Does the NHS Talking Therapies service have an attrition problem?

Mental health problems are estimated to affect one in four adults in England each year. These issues are around us all the time. In a crowded train carriage in the morning or a long queue at the bank, for instance, it is safe to assume that a handful of people might be experiencing mental health difficulties.

Governments, both current and past, have been trying to manage this. Investment for the NHS Talking Therapies service, which offers psychological therapy for adults in England suffering from depression and anxiety-based conditions, has increased. In last year’s Autumn Statement passed by the previous Conservative administration, an additional £500 million was promised to this service, in part to enable more people to be well enough to work. The current Labour government has also promised to expand the mental health workforce, most of whom are employed under NHS Talking Therapies. Even prior to its framing as a tool for boosting economic activity, targets for increasing staff and the number of people accessing the service have been increasing each year.

The political spotlight on the service prompts us to question whether it is performing well. In this blog, we use publicly available NHS data to take a closer look at patient pathways for NHS Talking Therapies in England and identify where improvements can be made to build a better service. 

How has use of NHS Talking Therapies changed over the years?

Referrals to Talking Therapies have increased in the past decade, from over 1.1 million in 2013/14 to 1.8 million in 2023/24. However, only 37% of those referrals completed treatment, and this proportion has wavered only slightly in the past 10 years.

The number of individuals being referred to NHS Talking Therapies and those completing treatment have increased in lockstep – median year-on-year growth has been 4.6% for all referrals and 4.5% for referrals that finished treatment. Although this increase in number for those finishing treatment is positive, there is a conspicuous lack of improvement in the proportion of referrals finishing treatment. 

What happens to referrals along the pathway?

A key feature of NHS Talking Therapies is that any adult living in England can complete a referral request online without needing to consult a health professional. In 2023/24, 69% of referrals received were self-referrals. Referrals from the health service, most of which came from GPs, accounted for 17%, and the rest came from other sources, like carers and employers.

Of the approximately 1.8 million referrals in 2023/24, 16% were not assessed and 11% of individuals who made the referral declined the therapeutic treatment on offer. A fifth (20%) were considered unsuitable or the referral was terminated under mutual agreement, and 23% left treatment incomplete.

Describing outcomes for people finishing treatment is complicated by inconsistencies in data. The proportion of referrals marked as ‘complete’ by providers (25%) is likely an underestimation, and the numbers given below are based on more accurate system-derived data. This shows that 37% of referrals finished treatment.  

Most of those (67%) who finished a course of treatment showed some improvement, measured by a change in their first and last clinical scores, and 50% met the criteria for “recovery”, i.e. scored below the clinical threshold for the psychometric test they were administered. However, the main NHS benchmark of “reliable recovery” – i.e. those who showed clinical improvement and recovery – was met by 47% of those who completed treatment. Everybody who has “reliably recovered” has also improved and recovered, but these categories have been made distinct in the sankey for the sake of clarity. Over a quarter (26%) showed no change and, perhaps more soberingly, 6% reported deterioration.

In summary, of the approximately 1.8 million people who sought help from NHS Talking Therapies in 2023/24, only 17% (around 300,000 people) underwent a complete course of treatment and “reliably recovered”. This pattern of attrition for incomplete referrals has a history of being a weak link, with data from 2017/18 reporting recovery for only 19% of all referrals.

What form of therapy do patients receive?

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Distribution of types of treatment for NHS Talking Therapy appointments in 2023/24

Chart

• 25/11/2024

NHS Talking Therapies Monthly Statistics Including Employment Advisors

Types of therapy offered through the service are varied, although some are used a lot more than others. In 2023/24, at least one in three (34%) appointments made under the Talking Therapies programme were for cognitive behavioural therapy (CBT), a modality of treatment based on trying to change patterns of thoughts, feelings and behaviours. A very small minority of appointments were made for other high intensity modalities like interpersonal psychotherapy (1%) and psychodynamic psychotherapy (0.2%). Low intensity treatment like signposting, psychoeducation and self-help activity accounted for 39% of all appointments. 

What can improve?

It has been suggested that not being given a choice of treatment may be the reason that a sizeable proportion are declining or dropping out. The treatment is heavily skewed towards CBT, which despite being a well-established form of psychotherapy, can be considered overly distressing or invalidating to those who prefer other modalities of help. Besides, a fifth of appointments are dedicated to psychoeducation, physical activity, signposting, and employment support, which can be available through other avenues and are not exclusive to Talking Therapies. Aligning what patients need and prefer to what the service offers is one of the solutions to curb attrition.

It should be acknowledged that the high volume of self-referrals means that some attrition will occur. The challenges of asking for help for psychological issues makes it vital that NHS Talking Therapies can be accessed independently and easily. However, receiving referrals that may not be appropriate for the service (20% of referrals were declared unsuitable in 2023/24) results in wasted resource at the front door. It may be controlled by making the purpose of the service very clear – in fact, the old name of the service, “Improving Access to Psychological Therapies”, was changed in part to address the misconception that it was a conduit to other mental health services.

Although the NHS Talking Therapies dataset is reasonably comprehensive, adding detail on why patients decline or drop out of treatment might help us understand and address these relatively high attrition rates. Provider coding of referral outcomes should also be more accurate, so that they can be matched with treatment outcomes and form a clear picture of patient flow.

These steps are important in making the service more helpful to patients and resilient to attrition, without which the burgeoning investment in the service will be unacceptably unproductive.

Acknowledgements

I’d like to thank Joanne Cullen, Clinical Programmes Manager for North East and Yorkshire Regional Mental Health Team for her thoughts and insights on the topic that helped shape this research. I would also like to thank the subject matter experts at NHS England and the wider Digital Enquiries Team for providing clarification re the parameters and definitions of the data.