In this excellent article, Drew et al (2021) address the important and under-researched area of protocolisation or standardisation; relevant not just for mental health, but for healthcare in general in the UK and worldwide. The increasing push for standardisation of practice, whether to avoid postcode lottery, promote evidence based medicine or to limit risks for organisations, protocolisation of healthcare has become a common goal. For practitioners, protocolisation can be seen, depending on perspective, either as a shield to protect them through justifying that they are doing the right thing, or as an unwelcome constraint preventing them from providing what they think is the right care (Garcia, 2020).
This paper examines the delivery of CBT oriented psychological therapies within the Improving Access to Psychological Therapies (IAPT) services in the UK, to understand how these general issues play out. IAPT is seen as one of the largest scale successes in delivery of evidence-based practices within mental health. Indeed, it has led to large numbers of individuals receiving CBT who would not have done previously (Moller et al., 2019).
The background of the paper highlights the concern that evidence-based medicine, particularly in the area of mental health, has led to a diminution of the individual’s narrative, but also shows how it is possible to apply personalised approaches and evidence-based practice. In particular, it explains that national guidance for the delivery of CBT through IAPT is in line with this ambition to combine principles of evidence-based and person-centred care. For example, guidance stresses that practitioners should use ‘funnelling’; that is starting by asking open questions about individuals’ symptoms, concerns and problems (and, others would argue, personal goals and strengths). This suggests that there need be no conflict between person-centred approaches and standardisation, especially when the protocol is to start wide and to ask open-ended questions in order not to exclude a patient’s narrative.
The paper is important in terms of its method as well as its subject area. Actual recordings of telephone encounters between psychological wellbeing practitioners within IAPT services are used as the primary data source. Much qualitative research relies on interviews with practitioners and patients, and while these are very helpful in understanding different perspectives, the study of actual interactions through conversation analysis and other techniques allows researchers to understand both what happened and the interaction between parties in the encounter.
In this study, the use of conversation analysis and recordings of practitioners across several services in the north of England examining the ordinary, everyday care they provide in a highly structured healthcare setting, aiming to provide high volume, standardised care, is an excellent method and one that is underused in research. The transcripts in the paper are so helpful, and likely especially so for those who have not observed mental health care as its delivered.
The results of the paper are hard hitting. The background has lulled us into a sense of false security that the guidance for delivering IAPT proposes practitioners should be open and start with an individual’s narrative. Instead we find that practitioners, in virtually all cases across the three sites examined, are working in ways which appear to detract seriously from a person-centred approach to care.
Protocol requirements versus patients own story
The paper firstly shows how the personal goals of individuals are relegated to the end of initial encounters. It then goes on to provide a detailed analysis of how outcome measures are used to derive numerical scores as a way of representing the extent to which individuals suffer from anxiety and depression. It is these numbers that are used by the organisation to indicate the nature of the problem and provide data for monitoring. Worse still, the numbers (representing the extent of anxiety or depression on linear scale) are given back to individuals as the key means of helping them understand their situation, often even before practitioners have heard and understood the narrative of individual patients.
The emergence of patients’ own accounts of their stories and unresponsive information gathering
Patients are heard trying to work around and subvert the constraints of the protocolised baseline assessments by not responding in the way intended and instead providing a narrative account of their distress. Effectively, they are resisting the ‘constraint’ of the protocol. However, mostly these attempts are ignored and individuals are often told that these issues can be taken up later. Worse still, the protocolisation appears to lead to ‘ill-fitted’ responses from practitioners in relation to traumatic events.
Reading the transcripts, I would say that this is a very generous assessment of the responses. My interpretation of these transcripts is that practitioners appear to be floundering to find their way between their natural humanistic instincts and the requirements of their employing organisations that have to meet targets based on throughput and measurement of outcomes.
This paper provides hard evidence that care is protocolised to involve the collection of baseline measures before listening to an individual’s personal narrative. This deprives practitioners of the real evidence they require to think about what is needed for the individual they are working with. This study also provides an insight into how protocolisation to demonstrate performance is likely leading to a waste of resources through neglecting individuals’ understanding of their own distress, which is needed to determine what care should be given.
There are limitations to this study:
- Firstly, it may be that the protocols developed by the three services in the North of England are unusual for IAPT. However, experiences of both practitioners and patients that have been discussed elsewhere (Marshall et al., 2016; Turner, Brown & Carpenter, 2018) indicate this is probably not the case.
- Secondly, the study examines initial encounters and it may be that a more person-centred approach develops later in therapy.
- Thirdly, the study could have been extended to include discussion with the individual practitioners and patients to help understand the encounters that have been recorded. This process of interpersonal process recall (IPR) can help researchers understand the emotional and cognitive responses of patients to practitioners’ practices and for practitioners to offer a rationale as to why they are working in particular ways. This would avoid researchers having to take on all the work of interpretation as in pure Conversation Analysis (Baker et al., 2019).
Implications for practice
As a practitioner as well as a researcher, I found this paper both illuminating and confirmatory of my own impressions – or perhaps biases! As a researcher and advocate of person-centred approaches, I believe that practitioners should have more autonomy to work around protocols, and advocate that job descriptions should include the phrase ‘follow guidelines and protocols, and knowingly deviate from them in the interests of patient care’. This paper shows how badly wrong health care delivery can get when protocols are based on the need not just to deliver treatment of modest effectiveness, but also to demonstrate that outcome measures of uncertain value have been collected.
Perhaps the most worrying aspect of this paper was the description of individual practitioners responding in highly insensitive ways to very distressing narratives from patients. However, as a practitioner myself, I am also very cognisant of other practitioners struggling within the constraints of organisations’ requirements, particularly in delivering high volume care in a timely way. Professionals in general practice, and many other practitioners across the NHS such as in Emergency Departments, are under enormous workload pressures to run to time and see large numbers of individuals. This can provide stress, both through overrunning or alternatively by running to time and feeling bad about not exploring each individuals concerns fully. Being able to reflect and avoid ‘ill fitted’ comments requires a sense of wellbeing and a fantastic flexible team around you in order to maintain a compassionate, person-centred approach.
The implications of this paper are enormous. As organisations, we need to provide better support for patients and practitioners, with IT systems that assist and the autonomy to use time better. Organisations therefore need to recognise the tensions between a person-centred approach and protocolisation, and the harms that can come through organisations wanting to achieve measurable targets, while doing so at minimal cost. High volume, low intensity work carried out to time, where every patient and practitioner can be represented as units of time on spreadsheets to be distributed evenly rather than flexibly according to need, is much easier to manage. In the case of IAPT, while changing symptom outcome scores was seen as the most important initially, it was then recognised that they are relatively insensitive to change, and instead numbers of individuals with before and after outcome measures collected has become a more important measure of performance.
Statement of interests
Drew, P., Irvine, A., Barkham, M., Faija, C., Gellatly, J., Ardern, K., … & Bee, P. (2021). Telephone delivery of psychological interventions: Balancing protocol with patient-centred care. Social Science & Medicine, 277, 113818.
Baker, E., Gwernan-Jones, R., Britten, N., McCabe, C., Gill, L., Byng, R., & Gask, L. (2019). Using interpersonal process recall to understand empowerment processes in a collaborative care intervention for people with a diagnosis of psychosis. Psychosis, 11(4), 350-361.
Garcia, J. C. (2021). From Protocolization of Care to Nursing Care Practice: A Qualitative Research. American Journal of Nursing, 9(1), 15-19.
Marshall, D., Quinn, C., Child, S., Shenton, D., Pooler, J., Forber, S., & Byng, R. (2016). What IAPT services can learn from those who do not attend. Journal of Mental Health, 25(5), 410-415.
Moller, N.P., Ryan, G., Rollings, J. et al. The 2018 UK NHS Digital annual report on the Improving Access to Psychological Therapies programme: a brief commentary. BMC Psychiatry 19, 252 (2019).
Turner, J., Brown, J. C., & Carpenter, D. T. (2018). Telephone‐based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low‐intensity service. Journal of psychiatric and mental health nursing, 25(5-6), 285-296.