An NHS worker warns that gains in mental health care must be defended by focusing on staff retention.
“I work in a busy centre delivering the Improving Access to Psychological Therapies (IAPT) programme, which treats those suffering from common mental health problems such as depression and anxiety. We’re funded by the Department of Health, now via the new GP clustering groups, and see hundreds of patients referred by their GPs every month.
We mainly deliver Cognitive Behavioural Therapy: a talking therapy designed to help patients change their outlook and behaviours. Our results are clearly measurable, so we can identify effective approaches and submit data back to Department of Health in order to inform and develop future practice. This system is surprisingly straightforward and transparent: although all data is anonymised, the results are published on the DH and IAPT websites.
IAPT has transformed access to therapy. It used to take 8-9 months to see a psychologist; now it’s 4-6 weeks. Our treatments involve lots of patient contact, but we reach more people by running telephone and group sessions, following up with face-to-face treatment where problems are more severe or prove resistant to the initial treatment.
Steering patients towards telephone work can make it hard to visualise them and to respond to them empathetically. While there’s evidence that telephone and group treatments work just as well as face-to-face, these treatments are prioritised to keep costs down. Whether or not this is the right approach remains open to debate. Where possible, I think it’s better to have a mixture of face-to-face and telephone sessions with patients.
One of our priorities is minimising the risk that patients harm themselves or others. Of course, not all mentally ill people present a danger, but we do have patients who cause alarm or leave suicide messages on our email or voicemail. I think many patients don’t know how to access help if they need it, and unfortunately we are only a 9-5 service and cannot respond out-of-hours. Many NHS trusts therefore have a crisis helpline or advise patients to contact their GP or A&E if they need urgent help,
More public information about this would be helpful, as IAPT services are not crisis services and we can’t offer help for those who are actively suicidal. We do, however, have to tell other professionals if we think there’s a risk to themselves or others – particularly if children are involved, as legal changes mean we are now required to act if we think there might be a risk to children.
This can actually get in the way of treatment, as many patients fear that if they’re diagnosed with a mental health problem their children will be taken away – particularly if they admit to suicidal thoughts. We try to reassure patients that this is not automatically the case, but if we believe there is a risk of harm to children we have to act within safeguarding procedures; think of the consequences of not acting (eg. in the Baby P case).
The downside of IAPT is common to a lot of public services: high demand. The volume of work is physically and emotionally exhausting; my caseload averages 60 patients, and I have to try to meet all their needs within the two-week timescale set by IAPT central. Like A&E departments, we are monitored on waiting times and penalised if we don't meet them.
There’s also the problem of joblessness. Ultimately, we’re supposed to help these people – who are losing their disability benefits – back into work. But how does this work if there aren’t any posts to fill? How can we do a decent clinical job when people’s main focus is their finances and employment status? I think people shouldn’t have their benefits cut until there’s a job to go to, and it should be easier to reduce support gradually as people move slowly into work.
I also worry about a lack of career progression in IAPT. There’s no promotion route internally within each office, so staff need to apply for higher-level posts through a clearing system. That only operates once a year, so if you miss out you don’t have another chance for 12 months.
As a result, many qualified staff ‘bed-hop’ to different services in search of new opportunities – something IAPT got wind of in 2012, and tried to address by offering 'Top-Up' training to staff over a six-month period. This certainly injected a new energy into the work, along with more daunting challenges – such as treating people who have depression or anxiety alongside long-term conditions such as chronic pain.
IAPT could offer members of staff the opportunity to train in specialist areas, like family work or psychosis. They could then get banded pay for these areas, rather than staying on the same pay indefinitely. I think that would be better than trying to increase the skill-set whilst keeping the pay ceiling: after all, this way, you’re giving people more work and increasing their value in the job market, without addressing the search for promotions that caused the problem in the first place.”