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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