Health CommitteeWritten Evidence from the British Association for Counselling and Psychotherapy (NICE 39)
1. Executive Summary
The NICE guideline development process, which makes recommendations about the commissioning of cost effective treatments, is a robust process and an important aid to decision making.
The current hierarchy of evidence utilised by NICE results in guidelines based on a high quality but narrow evidence base. BACP believes that, in addition to the findings of RCTs, high quality practice-based evidence should inform the NICE review process.
NICE needs to review its evidence evaluation process to admit a range of quantitative and qualitative evidence in the evaluation of psychological therapies, including controlled studies, case studies and effectiveness studies.
NICE’s limited evidence base for psychological therapies disadvantages patients through restricting patient choice and access to a range of interventions. It currently leads to an over emphasis on cognitive behavioural therapy (CBT) for patients with depression or anxiety.
In the context of the new commissioning environment, NICE guidelines should be used to inform and not replace clinical judgment.
Future development groups set up by NICE for mental health guidelines should have a broader balance and cross-section of professional stakeholders and peer reviewers to try to prevent researcher/intervention-allegiance bias.
The Department of Health should work with NICE, the professional bodies in psychological therapies and mental health charities, to agree a national research programme, which identifies the gaps in the evidence.
A better system of monitoring of whether clinical guidelines are having beneficial impacts on patient care should be developed including the DH, professional bodies, mental health charities and NICE.
2. Inquiry Response
The Health and Social Care Act 2012 has introduced a large-scale reorganisation of the NHS against a backdrop of rising demand, changing need, efficiency drives and economic pressures. The Government has devolved decision-making for health and care to new local leaders, namely local authorities and GP-led Clinical Commissioning Groups.
Evidence-based psychological therapies are an important part of the delivery of health care within this new commissioning environment. The NICE guideline development process, which makes recommendations about the commissioning of cost effective treatments, is a robust process and an important aid to decision making. The inclusion of guidelines on mental health and behavioural conditions within the wider framework for evaluation by NICE means that treatment of mental health problems has directly benefited from additional investments in service development and education.
Within the new NHS structure it is unclear how effective the mechanisms designed to encourage the commissioning of psychological therapies over other local health priorities will be. NICE guidelines and quality standards will be used as a basis for new commissioning strategies or for re-designing existing psychological therapies. Commissioners of NHS services may quite reasonably look to guidelines from NICE to inform their decisions.
NICE’s rigorous evidence review process puts great value on randomised controlled trials (RCTs) and systematic reviews, which are costly to carry out. Without the resources of the pharmaceutical industry, with competing priorities for limited health research funding and with no specific monies for mental health research there is consequently limited evidence for NICE to draw upon when developing its guidelines. As a result, the guidelines that do exist, and underpin the Improving Access to Psychological Therapies (IAPT) programme, lean heavily on a narrow evidence base which privileges cognitive behavioural therapy (CBT), an effective intervention which enjoys a robust evidence base.
CBT lends itself to RCTs, as a manualised treatment that fits with the biomedical paradigm. A key factor in the efficacy of treatment which is hard to capture in trials is the importance of the therapist-patient relationship; the influence of this tends to be best captured by qualitative research and case studies.
The heavy focus of recommendations in NICE guidelines on CBT results in a narrow range of treatments that patients can access, and therefore less patient choice and access to a limited range of interventions. Studies have shown that giving patients a choice of treatment can itself contribute to the recovery process. CBT is a groundbreaking technology and has the capacity to help great numbers of people, but it can be unsuitable for some people and some conditions (Enright, 1997). Routine outcome data collection and analysis has shown that counselling for depression is equally as effective as CBT (Glover, Webb & Evison, 2010), but this is not reflected in guidance.
Thus the NICE approach can underplay the importance of methodologies that complement trial data by assessing—through audit, benchmarking and quality evaluation, whether and how a treatment works in practice. Studies that show a therapy can work in the trial context ought to be complemented by other methodologies (such as audit and benchmarking) that can assure that their delivery in routine settings is still producing positive outcomes.
NICE does acknowledge the limitations to its guidelines and that “they are not a substitute for professional knowledge and clinical judgement”. Commissioners can therefore still design psychological therapy services that are evidence based and use a broader range of treatments than those recommended in NICE’s guidelines. If commissioners look beyond NICE guidelines when designing services, they must still ensure that the practitioners providing treatments are competent and ethical. All BACP members sign up to an ethical framework, which informs their practice and BACP promotes an accreditation scheme which identifies those of its members who have demonstrated mature competence in counselling and psychotherapy training and practice. Commissioners can use this system as a robust basis for determining which practitioners are suitable for the delivery of NHS-funded services.
The Government should set up a review of the evidence hierarchy which NICE relies on for its guidelines on mental health and behavioural conditions, to investigate the impact of current criteria for evaluating research into psychological therapies and consequent clinical guidelines on patient choice, innovative services, and patient care.
The relationship between RCT evidence and systematic data collection from routine settings (audit, benchmarking, quality evaluation) and the role of qualitative research need to be reviewed in order to improve the NICE evaluation process, so as to make NICE guidelines relevant and applicable to the NHS.
Future guideline development groups set up by NICE for mental health guidelines should involve a combination of expert clinical researchers, clinicians, service users, carers and methodologists. It is important that individuals who contribute to guideline development groups are appointed on the basis of their specific expertise. These appointments should be transparent and decided by elected representatives from the stakeholder organisations.
The Department of Health should work with NICE, the professional bodies in psychological therapies and the mental health charities, to agree a national research programme, which identifies the gaps in the evidence (across all the guidelines mental health and behavioural conditions), and priorities for research, and provide funding for these to be undertaken as an important part of the development and implementation programme for NICE guidelines.
NICE and the Department of Health should work with the professional bodies, with research departments for psychological therapies and with mental health research charities to establish an evaluation and audit infrastructure within NHS services which will enable ongoing improvements in practice, and better monitoring of whether clinical guidelines are having beneficial impacts on patient care.
3. British Association for Counselling and Psychotherapy
As way of background, The British Association for Counselling and Psychotherapy (BACP) is the leading and largest professional body for counselling and psychotherapy in Europe, with a membership of over 38,000 practitioners, drawn from the various professional disciplines in the field of counselling and psychotherapy and based in a range of settings.
All BACP members are bound by the Ethical Framework for Good Practice for Counselling and Psychotherapy and within this, the Professional Conduct Procedure.
BACP is a regular respondent to NICE guideline consultations and has worked with NICE as a consultee in their development of mental health guidelines as well as a representative on NICE Scoping and Guideline Development Groups.
We use our experience as well as our research expertise and the knowledge of our practitioner members to assist the NICE in developing workable and evidence-based guidelines.
4. Further Information
Should the Committee be seeking further oral evidence, BACP would be delighted to provide additional information about the development and impact of NICE guidelines on the delivery of psychological therapies.
Enright SJ. Cognitive-behaviour therapy-clinical applications. BMJ 1997;314:1811–16
Glover G, Webb M, Evison F. Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year. July 2010. http://www.iapt.nhs.uk/wp-content/uploads/iapt-year-onesites-data-review-final-report.pdf