United Kingdom

Country

• Approximately 62 million inhabitants, which corresponds to a population density of 255 persons per square kilometer
• Expenditure on health 2008: EUR 148 billion (8.7% of the gross domestic product) (OECD estimate)

Psychotherapy in the health care system

• The UK National Health Service (NHS) provides a range of psychological treatments in primary, secondary and tertiary care free at the point of delivery for UK residents.
• Services are funded through national taxation but commissioned and paid for locally, under national guidance. 
• Therapies are delivered in family doctors’ surgeries, community mental health teams, inpatient and day hospital settings and through specialist psychotherapy teams.
• In practice these resources have been under-provided and inequitably distributed over the country, leading to long waiting lists for psychotherapeutic treatment.
• Over the last 10 years the National Institute for Health and Clinical Excellence has included psychological treatments in its systematic reviews of research evidence and clinical guidelines recommendations. This has lead to a realization that cognitive behaviour therapy in particular is underprovided.
• In 2005 the UK Government recognized that psychological therapies for common mental health problems were worth investment to reduce levels of depression and anxiety, to foster return to employment and hence reduce the amount paid in welfare benefits to those unable to work.
• In 2006 a major new Government initiative ‘Improving Access to Psychological Therapies’ (IAPT) was launched in two pilot sites and subsequently rolled out across England. This aimed to provide appropriate stepped-care across primary and secondary services, provided by a new workforce trained in either ‘low intensity’ CBT-based guided self-help or ‘high intensity’ cognitive behaviour therapy. £171m per year was committed. IAPT is currently developing to include other conditions and other therapeutic approaches.
• Other UK countries (Scotland, Wales, Northern Ireland) have not implemented IAPT but are increasing investment in psychological therapies and commissioning these on the basis of research evidence of effectiveness.
• It was emphasized that this initiative was not intended to reduce the availability of other therapies concurrently provided, but there is anecdotal evidence that there has been disinvestment from non-CBT services.
• Inpatient care for people with mental disorder is available but beds are in short supply and alternatives to admission are preferred, through crisis intervention teams, home treatment teams and assertive outreach teams. Inpatient psychotherapeutic interventions are not usual, although there are some therapeutic communities in a few major cities. 
• In addition to the NHS, there is a private sector for psychotherapy. Most of this is provided through fee-for-service with a lesser proportion reimbursed by private health insurance. There is also a voluntary and not-for-profit sector offering a range of services, notably relationship counselling, bereavement counselling and therapy for women victims of abuse.
• Under recent policy, NHS services including psychological therapies can be commissioned from the private or not-for-profit sectors and this ‘mixed economy’ looks set to grow.

Psychotherapeutic Professionals

• Therapies are delivered by employees of the NHS; clinical psychologists, psychiatrists, mental health nurse therapists, and other health care professionals with appropriate training.  Historically, medically qualified psychotherapists tended to train in psychodynamic approaches, clinical psychologists in a range of models and nurses in cognitive behaviour therapy. These distinctions are now less marked.  Psychotherapists without a core health professional qualification are also employed in the NHS.
• The psychotherapy profession also operates outside the public sector, and is in the process of becoming regulated by law through the Health Professions Council.
• Most recently, a new psychological therapy workforce in the NHS has been created through the IAPT initiative.
• There are no restrictions on the professional background of psychotherapists in the UK, which has a long tradition of ‘lay’ therapists without medical or psychological qualifications.

Psychotherapy for Depression

• The National Institute for Health and Clinical Excellence (NICE) recommends stepped care in the management of depression.
• It also recommends that psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide their structure and duration. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should: – receive regular high-quality supervision; – use routine outcome measures and ensure that the person with depression is involved in reviewing the efficacy of treatment; – monitor and evaluate treatment adherence and practitioner competence.
• For mild to moderate depression, NICE suggests that initial treatment should be low intensity, including guided self-help, group CBT, computerized CBT.
• For more persistent or more severe depression NICE-recommended first line treatments include cognitive behaviour therapy (CBT), Interpersonal Therapy (IPT), behavioural couples therapy, or behavioural activation. Second line recommended treatments are counselling or short term psychodynamic psychotherapy.
• For people who do not respond to the recommended interventions, or who have long term relapsing depression, other treatments which may be offered include cognitive analytic therapy, mindfulness-based cognitive therapy and psychoanalytic therapy. However, these are not recommended in NICE guidelines.
• Despite these positive developments, access to bona fide therapies for people with depression is limited, with inadequate follow up, given the relapsing nature of this condition for many people. There is more work to be done to develop adequate care pathways for longer term or relapsing depression.

Desirable Changes to Health Policy

• There needs to be a more intelligent approach to routine outcome measurement and reporting to benchmark outcomes in a way which is sensitive to case mix. This is slowly developing.
• At present the national minimum dataset includes PHQ-9, a symptom-based patient reported outcome measure for depression. Monitoring more generic outcomes, such as quality of life or patient-defined outcomes, would be useful.

Additional Information

• In the UK, there are a number of training and accreditation bodies for psychological therapists, including the British Psychoanalytic Council, the UK Council for Psychotherapy, the British Association of Counselling and Psychotherapy, the British Psychological Society and the British Association of Behavioural and Cognitive Psychotherapists. It is intended that members of these bodies will become regulated by the Health Professions Council, a statutory body. This has already happened for clinical psychologists and is in progress for others.

Author
Prof. Glenys Parry, PhD. Professor of Psychological Therapies, Centre for Psychological Services Research, University of Sheffield and NHS Consultant Clinical Psychologists & Psychotherapist (UK)

The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".

You can download the paper here.