Central planning in the NHS ensures consistent quality of service throughout the land…but only if it’s done right. Right?
In a recent discussion, some CBT therapists considered the matter of how many patients a therapist can see every full working day.
New CBT provision in the NHS is two-tier, with ‘low-intensity CBT’ (formerly known as guided self-help) as the lower tier and ‘high-intensity CBT’ (what you might call proper CBT) as the upper tier. This discussion was specifically about high-intensity CBT — ordinary, traditional CBT.
That makes it fairly easy. An appointment with a patient lasts about 50 minutes. The therapist has to spend some time beforehand reading the notes and planning for the session, and some time afterwards writing up notes, doing other administration, being supervised, and being trained so as to stay up-to-date. A reasonable total is about two hours of the therapist’s time for each session with a patient.
So in an 8-hour day: 4 patients.
Not so fast…
Ah, but the roll-out of CBT, the IAPT programme, is centrally planned. Experts in the Department of Health have helpfully worked all this out in advance. There is no need for anyone to re-invent the wheel by working it out all over again. We only have to look at the official guidance document (page 5) to see how many patients a therapist can see every working day:
- Each High intensity worker
- Has contacts per day 7
Eh? Seven? That’s nearly double. Opinion is divided over what this means.
One theory is that the experts were thinking of 20-minute sessions, like in low-intensity CBT.
Another theory is that nearly half the patients will not turn up, and the therapists can catch up on their admin when this happens.
My theory is that central planning is a form of madness. If internet addiction deserves to be in DSM-V, then central planning deserves to be in there too.
Rigidity and robustness
In fact the IAPT programme is not as rigid as to force therapists to see seven patients a day. Actual practice is determined locally, and is likely to result in therapists seeing four or five patients a day in most places.
But this is an example of how rigid systems are not robust. A failure at one point affects the whole system. A civil servant (known only as “DH user” in this case) writes 7 instead of 4, and makes nonsense of a national programme for improving mental health, if the system is rigid.
A system can only cope with failure by localising it, and for this to happen the system has to look different in different places. Then it can fail in a proportion of those places, but the system as a whole will not fail. A few NHS trusts might try 7 for a while, but others will try other numbers, and the IAPT programme as a whole will gradually correct itself.
The 7 versus 4 discussion is only one tiny part of IAPT, though. Much of the rest of the programme, like the division into low and high intensity treatments, the nature of those treatments, and the training that new therapists receive, is centrally planned and rigidly applied. Suppose “DH user” made another mistake that no one has noticed yet…
Despite some scope for local variation, the IAPT programme has been designed as a fragile structure that is vulnerable to errors of central planning. It could yet fail badly.