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Lord Goodhart: My Lords, I am most grateful to the noble and learned Lord for giving way. Does not this Bill go well beyond merely settling doubts? I have in mind particularly Clause 2(b) which would exclude any Bill,
Lord Donaldson of Lymington: My Lords, no. There are doubts, which are not shared by the Attorney-General, as to whether the 1911 Act authorises the other place to make changes to the constitution of this House. I propose to remove those doubts by simply saying that the other place cannot do it. But it is clearly
It was suggested by the noble Lord, Lord Shore of Stepney, that there should be provision for a referendum. So be it. However, that is not the intention behind this Bill. Overnight I pondered what could be done about this. One obvious possibility is that this House and the Commons should pass a sovereign parliamentary Act to provide that the other place can amend the powers and constitution of this House provided that, say, a Bill to that effect is passed in two Parliaments and x years have elapsed at the moment the powers of the other place come into existence. That is a very interesting field to be debated, which may happen soon. However, this Bill is of limited scope.
I raise only one other matter, because time marches on and many noble Lords will also want to march. The noble Lord, Lord Goodhart, said that I cast doubt on whether Welsh Bishops might still be Members of this House. I cast doubt on the validity of MEPs' membership of the European Parliament. Not so. I tried to stress--obviously inadequately--that it is a fundamental part of administrative law that subordinate legislation is good until challenged and set aside. That applies not only to subordinate legislation, it applies to judges' orders.
It was said on behalf of the noble Lord, Lord Baker of Dorking, when Home Secretary, that it was all right for him to ignore an injunction because it was wrongly made. I sat in the Court of Appeal which heard the appeal from that. We did not say that we entirely agreed with him that it was wrongly made, but we pointed out that it was a perfectly good order until it was set aside on appeal of the whole right. Otherwise there would be chaos, because whenever a judge made an order which people did not like, they would say, "Well, it was made without jurisdiction and therefore we are entitled to ignore it". It does not work that way. Therefore, I regret to say that Welsh Bishops will not be able to come to this House and MEPs will continue to be Members of that parliament.
Perhaps I should start by declaring an interest, or more correctly, explaining why I should have an interest in the registration of psychotherapy. Since 1988 I have been a consultant psychiatrist and psychotherapist in the NHS in Northern Ireland. I was appointed to develop psychotherapy services and training in the Province since at that time there were no psychotherapy clinics and the only accredited training was a Masters degree course at The Queen's University of Belfast which had recently been started by my colleague Dr Clare Adams and myself. As I immersed myself in this work I became increasingly concerned about what I might describe as "wild psychotherapy"; that is, psychotherapeutic work carried on by people of variable quality, not only in terms of their training and practice but even, on occasion, of their ethical standards. That was not good for the profession, but was extremely dangerous for the vulnerable people who sought help.
My concerns were shared by the DHSS in Northern Ireland and funding was made available for a short study to be undertaken by a member of staff in our psychotherapy department. The report by Ms Gillian Rodgers was completed in May 1995 and confirmed that while some patients were receiving help from good high-quality practitioners, there was every reason to be concerned about the standards and practices of others of the rapidly increasing number of practitioners in this broad field.
Of course we were in no way the first to make such observations. In 1971 Sir John Foster published his report into scientology; and in 1978 Mr Paul Sieghart published the outcome of a working party of senior professional psychological and healthcare organisations which recommended statutory registration. The parliamentary result of this work was that in April 1981 Mr Graham Bright brought a Psychotherapy (Registration) Bill to the other place. I am particularly delighted to see that the noble Lord, Lord Clinton-Davis, is in his place since he was one of the supporters of that Bill when it come forward in the other place 20 years ago this year. He has continued to maintain a substantial interest in the matter ever since.
In retrospect that Bill had a number of serious problems. First, it focused on specific organisations, which, while important, were not the only ones in the field. There are many more now than there were then. Secondly, while Sieghart had pointed towards a descriptive registration--that is the protection of the term "psychotherapist"--the Bright Bill tended towards a proscription of the ill-defined practice of psychotherapy, thus raising serious dilemmas for the work of psychologists doctors and others. I believe that despite the work of the working party, the
The 1980s saw a series of regular conferences to address the issue of statutory registration, culminating in the formation of the United Kingdom Council for Psychotherapy. That was a large body with many organisations involved and members. However, at the start there were deep concerns about it. I remember that well because at the time I was a member of the psychotherapy executive of the Royal College of Psychiatrists. I recall the discussions and the high level of anxiety about the range of therapists involved and the variable standards which applied. The result was that many of the most eminent psychoanalytically-orientated organisations split away and formed the British Confederation of Psychotherapists.
Since that time the UKCP and the BCP have made enormous progress in establishing and raising agreed codes of ethics and practice and the quality of education and training. I pay tribute to the excellent work done particularly by these umbrella organisations over the past years. However, succeeding governments have been understandably reticent to tackle what was clearly a divided profession.
Recent years have, however, seen a substantial increase in public concern about the practices of healthcare professionals of all kinds. Indeed one author has described this as an "age of ethical crises" particularly in healthcare. Even in professions such as my own medical profession which has a long-standing statutory instrument for dealing with such things--the General Medical Council--recent days have shown that the public and, indeed, the profession wants something more robust. How much more is this the case in the complete absence of any statutory registration for the thousands of psychotherapists throughout the country? I believe it will be difficult for the Government to dispute my contention that the protection of the public in these matters is a major responsibility of Parliament and government. To fail to provide sufficient protection must mean shouldering some of the responsibility for the adverse results of its absence. The Government must surely recognise that they could become increasingly vulnerable to such criticism.
Recognising this situation I drafted a Bill modelled on the Osteopaths Act 1993. Knowing many of those in positions of leadership in the profession, I invited most of the major stakeholders to send nominees to an advisory group to assist me in the process of the Bill. I was most gratified when they all agreed so to do. We have met regularly since the summer of 1999. The organisations concerned were the United Kingdom Council for Psychotherapy; the British Confederation of Psychotherapists; the Royal College of Psychiatrists; the British Psychological Society; the British Psycho-Analytical Society; the Association for Psychoanalytic Psychotherapy in the NHS; the Tavistock Clinic; the Association of Child
The various component sections of the BCP and UKCP, particularly the analytical psychology section and that of the humanistic and integrative psychotherapists, the experiential constructive psychotherapists and the hypno-psychotherapists, have had extremely helpful meetings with me on a bilateral basis. I pay tribute to the British Association for Counselling--now the British Association for Counselling and Psychotherapy--with which I have also had some useful and fruitful meetings. I shall discuss those later. I mention those organisations and groups because this has not just been a question of producing provisions for a Bill. It has been the development of a process in which an agreed structure could be formed to provide protection for the public and a focus for the proper development of the profession.
Perhaps I may refer again to the meetings with the British Association for Counselling and Psychotherapy. From the start, a major question was whether or not to have counselling and psychotherapy together as part of the Bill. In some ways, there could be a persuasive argument for that. However, as I began to look at the question and to know something of the feeling from my own professional background, I became persuaded that to widen the net too far would, if I may stretch the fishing analogy further, overburden the net to breaking point and we would find that in the end we had nothing at all. The Bill is also based on the protection of the term "psychotherapist", which is becoming increasingly understood and clear as a result of the work of the UKCP and the BCP. The term "counsellor" is much less clearly defined in the public mind at this point and more work will need to be done. I have no doubt that the same issues apply to counselling in general and that they will have to be addressed. But I was persuaded at an early stage that the Bill and this process were not the way to do it.
I turn to the Bill. The early clauses, Clauses 1 to 10, set out the arrangements for the general psychotherapy council, the registrar and registration itself. It seemed important to me to keep common to all the strands of a rather diverse profession as much of the regulatory system as possible. At this stage the Bill does not define separate modalities or psychotherapies; nor does it mention particular organisations. I hope that it will be possible to maintain a good deal of the unitary structure as already set out in the Bill. However, there has been a great deal of discussion on the issue of how to accommodate the different modalities of psychotherapy and the psychotherapies. As the Bill progresses, it is my intention to introduce, probably under Clauses 11 to 18 on professional education, an amendment or amendments to recognise that the differing modalities of the psychotherapies have differing requirements for education and training. Those amendments will probably involve the recognition of separate sub-committees whose role will be to give advice and guidance to the education
Clauses 19 to 28 deal with the establishment of a code of practice and the mechanics for tribunal and sanction. Clauses 29 to 31 deal with the process of appeals. Clause 32 is in a sense the heart of the Bill as it defines the offence of the unregistered use of the term "psychotherapist". It should be noted that no offence is committed if a person is already registered with the General Medical Council. There is no bar under the Bill to doctors registering as psychotherapists and I believe that many will. But there is no requirement, to avoid a criminal offence, that a registrant with the GMC would also register with the GPC. If there was subsequently a statutory registration scheme for psychologists, a similar provision might readily be applied to them too. I am not seeking to multiply the number of registers to which therapists have to sign.
Clauses 33 to 43 deal with monopolies and competition, the important role of the Privy Council and a number of other miscellaneous provisions, including the power to modify the Act by order. The schedule then sets out the proposed structure, powers and personnel of the council and of its committees.
I do not wish to detain your Lordships further at this point since the change in the order of business for today already leaves a number of noble Lords here much later than was expected. However, I believe that the profession of psychotherapy is now a corpus of responsible therapists who wish to develop and improve the standards and practices of themselves and their colleagues because they care about their patients and their work. I believe that the patients and their carers require the reassurance and protection that the Bill would provide. I appeal for your Lordships support for the Bill. Its subject matter is of genuine importance and what it seeks to do has been urgent but absent from the statute book for much too long already. I beg to move.
Lord Clinton-Davis: My Lords, it falls to me to congratulate the noble Lord, Lord Alderdice, on introducing the Bill. Together with the noble and learned Lord, Lord Steyn, I tried to introduce a separate Bill in 1997. In 1998 I tried again because the noble and learned Lord was not able to pursue the matter. I was then advised that the Government did not have time for the Bill. Moreover, I thought that it was necessary for there to be adequate consultation about the Bill, more than had occurred beforehand.
I congratulate the noble Lord, Lord Alderdice, on what he has achieved so far. I know that he will be the first to acknowledge that the Bill can slightly be improved. I shall return to that point subsequently in my remarks. The noble Lord was very kind to me in what he had to say. He did not know that my wife was a psychotherapist at that time and had a lot to do with what I was seeking to achieve.
It is more than 30 years since the Foster report concluded that psychotherapy should become a regulated, registrable profession and seven years since the United Kingdom Council for Psychotherapy was launched here, in the Moses Room of this House. It now has more than 5,000 individual members and embraces nearly all the modalities of therapy which the public are receiving through its eight constituent sections. It now compromises institutions of the highest calibre, such as the Tavistock Clinic, which is not far from where I live--it has overcome that difficulty already--the Royal College of Psychiatrists and the British Psychological Society.
The founders of the UKCP and, it must be said, others have had a long and hard struggle to reach this point today in their attempt to ensure through statute that the public will be protected from rogue practitioners who have as much capacity to harm their vulnerable patients as have some incompetent or exploitative doctors to harm their patients physically.
It is imperative that every one of the recognised specialties that are already on the registers of both the UKCP and the BCP--the British Confederation of Psychotherapists--should be represented in the regulatory process and the Bill, when it comes to Committee, must include that safeguard. I am glad that the noble Lord, Lord Alderdice, has paid tribute to the work which has been done by both of those institutions.
Without the Bill, I understand that there will be no control whatever over any individual or maverick grouping. They may present themselves as bona fide practitioners. That is something which the Bill will attack. With the Bill, obligations will be set down for at least minimal standards of training. Organisations, as well as their individual members, will be subject to responsible and independent inspection. There will also be a system for complaints and disciplinary procedures. That is particularly important and I congratulate the noble Lord, Lord Alderdice, on that. The entire Bill must not fail to be passed into law so that ethical responsibility to the public is finally upheld.
If I make one or two criticisms of the Bill as it stands, I know that the noble Lord, Lord Alderdice, will give those points his fair consideration before we reach Committee stage. At the present time, the whole question of analytical psychology, or Jungian psychology, must be recognised as one of the well-regarded, longstanding, worldwide modalities with high training standards, research methods and its own international organisation. So far, it has not been mentioned. I do not know whether the noble Lord, Lord Alderdice, has that idea within his sights for the amendment he proposes to table. I hope that he has. It is certainly something which ought properly to be considered.
It would be confusing to members of the public if, in the event of restructuring by modality under the Bill, analytical psychology were to be muddled up with another modality altogether. As the noble Lord said,
Another vital point to be considered is that registration under the Bill is indicative and not functional; that is to say, you are registered according to what you call yourself, not what you do. At present, any analytical psychologist who registers under the terms of the Bill would, I believe, have to be regarded as a psychoanalyst/psychotherapist. I may be wrong about that, but no doubt the noble Lord, Lord Alderdice, will refer to that when he comes to consider the matter. I am concerned that analytical psychology is accorded proper legal status in this country.
Lord McColl of Dulwich: My Lords, I, too, am grateful to the noble Lord, Lord Alderdice, for instituting the Psychotherapy Bill, which has a thoroughly sound basis with the support of the Royal College of Psychiatrists and in consultation with many other organisations already outlined by the noble Lord. The proposed new general council will be good for patients or clients, as it will set standards for the competent, safe and ethical practice of psychotherapy, and the education committee will promote high standards in education and training.
The problem at the moment, as has already been pointed out, is that the entire field of counselling and psychotherapy remains unregulated so that anyone can set themselves up in this field with virtually no training at all. The problem with the Bill is that it does not include the practitioners who call themselves counsellors. Furthermore, we do not know how many of them there are. The Sunday Times of 6th July 1993 stated that some 30,000 paid counsellors or therapists and 140,000 volunteer counsellors practise in this country. Other "guestimates" suggest that up to a quarter of a million people may be using the skills of counselling in the UK and the professional bodies regret that no accurate count has been made so far.
A number of professional bodies offer registration of counsellors, the largest being the British Association for Counselling and Psychotherapy, which recently changed its name from having been known as the British Association of Counselling. The organisation has 18,000 individual and 1,000 organisational members. Those it accredits have, I believe, undergone a minimum of 450 hours training, plus 450 hours of supervised practice.
Some controls are in place within the National Health Service. The noble Baroness, Lady Jay, speaking for the Government in a debate the House of Lords in November 1999 pointed out that in the NHS employers and those medical or other practitioners who refer people to counsellors, clinical psychologists or psychotherapists must ensure that the person to
This week, one of our splendid researchers tried to establish how easy it is to find a registered counsellor or psychologist by accessing all the appropriate websites of registers. Thirteen out of the 19 institutes, councils, trusts, services, networks and associations studied either had no list or the website failed. The British Association for Behavioural and Cognitive Psychotherapies had an easy link called "Find a Therapist" which stated that an online database of accredited psychotherapists would become available soon. The website of the British Confederation of Psychotherapists also had an easy link, "Finding a Therapist", but warned that,
As has been pointed out, the professions have wanted to be regulated for a long time. The Royal College of Psychotherapy has for many years been concerned about the difficulty which members of the public have in assessing the competence of those who use the term "psychotherapist" to describe themselves, particularly when they work outside the National Health Service.
The House of Commons Library has explained that the Health Act 1999 has made provision to enable the Secretary of State to bring in the statutory regulation of professions allied to medicine, including counselling, if this is considered appropriate. This can be done by statutory instrument, but there would have to be a period of consultation and the approval of both Houses of Parliament would be needed. There are no plans at present for such a statutory regulation to be put in place for counselling. Priority is expected to be given to the more invasive areas of medicine, such as acupuncture.
An alternative route provided by the Health Act allows professions to establish a statutory self-regulatory framework by joining the new Health Professions Council, which will replace the Council for Professions Supplementary to Medicine. Before joining, the profession would have to be represented by a single professional body.
Some believe that this Bill would have only one concrete effect: it would prevent counsellors from calling themselves psychotherapists. They point out that the Bill would not protect the public against a certain infamous psychotherapist, and I quote the Guardian as follows:
A moment's thought, however, shows that it is futile to regulate just one section of the talking therapies. What would otherwise stop a miscreant psychologist from turning up again as a psychotherapist or a counsellor?
The noble Lord, Lord Alderdice, has said that he is planning to introduce an amendment at Committee stage bringing in an element of structuring by modality. But the only major modality in the UK not to be represented in its own right, as the noble Lord, Lord Clinton-Davis, said, is that of analytical psychology, the practitioners of which are known as "Jungians". It will possibly be put in together with psycho-analytical psychotherapy. It has been argued that as analytical psychology is of long-standing repute, it should be represented in its own right.
As the noble Lord, Lord Clinton-Davis, said, registration under the Bill is indicative, not functional; that is, practitioners are registered according to what they call themselves, not to what they do. As the amendment currently stands, this would mean that, if the Bill became an Act, any analytical psychologist registering under it would have to be registered as a psycho-analytical psychotherapist. This would further mean that analytical psychology would have no legal status in the United Kingdom. Perhaps this could be clarified when the Minister replies.
Finally, perhaps I may draw your Lordships' attention to the King's Fund study published in the British Medical Journal in December last year. It concluded, first, that the most effective help for the treatment of depression lasting less than a year is counselling; secondly, that counselling is more effective over four months than obtaining anti-depressants; thirdly, while long-term drug treatment is effective, counselling helped patients more quickly and was of most benefit to those whose depression was of less than 12 months' duration.
I have learnt something about psychotherapy over the years, mainly because my wife was trained as a psychiatric social worker at the LSE many years ago. Thereafter she practised as a family therapist at the Westminster Pastoral Foundation and subsequently in private practice as a family therapist. Our house is littered with books on the subject. After 40 years of happy marriage one finds that one learns something about one's wife's profession by a kind of osmosis.
In addition, I have sat for more than five years in the Judicial Committee of the Privy Council. I still sit there from time to time. Noble Lords in the House today will realise--but not everyone outside--that when a doctor or a dentist is struck off by the GMC or the General Dental Council he has an absolute right of appeal to the Queen in Council. We have about five or 10 such appeals every year. During the past year we had six appeals from doctors, one from a dentist and one from a vet.
So, sitting there, one becomes familiar with the general structure of the regulations governing doctors and dentists and with some of the detail. In the case of doctors, the structure goes back to the Medical Act 1956, which was itself a consolidating Act. It consolidated legislation which goes back far, far longer than that. I do not know how far it goes back. In the case of dentists, the consolidating Act was the Dentists Act 1957. Again, before that there was an Act of 1878 and so on. I am very glad to see that the noble Lord has incorporated the same process and procedure in Clause 31 of his Bill, whereby there would be an ultimate appeal to the Judicial Committee of the Privy Council.
If one asks what is the justification for regulation at all in the cases of doctors and dentists--about which I know most--the answer must surely be twofold. First, the need to maintain professional standards; and, secondly, and equally important, the need to protect and reassure members of the public. It seems to me that exactly the same considerations must apply to psychotherapists.
Doctors and dentists are not the only professionals concerned with our health who are subject to regulation. In addition there are nurses, midwives, pharmacists, opticians, osteopaths, who were mentioned earlier, and, indeed, vets. All are required to register. Therefore, if we take such care--as we rightly do--to protect patients who seek treatment for their bodily ailments, including the bodily ailments of their cats and dogs, should we not also provide an equal measure of protection for those who seek treatment for their minds?
Indeed, in the case of the mind, the need is surely all the greater. For those who need treatment for their minds are surely the most vulnerable members of all in our society. Someone once said--I think it was a judge in the last century in a case of undue influence--that all forms of domination by one human being over another are, to some extent, sinister and certainly dangerous; but of all forms of domination, none is more dangerous than domination over the mind.
A patient who is possibly seeing his psychotherapist two or three times a week is likely to form a strong attachment to, or a dependency on--I do not use the word in any technical sense--his psychotherapist, especially, one might think, although I have no knowledge of this subject, a female patient who is seeking help from a male psychotherapist. That is quite proper and normal. But the corollary must surely be the importance of ensuring that that relationship is not abused. In the case of psychiatrists, protection is currently afforded by the strict discipline enforced by the General Medical Council. Surely, psychotherapists, who often use a similar technique, should be subject to the same strict discipline.
My only doubt about the Bill is whether it goes far enough. Should it be extended to cover the other counselling agencies that have been mentioned? I think that that should not happen for the moment. Psychotherapy, although not defined in the Bill, is well recognised in practice. Although the boundaries may be somewhat imprecise, it is well established as a separate profession. If one were to go wider than psychotherapy, it would be difficult to know where to draw the line. It is best to start with this Bill regulating the practice of psychotherapy on a similar basis to that which applies to psychiatrists and possibly extend it later on a wider basis. For the moment, let us give all our support to the Bill that is before us. I hope that it will be given a fair wind by the Government.
My wife is not a psychotherapist, I am not a psychotherapist, and I have no specialist knowledge about this subject, except in so far as I have come across it in my personal and professional life. Therefore, I speak as the "man on the Clapham omnibus". If I am wrong and ignorant about the profession, I hope that the noble Lord, Lord Alderdice, will forgive me and put me right in due course. I have no doubt that this is an important area, and that it is gaining in importance. It is also gaining in public recognition, therefore giving rise to the growth in public concern.
The noble Lord, Lord Clinton-Davis, was right to draw our attention to the importance of education. This is an area that people tend to shy away from. Individuals are often embarrassed to acknowledge that they have found psychotherapeutic treatment to be of value. To paraphrase, in many circles "psychotherapy is for wimps". Recommendation M in the government's response to the Health Select Committee's report into mental health services--not exactly the matter under discussion today but very close to it--states:
My professional life has been spent in the City. It is seen as a place where young men in striped braces earn million-pound bonuses. Some do--but the million-pound bonuses do not come without strings attached. Pressure of work, long hours, alienation from family and friends and hobbies are the price that people pay. For every person who is reported in the Evening Standard as earning a million-pound bonus, plenty of others have suffered those same conditions of long hours and hard work but have not earned a bonus. In many cases that has resulted in physical and mental illness. The problem often begins with nicotine and alcohol and moves to drugs. Such people have benefited from psychotherapeutic treatment to enable them to consider their lives.
Here we come to the problem posed by my noble friend Lord McColl. One begins to move from psychotherapy to counselling. As a mere layman, I find it hard to understand where the line should be drawn in terms of the practical implications that I have seen in the City of London. But if the problem exists in the City, I am sure the same is true of other walks of life with which I am not familiar.
I have no doubt about the enormous value of well-provided psychotherapeutic services. However, as was pointed out by several speakers, although there is the capacity to do enormous good, there is also the capacity for enormous harm. That is why I welcome the strategy behind the Bill. One of the issues that we shall have to consider will be the measurement of clinical effectiveness. Speaking again from a layman's point of view, I can understand how clinical effectiveness is measured in conventional physical medicine. The measurement of clinical effectiveness in psychotherapeutic medicine seems harder to judge. It will, therefore, place a higher burden--a very heavy burden indeed--on the general council to set and uphold proper standards.
Having given my unguarded support to the Bill, perhaps I may raise two or three points about which I have concerns. If I have misunderstood what is planned, I am sure that the noble Lord will put me right in due course.
My first point concerns the "grandfathering" provisions in Clause 3, described as "transitional" provisions. Perhaps I may refer again briefly to my experience in the City. I was involved with the implementation of the first financial services Act in 1987, the Act that will be replaced by the legislation passed by your Lordships last summer. This brought to the financial services profession for the first time a cohesive structure of regulation. All of us recognised that it was a unique opportunity to impose some standards. By means of "grandfathering"--by setting the sieve by which people were permitted to enter the City or the professions--one was able to raise standards once and for all. It became clear to us early
It seems to me that there is a similar unique opportunity for the profession to which this Bill relates. I was, however, concerned to see in Clause 3(5) relating to grandfathering rules the reference "(if any)" in relation to the general council making rules. This should not be an option for the council. We need a clear definition from the beginning of who is and who is not to be allowed into the profession. The weasel words "if any" leave me with some concern that when push comes to shove, the council may pull away from difficult issues. It is the action of the council in early days--being prepared to set and uphold high standards--that will lead to the building of a proper reputation.
I turn, secondly, to the question of education and training. I was pleased to see the words "education and training" linked in Clause 11. The education and training aspects of all professions are of enormous importance, given the speed at which the professions are developing and the rate at which change is taking place.
However, I see that Clause 12(2)(b), referring to the position of registered psychotherapists after registration, does not include a reference to education but merely to "training". I believe that to be a mistake. Registered psychotherapists, along with chartered accountants and other professions, need continuing professional education. It might be worth while considering some possible change in the Long Title of the Bill; for example, where it talks about "professional education", we could have reference to "continuing professional education".
I accept that education shades into training and that training shades into education, but from my point of view as a layman there is a difference. Perhaps I may give your Lordships a specific example: training is about the carrying out of an exact, precise procedure. A doctor may take out my appendix, but it is how he does so that matters. The education relates to the way that he treats me as a patient. He cannot be trained in that respect; he has to be educated. It is a much more holistic sort of experience.
I am a director of a listed company which owns/operates a number of acute private hospitals. We have about 1,000 beds in 25 hospitals around the country. The complaints that we receive are as much about the education of doctors as about the training of doctors. For example, patients arrive for an operation or to undergo "procedure", as the doctors rather euphemistically call it, in a nervous state. They are clearly going through an experience that they have not had for some time; indeed, they may never have done so or it may be years since they have been under, say, a general anaesthetic. They are, therefore, in a highly anxious condition. But for the doctors it is, inevitably, just another "day at the office", so to speak. The doctor, quite rightly, is focused on obtaining the best possible clinical outcome. That is where the mismatch
I am afraid to say that this mismatch often occurs where doctors who have been in practice for some years have become very "routinised" in their approach to treatments. When we consider this issue in Committee, I hope that we shall be able to find ways to encourage, empower and require the council to do more to ensure that that mismatch is avoided. It must recognise that there is a need for continuing professional education as people progress through their careers.
I turn now to a point relating to the burden placed on the members of the council. As I read the schedule, it appears that there will be 20 on the council. I see that 13 of them will serve on the education committee, eight will serve on the investigating committee, six will serve on the professional conduct committee and six further persons will serve on the health committee. However, will psychotherapists wish to undertake this burden of work? High quality psychotherapist input will be of critical importance in the early years of this council's existence. There is a hearts and minds job to be accomplished. We have to ensure not only that the council wins over public confidence but also that it wins the confidence of members of the profession.
Members of the profession will be guided by people who serve on that council and who are of the very highest calibre. I am concerned that the provision in Part I of the schedule may so overload members of the council that good quality psychotherapists may prefer to continue with their clinical practice and not be prepared to give the proper time and effort to the deliberations of the council and its committees. As a consequence, I fear that some of the less- well regarded members of the profession may take on this particular role.
I turn now to what is possibly my most serious concern; namely, the level of lay involvement in the council and its committees. There is no doubt that a proper level of lay involvement will be critical in building public confidence in this new profession. There will, inevitably, be problems and difficulties. The way to resolve them must be faced openly; those concerned must not appear secretive. Lay involvement is the key to that aim. Of course, achieving the right balance is always difficult.
As for the general council, I see from the Bill that six out of the 20 members are to be appointed by the Privy Council and, therefore, appear to be lay persons on first reading. I then observe that one of those six members will be a registered doctor, while the other five are not required to be registered psychotherapists. The provision does not actually state that they could not be doctors. It only says that they must not be registered psychotherapists at the time of their appointment. Therefore, someone could be appointed by the Privy Council as one of the representatives on the general council and subsequently become a psychotherapist. He or she would not then be disbarred from remaining in that position. It is clear to
That brings me to the question of the balance on the committees, especially the investigating committee, and the use of the chairman's casting vote. I very much welcome the proposal for establishing an investigating committee, although it will require enormous self-discipline by the proposed professional conduct committee and the health committee to avoid re-tilling the ground that has already been covered by the investigating committee. Inter-committee confidence will be absolutely critical.
However, as regards the make-up of the committee, there are to be two Privy Council members out of eight, according to the schedule; that is, 25 per cent. If one of those two members were a doctor, that would be one lay member out of eight, which would represent 12.5 per cent. The committee can co-opt eight more to the committee. If it chose to co-opt eight more psychotherapists, that would mean a 6 per cent lay representation; in other words, only one person out of 16 would be from the lay side of the profession.
The Minister may say that I am pushing the envelope too far and that I may be wrong in the way that I have read the provisions of the schedule. Circumstances could arise whereby there would only be one lay member on the investigating committee out of a total of 16. That sort of balance is not likely to carry public confidence with it. Indeed, that situation, allied to the provisions in paragraph 32(4) of the schedule--where the chairman has an additional casting vote that he must use in favour of a psychotherapist--gives me the most concern. I say that because it is to be used in connection with the investigation of offences under Clause 20(9)(c), which relates to whether or not there is a case to answer in the opinion of the investigating committee. Moreover, Clause 21(2) refers to an emergency power which may be necessary to protect members of the public.
Is it really suggested that, in a committee of eight, where four members believe that there is a case to answer or that emergency action is required to protect the public, the chairman should pass a further vote and should do so in favour of the registered psychotherapist? I cannot believe that that is the right way to proceed. If half the committee members believe that there is a case to answer and that there is a need for emergency powers, surely the chairman of the committee should permit that investigation to go forward or permit that registration to be suspended pending further investigations.
I can foresee circumstances where the investigating committee looks at a case and there is a tie. The chairman would then have to cast his vote in favour of the psychotherapist. Subsequently one of the patients may take violent action or perhaps commit suicide--or do something terrible to himself or herself--which would mean that all the facts would ultimately become public. If that is the position, I believe that public
I conclude as I began, by welcoming the Bill. It will provide a vital framework in an increasingly important area for modern society. I am sorry if I have appeared to be carping, but my only wish is to ensure that this important Bill is in the best possible shape so that it can raise standards, provide protection for psychotherapists in the proper execution of their duties and, last but not least, encourage and enhance public confidence in the system.
Lord Wedderburn of Charlton: My Lords, like all other speakers, I congratulate the noble Lord, Lord Alderdice, on producing this most important Bill. During recent months when I have taken a proper interest in the Bill, I have discovered the work that he has done outside the terms of the Bill. I refer to his ability to bring together persons in the profession who frequently criticise one another and to persuade them to express a willingness to work together. The Bill cannot succeed except on the basis of some element of professional consensus. In that regard I leave aside many of the points that I intended to make, including the size of committees.
After I summarise my comments on the Bill I shall refer to a bombshell from the Government which exploded on my fax last night. I suspect that all of us agree that there is a case for regulation, but that there is no point in regulating for the sake of regulation, nor indeed in choosing a form of regulation which loses something which has been built up in the recent past. I speak as a layman. However, the noble Lord, Lord McColl, has encouraged me by saying that he is one too, although he is well informed for a layman. I cannot escape the fact that I am a lawyer, but I would not dream of adding to the comments of the noble and learned Lord, Lord Lloyd, with whom I broadly agree.
The regulation of the profession, or rather professions, that we are discussing should surely be undertaken in the manner which will most increase public confidence in the profession and its confidence in itself. It should be done in the public interest and for the good of ordinary men and women who are, or may be, patients. In that regard I have some sympathy with the concept that some element of patient or lay representation or, at any rate, a patient's voice, should be added to the Bill by means of amendments.
Over the past few weeks I have received a large number of documents and pieces of advice. They included, of course, advice from the BPC and the UKPC which have been mentioned but also advice from those at the other coalface, as it were. The Mental After Care Association stated that,
I must admit that I was rather surprised to see that he had taken on the template of the Osteopaths Act 1993 and, to some extent, that of the Chiropractors Act 1994. In places he has adopted them word for word and clause for clause. I shall question some of that wording in Committee. Although it was not possible in 1993 to enact a strict definition of "osteopath", nevertheless it is a profession--as the noble Lord, Lord Walton, said during the passage of the 1993 Act--known to use "gentle manual methods"--I hope that those words will be brought to the attention of my osteopath--by,
The 1993 and the 1994 Acts were in a sense the product of influential reports supported by the King's Fund after His Royal Highness the Prince of Wales had lent his support to the project. It is not quite the case that this Bill is supported by a similar report. I know that the King's Fund undertook work on this subject last year, but, historically, problems which range across the field of psychotherapy have arisen because of various orientations or modalities, as they have come to be called, which find their inspiration either in different analytical fields, or fields that now are called psychological psychology--as we heard today--or in more recent analysts than the masters such as Freud, Klein, Lacan or Winnicott.
There are other modalities of treatment which now have serious support. The noble Lord mentioned the National Health Service in respect of the minor regulation which it has managed to bring in. But, of course, even there questions arise as to the boundaries of regulation. Those who practise in group therapy, family therapy, behavioural therapy or cognitive therapy would not necessarily think that those were absolutely right. We must be careful not to lose what is a precious historical oddity; namely, the freedom of groups to find new ways to practise and to introduce new concepts to the field. The history of psychiatry in Britain this century has been one of remarkable free
Of course, as far as the Bill itself is concerned, I was alerted to the fact that people at the Maudsley Hospital take the view that their doctors are not covered by it. That is correct in so far as every doctor who is subject to the General Medical Council could claim, under Clause 32, to be immune from the Bill's regulation even if they describe themselves, as the Bill states nicely, "expressly or by implication" to partake of psychotherapeutic practice. To that extent the register will be defective in the sense that the man in the street does not think that there is a rigid line between doctors and therapists, or, indeed, between the Maudsley Hospital and the Tavistock Clinic, whatever their agreements or disagreements on methods of treatment. That is a difficult area of the Bill. At Second Reading I merely repeat that it is the work of the noble Lord, Lord Alderdice, with all these groups, that has made it possible to think not merely of regulation by another statute, as in the case of dentists, for example, but of co-operation which members of the profession may extend to one another.
That does not imply that there has to be a core of agreement about training and treatment common to all practitioners but it means that the Bill and those who implement its provisions must largely seek out different aspects of the profession, as he has done.
I could comment on many other aspects of the Bill. However, as a lawyer perhaps my only footnote is that in Committee one must keep an eye on the extent to which undue control might not be compatible with the European Convention on Human Rights. We laymen have to learn a great deal about what matters to the people who work in this field. I did not know until recently that the Guild of Psychotherapists insists that there is a difference between "psychoanalist" and "psycho-Analist". That may seem odd, but it matters to that body. I appreciate its reasons for that distinction.
My experience has been that, in the past, doctors in general practice have not always been exposed in training even to the vocabulary of one or other type of analysis or psychotherapy. They are busy people but they often wish that they could know more clearly about this hinterland. The Bill would help them. One excellent and hard-working general practitioner said to me, "Oh yes, Freud, Jung, Klein: I really would like to read about them--when I retire".
I do not make legalistic or academic points. Under the provisions of the Bill, there are criminal sanctions. I leave aside the details at present. However, in Committee we should debate not merely the Education Committee, the Investigating Committee, and so on, as the noble Lord, Lord Alderdice, suggested, but also define more sharply criminal liability which the Bill encapsulates.
The noble Lord, Lord Hodgson, made this clear. All serious orientations must have some kind of voice in the transitional period. The Bill will be made or broken by what is done by the Privy Council in the transitional period. That view was echoed among the many analysts and others with whom I consulted and at the coalface of treatment by others. From the Tavistock Clinic to what is now the Foundation for Psychology and Counselling, all are aware of the issue. I accept that there is a problem about counselling. We should not seek to include that in the transitional period.
I have omitted many points that I wished to address. However, none of them affects my warm support for the Bill. What was the bombshell for me last night? It was this. On an open fax I received a communication from my noble friend Lord Hunt, the Parliamentary Under-Secretary of State at the department. It is an issue on which we have had several general discussions. The Minister said:
I believe--my belief is shared by others--that an Order in Council under the Health Act 1999, which the Government have lawful authority to produce, would wreck the progress with the Bill that the noble Lord, Lord Alderdice, has made. It is not right for Whitehall simply to grab a convenient area to apply to psychotherapists, counsellors and goodness knows who else. It needs patient work, not an Order in Council, with those who treat patients and want to know--I named earlier such a foundation--where to send their patients and what advice they can obtain. There are two informal registers. Is there a register where they can look up the training of different modalities with regard to particular people?
I do not believe that that objective can be best achieved by an Order in Council. I am sorry to throw in this dissenting note but we would fail the objectives of the Bill and fail the person who drew up the Bill with such hard and patient work if we accepted that the right way forward is by regulation by Order in Council. I am sorry to end on a note of asperity. However, I can avoid that by repeating my congratulations to the noble Lord, Lord Alderdice, on the Bill to which we shall now give a Second Reading.
The Earl of Listowel: My Lords, I join in the universal welcome of the principle of this timely legislation. I congratulate the noble Lord, Lord Alderdice, on the Bill, and on the hard work he has put into it.
Through my work at Centrepoint I am aware of increasing numbers of deeply troubled young people in our society. Your Lordships' concern over their predicament was well reflected in the recent debate on marriage and traditional family values and, I have no doubt, will also be reflected in the forthcoming debate on support for boys growing up without the care of a father.
I have witnessed the immense benefit that confused young people can gain from consultation with a well qualified and highly trained psychotherapist. If, in Committee, it becomes clear that the Bill will ensure the highest standards of the profession, if it will enhance the reputation of psychotherapists and thereby encourage many more individuals--sadly, we need many more--to pursue this calling, I hope your Lordships will give it the undivided support it deserves.
Lord Burlison: My Lords, I join other noble Lords in thanking the noble Lord, Lord Alderdice, for bringing this issue forward. He has given us an opportunity to hear some professional people express their views on a very important subject. I also join the noble Lord, Lord Wedderburn of Charlton, in congratulating the noble Lord, Lord Alderdice, on bringing together so many groups in what he described as a divided profession, which the health service has found very difficult.
I have no difficulty with the principle behind the Bill. I know that there are concerns about psychotherapy practice. Anyone may offer services as a psychotherapist in the private sector without appropriate education or training. A number of high-profile cases of poor practice and abuse of patients leave me in little doubt that action is needed to strengthen regulation.
The public are rightly concerned that when such incidents happen--I am glad to say that they are rare--prompt action should be taken to put them right and to stop them happening again. I am also aware that there are difficulties in assessing appropriate psychological therapies and psychotherapy, not least because the public and employers are uncertain about who is qualified and who is not. That is a particular concern in the private sector, but it is not without difficulty in the National Health Service and the social care services.
However, we cannot accept that the Bill, well intentioned though it is, is the right approach at this time. There are two main reasons. First, as your Lordships are aware, the Government have given a high priority to improving service quality in general in the National Health Service and social care services, as well as in the private sector. A number of initiatives testify to that, including the development of a national service framework, the establishment of the National Institute for Clinical Excellence, the new framework of clinical governance and the proposals set out in the National Health Service Plan.
The noble Lord, Lord Hodgson of Astley Abbots, made an important point about the clinical effectiveness of psychotherapy. The Government are taking action to ensure that practice is evidence-based. We have established a national workforce action team to help us to ensure that the workforce is equipped to deal with mental health problems. It will focus on all members of the workforce in health and social care, including paying some attention to those delivering psychotherapy. We have also commissioned guidelines on treatment choice decisions in psychological therapies and counselling, which will help commissioners, employers and the public to know more about what works for whom in this complex field.
As your Lordships know, the Government believe that a requirement in law to register practitioners is among the strongest protections available to the public. That is why we have made it clear that we wish to work with the health professions to strengthen the system of professional self-regulation, using the order-making power in the Health Act. That is the approach that we propose for the introduction of statutory protection of title for professions, such as psychotherapists, that are not already regulated.
Our proposals for the new health professions council are eminently suitable for the group of psychotherapy professions that we are considering today. Our purpose is to establish universal independent standards of training, conduct and discipline for the protection of the public and to guide employers. Those standards are underpinned by the personal accountability of practitioners and by systems to deal with individuals whose continuing practice represents an unacceptable risk.
In designing the proposals, we have had to find a balance between three interests: the public--the patients and service users--who need effective, evidence-based treatments delivered by trained staff; the professional staff and therapists who provide care and treatment for those in need; and the health service, where the majority of the care and treatment is given.
We want to ensure that regulatory bodies are small enough and sufficiently fast-moving to be able to agree on necessary action and act quickly to respond to patients' needs. That means getting away from the long, tortuous legal procedures which currently are necessary in order to bring about rule changes to address issues in individual professional conduct cases.
We want to ensure that consumer organisations and patients' representative groups are present in force in the new regulatory bodies. We propose a membership ratio of approximately 50:50, with either a lay or professional president. We plan to continue with an approach based on professional self-regulation because the professions support us in upholding professional practice standards. They provide for cases of misconduct or deficient competence to be dealt with speedily. We need to be confident, as do the professionals, that there is sufficient involvement of
I have referred to the important needs of the public and the patients. I have also spoken about the interests of the professionals who deliver treatment and care. All those matters must be addressed in a robust system for regulating professional practice. Some of them are addressed in the proposals put forward by the noble Lord, Lord Alderdice. However, what about the interests of the National Health Service and of the professionals and staff, including commissioners and the employers of those who deliver treatment and care? Concern for those interests brings me to the second reason why we do not support the proposals for a stand-alone psychotherapy council.
Psychotherapists are among a number of key professionals who provide psychotherapy services in the National Health Service and social care services, as well as in the private sector. Together with psychiatrists, psychologists, counsellors and others, they play an important part in the delivery of effective "talking treatment".
However, psychotherapists are not the only providers of psychotherapy in the NHS, where the main responsibility for the provision of treatment and care for the public lies. Most talking treatments in the NHS are provided by nurses, social workers, psychiatrists, psychologists and counsellors, some of whom deliver psychotherapy as the main component of their work within the NHS. What impact would the proposals, which concern psychotherapists alone, have upon them?
I cannot agree that an approach which addresses the needs of one group to the exclusion of the others is responsible, even though I readily acknowledge the importance of public protection in the private sector. Although protections are in place for members of the public who seek help through the use of psychological therapies in the National Health Service--for example, employers must be assured that practitioners are qualified for the tasks which they undertake and referrers must be confident that the treatment is right for the condition--we would not be reforming the legislation concerning regulation if we believed that those protections were sufficient.
We must also consider the issues which arise from the delivery of treatments by unregistered practitioners in a number of professional groups; for example, unregistered counsellors deliver treatments in perhaps as many as half our general medical practices, and psychologists are not registered either.
This is an important issue. I cannot accept that where counselling is offered by a trained practitioner to the high standards set by the leading professional bodies it is distinguishable from psychotherapy in anything but name. I cannot accept that the practice of clinical psychologists trained to deliver cognitive behaviour therapy or family therapy, known as psychotherapy, should be outlawed. Therefore, we should not, in all conscience, exclude those providers from our regulatory framework.
Therefore, if we pursue this route to registration, our proposals for the new health professions council will contain significant advantages for those who deliver psychotherapy. First, the proposals contain scope to accommodate the range of modalities for psychotherapy. Secondly, they accommodate the different approaches to psychotherapy and contain scope to accommodate the range of different professionals and responsibilities in this area. Thirdly, they give psychotherapists the benefit of consistency with a much larger group of health professionals, with all that that means in terms of access to good regulatory practice developed over time.
My noble friend Lord Clinton-Davis made a point about analytical psychology. That is a branch of psychotherapy with a distinct and different training. We know that different training standards matter. We can accommodate that. However, what matters about different approaches when it comes to regulation is that they can join others in a common approach in the action to take when a member of the public seeks redress because of poor, unprofessional practice.
We propose to bring together a large number of diverse professions and provide consistent policy and handling of education, training and professional conduct standards by means of statutory joint committees. Those committees will be able to draw on advice from uni-professional advisory panels which will cover the specific concerns and requirements of each profession or each different modality. The council itself will be required to take account of the different needs of each profession or group of professions
That will, we hope, satisfy the need for consistency across the board where it is necessary, and will also provide the need for sensitivity to professional differences. It will give psychotherapists themselves the reassurance that their own specific clinical training, practice and standards will be based on what only they themselves can know. It will also provide reassurance for the public that any problems which might arise from poor practice or conduct by a psychotherapist will be dealt with according to the same rules applying to any other health profession regulated by the new council.
The noble Lord, Lord Alderdice, proposes to protect the title of the psychotherapist so that only those registered as such may use that title. He recognises that members of other professions already regulated elsewhere, for instance by the GMC, practise psychotherapy. The proposals for the health professions council will provide for protection of title and will recognise the need to safeguard members of other professions so that they can continue to practice psychotherapy.
The noble Lord, Lord Hodgson of Astley Abbotts, mentioned "grandfathering"--the process by which existing practitioners might seek registration by virtue of length of practice rather than by meeting professional standards. I hope that that will be covered under our proposals for the health professions council. Our approach will enable professional staff to take
My noble friend Lord Wedderburn made a point in respect of the view suggesting that the Government's approach would not have the support of the relevant professions and other stakeholders. It is an approach based on the proposals contained in the Bill on professional self-regulation but it offers significant additional benefits.
I know that psychotherapy has much to offer modern mental health and social care. However, we know also that it is a field beset by divisions and differences in training, practice, organisation, commissioning and self-delivery. I want to say therefore how impressed I am with the work of the noble Lord, Lord Alderdice, in bringing together so many different psychotherapy practitioners to discuss those issues. He progressed the debate in a significant way.
I have listened carefully to the case the noble Lord made and to the points made by other noble Lords in the course of the debate. I have no doubt that the case for registration of psychotherapists is a strong one. But while I want to reassure your Lordships about that, I must emphasise that we are convinced that using the powers of the health Acts is the most appropriate way to proceed. It cannot be appropriate to address but one section of the field in a manner which separates it from the approach we propose for the rest.
We believe that the Health Act is the right vehicle for the registration of psychotherapists, counsellors, psychologists and other related groups. We intend to scope the requirements, building on the excellent work started by the noble Lord, and assess the other important factors such as the professionals' readiness for registration and the availability of parliamentary time with a view to positive and early action.
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