Evidence-Based Policy in Practice

1. Evidence-Based Policy in Practice The Case of IAPT

2. Aims for Today Link to Policy Literature Theoretical Framework: Local Universality The Creation of the IAPT Policy The IAPT Trials: bridging policy and practice IAPT in Practice

5. Local Universality Traditional view of universal standards: making actions comparable over time and space Tensions in the way we think about universality: Relationship to pre-existing resources, infrastructure and practices Renegotiated because of people�s personal goals and interests CPR protocol development in Belgium and US Local universality: process of �tinkering� designed standards to make them workable in practice Helps achieve compliance

6. Hard and Soft Facts �an apple a day keeps�.� = soft fact -margin of negotiation: re the meaning, so each actor can translate the statement as s/he sees fit, adapting it to local circumstances Easier to interest more people since less control is exercised Also meaning will be transformed, as people adapt to their past experience, context Harder facts are not necessarily better than soft ones; hard facts bring together more allies for the purpose of increasing control and decreasing the margin of negotiation.

7. Methodology On-going project still in progress Analysis of published policies, Commissioning and Implementation Documents NICE guidelines Lord Layard�s 2006 Depression Report Commissioning Guidance Analysis of Trials IAPT website: www.iapt.nhs.uk 10 interviews with stakeholders working within and around the NHS In London And in primarily 2 PCTs in the East of England (compare and contrast)

8. Increasing Access To Psychological Therapies

9. The Impetus for IAPT:Clinical and Economic �Our sole mission was to help the NHS implement NICE guidelines, and that really draws a line around what the evidence-base is. If it�s in NICE, that�s what we�re going to do.� Programme Director for IAPT in the DoH

10. Evidence for the Treatment within IAPT 1 in 6 suffer from Depression or Anxiety but only 1 in 4 receive treatment More than 1 million receive incapacity benefits due to mental illness Loss of output �12bn a year, compared to �0.6bn annual cost of �proper therapy service� Therapy more effective than drugs in �hundreds� of clinical trials Service should be rolled out over 7 years to ensure quality is maintained at every stage England needs 10�000 new therapists

11. Creating Policy around Evidence-Based Treatments Distinction between adapting the treatments within IAPT and adapting the service provision of IAPT itself PCTs can do the latter but not the former: Choose what proportions of each treatment will go to make up their service offering But the CBT itself remains the same wherever you are, etc. Licensed computer programmes: �Beating the Blues� and �Fear Fighter� Aiming for equitable data collection to produce on-going evidence

12. Evidence for Policy? �The key thing that we did is that we haven�t required the evidence � in some ways, different from other policy makers where you have to work through in detail the longitudinal, the long term evidence base before you progress and then come up with a fully worked out service delivery model you�ve dreamed up in a smoke filled room with a few experts . . . We kind of were more organic about the process . . . the evidence base was there but we developed and stretched and interpreted it in the way it was implemented. I think that all worked really well.� A quotation from within the Department of Health

13. The IAPT Trials as a Bridge between Policy and Practice

14. The Trials: a True Bridge between Policy and Practice? Criticism of the trials is common Hawthorne effect among workers and patients Evidence not collected to be appropriated into practice Simultaneous roll-out Too soon an evidence on practice

15. IAPT in Practice:Our Findings

16. Integrating Human Resources in IAPT Service Delivery Prior lack of government organised provision for mental health has ensured strong private counselling services throughout Britain Counsellors: Resist challenges to their autonomy Resist therapies involved Strongly influence GPs Positive Human Resource issues also have effect Neighbouring trial similar to IAPT lessened resistance at one site of study

17. Matching the Workforce to the Treatment Group �It is an important principle that the IAPT workforce should reflect and be representative of the local community. Recruiting low-intensity and high-intensity workers from represented BME communities or religious groups should be encouraged.� 2008 �Culturally competent practice does not require first hand experience or knowledge of a client�s experience. Instead, it is the ability of a practitioner to understand cultural influences on their own perceptions.� 2011

18. Financial Resources Higher levels of funding were provided to early adopters (contentious among stakeholders): �The laggards, they don�t want to learn. So putting money into their system would mean it was spent on other things. What�s happening is that those who are late adopters are seeing the benefit and having to look for the investment.� Policy Advisor to the DoH �I would start off with more modelling as to what�s actually available already, so places who perhaps already had a little bit more to start off with would share out the funding relevant to what they�ve actually got.� IAPT Lead in a SHA

19. Differences in Existing Infrastructure

20. Summary of Findings IAPT is successful in that it is meeting and exceeding national targets Some areas have no attained this level of success, and may never do so if they are not aided in a way which their successful neighbours were not Flexibility is a key component of success Isomorphic theories of change do not allow for time pressures programme faces Rigours of evidence need to be applied to ensure nationwide take-up

21. References Being Fair, Including All (2011), Analysis of the Analysis of the Impact on Equality (AIE) Guidance for Commissioners: iapt.nhs.uk. Black and Minority Ethnic Positive Practice Guide (2009) iapt.nhs.uk The Depression Report: A New Deal for Depression and Anxiety Disorders (2006), The Centre for Economic Performance�s Mental Health Policy Group: London. Impact Assessment of the Expansion of Talking Therapies Service as Set Out in the Mental Health Strategy (2011), Department of Health 7026. NICE Guidelines for Depression and Anxiety: http://www.nice.org.uk/CG023 Bruno Latour (1987), Science in Action, Harvard University Press: CA Massachusetts. Stefan Timmermans and Marc Berg (1997), �Standardization in Action: Achieving Local Universality through Medical Protocols,� Social Studies of Science 27:2, pp.273-305.