Essay

“The implementation of IAPT has improved primary care mental health services.” Critically Evaluate.

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Course
Clinical Psychology - PYCM067

Institution
University Of Exeter (UoEX)

A critical evaluation of how IAPT has improved primary care within the NHS mental health system. A balanced argument for and against the implementation of IAPT within the NHS, taking into account the evidence base.

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Uploaded on July 12, 2023
Number of pages 7
Written in 2022/2023
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iapt
critical evaluation
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clinical psychology
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Institution
University of Exeter (UoEX)
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Course
Clinical Psychology - PYCM067

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690016892

“The implementation of IAPT has improved primary care mental health services.” Critically
Evaluate.

The Improving Access to Psychological Therapies (IAPT) programme, which was rolled out
in 2008, is an ambitious and large-scale restructuring of mental health services in England. Under this
programme, more people should be able to access help for common mental health disorders through
a stepped-care structured network of services (NHS, 2022). It saw the integration of low-intensity
mental health treatments and primary health care, as well as the formation of a collaborative
relationship with higher intensity services. The programme has been celebrated globally due to the
increase in people accessing the service, the economic benefit of the programme and due to the overall
positive recovery rates. However, a number of studies question whether the IAPT programme has
truly been as beneficial to primary care mental health services as NHS figures suggest. This paper
discusses the benefits and limitations of IAPT on primary care mental health services in terms of cost-
effectiveness and accessibility.

Considering that the IAPT initiative was originally aimed at reducing cost-pressures on the
NHS, the economic improvement upon primary care mental health services is a pivotal consideration.
The Department of Health (DH) Impact Assessment (2011b) predicted that a single low-intensity
treatment would cost £32.50. However, later studies have found estimates upwards of £102.31 (Steen
& Griffiths, 2013; Radhakrishnam et al., 2012). These discrepancies between the original forecasts
and data taken since the programme was rolled out on a large scale suggest that there is lacking
evidence for the cost-effectiveness of IAPT primary care in practice. However, there is some
suggestion that IAPT does positively impact mental health care services. Toffoluti and colleagues
(2019) found that within the first three months of treatment, IAPT decreased cost pressures on health
services by, on average, £497 per person. However, upon further inspection, the cost reduction found
by Toffoluti and colleagues was upon A&E inpatient stays, relating to physical health-related
symptoms (Martin et al., 2021). Whilst this does not necessarily improve primary mental health care
services, there is evidence of cost-reductions elsewhere, such as GP surgeries, social workers and
health visitors (Mukuria et al., 2018). Crucially, however, Mukuria et al., (2018) found that any
improvements to primary mental health services were not significant, and cost-effectiveness analyses
suggested that IAPT’s probability of being cost-effective is less than 40%.

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The key question here is why IAPT is not living up to the original promise in terms of cost-
benefit to primary care mental health services. One consideration is the high re-referral rate of those
accessing low-intensity treatment with IAPT. Hepgul et al. (2016) found that a third of patients within
their sample had previously accessed the service, and Steen (2020) notes that this figure is not
improving. This begs the question of whether IAPT primary care mental health services are truly
cost-effective if patients are repeatedly accessing therapy. Furthermore, there is a high relapse rate
for patients accessing low-intensity treatments within IAPT primary care (Scott, 2018; Steen, 2020).
It has been suggested that an overall bias for prescribing low-intensity treatment, and a decline in
therapist contact time, may be contributing to these figures (Steen, 2020). Furthermore, researchers
argue that there is a toxic target-driven culture within the IAPT primary care services, leading to a
propensity to accept patients that are not suited for step 2 care (Rizq, 2019, pp. 189–209). With these
factors in mind, any cost-effectiveness and cost-benefit analyses of IAPT become increasingly less
favourable. Finally, there is evidence that the IAPT framework of stepped care is effective, with more
utilisation of the ‘stepping up’ system being correlated with higher recovery rates (Gyani et al., 2013;
Boyd et al., 2019). However, in terms of the primary care services, this further demonstrates that there
are a high number of patients for which the lower steps of IAPT are not appropriate (Rizq, 2019, pp.
189–209), and that these patients end up accessing higher levels of care anyway. This may deduct
from any possible economic benefit provided by the integration of IAPT in primary care mental health
services.

Another primary incentive for the roll-out of IAPT was to increase the accessibility of mental
health treatment (National Collaborating Centre for Mental Health, 2021). The ability to self-refer is
one major benefit of implementing IAPT into primary mental health care services, which allows
under-represented groups, and those too resistant to reach out in person, to access help (Clark, 2011).
Despite the perceived benefit of this, it was found that 75% of patients within a large-scale survey
had been referred into IAPT services through their GP (Hamilton et al., 2011). Considering that the
purpose of introducing self-referral was to reduce strain upon GPs, who previously would have had
to refer patients on to mental health services; this demonstrates a limitation within IAPT’s ability to
improve accessibility (Clark, 2011). In a qualitative study, it was commented on by multiple patients
that there is inadequate advertising for IAPT primary care services, which may explain the lack of
self-referrals (Hamilton et al., 2011). The IAPT programme also aimed to improve accessibility
through decreasing excessive wait times that had become characteristic of NHS mental health
services. The NHS digital states that IAPT aimed to get at least 75% of patients into treatment within

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