It actually doesn’t mean 15 per cent because only in fact 9 per cent within the 15 per cent are actually given a course of treatment meaning they are seen at least two times. And of course we are not touching the huge problem of co-morbid physical and mental illness. So it is really important that we have an ambitious target for 2020. And the target we have been suggesting is that 25 per cent should be seen so up from 15 to 25 per cent which is basically continuing the expansion at the rate at which we have had it so far which seems to be eminently possible.

We have got this figure I think into the Labour party report that came out yesterday. I think that there is good support in the Liberal Democrats as we saw yesterday morning and let’s hope the Conservatives will also support it. But I have also contacted UKIP and the Greens. Okay so that is adults, now children. The position with children of course has been even more desperate. And the extraordinary thing is that there has been no target for access for children. And if you want to understand why it was so easy for the CAMHS to be cut, it is a very simple reason, that there was no target for children and there was no leverage or pressure that could be applied to commissioners to deliver or to respond to what was happening with the local authority finances. So the target we are suggesting for children is 33 per cent which in the light of the figures we have also seems feasible. It involves something like a 25 per cent expansion. And we think that this should be almost totally school based so that CAMHS is much more an outreach service seeing people early rather than waiting for them to reach that horrific threshold where they have to go to some clinic. 

So this will need a training programme for adults and child psychological therapists of the scale we have had, or we were meant to have been having for adults something like a thousand therapists a year and for children something like five hundred therapists a year. 

Now let’s come on to quality because people sometimes worry about these access targets because they are leading to a reduction of dosage. And that certainly has happened and that has to be monitored extremely closely. We are not just saying people should be offered nice recommended treatments but they should be recommended the dosage in terms of numbers of sessions that a person is seen. So that is one thing. The other of course is to get the wider range of therapies which are recommended by NICE. So basically what we have at the moment and within IAPT is either CBT or counselling. And we have to get the other therapies which are interpersonal therapy, brief psychodynamic mindfulness based cognitive therapy and couples therapy. Couples therapy I think is very important and I think whatever government comes in is going to want to deal with a crisis of conflict in the family and domestic violence through much wider roll out of couples’ therapy. 

But then there is also the problem of the comorbid people with physical illness. We need therapists who understand particular conditions. Breathlessness, heart problems and so on. And that is going to be another crucial phase in the development of trained therapists. People who can work with people who have comorbid problems. And then there is the question of where they should work. This has to be worked out. But I think that our general view is that these therapists ought to be out there with the acute specialists or with the GPs. They shouldn’t be seeing someone in a separate place not working with the team who are treating the physical problem. But we think that it is best if it is organised with them within an IAPT team where there is a professional standard and supervision as well.

Quality is also of course crucial for children. And the IAPT programme for children and young people is currently transforming CAMHS away from a not very evidence-based service to providing NICE-recommended therapies. It only covers, I think, two thirds of the country. That has to expand, that transformation process. Third, outcomes and outcome monitoring. This has been crucial for the effectiveness of IAPT in that the therapists have a much clearer idea of how their patients are getting on. So we have session by session monitoring. But it has also, of course, been crucial for the politics of it because it persuades politicians and commissioners that it is not money down a black hole when they are financing therapy. And we have achieved extraordinary rates of completeness in outcome monitoring. 95 per cent of all the patients we have outcome monitored for essentially every session of adults. And this is partly the reason why the journal Nature has called IAPT world beating and I think it probably is the best effort to deliver evidence-based psychological therapy that there is anywhere in the world at the moment. And we have got ten countries now considering introducing their own version of the IAPT arrangements.

For children we only have limited outcome monitoring at the moment and that has got to become complete. And of course for psychotic problems we have no outcome monitoring and this is a real problem. It leads to a much less focused approach to treatment because the thing which I learnt from David Clark – and this doesn’t apply to psychosis – but the thing which I learnt from David Clark which I thought was so striking was the idea that we are not talking about condition management when we are talking about depression and anxiety disorders, we are talking about recovery. And in particular by anxiety disorders where you can get complete recovery from all the anxiety disorders and, of course, much-reduced rates of relapse for depression. So we are talking very much about outcome monitoring as an instrument for not just proving something to politicians but for introducing a more purposive approach to the handling of people’s problems including psychotic patients.

When we are talking about staff in CMHTs and on the wards of course we are not talking about as we were with IAPT trying to build a new service, we are talking about the service which we have but transforming it by turning more of those people into people who can deliver psychological therapy with an outcome focus. 

Finally how can we make it all happen? So hopefully we will persuade the politicians to step up to the mark and that does lead to some pressure on commissioners and Barbara Hakin gets out and about. But in the end this very much depends on whether the commissioners themselves are persuaded that this is something they have to do. So how can we incentivise them? Well we now have a really good database where we can see how they are delivering on all the things I have been talking about on the mental health intelligence network website and it is very easy to get them into the league table if you want to as a way of applying pressure. So that is what, of course, NHS England are using when they go harassing. But it is also what all of us can do when we go harassing. And I think Jenny here is going to be making it much easier for ordinary citizen groups to harass their local CCGs by looking at this database and saying ‘now why aren’t you stepping up to the plate?’ I think that is incredibly important. 

But how else can we persuade commissioners? Well I think the other argument is the one that Claire mentioned, that it won’t actually cost them anything to provide more access to psychological therapy because there are such savings to be had.

So let me just end with a few really interesting facts. More than half of people – the 6 million that I mentioned – have a co-morbid physical condition. And, as Chris Naylor here has shown with Mike Parsonage – really, really important work – if a person has a given physical condition of given severity but they also have co-morbid mental illness their physical healthcare will cost the NHS £2,000 a year more. £2,000 a year more is a hell of a lot of money going on physical healthcare because the person has a mental health problem. That doesn’t prove that if we gave them treatment we could save all of that, but here is another extraordinary fact. There have been 91 trials in the United States where people have, in a proper controlled experiment, given one group of people psychological therapy and another match group not. And they have found that the physical health care usage of the people who got the psychological therapy was 20 per cent lower than of those who didn’t which is a saving, in British terms, of £1,200. 

I only know of one British study which is a very enterprising GP in Berkshire called Arek Hassy, who analysed patients who were referred to IAPT and another with the same mental health problems who were not referred to IAPT for various reasons. And he has compared the physical health care costs of the two groups in the subsequent year or two and he again found a saving of something like £1,000 from the people who were given the IAPT treatment. Now the IAPT treatment itself cost £650 so you can see it is paying for itself. And again in these American studies in the smaller subset of them they could compare the cost of the therapy with the savings. And they found that in all but two of the cases the therapy paid for itself in savings on physical health care. This is an incredibly powerful argument to use with commissioners. So that is the sort of case we should make.

Now out there was put the piece of paper that we are circulating to the political parties so I would greatly appreciate any help that we can have in these efforts from any of you. And I think this is a really important cause and I think we can really relieve an incredible mass of suffering. I will say one thing more, my motivation for this is suffering, of course, and not the economics at all. And in the work that I have done where you have measures of people’s life satisfaction and then you try to explain it by various aspects of their lives, mental illness comes out as the biggest single cause of misery in advanced countries. I have done it in four countries. Physical illness comes next. And the things that politicians worry about like poverty and unemployment and I spent most of my life working on are much less important causes of misery and mental illness. We absolutely have to get that across to the politicians in our country.

Thanks a lot.

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