briefing
April 2011 Issue 217
Talking therapies: a four-year
plan of action
Key points
• Improving access to
psychological therapies (IAPT)
is a central theme of the mental
health strategy.
• This plan outlines how the
roll-out of IAPT services for
adults will be completed.
• Provision should be extended
to people with long-term
conditions, medically
unexplained symptoms and
for people with severe
mental illness.
• The Government commits
to establish a programme for
children and young people.
Produced in association with
On 2 February 2011 the Government published No health without
mental health, a cross-government, all-age strategy for mental health
in England.1 Alongside the strategy, the Department of Health also
published Talking therapies: a four year plan of action. The plan aims to
complete the roll-out of improving access to psychological therapies
(IAPT) services for adults, and to improve access to talking therapies
across a number of groups, including children and young people. Making
this ambitious vision a reality will be a key test of the Government’s wider
reform programme.
This Briefing summarises the main points of the plan and outlines the
key questions that boards should be asking.
Background behavioural therapy (CBT) workers
have been trained.2 Between
The Improving Access to October 2008 and December
Psychological Therapies (IAPT) 2010, 491,000 people started
programme was established in treatment, over 282,000
2006. By April 2011, 147 of the completed it, 95,000 moved to
151 primary care trusts (PCTs) in recovery, with many more
England have a service in at least experiencing significant
part of their area,2 covering improvement in their symptoms.
approximately 60 per cent of the In the same period, more than
population in England.3 By April 18,200 people moved off sick pay
2011, 3,660 new cognitive and benefits.2
briefing 217 Talking therapies: a four-year plan of action
‘Investing in mental health
interventions for people with
long-term and medically
unexplained symptoms in
themselves should save money
elsewhere in the system’
Over the next four years, the
Government aims to complete the
roll-out of IAPT for adults. This
would allow services to treat an
estimated 400,000 more people
per year than at present.4
Improving access, particularly for
older people, alongside developing
services for people with long-term
conditions, medically unexplained
symptoms, those with a serious
mental illness, and for children
and young people, are also key
elements of the vision.
The financial context for these
plans is challenging. Over this
Spending Review period the overall
NHS settlement will be flat in real
terms. In previous years, some of
the funding for IAPT has been
ring-fenced. This will not be the
case for the lifetime of this plan.
On the launch of the strategy, the
Government said that “central to
these plans is an additional
investment of around £400 million
to improve access to modern,
evidence-based psychological
therapies over the next four years.”5
The Mental Health Network (MHN)
understands that this funding has
been allowed for through the
Multi-Professional Education and
Training (MPET) budget and
primary care trust (PCT)
02
allocations, and that final spending
is subject to local decision making.
Delivering the extra investment
required to deliver these valuable
improvements in access to
psychological therapies will require
commissioners and providers to
work together to make savings
elsewhere. Investing in mental
health interventions for people
with long-term and medically
unexplained symptoms in
themselves should save money
elsewhere in the system.
Training
In order to complete the roll-out,
cohorts of trainees will be
recruited in each of the next three
academic years to bring the total
of additional CBT therapists to
approximately 6,000. This equates
to approximately 800 additional
therapists per year.4
Top-up training to help existing,
qualified therapists in the other
four NICE approved modalities for
treating depression (alongside
CBT) will continue. The levels of
top-up training will be determined
locally, although a conservative
assumption of 190 therapists
trained per year has been used
(excluding attrition).4
The cost of training has been
estimated at £5,000 per trained
psychological wellbeing
practitioner (delivering
low-intensity interventions), and
£10,000 per trained high
intensity therapist, though
strategic health authorities
(SHAs) will want to consider
how training needs can be met in
the most cost-efficient way
possible. Training costs for the
other four modalities are
estimated at approximately
£3,000 per trained therapist.4
Training fees and salaries of
trainees will be met through the
MPET budget currently held by
SHAs. It will be for SHAs to decide
how best to use their available
resources to invest in this training.
The MPET service level agreement
(SLA) between the Department of
Health and SHAs is expected to
be published by 31 March 2011.
At the time of writing, we expect
some measures to be included
within the SLA to monitor training
relating to the commitments in
the four-year plan for talking
therapies.
The IAPT central team is currently
in discussion with the Department
of Health Workforce Department
to agree how the MPET Financial
Information Monitoring System
(FIMS) return can be used to
monitor progress. Guidance for
commissioning IAPT training
2011/12–2014/15, aimed at
SHAs, has been published on the
IAPT website.
The MHN understands that
training relevant to improving
services for older people will be
developed this year, with an aim
to include a brief module in the
current curricula from October
2011. Training relating to
children and young people is also
briefing 217 Talking therapies: a four-year plan of action
expected to begin at this time.
Training to support extending
talking therapies for people with
long-term conditions, medically
unexplained symptoms and severe
mental illness is expected to begin
in October 2012.
Improving access
Analysis of data from IAPT’s
first-wave sites indicated that
adults over the age of 65
represented an average of only
4 per cent of those accessing IAPT
services between October 2008
and September 2009.3 The plan
suggests that the expected rate
of over-65s in IAPT services is
12 per cent.
Ensuring older people have equal
access to services is an issue for
the whole NHS. Age is a protected
characteristic under the Equality
Act 2010. The Department of
Health will be involving
organisations that represent older
people in the development of
patient reported outcome
measures (PROMs) as part of the
routine sessional outcome
measurement for older people in
IAPT services. It will also be
engaging with specialists in
older people’s care, including
dementia, in designing
appropriate care pathways that
take account of older people’s
needs for flexibility in services,
which may involve longer
treatment sessions or offering
treatment in accessible and
suitable alternative venues,
including in their own home.
‘Evidence shows talking therapies
can be effective in meeting the
needs of children and young
people with depression, anxiety
and conduct disorders’
On equalities, the plan states that
success would mean the
proportion of patients using IAPT
services is in line with both
prevalence and the demographic
profile of the community, and that
recovery rates are unaffected by
age, race, religion or belief, sex,
sexual orientation, disability,
marriage and civil partnership,
pregnancy and maternity, or
gender reassignment. Providers will
want to ask themselves how they
perform relative to those measures,
and how they might improve the
accessibility of their services.
Developing PROMs
and choice
All IAPT services routinely collect
sessional PROMs. Historically,
these have informed national
performance indicators. However,
from 2011/12, the intention is to
transition to a new reporting
system that will facilitate local
benchmarking and outcome
reporting, improved patient choice
and satisfaction outcome
monitoring, the development of
an outcome tariff to enable the
piloting of payment by results
(PbR) in IAPT services in 2011/12,
and the inclusion of non-clinical
outcomes, including social and
economic participation outcomes.
A data handbook and information
standard notice are expected to be
issued by the end of March 2011.
A new reporting system to receive
the data will be developed over
the summer. Local services will
be supported to achieve a state
of readiness by April 2012 when
the new system will come into
operation.
The Government has publicly
committed to extending choice in
some mental health services. This
includes enabling greater choice of
treatment, as well as choice relating
to session times and venues, and
of provider. Many mental health
providers will already be offering
choice of treatment to their
service users wherever possible.
NICE has approved a number of
evidence-based therapies for
treating depression. Providers will
want to ensure that they invest in
staff training in approved therapy
modalities, and have delivery
arrangements in place to ensure
service users are offered choice
of treatment.
Children and young people
Evidence shows talking therapies
can be effective in meeting the
needs of children and young
people with depression, anxiety
and conduct disorders. However,
the plan states, many children
and young people with these
needs are unable to access such
treatment partly due to a lack of
skilled therapists within the
CAMHS workforce, and partly for
capacity reasons.
03
briefing 217 Talking therapies: a four-year plan of action
Whilst plans are still in
development, the Department of
Health aims to improve outcomes
for children and young people
through developing quality
measures and building capability
amongst the CAMHs workforce in
existing tier 2 and 3 provision. The
Department of Health envisages
that the programme will develop
over time, with a focus in year one
on anxiety, depressive disorders
and conduct disorder. It is intended
that children, young people and
their families will be involved in
developing patient reported
outcome measures (PROMs).
The project will train staff to an
agreed national curriculum for
best evidence-based (NICE
approved) treatments with
frequent, nationally agreed
outcomes monitoring used to
directly inform clinical practice,
session by session with close
supervision. The curriculum will
include training for service
managers, supervisors and
therapists in service development
and change management.
Plans are in development to
establish programmes during
phase one, which will be identified
by a competitive process. To
secure participation in phase one,
local partnerships including
health, local authorities, education
and providers must demonstrate
that they have the capacity and
commitment to deliver. The MHN
will keep members updated on the
arrangements for participating in
the programme.
LTCs and MUS
The scale of savings that the NHS
will need to make over the
forthcoming period will be
undoubtedly challenging. As part of
the focus on Quality, Innovation,
Productivity and Prevention (QIPP),
the whole of the NHS must consider
how more efficient use of financial
resources can be made, whilst
maintaining a focus on improving
quality. Considerable savings can be
made by investing in psychological
therapies for people with long-term
conditions (LTCs) or medically
unexplained symptoms (MUS).
Compared with the general
population, people with diabetes,
hypertension and coronary artery
disease are twice as likely to suffer
from mental health problems.
People with two or more LTCs are
seven times more likely to have
depression.3 Untreated mental
health problems often results in
increased costs. Co-morbid
depression is associated with a
50–75 per cent increase in health
spending among diabetes patients.3
It is estimated that between 20 and
30 per cent of consultations in
primary care are with people who
have medically unexplained
symptoms and no clear diagnosis.6
Improved access to psychological
therapies can lead to decreased
service utilisation, improved well-
being and between 9 and 53 per
cent reductions in cost, especially
when implemented at the primary
care level.7 Systematic review shows
that the use of liaison psychiatry
‘Many local health economies are
already examining how making
greater use of talking therapies
for these groups can help reduce
costs elsewhere in the system’
services can help reduce length of
stay.8 For older people, return to
independent living can be improved9
and subsequent healthcare
utilisation reduced, including
emergency care and clinic visits.10
The national QIPP team for LTCs is
currently looking at the potential
benefits and quality gains from
managing co-morbid mental
health problems effectively. A new
module for the IAPT national
curricula will be developed to help
support therapists to work with
people with LTCs. The Department
of Health will also produce a cost
calculator for commissioners and
a compendium of good practice.
Many local health economies are
already examining how making
greater use of talking therapies for
these groups can help reduce
costs elsewhere in the system.
There is a strong economic case
for including action in this area in
any local QIPP plans.
Severe mental illness
More than 1.5 million people in
England have a severe mental
illness. NICE, in its 2009 updated
schizophrenia guidance,
recommends that CBT should be
offered in an acute episode.
04
briefing 217 Talking therapies: a four-year plan of action

Research from service user groups treat people with severe mental Mental Health Network
suggests that such treatment is illness, incorporating appropriate
viewpoint
not always available. NICE additional material in future IAPT
suggests possible net savings of training courses. The MHN supports the vision set
£1,000 per person with out in the plan for talking
schizophrenia treated with CBT Making it happen therapies. The full roll-out of
could be made, based on the first services for adults is welcome,
18 months after initial treatment. We are in a period of significant as is the ambition to improve
change for the NHS, including provision for those groups singled
changes to the approach out in the plan. There is a strong
The Department of Health will
traditionally taken to deliver large- economic case for improving
include stakeholders, including the
scale improvements. As we move access, particularly for people
MHN, in the development of PROMs
into 2011/12, the responsibility with long-term conditions and
for people with severe mental illness
for completing the roll-out of IAPT MUS. The MHN has lobbied
who receive talking therapies. It will
services will begin to move from for this issue to be taken up
work with professional groups to the Department of Health to the
develop appropriate care pathways by the national QIPP programme,
NHS Commissioning Board. and we are pleased that it has
that ensure that the benefits of IAPT
done so.
are available to people with severe Meanwhile, the development of the
mental illness. It will also work with new talking therapies workstreams However, there is much to do to
clinical leaders, including GPs and will be the responsibility of the ensure this vision is translated
mental health specialists, to develop Department of Health. It is into reality. Whether this vision is
competency frameworks and envisaged that necessary leadership successfully implemented will be
appropriate additional training for to drive the expansion in services a key test of the Coalition’s reform
the doctors and therapists who will need to come locally. programme. Commissioners will
face tough decisions about what
to disinvest in, if they are to make
Key questions for boards to ask the large investment required in
• What does the full roll-out of IAPT services for adults mean for the talking therapies. We must ensure
provision of talking therapies in our local area? Are there opportunities that the objectives set out in this
to expand our current offer? plan are translated into
• How accessible are our services? Does the demographic profile of our meaningful indicators for the NHS
service users fit with what we would expect to see? Outcomes Framework, and the
Commissioning Outcomes
• Have we had a conversation with our SHA about how training plans for Framework being developed for
talking therapies will be taken forward, and what opportunities there are GP consortia. The MHN will
for our staff to develop their skills? continue to work closely with the
• Are we in a position to become an early adopter site for delivering DH and the NHS Commissioning
talking therapies as part of our CAMHs service? Board on the development of
initiatives in this area.
• Do we routinely offer talking therapies to our service users with a severe
mental illness, in line with relevant NICE guidance? For more information about the
• Have we had a conversation with our commissioners about how they issues raised in this Briefing,
plan to take forward extending providing talking therapies to people please contact
with LTCs and MUS as part of local QIPP plans? rebecca.cotton@nhsconfed.org

05
briefing 217 Talking therapies: a four-year plan of action

References
1 Department of Health (2 February 2011), No health without mental health: a cross-Government mental health outcomes strategy for
people of all ages. Available at: www.dh.gov.uk/en/Healthcare/Mentalhealth/MentalHealthStrategy/index.htm
2 Taken from IAPT website, accessed March 24th 2011: www.iapt.nhs.uk/about-iapt/
3 Department of Health (February 2011), Talking therapies: a four-year plan of action. Available at:
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123985.pdf
4 Department of Health (2 February 2011), Talking therapies: a four year plan of action – impact assessment. Available at:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_123994
5 Department of Health (2 February 2011), Press release: ‘Mental Health Strategy to transform health and wellbeing’.
Available at: www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_124018
6 Improving Access to Psychological Therapies (October 2008), Medically unexplained symptoms: positive practice guide. Available at:
http://iapt.nmhdu.org.uk/silo/files/medically-unexplained-symptoms-positive-practice-guide.pdf
7 Bermingham S: Research for London School of Economics and the Sainsbury Centre for Mental Health – personal
communication. Cited in Department of Health (November 2009), Quality and productivity examples: psychological management
of long term conditions, including medically unexplained symptoms. Available at:
www.library.nhs.uk/qipp/ViewResource.aspx?resID=330623&tabID=289
8 Strain et al (1991) ‘Cost offset from a psychiatric consultation liaison intervention with elderly hip fracture patients’, Ann. J.
Psychiatry, vol 148; pp1044–9. Cited in Department of Health (November 2009) Op cit.
9 Cole et al (1991) ‘Effectiveness of geriatric consultation in an acute hospital’, JAGS vol. 39, pp1183–8. Cited in Department
of Health (November 2009) Op cit.
10 Kommiski et al (2007) ‘Survival in the community of the very old depressed discharged from medical inpatient care’,
Int. J. Geriatric Psychiatry, vol 22, pp974–89. Cited in Department of Health (November 2009) Op cit.

The Mental Health Network

The Mental Health Network was established as part of the NHS Confederation to provide a distinct voice for
mental health and learning disability service providers. We aim to improve the system for the public, patients
and staff by raising the profile of mental health issues and increasing the influence of mental health and
disability providers.
For further details about the work of the Mental Health Network, visit www.nhsconfed.org/mhn or email
mentalhealthnetwork@nhsconfed.org

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