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Archive for April, 2012

Recently, the Centre for Social Justice published the report “Commissioning Effective Talking Therapies” (pdf).

I find this interesting politically, as the CSJ was started by Iain Duncan-Smith, and so is broadly aligned with the Department for Work and Pensions. As the commissioning of talking therapies is the business of the Department of Health, this is an interesting intervention, about which I will have more to say in a future post.

The central message is fairly simple: to commission effective talking therapies, the service should be opened up to the private sector. Now, there’s not much in the way of hard stats on why that should be the case, which makes the report’s one key statistic a bit of a silver bullet to the head of the Improving Access to Psychological Therapies (IAPT) service.

Frankly, when what looks like a hatchet job in the name of free market economics rests its case on pretty much one damning statistic taken from one quarter of key performance indicators, I smell an undead gerbil. And so, inspired by the many, many smack downs delivered to the makers of suspect claims by Cathy Newman’s Fact Check blog, I thought I’d have a go at Fact Checking this core statistic for myself.

The claim:

“The Government has committed to spend an additional £400 million over the next four years on a limited range of National Institute for Health and Clinical Excellence (NICE) approved talking therapies, despite a recovery rate of only around 15% of all referrals” (p4)

The authors are unequivocal about this key fact: the IAPT service has a recovery rate of only around 15% of all referrals. Not only that, but the NHS is actually engaging in statistical skullduggery to disguise this alarmingly low figure:

“In the case of IAPT, it cites ‘recovery rates’ as a proportion of patients treated and also above ‘caseness’, rather than as a proportion of the baseline (patients referred), thus improving the outcome percentage. As described in more detail below, IAPT figures claim recovery as over 40 per cent… but from the point of view of commissioners and referring GPs, 86 per cent are not being helped by the IAPT service” (p37)

The background:

With the passing of the Health and Social Care Act 2012, NHS services are rapidly being opened up to tender by any qualified provider (AQP). The Act specifically opens up NHS services to tender from the private sector; de facto privatisation.

One of the areas open to AQP is adult psychological therapies. Currently, the vast majority of this service is delivered through IAPT. In order to prevent commissioning clusters from effectively defining AQP as an IAPT equivalent service, the CSJ’s report aims to demonstrate that IAPT is failing its users.

The analysis:

First, let’s get our terms clear. The IAPT service uses a peculiar language that aims to do what the majority of therapists tend to claim is not doable; quantify human suffering in statistically measurable terms. When someone is referred to IAPT, they are assessed for ‘caseness’. If someone has caseness, it means they meet the clinical definition for anxiety and/or depression as measured by a specific statistical tool. At the end of someone’s period of therapy, there is a final assessment; if the person’s scores have dropped below ‘caseness’ then they are deemed to have achieved recovery.

The report authors cite the IAPT key performance indicators for Quarter 1 2011/12 (April to June 2011). These figures claim a recovery rate (in England) of 42.5%. Step by step, we get there by:

Step 1. Taking the number of people who a) completed treatment in the quarter, and b) are moving to recovery (this is KPI 6a, and the number is 28,470)

Step 2. Taking the number of people who have completed treatment in the quarter (this is KPI 5, and the number is 75,697)

Step 3. Taking the number of people who a) completed recovery in the quarter, and b) were not at caseness at the start of treatment (this is KPI 6b, and the number is 8,725)

Step 4. Remove the people who didn’t have caseness to start with (step 3) from the total completed cases in the quarter (step 2) to get the number of people who a) completed recovery in the quarter, and b) had caseness at the start of treatment (the number is 66,972)

Step 5. Work out Step 1 as a proportion of Step 4 to get the percentage 42.5%

Phew! At least the stats add up in the way they’re supposed to; so far so gravy, though frankly, a 42.5% recovery rate is not exactly inspiring. But where has this 86% failure rate come from?

Well, the report authors’ claim is based on different stats. They work things out by:

Step 1. Taking the number of people who a) completed treatment in the quarter, and b) are moving to recovery (this is KPI 6a, and the number is 28,470)

Step 2. Taking the number of people who have been referred for psychological therapies in the quarter (this is KPI 3a, and the number is 206,918)

Step 3. Work out Step 1 as a proportion of Step 2 to get the percentage 13.8%

Now, pop-quiz, have you spotted the two sleights of hand that qualify the report authors’ calculations as bad science? Watch carefully:

Sleight of hand 1. The report authors use a suspicious tone of voice whilst pointing out that the NHS are using a smaller subset of the total available stats. This allows them to remove KPI 4 from view, an indicator that gives the number of people who have actually entered psychological therapies during the quarter. This is 123,792, meaning only 59.8% of referrals actually enter therapy. How can someone reach recovery when they’ve never even entered therapy? As a bonus, by the way, these figures contain a clear footnote stating that the number of people referred in a quarter don’t necessarily complete therapy in that same quarter; this is a totally unreliable figure to use as a baseline.

Sleight of hand 2. This one is the smarter move, and takes advantage of the ridiculous language IAPT is using. The very word ‘caseness’ presses the jargon button of all who hear it, making it a great primer for anti-IAPT sentiment from the outset. And so, because we all think we know what recovery means, but have only a vague idea of what caseness means, we are invited to stick with what we know and ignore a vital piece of causation: without caseness, there is no such thing as recovery. By definition, recovery means going from caseness to non-caseness; how can someone reach recovery when they didn’t have caseness in the first place?

The verdict:

It is incorrect to assert that IAPT has a recovery rate of only around 15%. Out of the total number of people referred into the IAPT service in the quarter examined, only 59.8% received therapy. Furthermore, people entering therapy in the quarter didn’t necessarily finish therapy in that quarter, making the figure unreliable for calculating recovery. Besides which, recovery in IAPT terminology means going from caseness to non-caseness using a specific measure. The inclusion of people who started therapy below the threshold for caseness invalidates the recovery rate because these people have nothing to recover from!

Let’s be frank, even if we’re convinced that recovery can be statistically measured (and whilst that’s an a priori assumption of the NHS, it is by no means a consensus in the wider professional field), a recovery rate of 42.5% is not inspiring. It’s enough to criticise IAPT using its own stats; the use of smoke and mirrors to make it look like a failing service is disingenuous at best, dishonest at worst.

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I have just finished my first week of paternity leave from therapy practice. Baby is due today and, so far, is declining to make an appearance. What does this have to do with May 3rd’s city wide referendum on whether or not Bristol should have a directly elected mayor? Pretty much everything.

As I started exploring in psychotherapy in a time of political crisis, I am already alive to the overlap between therapy and politics, and to therapy as a distinctly political activity in its own right. Now, it is a gestalt axiom that need organises the organism/environment field, the dynamic interplay between self and situation.

Accordingly, as I start to feel the physical reality of becoming a parent, I become increasingly aware of the social world into which my child will be emerging. The challenge this throws me is simple, difficult, and powerful. I look around me at my situation, and I tune in very quickly to the political domain. I feel urges towards action rise within me and… I explain them away. I’m a therapist, not a politician. There’s no point, I should focus my action in a better direction. Many of the self-same justifications for inaction that I support people in working through in therapy so that they can more fully be who they really are, not who they have been moulded to be.

My experience of starting to become a parent is of suddenly experiencing a need to take action that is stronger than my need to refrain from taking action. It’s not quite that I feel responsible for the world into which my child is being born in a way that I didn’t before, though that is a factor. It’s more that the projection of how my child might see me has revealed to me more starkly how, out of awareness, I am viewing myself. That is, I am fully in contact with the consequences for me of not acting on my political needs. Realising that I owe it to my child to be as fully myself as I can is a bridge to realising that I owe the same to myself. As a therapist, I am constantly re-learning this.

On 3rd May 2012, there will be a city wide referendum on whether Bristol should have a directly elected mayor. There is a yes lobby. There is a no lobby.

The key arguments in favour involve the direct accountability of the mayor vs a current leader who is elected by Council; the transfer of more powers and money (of an as yet undescribed nature) from Westminster to Bristol if we vote yes; and to shake up a tired political system.

The key arguments against involve the belief that the cost of implementing the mayor model will be too high; that the election will descend into a Ken vs Boris style personality contest; that the mayor will not be accountable to Council in the way the current Leader is; and that the candidates will be uninspiring.

In the midst of making up my own mind, I saw Salma Yaqoob‘s article ‘Yes’ to a Mayor who says ‘No’ to Austerity and realised what I want. I want to switch to the directly elected mayor system, and actively seek out the kind of candidate I want to vote for, instead of passively waiting for existing interests to make their offers. In parallel, I’m also seeking to form a political party with a mission to forge a politics of compassion grounded in core therapeutic principles.

I am unlikely to pull off such a feat on my own, so this is my call for support. Here is the kind of Mayoral candidate I am looking for:

A Mayor who opposes austerity: the austerity drive has failed and continues to fail. Britain is not only in a double-dip recession, but in a depression that is now more prolonged than the Great Depression of the 1930s. I want a Bristol Mayor who will actively oppose austerity.

A Mayor who will devolve power: one of the dangers of an elected mayor is that power becomes more centralised. I would like to see Bristol become a functioning e-democracy in which any Bristol citizen with an interest can be part of the decision making process. I want a Bristol Mayor who would seek to make that a reality.

A Mayor who is a woman: the mayor debating panels have been dominated by the usual white, middle-aged men, and the candidates so far proposed belong to this demographic. According to the 2001 Census Bristol’s population was 51.2% female. Austerity measures disproportionately affect women, who, absurdly, form the majority of the population but hold a minority of political posts. I want a woman for Bristol Mayor.

A Mayor who places humanity above economy: we are living through a time of atrocity in the name of balancing a national budget sinking under the weight, not of excessive public spending, but of bailing out the banks. Welfare is under attack, and the NHS is being thrown to the wolves. This is not unique to the Coalition; all three main parties are part of a neoliberal consensus that equates human activity with economic activity. This then justifies the most ruthless of decisions, as economy and humanity are one. I want a Bristol Mayor who will place humanity above the economy.

You might not want what I want, and that’s fine (and if I’ve inspired you to do the same thing as me but for a different kind of candidate, then even better!). Possibly I will get no further with this than the warm glow I get after publishing a new blog post. And if Bristol votes no on 3rd May, it’ll all be fairly academic anyway.

But suppose you want the same thing as me. And suppose Bristol votes yes on 3rd May. Then maybe you can take your own step towards action, and instead of waiting for the usual suspects to offer us up a selection of the same old faces, lend me your support.

Let’s get together, and find a candidate worth voting for.

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