4.6.1 Widely promote that IAPT can and does offer support for people with learning disabilities and increase the number of people with learning disabilities accessing IAPT.
In phases one and three, service users and clinicians highlighted a need for IAPT to better promote that it can offer support to people with learning disabilities. This is consistent with the LD- PPGs
(2015) emphasis on publicising IAPT’s inclusivity to enhance access. Promotion may be particularly important given Chinn et al’s. (2014) reference to candidacy (Dixon-Woods et al., 2006), which proposes that people with learning disabilities may not see themselves, nor be viewed by the systems around them, as candidates for IAPT. Better and wider promotion of clear statements of inclusion may enable people with learning disabilities experiencing anxiety and/or depression (and those around them), to identify them as candidates for IAPT. This in turn may lead to increased numbers of people with learning disabilities accessing psychological support, which may not only be advantageous for them, but would also lead to greater ‘exposure’, experience and confidence amongst IAPT clinicians. As well as a lack of training, clinicians frequently referred to feeling ill-equipped to work with this population due minimal ‘exposure’. Both factors are conceivably a consequence of the low numbers of people with learning disabilities entering IAPT, causing a self-perpetuating cycle as highlighted in Figure 2 (section 3.2.2.2.1), where low numbers mean a lack of ‘exposure’, and this group not being seen as a priority, warranting allocation of funding for training. Supportively, several clinicians implied in phase three that low numbers of people with learning disabilities accessing IAPT limited the opportunities to practice what they learned in phase two, echoing issues raised in previous studies (Bouras & Holt, 2004; Marwood, 2015). Rose et al. (2007) similarly found that while training was considered important, numerous staff participants in their study felt that much of the expertise in this field could only be gained from learning ‘on the job’. Relatedly, the LD-PPG (2015) states that access to treatment in IAPT will improve the competencies of IAPT clinicians. Training combined with experience and permission to work flexibly may also minimise premature drop-outs from this group, which may unhelpfully reinforce the idea that this client group are unable to benefit from mainstream psychology services (Chinn et al., 2014). This underscores the importance of increasing the numbers of people with learning disabilities within IAPT.
4.6.2 Conflicts with IAPT ideologies: Limits to flexibility in a high-volume, high-pressure service Many clinicians made unprompted remarks highlighting their uncertainty regarding the ‘achievability’ of effectively working with people with learning disabilities within the current IAPT framework. IAPT clinicians often spoke of the pressures of working within IAPT generally, echoing Stenfert- Kroese et al’s. (2013) reference to staff participants utilizing interviews as opportunities to describe the challenges their jobs entailed. Clinicians in the current study expanded on this by stating that there were unrealistic expectations on them to incorporate a learning disability population, and provide best practice, whilst working within a “high-volume, high-pressure service”. As alluded to in section 4.4.5 and 4.5.6, practical concerns about adapting materials, joint working and consideration of systemic interventions when already struggling with heavy workloads were also mentioned. This provides
the time necessary to support people with learning disabilities (e.g. Bouras & Holt, 2004; Chinn et al., 2014; Marwood, 2015; Rose et al., 2007). Sparse time and heavy caseloads, have been linked with emotional exhaustion for IAPT workers in particular (Steel, Macdonald, Schröder & Mellor-Clark, 2015). Accordingly, commissioners and senior management need to set more realistic targets for IAPT clinicians working with this population, not only to enable them to be able to support this group on a practical level, but also to minimise the risk of emotional exhaustion.
Some clinicians insinuated that IAPT was inadvertently “discriminating” againstpeople with learning disabilities through stringent adherence to existing polices, supporting existing studies that similarly indicate that the rigidity of IAPT service protocol places people with learning disabilities at an unfair disadvantage (Chinn et al., 2014; Marwood, 2015). Clinicians in the current study acknowledged that commissioners set targets that needed to be met to ensure continued funding. Intertwined with this, many noted that change and clarity from “the top”’ was required to prevent “things get[ ting] messy on
the ground”. Perhaps due to unclear guidance, many clinicians directly or indirectly implied that people with learning disabilities were not IAPT’s “core business”. Many commented that IAPT was not set up to meet their needs and therefore felt that working with this population was beyond what could realistically be expected of them. This adds further support to proposals that from clinicians’ perspectives, IAPT is neglecting to acknowledge and implement policies and legislations pertaining to equal access to health services for people with learning disabilities (Marwood, 2015), and implies clear access targets and guidelines regarding flexibility set by commissioners is required facilitate people with learning disabilities’ access to IAPT.
4.6.3 Prioritising and competing demands
Several clinicians expressed belligerence towards IAPT’s efforts to offer ‘specialist’ support to an increasing array of groups not covered in the IAPT training, such as to those with long-term health conditions, carers, as well as perinatal individuals. This supports existing findings that some clinicians feel frustrated by IAPT’s expanding nature (Marwood, 2015). Awareness of these “competing
demands” led several clinicians to suggest that learning disabilities needed to be prioritised by services and commissioners via specific learning disability policies and targets in order for inclusion to be truly successful. This could be encouraged by making it a requirement for IAPT to ‘flag’ people with learning disabilities on their data systems and commissioners setting and monitoring clear access targets, as noted in the LD-PPG (2015). Relatedly, whilst we saw that service users and clinicians recommended various reasonable adjustments to improve IAPT, we also saw clinicians doubting the workability of such adjustments within the current IAPT model, and implying managers were more keenly aware of meeting existing targets. This could be rectified by commissioners making reasonable adjustments a clear requirement of services and ensuring they have sufficient flexibility in terms of
meeting targets to allow sufficient time for clinicians to meet the needs of people with learning disabilities.
Through commissioners setting access targets, IAPT services may see an increase in the numbers of people with learning disabilities, which may increase clinicians’ confidence and competencies in working with this client group. However, as noted by service users and clinicians, ongoing training and access to funding for this will be necessary. This corresponds with Chinn et al’s. (2014) recommendation, and suggestions made within this chapter, that commissioners set clear access targets for people with learning disabilities and ensure support within IAPT is funded appropriately, and the LD-PPG (2015) suggestion that commissioners adjust funding and data collection
requirements to enable effective engagement. The ongoing commitment many clinicians spoke of may more specifically be achieved via the LD-PPG’s (2015) proposal that commissioners incentivise inclusion through Commissioning for Quality and Innovation (CQUIN) payment frameworks. Since the LD-PPG (2015) publication, ‘Learning Disabilities’ has been listed among seven priority areas on the CQUIN Menu for 2016/17 (NHS England, 2016). Whilst the longer term implications of this for IAPT are currently unknown, it has the potential of allowing IAPT to allocate appropriate funding for this area.