How equitable are psychological therapy services in South East London now? A comparison of referrals to a new psychological therapy service with participants in a psychiatric morbidity survey in the same London borough

High quality care should ideally be both effective and provide equitable access for the population based on need [1]. In mental health, access to services is poor worldwide, with only about 30–40 % of individuals with mental disorders consulting their general practitioners (GPs) [2‐4]. Access has been traditionally through GPs in publicly funded systems but has been problematic for several structural and individual reasons. GPs often fail to recognise mental disorders in patients [5]; may lack resources to manage them effectively [6, 7]; and individuals may be reluctant to consult GPs about emotional problems [8, 9]. In addition, access may be influenced by patient characteristics such as socioeconomic status and ethnicity [10, 11] which is a pattern of particular concern because inequitable access to services may perpetuate existing patterns of disadvantage [12].

Patterns of access to primary care services do show some problems of inequity. Epidemiological data indicate that up to 50 % of all adult mental health problems start by the mid-teens and 75 % by the mid-20s [13]. However, younger adults [14, 15] are much less likely to access services than those of working age [2, 14, 16]. Older people over 65 are also much less likely to access services [14]. Some ethnic inequities have also been found. GPs have been shown to be less likely to detect common mental health problems in black people compared to white people [10]. In addition, South Asians are less likely to consult, even after controlling for severity [2].

The role of psychological therapies is becoming increasingly recognised. In the UK, the National Institute for Health and Clinical Excellence (NICE) has advocated the use of evidence-based psychological therapies as first-line treatments for the treatment for depression and anxiety [17] In addition, the lack of change in the prevalence in neurotic disorders between 1993 and 2000, despite a two- to threefold increase in the prescription of antidepressants has led to recommendations that other treatments, notably psychological and social interventions, are needed to reduce prevalence [18].

However, psychological therapy services have sometimes been characterised as small and inequitable with white middle class women over-represented among service users. Following recommendations by Layard [19] who has emphasised the economic implications of untreated mental disorders such as depression and anxiety, the Improving Access to Psychological Therapy (IAPT) programme was introduced by the government-funded National Health Service (NHS) to increase the capacity of psychological therapy services in an equitable way. Under this programme, extra resources were invested in England to increase the number of psychological therapy staff as well as ensure NICE compliant standards were achieved through high-intensity psychological (HI) and low-intensity psychological (LI) training. Outcomes of treatment as well as service utilisation by different socio-demographic groups were also carefully monitored to assess equity.

Prior to the national roll-out, an analysis of users of the IAPT services in the two IAPT demonstration sites in Newham and Doncaster during the first 13 months of service had showed some patterns of inequity [20]. Less than 4 % of service users were under 18 or over 65 years of age, with the majority (58 %) aged between 25 and 44 years. A comparison of ethnicity in the local population, (independent of need), showed that whilst 61 % of the local population were from black and minority ethnic (BME) groups (38 % Asian, 20 % Black) [21], only 49 % of IAPT patients in Newham came from BME groups (25 % Asian, 17 % Black), supporting the previous findings about psychology services not being equitable [22]. However, data from the Newham service comparing GP and self-referrals indicated that the introduction of a self-referral route improved access for BME groups, with the proportion of people from black ethnic groups only coming through this route increasing to 22.2 %, whilst the proportion of black ethnic groups being referred by GPs remained low at 15.9 %. This supports work by Brown and colleagues [23] showing that the proportion of black participants self-referring to a psychological intervention was comparable to the rate in the local population. Sixty percent of those accessing the IAPT service were found to be female. In the demonstration sites, employment data were not complete (54 % Newham and 27 % Doncaster) but indicated that 31.7 % were on benefits. As these sites demonstrated the feasibility of the service, the new IAPT services were rolled out nationally.

The question that now arises is whether IAPT services are equitable in practice. Comparisons of socio-demographic and economic variables between patients using a service and the general population are often only partially informative because differences identified may be due to several factors including differences in geographical area (e.g. local, regional or national), access to services (e.g. capacity of services) or whether mental health need is measured and controlled for. It has been recommended that local data are essential to accurately examine inequities in mental health [24]. Equity here is defined as equal (or not unfairly restricted) access to health care services.

Southwark is a deprived borough in London [25]. It is also ethnically diverse with a greater number of Black-Caribbean residents but fewer South Asian residents than other areas of London [21]. The South East London Community Health Study (SELCoH) study is a community survey which was conducted to improve understanding of the health needs of the Southwark as well as Lambeth community, and make recommendations about improved service provision [26]. The present study will be the first to directly compare socio-demographic and socioeconomic characteristics of patients who are using an IAPT psychological therapy service in Southwark with individuals identified with mental health needs from the same catchment area (Southwark) who are participants in a community psychiatric morbidity study.

Table 1 gives details of the Southwark IAPT group (n = 4,781), the overall SELCOH group (n = 852) and the SELCOH12 group (n = 196). Of the SELCOH12 sample, 31.8 % had consulted their GPs in the previous year for a mental health problem. The most common diagnoses were depression (46.8 %), non-specific neurotic disorder (19.7 %) and generalised anxiety disorder (16.2 %). There was missing data, particularly for ethnicity (37 %), employment status (36.8 %) and benefit status (38 %) for GP referrals, largely because data on these variables were not available for those who did not come for their assessments. Clients whose data were missing were still included in the analysis.

This study aimed to assess the extent of equity among patients accessing the Southwark IAPT Service, by comparing them with a representative group of individuals from the local population with diagnosable mental health problems. Results indicated that the overall Southwark IAPT group and GP referrals differed from community participants significantly on all six indices of equity examined. It needs to be noted that one of the differences found was in employment status, with a higher proportion of unemployed patients than SELCOH-12 participants. On the other hand, Southwark IAPT self-referrers did not differ significantly from the SELCOH 12 group on four indices (mean age, gender, and ethnicity and benefits status), but there were differences in two criteria, age (categories) and employment status. Again, more unemployed people were accessing the service through the self-referral route. This indicates that while both GP and self-referral pathways were accessible to unemployed people, the IAPT self-referral route may lead to a more equitable provision of psychological therapies compared to the GP-referral pathway, particularly with regard to ethnicity.

To our knowledge, this is the first time that the importance of the self-referral route in leading to greater equitable provision has been shown through a direct comparison of referrals to a psychological therapy service with a community sample with mental health problems from the same geographical area.

There may be several reasons why people came through the self-referral route rather than the more conventional GP-referral route. One possibility is that they felt able to self-refer to the Southwark IAPT Service as they did not have to face a potentially difficult consultation with the GP. Reasons cited in the literature about individuals’ difficulties include fearing the GP would not understand or have the time for mental health problems [8, 29]; differences in attitudes such as health beliefs such as perceptions of problems [30]; fearing being stigmatised [31]; or not wanting to be prescribed medication despite recognising its effectiveness [32]. Some of the above could apply to BME people who have often been reluctant to consult [2]. Another possible reason is that people coming through the self-referral route were more able to conceptualise their problems in a less medical way [9]. For example, those on benefits may have recognised their anxiety and depression as something the Southwark IAPT service could help with and self-referred. Another possible practical reason is that given a common obstacle to seeking help is that people often did not know about services [33], the publicity for the self-referral route that was placed in community settings, such as libraries, leisure centres and GP surgeries would have raised the profile of the IAPT therapy services among people who may previously have been reluctant to consult.

A key finding is that self-referrals did not significantly differ from the ethnic composition of SELCOH12 group participants while ethnic groups were under-represented in both the overall Southwark IAPT service and the GP-referral groups. This indicates that the self-referral route is more effective than the GP-referral pathway in ensuring equity in terms of ethnicity, particularly among Black-African people and Black-Caribbean people. It should be noted that ethnic differences between SELCOH12 and overall IAPT or GP referral patients were found for Black-African but not for Black-Caribbean participants, suggesting that Black-Caribbean participants are slightly more likely to consult their GPs than Black-Africans. These robust findings utilising a psychiatric morbidity survey support previous studies which have found BME self-referrals to be comparable to ethnicity rates in local populations where psychiatric morbidity has not necessarily been assessed [20, 23]. This finding therefore suggests that the self-referral route may be an important way of circumventing key barriers to access such as poorer GP detection of mental health problems of BME groups [10] and/or cultural differences in illness perceptions leading to reluctance to consult [9], or only being in touch with services at crisis points [34, 35].

The comparison of self-referrers with SELCOH12 participants suggests that more women with problems are coming through the self-referral pathway than through the GP pathway, indicating the self-referral pathway is allowing more equitable access. There is some evidence to suggest that male and female patients with common mental health problems are treated differently by GPs. For instance, Hyde and colleagues [36] found that males were more likely to be offered active treatment for depression by GPs than females. These differences may be due to a number of factors such as concern regarding higher suicide rates in young men or that they are considered less likely to return for follow-up appointments than women, and are therefore managed more actively at the initial consultation [37].

Our results indicated that adults in mid-life had more access to the service than young and older adults. Similar findings have been shown in comparisons with census data [16, 20]. The 16–24 category, and those aged 55 years and above therefore still remain under-represented.

More unemployed people are coming through into the Southwark IAPT service compared to the local population with mental health problems. Whilst it may be that there is greater need, our analysis where we controlled for need by only including those with CIS-R scores above the threshold, would indicate that this may not be the case. It may be that the service provides additional support for those people with mental health problems but who may lack a social support network. It may also be that unemployed people have more time to attend services or be more likely to be referred or self-refer.

In terms of receiving benefits, the proportion receiving benefits among self-referrals (37.2 %) was similar to that of the SELCOH12 group (41.4 %), and higher than those coming along the GP pathway (25.3 %). It is possible that this pattern may be the result of self-referrers being more likely to conceptualise their social problems as benefitting from psychological help, whereas those on benefits who consulted their GPs may have seen their problems as amenable to help from a doctor. It is also important to note that those who were working can still claim benefits, such as housing and child benefits.

The findings from this study would suggest that the IAPT service has been partially successful in providing an equitable service in Southwark. It clearly provides a service that unemployed people can access. Nevertheless, when compared to people in the local community with common mental health problems on other indices of equity, clear disparities were found with the overall Southwark IAPT service and GP referrals in particular. Even though relatively few people use this pathway into care at the moment, the self-referral pathway has been shown to help provide a more equitable provision in the IAPT service.