9. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.
10. Mr O is understandably concerned about the length of time he waited for ‘step four’ mental health therapy and the reasons for this. We recognise it must be very worrying for Mr O to have these concerns. We appreciate he waited a long time and this could affect his mental health in the way he has described.
11. NICE guidelines on common mental health problems give guidance on ‘stepped care’. These common mental health problems include depression, generalised anxiety disorder, panic disorder, obsessive compulsive disorder (OCD), PTSD and social anxiety disorder.
12. A stepped care model is used to organise how services can be given and to help people with mental health disorders, their families, carers, and health care professionals to choose the most effective help. It is about increasing intensity and escalating therapies if a person does not respond to simpler treatments. ‘Step one’ is the first treatment, usually working up to ‘step three’.
13. The guidelines say, ‘when offering treatment or making a referral, follow the stepped care approach, usually offering or referring for the least intrusive, most effective intervention first.’
14. The guidelines include advice on assessment, referral, and treatment for steps one, two, and three care. They do not include guidance on ‘step four’ therapy. They also do not give timeframes for Trusts to meet when referring and treating patients on the steps after the first referral.
15. The medical records show that Mr O attended a ‘step two’ workshop on 21 December 2018 and had his first ‘step two’ treatment session on 6 March 2019. This therapy continued until 25 April. At the last appointment, the Trust planned to move him up to ‘step three’ therapy as Mr O wanted to work on his confidence and self-esteem. This decision was in line with the NICE guidance on stepped care as the Trust thought he would benefit from more treatment.
16. Mr O started ‘step three’ therapy on 17 June 2019. At the end of his sessions on 20 November, the Trust decided he should be moved up to ‘step four’ therapy and added him to the waiting list for an assessment and possible treatment. Although he had made some progress, his problems continued and affected his daily functioning. The Trust felt that because his problems continued to have a big impact on his life, he may benefit from a different approach to help him work through his problems. The Trust’s decision to do this follows the NICE guidance on stepped care.
17. The Trust explained the waiting list for therapy is in date order and is based on the date of the original referral into the step programme. It explained that if a full series of appointments have been offered at a lower step, it adds six months to the original date of referral and this is where the patient will be placed in the queue. The Trust explained it does this to be as fair as possible given its limited resources. It said it understands this is not a perfect solution but it tries to balance everyone’s needs and take into account that some people have not had any help at all.
18. Mr O was put in the queue for ‘step four’ based on an original referral date of six months later than it was actually made. We can see the Trust has explained what happened and its rationale for adding six months to the referral date. Its actions seem to be in line with GMC guidance to listen to patients and respond honestly to concerns, in this case about his referral start date.
19. Mr O complains the Trust delayed his treatment as he wanted to be seen face-to-face. He says he cannot process information over the phone and the Trust treated him differently because of his request. Mr O spoke to the Trust in July 2020 during COVID-19 restrictions, saying he would wait for a face-to-face appointment to become available. The Trust told him it would offer him a face-to-face appointment when it was safe. It seems at this point that Mr O was prepared to wait for a face-to-face appointment as he was aware of COVID-19 restrictions.
20. The Trust explained why there was a delay for patients wanting to be seen face-to-face. It said there was an issue with room availability due to the restrictions in place during the COVID-19 pandemic. It said most of its work had to move to online and phone.
21. It reassured Mr O that it respected his needs and said he would be offered a face-to-face appointment as soon as he got to the top of the list. It also said it was confident the delays due to the COVID-19 pandemic would soon be addressed by reducing the restrictions. This explanation seems to be in line with GMC guidance because the Trust communicated and responded honestly to Mr O’s concerns.
22. The Trust assessed Mr O for ‘step four’ therapy on 10 January 2022 and added him to the individual therapy waiting list. On 3 February, the Trust wrote to Mr O to confirm his goals and that it would take an integrated approach to his therapy. It also confirmed he wanted to be seen face-to-face and the waiting time for therapy was likely to be around two years although this could change.
23. Mr O complained about the time it was taking for him to get ‘step four’ therapy. In February and March his GP and consultant from another Trust asked for his therapy to be prioritised.
24. The Trust explained it was unable to speed up his wait because its capacity was limited. It advised that referrals were being seen in date order and apologised that Mr O had to wait to be seen.
25. It said it could only prioritise patients in line with NICE guidelines that said maternity mental health and the MOD Military Covenant were the only reasons to give priority. It said unfortunately Mr O did not meet these criteria.
26. Our adviser confirmed that mental health services do not have a process to speed up treatment and there are no national guidelines in place apart from those above. They said there is no rationale for saying one patient is more urgent than another apart from the above.
27. During the referral process a GP can give their opinion if they think a patient has urgent needs. If a patient has an urgent need for treatment, a higher level of therapy can be considered as the first step of treatment. As Mr O went through all of the steps and this does not apply.
28. The Trust also explained that a person’s situation can change and deteriorate while they are on the waiting list for therapy. But, it is unable to change the waiting time so Mr O’s first point of contact should be his GP, an out of hours service or 111 services. In April the Trust directed Mr O to other services he might find useful while he waited.
29. This explanation from the Trust seems to be in line with the GMC guidance. We can see the Trust replied honestly to Mr O’s question about prioritisation.
30. Mr O attended his first ‘step four’ therapy session on 6 June 2023, over a year and five months after his assessment.
31. Our adviser confirmed that nationally there is a long wait for ‘step four’ therapies, so unfortunately the wait Mr O experienced is not unusual. As the guidelines do not say how quickly treatment should be given, we cannot say the Trust did anything wrong.
32. We recognise Mr O would have found the wait for therapy frustrating and he was worried about how the wait would affect his mental health. We hope this information helps explain that what happened was in line with the guidelines available.