IX Models for Enhanced Access to Psychological Services
IX.5 Models Based on the IAPT Experience
The IAPT model was described in International Models and Access to Psychological Services. It offers advantages where there is a desire to provide a comprehensive approach and to incorporate training and rationalization of roles in the program. It is considered to be especially effective for the treatment of anxiety and depression. The program was not meant to substitute for existing services, but to provide access to the most appropriate levels of care for persons who are not receiving treatment or assistance at present. Although the UK IAPT model is national in scope, in Canada, provinces could choose to adopt the model and to roll it out incrementally, as was done in the UK. The existence of training programs in the UK and a considerable body of evidence about the most effective means to deliver IAPT will be an advantage when planning implementation. Characteristics that would facilitate adoption of the program to the Canadian context are:
ii. Delivery sites would be concentrated in existing practice environments, allowing efficiencies in administration, professional collaboration and economies of scale in providing treatment. The following sites could host IAPT programs:
• Hospital ambulatory care clinics • Community mental health centres • Large primary care group practices iii. Roles of psychologists would include:
• Team leaders • Supervisors • Educators
• High intensity care, primarily in the form of cognitive behavioural therapy. iv. Roles of other health care providers would include:
• Social workers and others who complete designated courses – psychological well being counseling
Psychological wellbeing professionals (PWP) provide services, described as high volume, low intensity care, specifically, counselors undertake patient-centred interviews, identifying areas where the person wishes to see change, make an assessment of risk to self and others, provide assisted self-help, liaise with other agencies and provide information about services. This work may be face to face, telephone or via other media. PWPs work under supervision and refer on those people, who require it, for high intensity therapy.130 Costs of an IAPT Program
UK initial supply projections estimated a requirement for 40 IAPT teams per 250,000 population. Team sizes vary and a detailed review of the data suggest that at maturity there will be one therapist for every 5,572 persons of working age131. Projections used as guidelines in the program call for approximately 900,000 persons treated by 6,000 therapists annually when the program is mature – an average of 150 patients seen by each therapist, with 50% of those treated moving to a cure. The composition of teams between high intensity therapists and psychological well being counselors is projected to be 60% and 40% respectively. These supply targets will vary with local circumstances and teams will have different ratios depending on these circumstances and the types of service that are offered.132
Salaries presently paid by NHS vary by type of therapist and level of responsibilities. Salaries for high intensity therapists range from £25,500 to £40,200 (NHS bands 6 and 7) while salaries for PWC are normally £18,700 – 21,800 (NHS band 4) and can move to higher levels depending on future
Salaries in the UK health system are typically less than salaries in Canada. In order to estimate cost of an IAPT team in Canada, an estimate of $112,000 per year is used for a hospital psychologist, as a reference point (based on salaries in Ottawa at present).133 Based on the ratios of salaries of PWP to high intensity therapists in the NHS, the salary for a PWP would be in the range of $67,000
(approximately 60%). A team comprised of three high intensity therapists and 2 PWPs would incur salary costs of approximately $460,000 per year and would be expected to serve an area with 27,800 population. Benefits and institutional overheads would be expected to add approximately 40% (assuming average benefits of approximately 33% and institutional overheads of 8%). These estimates would indicate that program cost per 1,000 persons would be approximately $27,500. Training costs, which would be higher in earlier years, would add to this cost, but they could be considered a one-time investment associated with the introduction of the IAPT service. In future, education costs could be assumed by provincial governments, trainees or through cost sharing arrangements between employer and employee. Start up costs would be highly variable depending on whether or not the IAPT service was located in existing facilities of if new facilities were to be rented or constructed.
An estimate of annual operating costs for a series of IAPT programs covering the entire Canadian population would be $962 million. As noted above, staff training and start-up costs would add to this estimate in the early years of the programs and would be highly variable based on choices to be made about the locations of training (universities for intensive care therapists and community college for psychological wellbeing counseling).
In any event these costs would be modest compared to potential benefits. A recent report on IAPT program results in the UK to the end of the 2011-2012 fiscal year documents persons treated, rates of completion, recovery and return to work by persons on disability when they entered the program.132 These data indicate that 45,000 persons have been able to go off disability and return to work (pg. 22). Since the total number treated to date has been approximately 1 million, these data are
equivalent to a rate of 45 persons going off benefits for every 1,000 persons treated. The rate based on persons actually on disability benefits would be much greater. The report also anticipates
reductions in NHS costs for other health services, reductions in hospital inpatient and outpatient utilization and prescription drugs by IAPT clients and reductions in costs from lost time at work.
IX.6 Summary
This section has discussed three types of models for enhanced access to psychologists care that are believed to be viable in the Canadian context. All of these models have the potential to produce considerable benefits in terms of cost effective care. Positive returns on investment will be realized, both in terms of improved health in the population and a reduction in the economic burden of mental
neutral or cost saving in terms of existing expenditure. Instead, the main rationale should be improved health, an increase in rates of needed care and an overall increase in the cost effectiveness of care. On the other hand, the potential reduction in the monetary and non-monetary burden of mental illness is real and, although difficult to quantify, should not be ignored.
Primary collaborative care is the first model discussed. Bringing psychologists into the primary care team has great potential to improve the quality of care, effectiveness of care, professional
collaboration and satisfaction. Considerable effort has been made over the last decade to understand the potential of collaborative primary care. Where collaborative mental health care has been included in primary care models, results are positive. There is no single model that stands out, however, but rather a number of models that have been developed in ways that are consistent with local conditions and provider practice styles. We discuss some key elements of these models in terms of how they should be funded, where services are to be delivered and the roles of psychologists in collaborative care. We believe the approach taken by the Premiers Council to the development of innovative primary care models is appropriate. That approach is to identify best examples and share knowledge between jurisdictions so that promising models can be expanded to provinces and health regions that are ready for them. This is best seen as a pragmatic, rather than an ideal, approach but it is consistent with the development of health services and the adoption of best practices in Canada to date.
The second model is fee-for-service. We estimate that fee-for-service care by private practice psychologists presently accounts for approximately $950 million in expenditure annually. The
fee-for-service model provides a valuable service for those who are able and willing to pay. It provides a private practice option for many psychologists, both those in full time private practice and those in part time private practice. The main concerns about this model are that the costs are
disproportionately paid by patients and that out-of-pocket costs provide a barrier to access for many who could benefit from psychologists care.
There are compelling arguments that the distribution of costs in fee-for-service practice should change, with employers bearing a much greater share through their employee insurance plans. There are clear benefits for employers and insurance firms in doing so – in particular a reduction in the costs to employers through lost productivity and a decrease in disability claims paid by private insurers. The discussion above offers suggestions for increasing the rates and levels of private insurance coverage, including the elimination or reduction of measures that limit access, such as service limitations and the requirement for physician referrals.
There are no compelling arguments that suggest fee-for-service as a method for increasing public sector funding of psychologists services through departments of health. The trend in funding primary care practices, in particular, is moving away from fee-for-service to alternative funding models that allow greater flexibility in organizing and delivering a full range of interventions that benefit clients and patients.
The third model is based on the UK IAPT program. This model should be attractive to provinces that wish to scale up, quickly, the provision of psychological services. It rationalizes the roles of highly
from modest interventions or directed self-help programs. There is a considerable amount of
information based on experience with the UK plan that provinces can access if they wish to explore the potential of adopting a similar plan adapted to the Canadian context.
Most importantly, the models, as explored, need not be exclusive. It is quite possible to adopt a number of variations on the primary care collaborative model across Canada, based on local requirements and practice styles. Collaborative primary care models should be expanded. A key aspect of this model is the increased role played by the client and the client’s family. The models are, essentially, community-based, and build upon and utilize other appropriate mental health services. Fee-for-service can be expanded with greater funding from private insurers. IAPT models can also be adopted where there is a determination to do so. It is unlikely that any one jurisdiction would choose to implement all the possible variations. Yet, there is significant potential to adopt specific models to local cultures and funding environments.