Introduction
In recent years, considerable advances have been made in improving access to psychological therapies in England (IAPT; Layard and Clark, Reference Layard and Clark2015). Layard and Clark (Reference Layard and Clark2015) reviewed evidence showing that mental health difficulties carry a high cost, in both human and economic terms, and that improving access to evidence-based psychological therapies can reduce both of these. Results from IAPT demonstrate that a large workforce, trained in an evidence-based therapy, can improve service user outcomes and reduce health and social care costs (Layard and Clark, Reference Layard and Clark2015; NHS Digital, 2018).
The Welsh Government has not utilized the same IAPT initiative, but has endorsed the principles of improving access to psychological therapy and increasing staff capability (Together for Mental Health, Welsh Assembly Government, 2016). In 2016, the National Psychological Therapies Committee produced guidance for evidence-based treatment of psychological difficulties (Matrics Cymru 2017). The Matrics recommends cognitive behavioural therapy (CBT) for many difficulties, including social anxiety, health anxiety, generalized anxiety, obsessive-compulsive disorder and depression, amongst others (Matrics Cymru 2017). A recent delivery plan for the Matrics (NPTMC, 2018) aspires to ‘a position where all services in Wales are able to offer broadly similar, effective and equitable interventions’ (NPTMC, 2018, p. 5). However, there is no centralized training plan for developing CBT in Wales, with each Health Board taking their own approach. The diversity and range of psychological therapies that can be offered in each Health Board raises an important question about the standard of training and delivery, which can be offered in each. Within CBT, the importance of staff training to deliver effective CBT is well established (e.g. Westbrook et al., Reference Westbrook, Sedgwick-Taylor, Bennett-Levy, Butlet and McManus2008; McManus et al., Reference McManus, Westbrrok, Vazquez-Montes, Fennell and Kennerley2010) with staff who have been trained in CBT more likely to achieve positive outcomes with patients (see review by Rakovshik and McManus, Reference Rakovshik and McManus2010).
All Welsh Health Boards have been required to establish a ‘Psychological Therapy Management Committee’ (PTMC) to oversee investment in training and evidence-based psychological therapies (Policy Implementation Guidance, 2012). In addition, these Health Boards have been allocated funds from the Welsh Government to spend on improving access to psychological therapies in adult services (National Assembly Wales, 2016). In line with the ambitions of Together for Mental Health (Welsh Assembly Government, 2016) and consistent with evidence on the impact of CBT training (e.g. Rakovshkik and McManus, 2010) the PTMC in this particular Welsh Health Board elected to invest in staff training in CBT (Management Committee Annual Report, undated). The plan for developing CBT included funding mental health staff to take up places on the only British Association for Behavioural and Cognitive Psychotherapies (BABCP)-accredited training programme in Wales: the postgraduate certificate and diploma in CBT at Cardiff University, both accredited at Level 1. At the time of the study a total of 29 staff had taken up places on this training programme: the largest take-up by any Welsh Health Board and an innovative approach within Wales.
Benchmark standards of support for CBT delivery
Standards for effective CBT practice are available from the National Institute of Health and Care Excellence (NICE, 2004, 2005a, 2005b, 2009). These guidelines are based on high quality RCTs for specific ‘disorders’ (e.g. social phobia, panic, PTSD, depression; Roth and Pilling, Reference Roth and Pilling2008; Roth et al., Reference Roth, Pilling and Turner2010) and recommend specific treatment approaches and modes of delivery. Roth and Pilling (Reference Roth and Pilling2007) devised a Competency Framework for CBT in order to link policy and guidance such as NICE with ‘the treatments actually delivered’ (Roth and Pilling, Reference Roth and Pilling2007; p. 22). The framework provides detailed standards of core competence for CBT with depression and anxiety disorders, and is published as best practice guidance by the Department of Health (Roth and Pilling, Reference Roth and Pilling2007) and endorsed in Wales by the National Psychological Therapies Management Committee, supported by Public Health Wales (2017).
The authors of the competence framework comment that ‘It may be unhelpful to see the treatment procedure alone as the evidence-based element, because this divorces technique from the support systems that help to ensure the delivery of competent and effective practice’ (Roth and Pilling, Reference Roth and Pilling2007; p. 21) They also suggest the support required includes provision of high quality training addressing all areas on the competency framework, supervision in line with NICE guidance (i.e. provided by a BABCP accredited practitioner); monitoring therapist performance via recording in line with practice on research trials; and enabling practitioners to follow treatment protocols which may require 90 minute sessions or bi-weekly sessions (Roth and Pilling, Reference Roth and Pilling2007).
Groom and Delgadillo (Reference Groom and Delgadillo2010) developed an audit tool to review the standards of CBT delivery in an IAPT service in England. The tool is shown in full in this paper and draws together standards of workplace support for CBT from NICE guidelines (2004, 2005a, 2005b), the Competence Framework for CBT (Roth and Pilling, Reference Roth and Pilling2007) and standards of confidentiality and ethical practice from the BABCP Standards of Conduct (2009, 2016). The standards refer to training and development, supervision, ability to carry out treatment outside the office and use internet resources, access to audio/video recording for therapy, ability to use audio/video for supervision and self-reflection, suitability of the clinical environment, and capacity to offer extended or increased frequency of sessions.
In the present study, we used an augmented version of Groom and Delgadillo's (Reference Groom and Delgadillo2010) audit tool, with additional questions covering training, accreditation and everyday practice in order to benchmark standards of support for CBT, level of training and accreditation, and use of CBT in routine clinical practice in one Welsh Health Board.
Method
Procedure
Approval for this project was granted by the audit officer in the Health Board. To ensure confidentiality, staff names were anonymized, and the database was password protected (British Psychological Society, 2009). Staff were contacted via telephone and subsequently sent an email with a link to the online survey asking about their CBT training and about standards of support for CBT in their workplace (Bristol Online Survey, BOS). There was an option to ‘save for later’ and return to compete the questionnaire at a later stage. Staff responses were exported from BOS to an Excel file. Staff names were given a numerical unique identifier, and the Excel file was password protected.
Participants
Participants were mental health staff working in the Health Board. Staff were recruited through opportunity sampling from a database of people who had or were completing CBT training at Cardiff University (PG Certificate/PG Diploma). Twenty-nine staff members were approached and 23 completed the questionnaire. Participants represented a range of professional backgrounds and stages of CBT training (see Table 1).
Table 1. Percentage of staff who have completed various stages of CBT training and accreditation
The questionnaire
Staff were asked whether each standard was applicable to their workplace. The available responses were ‘yes’, ‘somewhat’ or ‘no’ and they were invited to make comments. Staff were also asked for information about their CBT training, accreditation status, and use of CBT in everyday practice.
Results
CBT training, accreditation and self-reported integration of CBT into everyday practice are shown in Table 1.
In line with the recruitment strategy, 22 of the 23 participants reported that they had completed the PG certificate in CBT or would have done so within the next 12 months, with one participant taking an interruption in studies. Fourteen staff had also completed the PG diploma in CBT and of these, 12 were working towards full accreditation with BABCP and three had already achieved provisional accreditation. The two staff who had completed their PG certificate and diploma but were not working towards their provisional CBT accreditation attributed this to role constraints and an expectation they provide another form of specialist therapy or personal circumstances. The latter was keen to emphasize that this was not due to a lack of support: ‘the organisation have been very supportive of staff training. . ., it's mainly been about timing and other factors making it difficult to complete it at the moment’ (P21). All except two members of staff reported being able to integrate CBT into their everyday practice during and after competing CBT training at either PG Certificate or PG Diploma level, and a typical comment was: ‘The certificate [PG Certificate CBT] has been an excellent vehicle for enhancing skill delivery and improving knowledge base’ (P21).
The two staff members who experienced difficulties integrating CBT into their everyday practice described having additional work demands as part of their specialist role [‘I am also the lead for another evidence-based practice’ (P12)] and pressure to carry out other specialist interventions at the same time [‘Having to undertake other psychological interventions such as DBT’ (P20)].
Standard 1: training and development
The majority of staff believed that the service was providing appropriate personal development plans related to CBT training (74%, criteria 1a) and monitoring these regularly to ensure that staff were meeting standards (83%, criteria 1b; see Table 2 and Fig. 1). The majority (83%) also reported that the service met criteria 1d – the provision of adequate training approximating NICE guidelines. However, few staff thought the service had a clear policy regarding resources and funds for CPD (1c, 30%).
Table 2. Criteria relating to audit Standard 1(training and development)
Figure 1. The number of staff who reported that the service met the criteria set in audit Standard 1.
Consistent with the high number of staff who felt that the service was broadly meeting this standard there were some very positive comments: ‘The Health Board has been forward thinking and progressive in ensuring well trained and appropriately supervised staff to deliver high quality CBT treatment with excellent outcomes’ (P21). However, consistent with the rather lower number of staff (6/23) who felt that there was a clear policy regarding funds for CPD, qualitative feedback indicated some confusion: ‘Initially I was offered a place but my funding was turned down so I had to reapply’ (P16).
Standard 2: supervision
Staff gave a strong endorsement of service support for supervision (criteria 2a, see Table 3 and Fig. 2), with 91% reporting adequate supervision to deliver evidence-based CBT, 87% reporting good quality supervision of appropriate frequency, and 91% (criteria 2c) reporting a supervisor equipped with the appropriate skills. Furthermore, staff responses indicated that 87% (criteria 2d) of supervisors were BABCP accredited. Qualitative data confirmed this endorsement: ‘The Health Board takes this responsibility seriously and as well as training a number of staff in CBT skills, also provides accredited CBT supervisors’ (P21) and ‘my supervisor is brilliant’ (P16).
Table 3. Criteria relating to audit Standard 2 (supervision)
Figure 2. The number of staff who reported the service met the criteria set in audit Standard 2.
A small minority of staff (n = 2) reported that standards for supervision were not met. Qualitative feedback showed that this reflected difficulty accessing CBT supervision rather than concern about quality: ‘Despite repeated requests I have never received supervision apart from the essential hours required for the CBT certificate’ (P9) and ‘there was no specialist (in that field) accredited with the BABCP’ (P23).
Standard 3: access to audio/video to support supervision and self-reflection
All staff rated the service as at least ‘somewhat’ able to provide access to audio/video recording equipment for supervision (criteria 3a, see Table 4 and Fig. 3), provide protocols for recording clinical sessions and being able to listen to these in a suitable environment. However, seven staff (criteria 3d) reported that they were not provided with admin time to review these recordings or prepare for supervision, illustrated with comments such as ‘Practitioners do not have enough time to prepare/reflect’ (P9).
Table 4. Criteria relating to audit Standard 3 (resources to support clinical supervision and clinical self-reflection)
Figure 3. The number of staff who reported that the service met the criteria set in audit Standard 3.
Standard 4: ability to use internet resources and offer treatment outside the office
Eighty-seven per cent of staff believed that the service provided appropriate protocols and permissions to carry out work outside the office (criteria 4a, see Table 5 and Fig. 4), and 78% reported actually being able to treat clients outside of the clinic (criteria 4b). A smaller number (35%, criteria 4c) reported access to appropriate online material required by the treatment protocol, reporting ‘intranet not being available in all rooms’ (P5) and ‘restrictions on certain internet sites’ (P11).
Table 5. Criteria relating to audit Standard 4 (working with real world materials outside the clinic)
Figure 4. The number of staff who reported that the service met the criteria set in audit Standard 4.
Standard 5: capacity to offer extended sessions or increased frequency of sessions
The majority of staff (74%, criteria 5a, see Table 6, and Fig. 5) reported service support to offer 90 minute sessions and more frequent sessions (65%, criteria 5b). One said they were not able to offer 90 minutes sessions and four that they were not able to offer bi-weekly sessions when appropriate.
Table 6. Criteria relating to audit Standard 5 (extended sessions or increased frequency of sessions)
Figure 5. The number of staff who reported that the service met the criteria set in audit Standard 5.
Standard 6: access to video recording for assessment and treatment
Only eight staff (35%, criteria 6a, see Table 7 and Fig. 6) reported that the service was able to provide access to video recording in the clinic room. Qualitative feedback indicated that equipment was often unavailable [‘no video equipment’ (P10)], procedures for recording were onerous or unclear [‘the procedure for recording and videoing can be very cumbersome’ (P1); ‘vague policy guidelines’ (P10)] and described a need to find creative solutions [‘. . . I used my own iPad and deleted the video recording with client straight after. . . not ideal’ (P16); ‘I. . . encourage client to use own devices’ (P10)].
Table 7. Criteria relating to audit Standard 6(extended sessions or increased frequency of sessions)
Figure 6. The number of staff who reported that the service met the criteria set in audit Standard 6.
Standard 7: suitability of the clinical environment
All staff indicated that the service was able to provide a suitable clinical environment at least ‘somewhat’ (criteria 7a:d, see Table 8 and Fig. 7) in relation to a confidential clinic room adequately equipped for therapist and client safety (78%, criteria 7b), with safe access and treatment for clients with disabilities (87%, criteria 7c). All staff reported that the service provided a room ‘fit for purpose’ although the number rating this item as a ‘yes’ was rather lower. Feedback indicated variability across different bases [‘some bases are better than others’ (P1)], some missing equipment [‘we are still waiting on white boards’ (P16); ‘computers installed into some of the rooms’ (P16)] and some concerns about sound proofing [‘Both (locations) have issues with sound. . . so not fully confidential’ (P7)].
Table 8. Criteria relating to audit Standard 7 (suitability of clinical environment)
Figure 7. The number of staff who reported the service met the criteria set in audit Standard 7.
Discussion
The results of the current audit provide an insight into levels of training, accreditation and use of CBT among those staff who have received a training investment from the Health Board. In addition, staff views of standards of support for CBT in the Health Board provide a means of benchmarking the service against NICE and DoH standards. There is as yet no other time point or service to compare with the standard in this Health Board.
Training, accreditation and use of CBT in everyday practice
Our results indicate a progression through staff completing the postgraduate certificate in CBT, the postgraduate diploma in CBT, working for provisional accreditation and achieving full accreditation. As we would expect from a development plan there were more staff at the early stages of this process and fewer at the end. The Health Board seems to be succeeding in increasing staff capability and improving access to evidence-based psychological therapy in line with Welsh Government policy (Welsh Assembly Government, 2012, 2016). The vast majority of staff reported that they continue to use CBT in their everyday practice, indicative of the service having a return on their investment (Layard and Clark, Reference Layard and Clark2015; National Assembly Wales, 2016).
Standards of workplace support for delivering effective CBT
Most staff answered ‘yes’ to a question asking if they have a professional development plan that identifies training priorities, and the majority said this was reviewed. Nineteen of the 23 members of staff felt that they had received adequate training to deliver treatment that closely approximates that of the RCTs in NICE guidance (‘bearing in mind practical and realistic limits on training budgets’). This suggests that staff feel that the Cardiff CBT programmes are succeeding in developing their capability and positive comments were offered concerning the training programmes. However, only a minority (7 out of 23) said ‘yes’ to the Health Board having a clear CPD policy specifying time and resources. Also some staff reported difficulties obtaining funding for the next stage of training (certificate, diploma or further CPD to achieve accreditation). This suggests that although the workforce plan is generally succeeding, staff would appreciate greater transparency and a clear model of progression.
The majority (20–21 out of 23) of staff were very positive about their CBT supervision. This supervision was determined to be to be the right type of supervision for delivering NICE recommended CBT, of sufficient quantity, offered by a BABCP accredited practitioner supervisor with CBT knowledge, skill and experience. Staff may have been referring to supervision provided by the CBT programmes as well as ‘in-house’ supervision, but in either case it indicates success for the Health Board. However, three members of staff said they did not have access to a BABCP accredited supervisor in line with NICE recommendations for the delivery of CBT.
All staff reported that the service was at least ‘somewhat’ able to provide recording equipment for supervision, and thought there were protocols for recording sessions and a suitable environment for listening to these. This positive feedback indicates that the Health Board is able to facilitate staff use of recordings in supervision in line with NICE and DoH recommendations. However, some staff reported that they did not have time to listen to recordings.
The majority of staff thought policies and protocols were in place to offer treatment outside the office (e.g. behavioural experiments, site visits) but some staff did not feel able to carry this out practice. Comments from staff suggest that this may be due to the protocols and policies being onerous, and a lack of equipment may also have played a part. In terms of being able to use appropriate internet resources only eight out of 23 said ‘yes’, and staff comments suggest this is partly due to a lack of resources and partly to Health Board IT restrictions on access to websites such as YouTube.
All but one member of staff reported being able to offer 90 minute sessions, suggesting that this has become an accepted part of CBT practice in the Health Board. Most (19 out of 23) also felt they could offer bi-weekly sessions as recommended, for example, for depression.
Seven members of staff responded with a ‘no’ to a question asking whether they have access to video equipment for therapy. The lack of access to video equipment for all staff is a cause for concern, as staff are treating disorders, such as social anxiety, which have a clear treatment protocol requiring the use of video. Some staff mentioned using solutions which included using their own equipment and commented that this was ‘not ideal’, which implies it may be causing them some anxiety.
All staff rated items related to the suitability of the clinical environment as at least ‘somewhat’ met. However, their comments suggested variability between clinical bases, a lack of some basic equipment (e.g. white boards) and some concerns about confidentiality due to rooms being insufficiently sound proof.
Significance of the overall findings
Although the results of this study have highlighted some areas for improvement, the overall picture suggests that the Health Board is succeeding well in supporting CBT in the workplace. It is worth noting that this Welsh Health Board has been compared against national standards for the UK, and is still performing very well across all standards. Unfortunately, an English service with comparable data were unwilling to share their results to allow a comparison.
Of note, our questionnaire was a self-report measure, which may be subject to social desirability effects (van de Mortel, Reference van de Mortel2008), and thus our results may reflect slightly inflated estimates of standards. However, asking for staff views allowed us to collect insightful and constructive critical comments from those who know the service well.
Recommendations
Overall, the Health Board is succeeding in offering a high level of support for the delivery of evidence-based CBT, as assessed against standards from NICE and the Department of Health. A comparable study carried out with an English service would provide an interesting comparison. Staff funded to undertake accredited CBT training continue to develop and to use CBT in their clinical practice. The Welsh Government ambitions to develop staff capability and provide effective, evidence-based psychological therapy for people in Wales (Welsh Assembly Government, 2012, 2016) are being enacted by the Health Board. The Health Board are recommended to share their development plan through the National Psychological Therapies Committee which ‘welcomes reports of innovative approaches for consideration and dissemination of best practice across all areas of Wales’ (NPMTC, 2018, p. 5).
Main points
(1) This benchmarking study provides evidence for a promising service delivery model for CBT for devolved nations such as Wales.
(2) Wales has not adopted the English IAPT system and each Welsh Health Board is developing its own approach to improving access to psychological therapies.
(3) The Health Board in this study aimed to develop access to effective CBT by taking up places on the only BABCP accredited programme in Wales.
(4) Staff funded to undertake accredited CBT training continued to develop and to use CBT in their everyday clinical practice and the Health Board performed well across seven standards of workplace support for the delivery of evidence-based CBT.
(5) The authors recommend that this be shared with other Welsh Health Boards and that a comparable study be undertaken within an IAPT service.
Acknowledgements
We would like to thank the individual staff members who gave their time to complete the online survey. We would also like to thank the Welsh Health Board that provided consent to conduct the benchmarking study. Thank you to Dr Nicola Thomas, Dr Kerry Donovan and Dr Evelyn Gibson for their support and comments with the benchmarking study.
Ethical statements
All authors have abided by the Ethical Principles of Psychologists and Code of Conduct. Audit approval for this benchmarking study was granted by the audit officer in the Welsh Health Board. As this study was deemed to be an audit/service evaluation, ethical approval from the Trust was not necessary – as decided by the Welsh audit officer.
Conflicts of interest
L. Hadden and M. Groom have no conflicts of interest with respect to this publication. However, L. Waddington is involved as one of the instructors on the Cardiff CBT training course, which could potentially provide a conflict of interest. Nevertheless, this was mitigated through L. Hadden, who has no direct links to the CBT training course (trainee clinical psychologist) conducting the benchmarking study and analysing the data.
Financial support
This research has received no specific grant from any funding agency, commercial or not-for-profit sectors.
Learning objectives
(1) To understand the service delivery systems for psychological therapy in Wales compared with England.
(2) To understand the need for a homogeneous approach to psychological therapy delivery in Wales, in line with Government recommendations.
(3) To understand that a staff training investment can streamline service delivery systems when compared with the gold standard of care in England.
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