Select Committee on Health Written Evidence


Evidence submitted by the British Psychological Society (WP 38)

EXECUTIVE SUMMARY

  The Society believes that it is very timely to be reporting to the Health Select Committee on NHS workforce planning processes. The demand for applied psychologists to work within the NHS has exponentially increased in recent years but increases in training commissions have failed to meet the demand. Indeed, in the last three years there has been a significant reduction in growth of clinical psychology training places and no promised expansion of funding for training other applied psychologists within the NHS. This is at time when the policy context is predicting unprecedented increases in the numbers of psychologists to fulfil patients' demands for increasing access to psychological therapies and interventions. We believe that this situation reflects the failures and shortcomings of existing workforce planning processes and that the current lack of direction surrounding workforce plans may herald an even bleaker future scenario. We believe that the following factors have contributed to this regrettable and worrying set of circumstances:

  1.  Poor involvement in workforce planning structures at both national and local levels by the smaller professions due to an appropriate focus on care group planning but at the expense of representation of a psychological perspective on healthcare delivery and implicit dominance by the major professions of nursing and medicine.

  2.  An over-reliance on bottom up forecasting through Local Delivery Plans which preserve an over-reliance on forecasting existing workforce requirements at the expense of smaller professions and a failure to anticipate strategic developments in new or more flexible practitioners such as psychologists.

  3.  Despite national estimates of demand for psychologists being determined by both the Society and external bodies such as the NHS Workforce Review Team or the Sainsbury's Centre forMental Health ranging far in excess of 15%, commissioning at a local level is constrained.

  4.  We believe that these constraints have arisen for a variety of reasons:

    —  Failure to set profession specific targets and reliance on general targets surrounding the Allied Health Professions resulting in commissioning of the cheapest common denominator.

    —  A perception of psychology training being expensive despite it being best value in terms of student drop out and retained years to the NHS.

    —  A failure to utilize or develop placement capacity due to inefficient local commissioning and the application of inappropriate initiatives to expand nursing placement provision.

    —  Organizational failures including the continuous re-organisation of NHS workforce planning and education and commissioning structures, failure to utilize evidence and advice from professional bodies, an over-reliance on competency-based models and the current dominance of Skills for Health whose expertise is constrained to the micro-skills level, and inappropriate local commissioning for small professions.

THE RESPONSE OF THE BRITISH PSYCHOLOGICAL SOCIETY

  The British Psychological Society welcomes the opportunity to submit information to the Committee's inquiry into Workforce Planning. The British Psychological Society is the learned and professional body, incorporated by Royal Charter, for psychologists in the United Kingdom. The Society has a total membership of over 44,000 and is a registered charity.

  The key Charter object of the Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge".

GENERAL RESPONSES

  1.  The Society believes that it is very timely to be reporting to the Health Select Committee on NHS workforce planning processes. Applied psychologists, including clinical, counselling, forensic, health, neuropsychological and occupational psychologists (please see Annex 1 for definitions and role descriptions) 18[18] contribute significantly to both health and social care. The public is also provided with the security of knowing that applied psychologists are Chartered and work to defined standards. Moreover, the government has promised better support for mental health and emotional well-being in response to the Citizen's consultation which placed mental health as its second area of concern.

  Some examples of the relevance and contribution of applied psychologists include the following:

    —  the demand for psychological therapies (ie talking therapies) has never been greater from patients;

    —  the NICE clinical guidelines endorse psychological treatments as clinically effective and in many cases safer, and with greater long-term efficacy than drug treatments for a variety of common mental health problems;

    —  psychologists have been the major researchers responsible for conducting the randomised controlled trials from which the evidence base for NICE guidelines have been developed;

    —  if access to psychological therapies can be achieved, this will result in better well-being and quality of life for patients and their families, and ma reduce economic burden through maintaining employment and reducing benefits; [19]

    —  the Choice Agenda and the requirement to manage treatment times below 18 weeks will place unachievable pressures on psychology services;

    —  psychologists also assess and treat people with complex mental health needs including those with severe mental health problems and personality disorders;

    —  psychological understanding of many physical health problems now provides the basis for public health interventions relating to life-style and behavioural risk factors;

    —  psychologists also work in services for children and families, and people with long-term intellectual and/or physical disabilities;

    —  psychologists are fulfilling new roles leading teams and services, and will take on even greater responsibilities under the proposed new Mental Health Act; and

    —  advising and supporting other health staff in how to deal more effectively with occupational stress and promoting healthy workplaces within organisations.

  2.  We firmly believe that evidence-based workforce planning has a major role in delivering psychological healthcare which is flexible and fit for purpose to patients. We have had a continuing dialogue with the Department of Health around estimating the demand for psychologists and how education and training commissions can meet such demands. We have surveyed the workforce profile of psychologists both in England and the devolved nations, published reports on the diversity of psychologists, and forecast the demand for psychologists in services for adults, families and children, people with disabilities, and older people.

  3.  In response to frequent requests from the Department of Health we have produced reports on how the supply of applied psychologists might be increased and have implemented changes within our education and training programmes to improve the quality, flexibility and training numbers of applied psychologists. Finally, psychology unlike many other health care professions has no problem recruiting graduate psychologists to train as applied psychologists. Psychology is the third most popular subject studied at degree level and produces around 13,000 graduates each year.

  4.  Our estimates for demand for applied psychologists within the NHS fall between an additional increase of between 15-30% of the current training commissions, and we believe these to be conservative. Indeed, the Workforce Review Team also estimate demand at 15% for clinical psychologists and refer to this as an under-estimate. We also believe that future policy initiatives, especially those already mentioned, will further increase demand. Future developments might see further growth in demand ranging from an additional 5,000 psychologists and upwards, over the next ten years. [20]The public health and integrated care White Papers, both, highlight the growing demand for providers of psychological healthcare.

  5.  As with many other health care professions, the current supply does not meet neither the existing nor the forecasted demand for applied psychologists (see supply data in Annex 1). [21]However, whereas for doctors, nurses and the other allied health professions, recent increases in financial investment in the NHS workforce has seen major increases in training commissions, we have actually seen for psychologists within England over the last three years a slowing down of expansion, and even a decline in estimated training commissions. In part, we believe that this has been a consequence of a failure to set profession specific recruitment targets for psychologists.

  6.  Furthermore, only clinical psychologists are commissioned by the DH; other forms of applied psychology training (ie counselling and health) which are directly relevant to the NHS are not NHS funded, despite re-assurances from the then Health Minister Rt Hon John Hutton that applied psychology funding would be equitably funded. Funding other applied psychologists has been consistently discussed with the DH for the last two years but no additional support has been identified.

  7.  We consider that the failure to meet the increasing demand for applied psychology identifies significant failings and short-comings in the workforce planning mechanisms both nationally and locally. Many of these issues, we believe arise from the dominance of workforce planning by the larger professions (ie medicine and nursing), which results in a lack of influence and representation by smaller but strategically important professions. The prevailing philosophy is to perform workforce planning around either care groups or service delivery frameworks, to the exclusion of uni-professional planning. Although we welcome this approach from a service development perspective; in practice, this still results in dominance by the major professions and the active exclusion of smaller professions. We consider a hybrid model that seeks input from all relevant professions, together with users' representations, around particular care groups or service models to be the most appropriate.

  With respect to short-comings of the existing system, we would stress the following issues which we believe the Select Committee should consider:

    —  We have found it difficult to influence the previous national workforce planning structures (WNAB, care group workforce teams etc.) and hence ensure that proper consideration has been made to patients' needs for psychological interventions within the workforce process. Effective involvement only occurred within the adult mental health care group, where we believed we made a significant and valued contribution as a profession contributing to a multidisciplinary strategic group.

    —  More recently we have enjoyed constructive dialogue with the Workforce Review Team, which has confirmed and validated our own workforce estimates. However, the nature of education and training funding, and the commissioning process, has meant that such estimates do not get translated into additional training places.

    —  The DH Annual Workforce Census derived from the pay-roll is unreliable and fails to properly to identify and assess the numbers of applied psychologists or psychological therapists employed within the NHS. This has been recognised by the DH and resulted in a one off survey of the psychology workforce (BPS/DH/HO, 2005). However, accurate annual data is required for effective workforce planning but is not currently available.

    —  Similar problems exist at a local planning level where psychology services and managers have only limited input into the development of Local Development Plans (LDPs). The difficulties of aggregating workforce estimates for the smaller professions from LDPs has been established through research by the Sainsbury Centre for Mental Health, but despite the widespread recognition of this problem, commissioning for the smaller professions is still heavily influenced by unreliable and inaccurate data collected at the local level.

    —  The continual and frequent re-organisation of education and training commissioners, together with their workforce planning procedures, leads to a lack of stability in policy development and implementation, periods of indecision, disruption of communications, networks and local knowledge due to staff turn over, and subsequent loss of expertise from the system. There is a continued organisational failure to recognise the importance of reliable workforce planning and to prioritise it or the staff responsible for its implementation.

    —  Along with other professions in the NHS, placement capacity is still a problem that can constrain expansion. However, despite the profession introducing greater flexibility for placement learning, commissioners have failed to provide the necessary additional resources (ie clinic space, office accommodation etc.) to capitalise on these changes. Initiatives designed to facilitate increases in placement capacity are invariably targeted at nurses and yield inappropriate inter-professional resources such as hospital-based clinical skills training suites that are of no relevance to the delivery of psychological therapies.

    —  The problems of recruiting clinical academics to staff training courses in Universities is a growing problem which has been recently exacerbated by the introduction of more favourable pay structures (Agenda for Change) within the NHS.

    —  Currently, we are concerned about the lack of structure and direction surrounding workforce planning within the DH and the NHS. There appears to be no overarching organisation co-ordinating the workforce process. We consider that the prominence given to workforce planning by A health service of all the talents (DH, 2000) has been seriously lost and dissipated. The current activities located around Skills for Health may be highly relevant for assistant and associate practitioners within the NHS, but we have some concerns about a purely skills-based competency model being applied to highly skilled and knowledgeable professional groups whose work requires a synthesis of skills knowledge and experience. Such approaches, we believe, may bring about major problems for commissioning services and the safety of the public, since they under-value the efficiencies of professional identity when recruiting to posts and the contribution that professions ought to make to regulation and public protection. We also have future concerns about the impact of foundation hospitals and trusts who appear outwith current planning and commissioning processes.

SPECIFIC RESPONSES:

How will the ability to meet demands be affected by financial constraints

  8.  We believe this to be the most important factor affecting commissioning at times of financial cut backs, due to the perception of psychologists being seen as expensive. This comes about since our training costs are compared to those of undergraduate trained allied health professions. However, we are a postgraduate trained profession and given our low attrition from training (3%) and high retention within the NHS (95% at five years), we are seen by the WRT as one of the most cost-effective professions to train, with respect to retained years. Unfortunately, this is seldom acknowledged by local commissioners who will have only a very limited knowledge of psychologists. Without effective national guidance, we believe that our perceived expense will always result in commissioners investing in cheaper professions since they are attracted by short-term gains in meeting expansion targets for training places overall.

  Nevertheless, putting expense to one side it may be important to the profession's advantage to look at skills mix solutions to funding training across a number of different levels of practice and competency. The profession is currently engage in such a process: New Ways of Working for Applied Psychologists (see later).

  Finally, the importance of establishing a viable National Benchmark Price for funding training will also be critical. Currently, although benchmarks exist for nursing and the major allied health professions, they have not been established for applied psychology.

the European Working Time Directive

  9.  This is unlikely to impact on psychologists currently since there are limited pressures to work out of hours or on call. However, it may become more important in the future when practitioners are required to work outside of normal hours either due the requirements of users from particular care groups or the implementation of new roles through the new Mental Health Act.

increasing international competition

  10.  Currently, due to the different systems of national regulation and licensing, the flexibility of movement of psychologists internationally can be problematic. This may change with the implementation of European Directive, but the UK is likely to benefit from an influx of psychologists rather than competition with health services overseas. The adverse impact of professionals trained in developing countries is limited, given the under-development of psychology training in the third world.

early retirement

  11.  The profession is relatively young given that training only really became established in the 1970-80s. Hence the impact of retirement and early retirement is just beginning to be recognised. O equal import ce, however, is the prevalence of part-time working within the professiornnexe L This is an important factor to consider in any future workforce projections.

To what extent can and should the demand be met, for both clinical and managerial staff, by changing the roles and improving the skills of existing staff

  12.  The Society is actively looking at skills mix solutions and how the 13,000 p.a. psychology graduates can be better employed within the NHS in order to contribute to health and social care. A New Ways of Working for Applied Psychologists project which is sponsored jointly by the BPS and NIMHE/CSIP is currently examining training models, and developing new or supporting roles (ie assistant or associate, graduate primary care mental health worker) for psychologists. We also consider that it is important that psychologists are actively involved in (re)-training other staff in psychological therapies.

  Greater thought is required as to how different training needs (applied psychology, graduate mental health workers, other professional staff and CBT, clinical supervision etc) might be co-ordinated across a single training provider. This would ensure efficiency and also promote inter-professional learning within psychological therapies. A possible solution might entail regional Centres of Excellence which are funded and bid for nationally to co-ordinate and provide these activities, together with other local psychological therapy providers. The scale of the enterprise would be like commissioning several new medical schools. They could also lead on evaluation and further developing the research and knowledge base behind psychological therapies.

better retention

  13.  Currently retention for psychologists within the NHS is extremely high. The majority of psychologists do return to work following maternity and career breaks, and continue to work on a part-time basis. The introduction of independent sector providers for psychological therapies ihight have a dramatic impact on the stability of the NHS psychology workforce. Competition from the independent sector currently is modest, but if expanded could lead to greater competition, further increases in vacancy rates, and inequalities of access for some care groups or geographical areas not well served by independent providers. The expansion of the independent sector for psychological therapies requires careful consideration and economic modelling.

international recruitment.

  14.  Currently little impact predicted.

How should planning be undertaken, to what extent should it centralised or decentralised?

  15.  The current system of planning and commissioning can be described as bottom up, relying on local determination of demand for staff, the setting of local priorities, and commissioning education and training to reflect these circumstances. Such an approach is consistent with a patient-lead NHS whereby patient needs for healthcare are assessed, translated into effective and evidence-based clinical protocols and care pathways, the skills and competencies to underpin the delivery of these care pathways identified, and the relevant education and training programmes commissioned. Although we believe that such an approach has its merits, we also have some major reservations that arise particularly for a small profession such as our own.

  We have already emphasized the limitations of workforce plans based upon LDPs. The Department of Health whilst agreeing with the problems faced by professions such as our own, have failed to take steps to rectify the situation. The result is that national estimates of demand based upon strategic considerations will yield conservative increases in the workforce of 15%, whereas local estimates will not even register a demand for clinical psychologists, let alone other types of applied psychologists.

  For small professions we would advocate a centralisation of workforce planning, together with either a regional or national system of determining education commissions as advocated by HEPI (2005). Devolvement of commissioning and training budgets for small professions such as our own to the primary care level would be both impractical and irresponsible given current research.

  We also need to emphasize the challenge to workforce planning, especially as it relates to psychological therapies, to ensure that it encompasses the private and voluntary sectors, as well as the NHS. However, this raises the problem that many therapists in the independent sector are not subject to regulation or necessarily posses recognised qualifications relevant to the evidence-based practice of psychological therapies.

How is flexibility to be ensured?

  16.  Variations in the workforce are subject to slow changes due to the long gestation times for commissioning education and training over the period of a three year course. Hence, only limited flexibility can be afforded without de-stabilising the system. Having a range of skill mix options across the family of applied psychologists and levels of practitioners, might introduce greater flexibility in commissioning.

What examples of good practice can be found in England and elsewhere?

  17.  We would wish to commend the following three initiatives and programmes:

    1.  Workforce planning: The Mental Health Care Group Workforce Team prior to its disbandment.

    2.  Commissioning:  The clinical psychology commissioning subgroup of the North/ Central London SHA (Nic Greeenfield).

    3.  Flexible working: NIMHE Workforce programme— New Ways of Working (Steve Shrub & Roslyn Hope).

Professor Graham Turpin and Pam Stirling

British Psychological Society

March 2006






18   Not printed here. Back

19   Layard, R, 2004, Mental Health: Britain's biggest social problem? Cabinet Office Strategy Unit Seminars. Back

20   Layard, R, 2004, op cit; Layard, R, 2005, Therapy for all on the NHS, Sainsbury Centre Lecture; Sainsbury's Centre for Mental Health, 2005, Defining a Good Mental Health Service, consultational document. Back

21   Not printed here. Back


 
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