Psychological therapies: From there to reality

1. Psychological therapies:From there to reality Kathryn Tyson Head of Mental Health Policy I�m Kathryn Tyson, head of mental health policy at the D of H. I feel privileged to be asked to speak to you, who know so much about the services I have only, since taking up post in September, begun to get to grips with. I was interested that you asked a policy maker to speak to this topic � not a professional or service expertI�m Kathryn Tyson, head of mental health policy at the D of H. I feel privileged to be asked to speak to you, who know so much about the services I have only, since taking up post in September, begun to get to grips with. I was interested that you asked a policy maker to speak to this topic � not a professional or service expert

2. Introduction Who am I? What can I tell you about? Policy maker �Handling� Use psychological therapies programme as worked example So I thought what I�d do as I struggled with these top two questions � well, perhaps not quite as existential as that! � was to describe to you what �being a policy maker � means. �Handling� is what we generally call the skills a senior civil servant exercises. Then I�d use the IAPT programme as an illustration. So I�ll talk for about 20 minutes, and there�ll be time for a couple of questions at the end. So I thought what I�d do as I struggled with these top two questions � well, perhaps not quite as existential as that! � was to describe to you what �being a policy maker � means. �Handling� is what we generally call the skills a senior civil servant exercises. Then I�d use the IAPT programme as an illustration. So I�ll talk for about 20 minutes, and there�ll be time for a couple of questions at the end.

3. IAPT � it�s simple really Improving Access to Psychological Therapies Let�s look at how the problem has been set out� �then at proposed solution Then how it can be so difficult Finally, how on earth I can help So � psychological therapies then �So � psychological therapies then �

4. The problem (Layard) There is a mass of untreated suffering in anxiety and depression which imposes severe burdens on the economy. Effective means of treating it are enshrined in NICE guidelines but these cannot be implemented with the current resources of people and money. Evidence-based psychological therapies like CBT are not adequately available. I�m sure you know that the case has been most compellingly analysed and argued by Richard Layard (Lord Layard) of the LSE, both in papers for the No10 Strategy Unit before the last election, and in his book �Happiness: lessons from a new science�. You know how the argument goes �I�m sure you know that the case has been most compellingly analysed and argued by Richard Layard (Lord Layard) of the LSE, both in papers for the No10 Strategy Unit before the last election, and in his book �Happiness: lessons from a new science�. You know how the argument goes �

5. Analysis (still Layard) For many people, work is a vital part of therapy and of the recovery process. At present there are more mentally ill people on Invalidity Benefit than the total number of unemployed people. Pathways to Work pilots show that many of these people can be helped back to work. These programmes should become available throughout the country.

6. The proposed solution (still Layard) We could meet reasonable demand within 5-10 years by a major programme to train more therapists. To maintain the quality of training and provision, this should be through psychological treatment centres, working on a hub-and-spoke basis� �with a clear funding stream to support the work � based on national targets. This should not be left to PCT discretion

7. What could be easier? Acknowledged widespread costly problem Evidence-based, NICE-endorsed treatment Popular demand Case argued by No.10 advisor Manifesto commitment Professional support In line with NSF �.. I could go on! So why all the difficulty? Why haven�t we just got on and done it? Well, let�s examine each of those sunny advantages in turn � this is an important part of my job � to understand the barrieirs to delivery of our wonderful policies, and through that understanding, to find ways of overcoming them.So why all the difficulty? Why haven�t we just got on and done it? Well, let�s examine each of those sunny advantages in turn � this is an important part of my job � to understand the barrieirs to delivery of our wonderful policies, and through that understanding, to find ways of overcoming them.

8. Acknowledged widespread costly problem But costs do not fall where spending is Burden �hidden� Unmet need is �cheap� Here�s the first one � remember? What this is saying is that you spend the money in health, but the savings do not accrue there. Government budgets are highly compartmentalised. Joining up is very difficult at a practical level. And these �mild to moderate� people are, for the most part, just quietly miserable at home, without the confidence to complain to clinicians or MPs. And we�re not doing much for them in Health now that we could save the costs of through this means.Here�s the first one � remember? What this is saying is that you spend the money in health, but the savings do not accrue there. Government budgets are highly compartmentalised. Joining up is very difficult at a practical level. And these �mild to moderate� people are, for the most part, just quietly miserable at home, without the confidence to complain to clinicians or MPs. And we�re not doing much for them in Health now that we could save the costs of through this means.

9. Acknowledged widespread costly problem But costs do not fall where spending is Burden �hidden� Unmet need is �cheap� Joined up Government Social Exclusion Unit CSR 2008 I�m not defending these arguments, just understanding and explaining them, remember, The answers lie with � The SEU has been and remains a powerful player, with the backing of the Chancellor. You�ll remember it reported a few years ago on MH and pressed (and continues to press0 for action across Government. The Comprehensive Spending Review (CSR) is the way Government will decide its patterns of spending for the next 3 (or 5) year period, form 2008. Work is starting now, and HMT have already said they will look favourably on joint bids from more than one department (in a further effort to tackle the �not joined up� issue. DH and DWP will work together with that enormous incentive.I�m not defending these arguments, just understanding and explaining them, remember, The answers lie with � The SEU has been and remains a powerful player, with the backing of the Chancellor. You�ll remember it reported a few years ago on MH and pressed (and continues to press0 for action across Government. The Comprehensive Spending Review (CSR) is the way Government will decide its patterns of spending for the next 3 (or 5) year period, form 2008. Work is starting now, and HMT have already said they will look favourably on joint bids from more than one department (in a further effort to tackle the �not joined up� issue. DH and DWP will work together with that enormous incentive.

10. Evidence-based, NICE-endorsed treatment + the people�s choice Not media-friendly But it�s not a drug! Requires workforce to do different things Here�s the next advantage we identified � so why isn�t it getting the Herceptin treatment? Miserable people don�t make nice news stories, not like the heartbreak of young mums, or high fliers struck down by a killer disease we�re used to the concept of the �wonder drug� but a wonder course of 6 to 9 sessions with a therapist talking things over is more difficult for us to grasp. And it requires GPs to do other than reach for the prescription pad; and therapists to train in specific techniques Here�s the next advantage we identified � so why isn�t it getting the Herceptin treatment? Miserable people don�t make nice news stories, not like the heartbreak of young mums, or high fliers struck down by a killer disease we�re used to the concept of the �wonder drug� but a wonder course of 6 to 9 sessions with a therapist talking things over is more difficult for us to grasp. And it requires GPs to do other than reach for the prescription pad; and therapists to train in specific techniques

11. Evidence-based, NICE-endorsed treatment + the people�s choice Not media-friendly But it�s not a drug! Requires workforce to do different things Technology �Making Slough happy� Extend implementation period White Paper What can we do then? Well, there�s a computer-based version � surely we can �sell� that! And recent TV has shown there really is public interest in this sort of topic To acknowledge the �more tricky than a new drug� point, we�ve extended the normal preparation period for implementation of a NICE appraisal (of the computer package bit) from 3 to 12 months, to allow for staff training And it�s very important that we use the forthcoming OOH white paper to describe it all againWhat can we do then? Well, there�s a computer-based version � surely we can �sell� that! And recent TV has shown there really is public interest in this sort of topic To acknowledge the �more tricky than a new drug� point, we�ve extended the normal preparation period for implementation of a NICE appraisal (of the computer package bit) from 3 to 12 months, to allow for staff training And it�s very important that we use the forthcoming OOH white paper to describe it all again

12. No.10 advisor + Manifesto commitment No money SR 2006 delayed NHS financial situation Reform agenda Thrust of Government policy New wave imminent 3rd set of benefits The proposed solution is expensive anyway; and the current climate highlights this further. Timing is bad � the end of a spending period that has been exceptionally good for the NHS. We don�t know what the next period will look like. Three points about the reform agenda � first Proposed solution highly centralist � not the way we do things now -National standards, Local action � etc And second, with that White paper I was talking about just now, we see the spotlight turning more fully onto primary care; echoing general government attention towards more local, accessible, community based services. Third, the next wave of NHS reforms is bound to cause a certain amount of turmoil � hardly a good time to be launching a significant new set of services! 3rd set of benefits The proposed solution is expensive anyway; and the current climate highlights this further. Timing is bad � the end of a spending period that has been exceptionally good for the NHS. We don�t know what the next period will look like. Three points about the reform agenda � first Proposed solution highly centralist � not the way we do things now -National standards, Local action � etc And second, with that White paper I was talking about just now, we see the spotlight turning more fully onto primary care; echoing general government attention towards more local, accessible, community based services. Third, the next wave of NHS reforms is bound to cause a certain amount of turmoil � hardly a good time to be launching a significant new set of services!

13. No.10 advisor + Manifesto commitment No money SR 2006 delayed NHS financial situation Reform agenda Thrust of Government policy New wave imminent CSR 2008 Fit with reform agenda Re-engineer solution So � We look to the CSR, of course � and I�ve already talked about the likely joint bid. We need to get our costings and our arguments sorted out, and all our evidence lined up. � a key part of the job of a civil servant in a spending department. Second � another important part of my job � find the bits of the reform agenda that this initiaive will help with. And sell it to busy, stressed out CEs that way. I�m going to look at the reforms in a bit more detail later on. Third look again at the Layard solution � can we meet the anxieties about lack of qualified staff, supervision, quality control, dissipation fo funding within PCT budgets etc � in other ways? Let�s try out some models �So � We look to the CSR, of course � and I�ve already talked about the likely joint bid. We need to get our costings and our arguments sorted out, and all our evidence lined up. � a key part of the job of a civil servant in a spending department. Second � another important part of my job � find the bits of the reform agenda that this initiaive will help with. And sell it to busy, stressed out CEs that way. I�m going to look at the reforms in a bit more detail later on. Third look again at the Layard solution � can we meet the anxieties about lack of qualified staff, supervision, quality control, dissipation fo funding within PCT budgets etc � in other ways? Let�s try out some models �

14. Professional support + In line with NSF We�re all very busy There are other priorities (MH Bill, public safety, BME etc Acceptability of link to unemployment So if the priofessionals � and others working in MH support this, and it�s in line with the ever-popular NSF, why isn�t it spontaneously bubbling up all over the country? I don�t mean this to sound pathetic, because it isn�t. People are busy. As well as delivering services, MH professionals are, for the most part, all engaged in continuous service improvement (NSF was 10 yr programme, remember) And their management and leadership structures, and those of their commissioners, are being continually reorganised. At central policy level (ministers etc) there are plenty of other worthwhile and or worrying things to be dealing with Some people working in the MH field have always had real problems with the concept of returning to work as the justifying aim or benefit of a new treatment or service. Much as with difficulties in using �reducing offed=nding�, feeling is that these things should be done because they are self-evidently good (the moral argument) or because of the future health gain.So if the priofessionals � and others working in MH support this, and it�s in line with the ever-popular NSF, why isn�t it spontaneously bubbling up all over the country? I don�t mean this to sound pathetic, because it isn�t. People are busy. As well as delivering services, MH professionals are, for the most part, all engaged in continuous service improvement (NSF was 10 yr programme, remember) And their management and leadership structures, and those of their commissioners, are being continually reorganised. At central policy level (ministers etc) there are plenty of other worthwhile and or worrying things to be dealing with Some people working in the MH field have always had real problems with the concept of returning to work as the justifying aim or benefit of a new treatment or service. Much as with difficulties in using �reducing offed=nding�, feeling is that these things should be done because they are self-evidently good (the moral argument) or because of the future health gain.

15. Professional support + In line with NSF We�re all very busy There are other priorities (MH Bill, public safety, BME etc Acceptability of link to unemployment Communicate Clarify and manage priorities Don�t be precious Plan new effort What I can do is ensure we communicate clearly that our overall direction of travel has not changed (as Prof Appleby made clear in 5 Yrs on) how priorities are identified and fit in and contribute to one another. And it won�t interest you at all, I shouldn�t think, to ehar that we�re just now doing the stuff within Dh to establish a firmer programme management process ! And Yes, plan for the new effort needsd � pretty much back to the CSR again It�s not my job to let the moral high ground block my view of the way ahead. However much I might sympathise with the argumetns. I need to recognise helpful initiatives and push factors wherever they sit, and whatever they may be disguised as � last week�s RESPECT stuff is very much a case in point � and plan to use them to best advantage. But I do need to underatnd and remember the reservations, and keep in mind the need to draw attention to other types of benefit along the wayWhat I can do is ensure we communicate clearly that our overall direction of travel has not changed (as Prof Appleby made clear in 5 Yrs on) how priorities are identified and fit in and contribute to one another. And it won�t interest you at all, I shouldn�t think, to ehar that we�re just now doing the stuff within Dh to establish a firmer programme management process ! And Yes, plan for the new effort needsd � pretty much back to the CSR again It�s not my job to let the moral high ground block my view of the way ahead. However much I might sympathise with the argumetns. I need to recognise helpful initiatives and push factors wherever they sit, and whatever they may be disguised as � last week�s RESPECT stuff is very much a case in point � and plan to use them to best advantage. But I do need to underatnd and remember the reservations, and keep in mind the need to draw attention to other types of benefit along the way

16. What do you think of it so far? Understand aims and outline of service/policy Understand pros and cons Understand wider context Identify push and pull factors � And employ them merrily to advance the cause Those of you old enough to remember will know the traditional answer to this But be that as it may In summary, it�s my job to do all of these things and I need to do them whenever we�re talking about developmetns or initiatives that need national coverage. You and your local teams and management will continue to move along the things at the top of your local priority lists whether I�m there or not.Those of you old enough to remember will know the traditional answer to this But be that as it may In summary, it�s my job to do all of these things and I need to do them whenever we�re talking about developmetns or initiatives that need national coverage. You and your local teams and management will continue to move along the things at the top of your local priority lists whether I�m there or not.

17. I said I�d talk a little bit about the current reform agenda. You know how the thinking goes � after a period of big investment, to increase capacity, it�s time to make radical changes to the system, to make it fit to meet the needs of a 21st century population. And so we have a full set of reforms, to every part of the health and social care system. I�ve taken this diagram formt eh NHS Reform document published just before Xmas � sorry it�s a bit pale, but it will serve to get some key messages across Message one � it�s about putting the patient or service user at the centre � here. And the whole set-up is aimed at improving what they get � better care, a better experience, and better value for the money they pay out in taxation. I think, had I been writing this document, I would have slipped a 4th element into here as well � better health and well-being. Message two � every part of the system needs changing to do this for patients and service users � so the diagram marshals things into 4 neat boxes � let�s just look at two: demand-side reforms, into which we see the strengthening of commissioning as a key theme, with CPLNHS etc. Commissioners will be expected to be the agents of the individual, making real efforts to watch and improve the quality fo the services they get on their behalf. and here, system management reforms, which is where PbR sits I�ve picked those two because they have a particular resonance, it seems to me, for mental health services. A dozen years ago, the Audit Commission recognised intelligent commissioning as one of only two factors that appeared to have a causal link to the quality of CAMHS in a given area; and now I interest myself in adult MH, I can see little to change that view. Commissioning all along the spectrum form basic communtiy based services through to expensive, specialist and forensic MH interventions has been, and remains with few exceptions, woefully poor. It would be na�ve to suppose that a few geographical boundary changes; or the revival of the �I know, let�s give the money to family doctors� approach might solve this unaided; but, if we can time some other work with commissioners to fit with this movement, then there is a real hope we can start to see what the model would look like in full working order. And PbR � really tempting to leave that one in the �too difficult� basket. But if devising the tariff can be the vehicle for refocussing us helpfully on both assessment and outcome measures; and thereby, help commissioners further, then it is worth all of the huge effort currently going into it.I said I�d talk a little bit about the current reform agenda. You know how the thinking goes � after a period of big investment, to increase capacity, it�s time to make radical changes to the system, to make it fit to meet the needs of a 21st century population. And so we have a full set of reforms, to every part of the health and social care system. I�ve taken this diagram formt eh NHS Reform document published just before Xmas � sorry it�s a bit pale, but it will serve to get some key messages across Message one � it�s about putting the patient or service user at the centre � here. And the whole set-up is aimed at improving what they get � better care, a better experience, and better value for the money they pay out in taxation. I think, had I been writing this document, I would have slipped a 4th element into here as well � better health and well-being. Message two � every part of the system needs changing to do this for patients and service users � so the diagram marshals things into 4 neat boxes � let�s just look at two: demand-side reforms, into which we see the strengthening of commissioning as a key theme, with CPLNHS etc. Commissioners will be expected to be the agents of the individual, making real efforts to watch and improve the quality fo the services they get on their behalf. and here, system management reforms, which is where PbR sits I�ve picked those two because they have a particular resonance, it seems to me, for mental health services. A dozen years ago, the Audit Commission recognised intelligent commissioning as one of only two factors that appeared to have a causal link to the quality of CAMHS in a given area; and now I interest myself in adult MH, I can see little to change that view. Commissioning all along the spectrum form basic communtiy based services through to expensive, specialist and forensic MH interventions has been, and remains with few exceptions, woefully poor. It would be na�ve to suppose that a few geographical boundary changes; or the revival of the �I know, let�s give the money to family doctors� approach might solve this unaided; but, if we can time some other work with commissioners to fit with this movement, then there is a real hope we can start to see what the model would look like in full working order. And PbR � really tempting to leave that one in the �too difficult� basket. But if devising the tariff can be the vehicle for refocussing us helpfully on both assessment and outcome measures; and thereby, help commissioners further, then it is worth all of the huge effort currently going into it.

18. Out of Hospital White Paper What it says on the tin New boost for MH NSF? Psychological therapies based in primary care New money/ basis for CSR bid So, I�ve given you a neat diagram to fit all your perceptions of NHS reform into. Great, isn�t it? Makes you feel the same as when you finish the day, and your desk actually is clear! But hold on a second, what�s this? Important policy drivers going off at a tangent? The purity of the NHS reform approach contaminated through contact with a wider, cross-government thrust? Surely not Work on the Out of Hospital White paper � the team has already bewailed the fact that all the good titles have been taken � is based on experiences and views recorded at a number of highly structured Listening events last Autumn. And guess what? Most people said they wanted more attention paid to their all-round well being. They don�t want just a top job on their ingrowing toenail, or even fast access to the latest NICE-endorsed CBT. They want all that alongside more help with, and consideration for, other aspects of their everyday lives. And it�s already been announced that this White Paper will contain the response to last year�s consultation on �Independence, Well-being and Choice� the Green Paper on Adult Social Care. We�re back with all the things the Social Exclusion report was calling for. So, a fig for your neat frameworks of reform, I hear you cry! I do, though, urge you to watch out for the White Paper when it comes. It does provide, as I�ve been hinting throughout, a very powerful vehicle for us to restate some of the main messages about the sorts of MH services we want to see; even to celebrate the enormaous progress we have seen since the NSF was published. The slide shows some of the opportunities � do look for them when it arrives. So, I�ve given you a neat diagram to fit all your perceptions of NHS reform into. Great, isn�t it? Makes you feel the same as when you finish the day, and your desk actually is clear! But hold on a second, what�s this? Important policy drivers going off at a tangent? The purity of the NHS reform approach contaminated through contact with a wider, cross-government thrust? Surely not Work on the Out of Hospital White paper � the team has already bewailed the fact that all the good titles have been taken � is based on experiences and views recorded at a number of highly structured Listening events last Autumn. And guess what? Most people said they wanted more attention paid to their all-round well being. They don�t want just a top job on their ingrowing toenail, or even fast access to the latest NICE-endorsed CBT. They want all that alongside more help with, and consideration for, other aspects of their everyday lives. And it�s already been announced that this White Paper will contain the response to last year�s consultation on �Independence, Well-being and Choice� the Green Paper on Adult Social Care. We�re back with all the things the Social Exclusion report was calling for. So, a fig for your neat frameworks of reform, I hear you cry! I do, though, urge you to watch out for the White Paper when it comes. It does provide, as I�ve been hinting throughout, a very powerful vehicle for us to restate some of the main messages about the sorts of MH services we want to see; even to celebrate the enormaous progress we have seen since the NSF was published. The slide shows some of the opportunities � do look for them when it arrives.

19. The Mental Health NSF - the vision Services that: Treat service users with dignity Value and respects the skills and role of carers Provide effective treatment Link provision to need Emphasise safety � especially of service users Is provided by a skilled and motivated workforce In conclusion then � here we are, part way through realising the grand vision set out in our NSF �In conclusion then � here we are, part way through realising the grand vision set out in our NSF �

20. The Social Exclusion Unit Report Six Themes: stigma and discrimination role of health and social care services employment supporting families and community participation getting the basics right making it happen The powerful Cross government SEU backed all this up a couple of years ago, and urged more action around all these themes�The powerful Cross government SEU backed all this up a couple of years ago, and urged more action around all these themes�

21. System Reform Key Themes: Payment by Results Foundation Trusts New providers Social Care Regime Commissioning Choice �Commissioning a patient-led NHS � and we find ourselves at a critical juncture in the NHS reform process� and we find ourselves at a critical juncture in the NHS reform process

22. Where are we now? NSF Progress � new types of service and roles SEU progress � direct payments, Green Paper ? White Paper Progress on System Reform � Choice, Foundation Trusts� CSR 2008 .. And as if that all wasn�t enough, we�re going into the next spending period with encouragement to think wide, cross-cutting and radical. .. And as if that all wasn�t enough, we�re going into the next spending period with encouragement to think wide, cross-cutting and radical.

23. Psychological therapies:From there to reality Given all that, it�s not going to take a genius to ensure that an evidence-based service that tackles a significant health and economic problem in a way people like gets put into place. Just someone familiar with the landscape, who speaks the language, and doesn�t easily get dizzy!Given all that, it�s not going to take a genius to ensure that an evidence-based service that tackles a significant health and economic problem in a way people like gets put into place. Just someone familiar with the landscape, who speaks the language, and doesn�t easily get dizzy!