Associate Psychologists –
is it ‘Groundhog Day’ again?
ACP-UK Director & Legal Lead
This article presents the author’s personal opinions and does not represent the views of the Association of Clinical Psychologists U.K. C.I.C. as an organisation.
Who knows that Groundhog Day was a 1993 American comedy fantasy film in which Phil, a weatherman, gets trapped in a time loop that no one else is aware of? Apparently the American military of the time soon recognised his experience as a regular part of their everyday life – “same stuff, different day”! The phrase has since come into common use to describe situations, usually unpleasant situations, which continually repeat without any progress being made.
There cannot be a clinical psychologist who does not know that many more psychology graduates want to train as clinical psychologists than there are places on clinical psychology training courses. You can see the details here but in 2018 there were 3,866 applicants for 593 training places. In other words, only 15% of applicants could be taken into training. And to the best of my knowledge that has been going on for well over 40 years, despite the NHS’ well known need for more and better mental health services, learning disability services, child and adolescent services, medically unexplained symptoms services, and so on and so on.
There are a number of different ways of looking at the same problem. Typically, people ask where shall the NHS get its staff from when it wants to expand its psychological services? Can other kinds of psychologists, or other professions, substitute for clinical psychologists? Are there ways in which the 85% of applicants who were not selected for training but still want to work as psychologists in healthcare both fulfil their aspirations and help the NHS solve its lack of clinical psychologists? And bearing in mind that the NHS is funded by the Government primarily out of general taxation, other questions follow those questions, about how to get the greatest expansion of services for the least money.
Those who are involved in trying to cope with or solve complex problems are always tempted to look for quick or easy solutions. In fact it is not just a temptation. They are usually under pressure to do so, because no one who needs help wants to wait for years for the services they need and no one who provides those services wants to feel that they can never meet those needs. Inevitably each group involved tries to come up with solutions that solve the problems as they see them. But planning and training sufficient professional staff involves many different groups who are all part of one complex system.
For the purposes of this discussion let us identify five broad groups. There are organisations which provide services and employ staff – NHS Trusts; let us call them the operational managers. There are the organisations which manage the funding of services and seek to ensure that the aggregate demand for staff is fulfilled – commissioners of one kind of another, and standing behind them, the Government; let us call them the strategic managers. There are the Universities who create and provide training courses and are dependent on the income from the NHS that they generate; let us call them the trainers. There are psychology graduates who need to see a future for themselves in clinical psychology despite only a 1 in 7 chance of being selected for training, and without whom the system would cease to exist; for convenience let us call them the graduates. And the fifth group? The clinical psychology profession, of course, although it has sometimes felt as though we are seen as peripheral by the other four. Yet without the existence of ‘the profession’, without the intellectual coherence and career opportunities that it offers, the services that it leads and provides, and the training that it offers through teaching and placements, the system would not exist in its current form, or perhaps would not exist at all. The system does not consist just of those five groups; for example the British Psychological Society and Health and Care Professions Council have important roles in relation to ensuring the standards of training but I think it is fair to say that they are a step removed from the first five groups.
Each group has its own view and its own priorities. Each, at different times, can and does take a lead in proposing and implementing its own solutions to the problems that it sees. But, I shall argue in this article, only if we can achieve a system in which all groups co-operate on a shared plan can that plan succeed in solving problems and satisfy some of each group’s needs.
I was a member of the BPS Professional Affairs Board in the early 1980s when Richard Nelson Jones explained to the Board that his university was starting a postgraduate qualification in counselling psychology. We were told, I recall, that the university had recognised that there was a massive unmet need for psychological therapies and a significant number of graduates who had not been selected for clinical psychology training. Those achieving the qualification would be able to demonstrate that they had trained in relevant competences. So far as I know the university did not concern itself with the NHS training system or the employment prospects of its postgraduates. The intention was not to make up the shortfall in NHS staff but for them to practise as self-employed counselling psychologists in GP surgeries, occupational health services and the like. Counselling psychology has come a long way since then. But questions about the employability of counselling and other applied psychologists in NHS settings, and the relationships between clinical and other applied psychologists, have never gone away despite the creation of the concept of an NHS ‘family of psychology’ in the 1990s.
I was also a member of the steering group of the NHS Manpower Planning Advisory Group Project in 1989 / 90 on increasing the numbers of clinical psychologists in training. That was the project which commissioned Professor Derek Mowbray of MAS (the Management Advisory Service) to review clinical psychologists’ roles and value to the NHS. Those projects primarily involved the strategic managers and the profession, aiming to satisfy the needs of the operational managers. So far as I know there was relatively little investigation into what the universities and the graduates thought and wanted. But in any case the project published its report just as the Prime Minister of the day, Margaret Thatcher, was turning the NHS upside down in order to create an internal market in health care. The report disappeared without trace, with no impact in the new and totally different system.
In fact clinical psychology kept on growing, as did counselling psychology and the next university-led development – health psychology. In the background there was an ever-growing demand for psychological therapies (“talking therapies” was a popular term, even for behavioural therapies), and there were a range of innovative attempts to create nurse therapists, primary care mental health workers, practice counsellors, cognitive behavioural therapists and so on. In the mid 1990s the Department of Health, particularly in the form of Glenys Parry and Anne Richardson who were clinical psychologists working for the Department at the time, sought to bring some strategic direction to developments. But my impression is that many developments were ‘bottom up’, that is started by a local NHS organisation or educational institution, and then emulated by others.
A turning point came in 2004 when Professor Richard Layard, an economist, told the Government of the day: “Mental illness is one of the biggest causes of misery in our society – as I shall show, it is at least as important as poverty. It also imposes heavy costs on the economy (some 2% of GDP) and on the Exchequer (again some 2% of GDP). There are now more mentally ill people drawing incapacity benefits than there are unemployed people on Jobseeker’s Allowance.” (Yes, ‘welfare to work’ was an ideological driver for the Government).
Professor Layard attributed the lack of political pressure to do something about the situation before then to the fact that: “much of society, including some policy makers, are unaware of how much can be done to help mentally ill people. Until the 1950s there was little that could be done beyond improving the social environment. But today both drugs and modern psychological therapies can make a huge difference to the majority of patients. The evidence-based draft Guidelines drawn up by NICE recommend the options of psychological therapy and drugs for all serious mental illness. As the NICE Guidelines on depression put it, “cognitive-behavioural therapy should be offered, as it is of equal effectiveness to anti-depressants”.
He went on to say that if patients were referred for psychological therapy: “the average waiting time is very long – typically 6-9 months, and in some places evidence-based therapy is not available at all. At the same time there are queues of people wanting to train as clinical psychologists, for whom there are not enough training places. So here is a problem that can be solved.” That was the moment of conception. The solution, when it was born in 2007, was the Improving Access to Psychological Therapies (IAPT) project. What (at least from our point of view, but I think also from the Health Services’ point of view) went wrong?
I am sure that the answer is complex and multifactorial, and I do not pretend to have a comprehensive knowledge of the problems. I shall just pick out a few elements which seem to me to be relevant to the present.
Firstly, IAPT was set up and developed separately from the existing clinical psychology services of the time. No public explanation was ever given but our Chair, Professor Michael Wang, was Vice Chair of the DCP. His understanding is that IAPT was originally going to be led by clinical psychologists on a hub-and-spoke model. However Professor David Clark, who was w