 Welcome everyone, I'm here with Professor David Clarke from Oxford University and from NHS England who's just given a talk here at the IAT Connect 19 conference. You gave a kind of whistle stop overview of IAT since the original idea in 2005 and since it began in 2008 and you also gave some kind of really interesting, more recent data. Give us in a nutshell what you think you've achieved so far with IAT and what you think you still need to achieve in the coming 5 or 10 years. Well, I think that one of the biggest achievements in IAT, which goes beyond IAT, is that it's changed the way people think about commissioning mental health services. Up until IAT, I think thought was all focused on input variables. How many people would you see in a particular service? How long they would wait? There was nothing about whether patients actually get better. IAT has introduced a sort of outcome monitoring system where you now collect data on how much people's symptoms change and how much their disability changes because you're measuring it each session and we can get data on, essentially everyone, 99% of people are treated and we publish that data. So it means that commissioners can now actually think about, well, how can we ensure that we commission services that are also effective in terms of the outcomes that they get with patients? And also because of the public transparency, it means we can learn an enormous amount about how to better deliver therapy. And so one of the slides I showed today was showing how the sort of outcomes of IAT have improved really quite dramatically over the last 10 years from round about less than 40% of people recovering in the services. Obviously there's more people get some benefit but about 40% are recovering. And now we've gone up to maybe 53% of that and almost 70% of people showing worthwhile improvement. And that's because we've learned from all of the outcome data. And I think that's a message that is really being picked up in many other countries. And there are services now being developed in many European countries and North American areas which are now focusing not just on what we provide but whether it really helps. And we're learning so much more from that. So I think that's in a sense the biggest contribution of IAT to mental health. Looking at the data over the last decade, one of the groups that haven't recovered as well from IAT services are people from BAME backgrounds. And you were talking about some recent data saying that there have been some improvements in that group. Tell us about that. Yes, so I mean the outcomes of the BAME group have gone up dramatically over this period of time. But they've tended to be a bit below the sort of average outcome. So at the moment the recovery is 52% for people in general. And if you're from the BAME community it's 14.9%. So only a small difference but one we'd like to completely remove. But it was much larger a few years ago. And I think because we published data on outcomes by different groups it allows people to then focus on those problems which you wouldn't be aware of if you didn't publish the data. So there is a very good practice guide for delivering treatment in an effective way in the BAME community which has just been published by people in IATs who work in the BAME community. And that I think will help even further. But it's only because of the public transparency that people get to do these initiatives and improve things. Andrew Beck from the BABCP was tweeting just as you were talking about the guide so we shared a link to it. Wonderful. And it was made available yesterday. And Andrew was one of the key authors of it. So wonderful. Great. What about people who don't get into IAT services or people who wait a long time or people who get in and then leave quite quickly. So you're talking about recovery rates within the service. What about the people that don't get on well with that? The first thing to say in terms of the outcome data is that the outcome data is on everyone who's seen it at least twice. So there'd be quite a number of people in that data setter you might say didn't have a full course of treatment but were still reporting their outcomes so that's really critical. So it isn't just the people who got on incredibly well and have many, many sessions that were reported on. It's more or less the whole treated cohort. But there is a problem that because IAT is such a big programme and in general so successful it tends to be the case that people with a whole range of mental health problems which may be different from what IAT was created for get referred in. And that's not really great for them because they get an assessment and then tell this isn't really the right thing for you and it's a frustration for them. But it's also not good for the services because of course it means that more time is taken up by doing this sort of triage rather than focusing on delivering treatments and reducing waiting times. So this is an area where things need to improve and there are two bits to that. I think IAT needs to help people understand much more what happens in the services and what are the things that IAT can really help people with and what are the things that somewhere else might be more appropriate for. And I think there's the London services that are now trying to develop a sort of digital triage programme where people online can find out much more about what would happen if you came into it and what were the treatments available. You can see is this the sort of thing that I think would help me or not and what are the sort of problems that it can help. And also do probably some of the screening you can do in the privacy of your own home in the digital thing and we hope that will help quite a lot. The other thing of course that we hope will help is quite a lot of the plans in the NHS long-term plan for mental health because it's not just IAT that is expanding at the moment. There are strong commitments to expand many other mental health services including creating a new mental health service for homeless people and these are all part of the tapestry that's required. If only IAT is expanding and we're not really getting expansion in other areas psychosis services and things like that, obviously we're going to have a problem that people with these other conditions are not getting help and tend to be steered in the wrong direction. You said in your talk IAT is not just a CBT service. That's correct. And that's certainly something that is often perceived. Tell us a bit about and we had a tweet actually during your talk from somebody who said what about people with personality disorder diagnoses. Tell us a bit about how IAT supports people with more severe difficulties what the high intensity options are that are available. Yes, so the first thing to say is that IAT really is defined as something which tries to deliver nice guidance and what it delivers will change as nice guidance changes because that's the defining feature of the services and nice recommends quite a number of different high intensity therapies for depression. CBT is one of them but also interpersonal psychotherapy. Couples therapy if you are depressed in the context of a relationship issue and your partner is still willing to work in therapy with you and try and help and also brief psychodynamic therapy and for those people who've got recurrent depression also mindfulness can be a good way of building resilience once you've got a lot of the recovery from your current episode. So these are all things that we support in IAT and we really ask all services to give patients who are depressed who are going for the high intensity treatment a choice of therapies and that is generally what's happening. So the latest data shows that 93% of all of the IAT services give patients a choice between at least two different therapies, high intensity therapies and depression. The most common one is between CBT or counselling for depression but many of the other therapies are coming in but in a smaller number of services and we think this is important because we think it gives people autonomy and is likely to improve outcomes if we can give choice because we know in the psychotherapy research that if someone sees a treatment as credible making sense to them they're more likely to respond to it and some therapies may seem more credible to people than others. So that's the sort of things that are available. You're asking about severity. It is a common misunderstanding of IAMS that it's only for mild to moderate problems and I think it is true that some of NHS's publicity about the programme described it that way. But the data has never borne that out. So if you look at say depression, the measure of severity is the PHQ-9 and NICE says the sort of cut off between mild to moderate and moderate to severe depression is 17. The average intake PHQ score in IAMS for depression cases is 17.8. So actually over half of the people we see are in the moderate to severe range and we still get very good outcomes with them. You had a question about personality disorders. Well for those who do some personality screening with SAPAs we find quite a lot of people who are treated in IAMS do also have a personality disorder and we're still getting good outcomes. But there is a distinction I think clinically between someone where you might say everyone agrees including the client that it is a sort of more general personality issue that requires treatment rather than someone who has personality issues and is also currently very depressed or disabled by anxiety and we can focus more on that and open things up for them. So it isn't a service that is aiming to deliver the sort of nice recommended long term therapies for personality disorders. There are things that we want to be made more widely available in the NHS but it's not part of IAMS. But there are a lot of people who also have personality difficulties who are benefiting a lot from IAM treatment. What's your long term vision for IAMS in terms of this question about triage and treatment choice? If you listen to the geneticists and the data scientists they'll say that it won't be too long before we can offer very personalised treatments and recommend to people which antidepressant is likely to help them more based on their personal setting, personal situation. How do you think IAMS will develop in that sort of sense? Well, there are several things you can say about that. The first is of course the IAMS data said is enormous and we can learn quite a lot from that about those people who are responding well. Those are not responding so well. Rob Sonders at UCL has done a very good project where he's created a number of what you call different late profiles and identified a subset of people who really don't do well at the moment. I know some of the services and how taking up that work and thinking how can we change the treatment somewhat to deal with those people. One of the features of these people that are interesting is that they tend to score very high on the phobia measures, particularly angrophobia and things, and that hasn't been picked up on them. They also have other social complications and problems and people tend to focus on that. But we think actually some of their phobias are really seriously under treated. So I know in some services they're actually looking at that particular subset of people and trying to evolve the treatment they offer them and see whether that helps. So I think that's one exciting development. The other thing is really to ensure that we use all of the complex features of the different high-intensity therapies that we use. So if we take CBT, for example, people talk about it as there is some sort of standardised thing as Thor record, activity schedule and things, that's not good CBT. Good CBT is really focusing on what's the very individual thoughts that cause distress to that particular person and how do those thoughts interlock with different changes in behaviour and emotion. And you get very different interlocking patterns for different patients. And actually really good CBT personalises the intervention to deal with that interlock. And so really ensuring that the therapists are trained to do that very personalised intervention. It's critical. But also that our new digital programmes do the same. So if you look at different online therapy programmes you find some of them are very much the same intervention for every patient. It might be CBT, but it's the same CBT. Others are incredibly personalised. So you will fill in some questioners about what are your particular fears, your particular depressing thoughts or fearful thoughts, and it would take you down a completely different set of modules depending on those particular thoughts. So in a programme that we did up for social anxiety we recently did a randomised controlled trial there and we have about 100 patients in that trial no two patients have the same intervention in the internet programme because the modules that they were led to depending on their thoughts were different and the sequencing was different. And so I think it's not just using the data in clever ways and doing digital phenotyping or genetic phenotyping it's also using some of the sophistication that we already know around these therapies to ensure that they're really properly individualised. The way the most skilled psychotherapists have always done. Our opening remarks from Pookie were all about giving therapists the space and the time and the skills to connect with patients and to gain trust and to communicate well. What do you think we can do to improve the current situation for IAT staff so that they're able to do that more? Well so Pookie made some very good points I think one of which is to say go beyond the diagnosis find out what it is that someone is individually fearful of that is of course a central strength of cognitive therapy which focuses on the particular thoughts that people have rather than their diagnosis and it's very important that people go with those strengths because it's very important for patients. But of course it's easier for people to do that if they feel that they have the resources to think about their work and the time to do it and so one of the big challenges for IAT is to ensure that as it tries to see more patients it also dramatically increases the size of its workforce and we've had some problems with that. The programme when it started would give PCTs at the time the full salary costs of the IAT trainees they might be working three days a week in the service and then two days a week in the university but the PCTs didn't have to pay for any of those five days and it was only when someone had qualified that the PCT would then have to take up the salary and the deal was if you accept a trainee you will give them a permanent job when they start as a trainee so if they pass the course you will commit to funding them and they've got a secure job. That was a system which worked incredibly well and almost everyone who came on as an IAT trainee ended up working in IAT services and so we were able to grow the workforce quickly. Then there was a sort of change and at one point it was said the CCGs need to cover the salary costs of the trainees as well but the announcement about this came out after CCGs had already made their budget allocations and said there was a big drop in numbers of trainees and so we have under-trained in the last few years and so we have a capacity problem in the way that the NHS has tried to address this to go back closely to where we started from so now NHS England has said it will cover 60% of the salary costs of all trainees on condition that the CCG guarantees that the trainee will then have a job afterwards because if you're going on a detailed one-year training course you want to know that you've got a job at the end of it and we also want to not waste training resources on people who end up doing the job so that's a very positive development but it's just happened and I don't think all CCGs are quite caught onto this and we do need them to respond to that and grow the workforce because otherwise it's just getting too stressful of course it's not just a matter of having enough people there it's also having the right climate in services and it is undoubtedly the case that there are some services where the management structure is really driving people towards certain targets rather than focusing on the overall aims you want to achieve for the service and the wellbeing of the staff in it and that needs to change and the IAP manual has quite a lot on that there's a section on don't get obsessed with targets realise that there's something more important that you're trying to gain and achieve with your patients just achieving a couple of metrics there's a proxies for something more broader and you need to focus on the broader thing but it's also the case that if we're spending a lot of time thinking about the wellbeing of our clients we also have to spend the same amount of attention thinking about the wellbeing of our own staff and this is morally the right thing to do but it's also helps a service and people are much more productive when they are enjoying their work and feeling they have space to do it properly so outcomes for services improve as well at that point so we've been very clear in the manual that we'd like all services to get together the staff and the clinical leads to develop their own in-house wellbeing programmes that are co-produced by the staff and the clinical leads just in the same way that therapy should be co-produced by the patients and the therapists we need to apply the same skills within our services as we apply with our clients As always, really interesting talking to you thanks very much for taking the time