Accessibility and efficiency of mental health services, United Kingdom of Great Britain and Northern Ireland

Abstract Problem Mental ill health in the United Kingdom of Great Britain and Northern Ireland has been a major driver of labour market exclusion through sickness absence, reduced productivity and job loss. Approach A government-supported programme for improving access to psychological therapies was launched in 2008 and expanded across England in 2010. The aim was to provide evidence-based treatments for people with common mental disorders through three principal strategies: (i) routine session-by-session outcome monitoring; (ii) integration with the wider care system; and (iii) delivery of psychological therapies as part of a stepped-care approach. Local setting Access to effective psychological therapies was previously low in the United Kingdom. In 2010, only about 35% of people with moderately severe mental disorders were in specialist or non-specialist treatment. Relevant changes The accessibility of quality mental health services has increased, as has the efficiency of the country’s mental health system. The numbers of people entering treatment have increased steadily from 0.43 million in 2012–2013 to 1.09 million in 2018–2019. The recovery rate of patients in treatment increased from 42.8% to 52.1% during 2012–2018. The number of people moved off sick pay and benefits rose from 3683 to 18 039 over the same period. Lessons learnt A clinical guideline on psychological therapies is a prerequisite for increasing the accessibility and efficiency of mental health services. An integrated approach allows mental health services to have better reach. Routine collection of patient-level outcome data plays an important role in the value and function of the mental health care system.


Introduction
The burden of mental disorders is rising worldwide. Around one in six people suffer from mental disorders, with the highest prevalences in North America, Western Europe, North Africa, the Eastern Mediterranean and South Asia. Historically, mental health services have often been neglected and segregated from physical health; this treatment gap is bigger in low-and middle-income countries, requiring innovation and improvement.
The burden of mental ill health in the United Kingdom of Great Britain and Northern Ireland is high relative to other members of the Organisation for Economic Co-operation and Development, with mental disorders costing an estimated 70-100 billion pounds sterling (£) or 4.5% of the gross domestic product (GDP) of £1849 billion in 2010. 1 Nevertheless, the United Kingdom has been more innovative in mental health than many other comparable countries. 1 Here we review some lessons learnt, focusing on working-age people and illustrating improvements driven by a programme of evidence-based psychological treatment services.

Local setting
In the United Kingdom, mental ill health has been a major factor causing labour market exclusion, through absence and reduced productivity. 1 Almost 40% of new claims for disability benefit were made on the basis of mental ill health in 2012. 1 However, a substantial gap existed between treatment need and treatment actually received. In 2010, only about 35% of people with moderately severe mental disorders were in treatment (specialist or non-specialist), and only about 65% of those with a severe mental disorder. 1 The United Kingdom's health system comprises primary care services, community-based specialist secondary care services and inpatient (secondary and tertiary) care. 2 There are several routes to access mental health services; the most frequent is through a patient's general practitioner in the primary care system. 3 However, general practitioners, by definition generalists, acknowledge a lack of expertise in psychiatry. 1 In 2005-2007, the commonest mental disorders (depression and anxiety disorders) were usually treated with antidepressants rather than psychological therapies, although the latter are cost-effective in keeping people in work or in promoting a return to work. 1 General practitioners could refer patients to counselling services or services delivering specific psychological therapies (such as cognitive behavioural therapy), but waiting times for psychological therapies were long. 1 A 2010 survey of 527 people found that one in five people had been waiting over a year for treatment, and one in 10 people had been waiting over two years. 1

Approach
The United Kingdom's current mental health services follow the implementation of a series of programmes involving public education, workforce training and early intervention. Nevertheless, a major part of the country's recent innovation comes from a programme called Improving Access to Psychological Therapies. In 2005, the public standard-setting body issued clinical guidelines that strongly recommended psychological therapies for the treatment of depression and anxiety disorders.
Lessons from the field Mental health services, United Kingdom of Great Britain and Northern Ireland Shanquan Chen & Rudolf N Cardinal Part of the subsequent economic case was that the cost of access to evidencebased psychological therapies (about £650 per patient per course) would largely pay for itself by reducing other depression-and anxiety-related public costs (such as welfare benefits and medical costs) and increasing revenues (such as taxes from a return to work). 4 In 2005, the incoming government's election manifesto was committed to improving mental health services, including behavioural as well as drug therapies. 4 The new health service programme providing evidence-based psychological treatments was piloted in 2006, launched in 2008, and expanded across England in 2010 (covering 52.3 million out of the 62.5 million population in the United Kingdom). 4 The priority was to ensure widespread access to simple, effective treatments for common mental disorders, primarily depression and anxiety disorders with mild, moderate or severe symptoms, via primary care or self-referral. 5 The aim was therefore to address the greatest population need, rather than very severe or very complex mental disorders that are treated by secondary or tertiary mental health services. The enhanced services have three notable features.
First, routine outcome monitoring is conducted on a session-by-session basis by the therapy service, 5 with 98% of patients having self-reported symptom scores recorded at the beginning and end of treatment. 6 Data are also collected on the person's disability (how their mental health problem interferes with their functioning in work and normal life); their employment; and their experience of the quality of care received. Summary data are made publicly available. Patients can see what their local mental health therapy service offers and the outcomes it achieves; service commissioners and clinicians can benchmark their service against others and develop collaborative networks for services to learn from each other. 6 Meanwhile, session-by-session data enable clinical monitoring and supervision, using objective measures of effectiveness. 5 Local, regional and national leaders use these data for policy-making. 6 Second, the programme provides evidence-based psychological therapies via a stepped-care approach (Box 1). 5 Therapy can be delivered by a single clinician, with or without concurrent medication management (usually by a general practitioner).
Third, services are integrated with the wider care system beyond mental health, such as social and physical health care, and across the lifespan (education and employment). 5 For instance, social prescribing is seen as supporting delivery of the enhanced services. 5 Social prescribing includes facilitated self-help, personal skills development and book therapy, with some components available online. These services may increase support for patients, particularly at an early stage of illness, although the evidence base remains weak. 8 Patients with comorbid long-term physical health conditions or medically unexplained symptoms may be referred into a focused pathway (Fig. 1). 9 The programme provides specific assessment and treatment protocols for students. 5 Employment advice has been integrated into the services and delivers a personalized service to patients based on their individual needs. 1,5

Relevant changes
Patients treated and measures of the programme's clinical success have increased steadily in England over the period 2012-2013 to 2018-2019 (Table 1). The numbers of patients referred to the programme's services almost doubled from 0.88 million to 1.60 million. The

Box 1. Stepped-care services in the Improving Access to Psychological Therapies programme, United Kingdom of Great Britain and Northern Ireland
Step 1. Primary care, usually provided by a general practitioner: includes identification and assessment of problems (including risk assessment); psychoeducation; active monitoring; and referral for further assessment and interventions.
Step 2. Low-intensity service, often provided by a psychological well-being practitioner: mainly offers low-intensity interventions, including guided self-help; computerized cognitive behavioural therapy; and group-based physical activity programmes. Targeted at patients with sub-threshold depressive symptoms and mild-to-moderate depression, as well as some people with anxiety disorders.
Step 3. High-intensity service: usually involves weekly face-to-face, one-to-one sessions with a trained therapist. Also includes cognitive behavioural therapy group work or couple therapy for depression.
Sources: National Collaborating Centre for Mental Health, 2018; 5 National Institute for Health and Care Excellence, 2011. 7

Fig. 1. Pathway for Improving Access to Psychological Therapies services, United Kingdom of Great Britain and Northern Ireland
Source: We created the figure using information from a service manual and clinical pathway description from the National Collaborating Centre for Mental Health. 5,9 Lessons from the field a Indicators used in the United Kingdom's National Health Service's annual report. Referrals are the primary entity being counted. A referral constitutes an episode of care for a patient (it is possible for a single patient to be referred more than once). b Appointments are the way in which patients' contact with services are recorded. c The denominator is the number of referrals where the patient entered treatment. d A patient has shown reliable improvement if they have a significant improvement in their condition following a course of treatment. Improvement is measured by the difference between their first and last scores on questionnaires tailored to their specific condition. The denominator is the number of referrals where the patient completed treatment. e Recovery in the programme is measured in terms of caseness, a term which means a referred patient has severe enough symptoms of anxiety or depression to be regarded as a clinical case. A referred patient has moved to recovery if they were a case at the start of their treatment, and not by the end of their treatment, as measured by scores from questionnaires tailored to their specific condition. A referred patient has reliably recovered if they meet the criteria for both the recovery and reliable improvement measures. The denominator is the number of referrals for patients who completed treatment minus those not at caseness. f The denominator is the number of referrals where the patient finished a course of treatment. NR: not recorded. Notes: We extracted data from the annual report on the use of Improving Access to Psychological Therapies services for England. 10  An economic evaluation of the associated employment support services in 2011 estimated that every £1 spent generated £2-3 in GDP, of which 30% benefited the individual and 70% the state. 11 For those patients with long-term physical conditions, early treatment was associated with substantial savings in hospital costs during the subsequent year, and these savings broadly covered the cost of the mental health treatment, ranging from over £400 saved for patients with comorbid diabetes to over £800 saved for patients with comorbid chronic lung and cardiovascular diseases. 12

Lessons learnt
In the United Kingdom, progress has been made towards the World Health Organization (WHO) 2013-2020 mental health goals, which include providing good physical and mental health care for all, mental health systems working with other sectors, and mental health governance and delivery via good information. The United Kingdom experience resonates with the WHO-Gulbenkian Global Mental Health Platform's strategies to improve mental health systems by adopting evidence-based practice, considering the whole life course, and enhancing inter-sector cooperation. The Improving Access to Psychological Therapies programme has been criticized for using predominantly self-report measures and for inconsistent provision of relapse prevention support, 13,14 while rates of improvement are not equal for all patient groups. 14 Nevertheless, the programme's experience may prove useful for other nations, even in resourcepoor settings (Box 2).
First, clinical guidelines are a prerequisite for increasing the accessibility and efficiency of mental health services.
National guidelines enabled large-scale training in evidence-based therapies, mitigating early concerns about staffing requirements. The programme recommends systematic screening for every condition that it treats. 5 This process is applicable to resource-poor settings without electronic information systems, using simple paper-based tools. While access to psychotropic medicines is important, the widespread provision of psychological therapies provides an additional treatment approach in settings with limited access to psychotropics.
Second, an integrated approach allows mental health services to have better reach. The vertical integration approach corresponds to the standardsetting body's stepped-care model, with broad access to treatments for common mental disorders in primary care, and patients being stepped up, including to secondary care if required, in complex or high-risk situations or following treatment failure. Horizontal integration of mental health services within a wider care system -including social care, physical health care and education and employment -increases the possibility to intervene early, especially for some at-risk groups. Although integration of services depends on the United Kingdom's well-developed information system, the idea or mechanism behind it could also be applied in resource-poor settings. Both vertical and horizontal integration depend on the foundations of trained personnel and a standard-ized diagnostic process, as well as the initial detection and referral of patients from primary care or opportunities for self-referral.