NCPS's submission to the independent prevalence review into mental health conditions
Professor Fonagy's review into the factors driving rising rates of mental health conditions in the UK is one of the most significant pieces of policy work in our profession right now. We submitted our response last week, and we wanted to share a bit about what we said.
You can read our response in full here.
The review is trying to understand why prevalence of mental health conditions, as well as autism and ADHD, is rising. It's important to note here that we aren't making any comment on autism and ADHD diagnosis, as that is outside of the remit of the Society, and not something the data and information our members share with us gives us answers to.
The submission draws heavily on data from our Annual Member Surveys. 70% of practitioners are routinely seeing clients who couldn't access timely NHS support, and nearly four in five have seen clients who completed NHS Talking Therapies and still needed further help.
We also drew on independent research, NHS data, and a sizeable body of clinical evidence to support the arguments our members' experience points toward.
Our perspective is, in short, that we think we're addressing people's needs, but we're doing so inside a system that isn't designed therapeutically. It's designed medically and therefore prescriptively, and on top of that, it's beset by lengthy waiting lists, with no choice of who you work with or how, and with no information about the large volumes of unmet need invisible to the data that shapes commissioning decisions (i.e. no clarity about the degree to which businesses, private practitioners, and the charity and voluntary sector, are supporting the mental health of those for whom the NHS service does not work).
So, we're not really addressing most people's needs at all, which means things are getting worse as few people are genuinely getting better.
Rising prevalence therefore partly reflects real increases in distress, but it also reflects people not getting support early enough, not getting the right kind of support, and falling through the gaps of a system that wasn't designed with them in mind.
What does our submission cover?
The submission covers five main areas.
On waiting lists, we raised how the NHS Talking Therapies six-week access standard measures time to a first appointment, but the average wait between first and second sessions, where treatment actually begins, is, on average, over 62 days. Our member data shows that 85% of counsellors working in private practice can see a new client within two weeks, so we make the long-standing point that by better engaging the counselling & psychotherapy workforce, we could do a great deal to reduce waiting times for people.
On relational support, we made the case that the counselling & psychotherapy workforce is already functioning as both a pressure valve and a continuation service for statutory provision: absorbing clients who can't access NHS support, and clients who've completed it but didn't get what they needed from it. This is largely invisible to national data, which means prevalence figures are structurally undercounting ongoing need. We'd like to work with NHS England and the review team to start changing that.
On medicalisation, we argued that requiring people to frame their difficulties in clinical terms in order to access support is itself a barrier, which impacts men, young people, and people from racially minoritised communities the most. Many of the issues our members work with every day (grief, trauma, life transitions, identity, relationship issues) don't map neatly onto diagnostic categories, but that doesn't make them less real, less impactful for people's lives, or less deserving of skilled support.
On the stepped care model, the evidence is increasingly clear that starting everyone at the lowest intensity of intervention and stepping them up through sequential failure is neither efficient nor effective. Over 60% of IAPT referrals in 2019/20 didn't complete treatment. Of those who did, around 60% didn't achieve clinical recovery. The therapeutic relationship is one of the strongest predictors of outcome across all modalities, and stepped care does not prioritise it, and also routinely disrupts it.
On digitalisation, we raise serious concerns about deploying AI chatbots as frontline mental health interventions, particularly for children and young people. There is a risk of digital disengagement, with people becoming disillusioned and dropping out of AI-mediated support, and then either going without help or moving to private practitioners who aren't captured in any national dataset. That would make the prevalence picture look better than it is, not because need has reduced, but because we've stopped counting part of it.
What we're hoping changes
The current system is entrenched, and we're realistic about that. However, it's also failing by its own metrics, and this review gives us a genuine opportunity to ask bigger questions and look to see how we could make something that truly works for as many people as possible.
A move towards neighbourhood and community-based health services creates some opportunities to change things, and we already know that community models work best when they're built around relationships and continuity, which is precisely what counsellors and psychotherapists are trained to provide. There's a strong case for embedding this workforce into community health structures properly, as a core part of how support is delivered.
More broadly, we need to move away from manualised, process-centred therapy as the default. CBT works for many people, and many of our members offer it, but it's one approach among many, and it's also, frankly, the approach most easily automated; the only thing you can't automate away is the neurological, physiological, non-verbal work that is a core part of relational therapy. As AI becomes more capable, we can envisage CBT-only practitioners being largely replaced in the NHS with AI tools, however there will always be a place for those who are trained to work across the therapeutic spectrum, at depth, with a range of issues and intensities.
We're also calling for patients to have a choice of modality and of practitioner, as well as better data collection that actually reflects where and how mental health need is being met across the whole system, and a commissioning framework that reflects what the evidence actually says about what makes therapy work, rather than what's easiest to manualise and measure.
Read the submission
The full submission is available here. If you have thoughts on what we've put forward, or want to share your own experience of the issues we've raised, we'd be glad to hear from you. And when the next Annual Member Survey lands in your inbox, which will be soon, please do fill it in! As you can see, it does genuinely shape what we say, and supports us when advocating for you and the profession more broadly.
