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 working with Professor Layard to develop IAPT, was unable to obtain assurances from senior clinical psychologists that the new money would only be spent on providing CBT. They took the view that patients should have access to a range of therapies depending on the nature and severity of their problems and their personal characteristics. In order to maintain the vision of a pure CBT service, a decision was made centrally to implement IAPT independently of the existing clinical psychology services. Thus IAPT had a very different approach and culture from the start. Specifically there was an emphasis on treatment of conditions with diagnostic labels – anxiety and depression – using evidence-based CBT with regular measurement of symptoms to demonstrate change. That was in contrast to the knowledge and experience of many clinical psychologists that ‘therapist variables’ and the therapeutic relationship are fundamentally important, that a wholistic approach to understanding patients’ problems through the use of formulation is essential, and that clinical psychology services had well-developed policies concerning governance, supervision and service standards to rely upon. It also meant that IAPT staff did not routinely have access to the knowledge and experience of clinical psychologists. One consequence of that may be that recovery rates amongst IAPT patients have remained around the 50% mark.

Graham Turpin edited a document published by the BPS in 2007 entitled ‘Good Practice Guide on the Contribution of Applied Psychologists to Improving Access for Psychological Therapies’ which sought to bridge the divide between psychologists and IAPT but it does not appear to have had a widespread impact. In some parts of the country evolution led to the bridging or healing of the divide. But in other parts of the country, a second element, the out-sourcing of IAPT services and other psychological therapies to private providers or consortia of NHS and private providers, stood in the way of joint working and positive volution.

Not that psychologists were inactive. In July 2005 the British Psychological Society (BPS) and the National Institute for Mental Health for England (NIMHE) set up the New Ways of Working for Applied Psychologists project. It was part of a wider NIMHE/ Care Service Improvement Partnership (CSIP) New Ways of Working Programme. It was a wide-ranging project which included proposals for new roles and new training pathways for pre-qualification graduate psychologists, one of which was the development of Associate Psychologists. These were mainly to be psychologists who did not aspire to becoming fully qualified clinical psychologists but would undertake individual and group casework under supervision indefinitely, although some might progress on to a more conventional career pathway. The documents published by the various New Ways of Working projects presented options and option appraisals which are still relevant but the funding of developments was in the hands of commissioners. Not only have they tended to put whatever money they can into IAPT but, as Professor Wang recalls with sadness, the New Ways of Working project was completed in 2008, just in time for the financial crash and the imposition of ‘austerity’. The idea of Associate Psychologists had come and gone, just as the idea of primary care mental health workers came and went. Why?

I was told that there was dispute with the BPS about whether or not Associates could or should be Chartered (this was before HCPC registration) and in the absence of 100% support from the profession, commissioners withdrew the funding. That may not be the whole story; the New Ways of Working project had wanted to create hierarchical pyramids of clinical staff, similar to medicine and nursing, with assistant, associate and trainee clinical psychologists all following planned pathways to qualification as a clinical psychologist. But that would have required investment which was not available.

I believe those experiences provide at least two important lessons for the here and now. Firstly, in a competitive and cash-strapped political environment only those with a clear shared vision of the organisation and management of services will retain the confidence of those who control the money. And because there are more registered clinical psychologists than all the other groups of registered psychologists put together, that puts a particular responsibility on clinical psychologists to lead and articulate that vision.

Various parts of the NHS have been developing a range of new roles including Adult IAPT CBT therapists, Psychological Wellbeing Practitioners (PWPs) Children’s Wellbeing Practitioners (CWPs) and Educational Mental Health Workers, all of which have different trainings and career structures. That means that our vision needs to be a multi-professional vision which co-ordinates, even integrates the various developments. The Psychological Professions Networks in the North West, South East and now in the North East and in Yorkshire have already moved in that direction. Find out more here.

Groundhog Day. Local developments led by local needs facilitated by a local university, perhaps without taking full account of the wider picture. For example there is currently a proposal for Clinical Associate Psychologist Degree; the details can be found here. That has been developed at Exeter University in response to local service needs in Cornwall. Other English Universities are likely to follow suit. Scotland has had CAPs for several years, although implemented differently,  and the BPS is said to have developed some standards around this role a few years ago, anticipating that the idea would be widely implemented. But where do CAPs fit with registered clinical psychologists? Can a CAP become a registered clinical psychologist? And does that not mean that we have to involve another element of the system – the Health and Care Professions Council?

Secondly, career pathways are composed of steps; the rationale for moving from one step to the next and the means of doing so need to be clear not only to those starting their careers but also to their employers and managers who often seem to assume that a graduate in psychology has undergone an initial clinical training in the way that doctors and nurses do. In other words, in order to create appropriate steps along the career pathway we are almost certainly going to need to move towards a mix of modular courses, accreditation of prior learning, and validated qualifications such as the now-defunct BPS Statement of Equivalence and plus further post-qualification qualifications.

In order to put this second lesson into effect we need to be clearer about why career pathways are composed of steps, what those steps are about, and what that means for strategies for service development. Fortunately a theoretical analysis of levels of work in organisations and professions has already been undertaken, and provides a framework for discussing the issues. Elliot Jaques was a qualified psychoanalyst from the Tavisotck Institute who went on to become an organisational consultant. He researched and applied a theory of individual development and its implications for the work that individuals are able to undertake (his final book on the subject was “Requisite Organisation”, published in 1989). The Brunel Institute of Organisation and Social Studies applied the theory to the design of the 1974 reorganisation of the NHS and one of their senior researchers, John Ovretveit, used it in in the 1980s in research on the organisation of clinical psychology services. Like Maslow’s Hierarchy of Needs, Jaques’ theory of Levels of Work captures an idea which has intuitive value and appeal, whatever its academic standing.

Very briefly indeed, through research in in which he analysed thousands of positions in a wide diversity of organisations, Jaques found empirically that there is a strong correlation between a person’s mental processing ability (their cognitive capacity), the time horizon of the decisions they need to make at work and the complexity of the information on which those decisions are based. An individual’s capacity develops through their life, at some point reaching a plateau and ultimately declining. He also found that there are strata of work in any substantial organisation, and that these strata are ‘as required by nature’. In other words they reflect an underlying order that will be found in any organisation. The different levels of work are as different in terms of modes of thinking as, by analogy, water is different to steam. In particular he found that the time horizons of the levels of work (i.e. the periods of time over which particular decisions will have effect) are remarkably consistent, regardless of the specifics of an industry or an organisation within it. Further, each level creates the context for, and sets the agenda for the work to be undertaken at the level beneath it; if one level of work is not undertaken effectively then the organisation and the people working in the levels below it will feel unclear, disorganised or chaotic.

To illustrate, a very simple summary of ‘levels of work’ applied to clinical psychologists and their jobs might look like this:

Level	Description of work	Upper limit of the judgements that the person is expected to make
4	Comprehensive service provision: an experienced clinical psychologist appointed to manage an organisation’s psychology services, who is expected to identify (with the help of information from appropriate colleagues) the needs for the whole range of those services in the population served, and nature and volume of services required to meet those needs, and is authorised to negotiate with senior management for them to be provided	Is not expected to make any decisions about the reallocation of resources (money, staff, facilities) to new or different services for which the ‘psychology services manager’ is not currently responsible.
3	Systematic service provision: an experienced clinical psychologist appointed to a consultant post and / or to lead the services for a particular category of patient or client, who is expected to identify (with the help of information from appropriate colleagues) the needs of those patients or clients and innovates assessment procedures, therapies and other service developments in response.	Is not expected to make any decisions about the reallocation of resources (money, staff, facilities) to services for any other category of patients or clients.
2	Situational response: a qualified clinical psychologist appointed to provide services to a particular category of patient or client, who is expected to judge the needs of each patient or client and apply clinical psychology knowledge and skills to achieve appropriate outcomes.	Is not expected to make any decisions about the services to be provided to other patients or clients who may come to the service in future.
1	Prescribed output: an assistant psychologist working under the supervision of a qualified clinical psychologist, is expected to carry out tasks assigned by that psychologist in the manner required by that psychologist.	Not expected to make any significant decisions about what tasks to undertake, how or with what outcome.

It should not be thought that there is a straight forward mapping of salaries onto level of work. For example, a skilled surgeon who specialises in a particular kind of operation may be undertaking level 2 work but nonetheless warrants a high salary because of the skill and responsibility involved.

Clinical psychologists tend to qualify in their mid 20s. By that time they will already be developing the capacity to undertake level 3 work and are likely to have been taught to innovate in response to perceived need. They may need time in a ‘junior’ post to build their confidence and develop their expertise but it is characteristic of qualified and experienced clinical psychologists that they treat their post as a level three post. In other words, in their work context experienced clinical psychologists typically:

• Seek to Improve the psychological health, wellbeing and performance of clients through knowledge and skill-based services
• innovate in response to clients’ needs and requirements by developing applications of psychology and related disciplines, and
• design, develop and support services to implement those innovations.

This is the natural course of development of the majority, irrespective of the demands and constraints of the posts to which they have been appointed. If the NHS does not use those abilities, then that is a waste of a valuable resource. The same will be true of the majority of ‘graduates’ and that is the issue that strategic and operational managers need to appreciate before creating more posts to undertake level 1 and 2 work. How will they use the developing skills and abilities of the staff or will they plan to lose them and replace them?

We can therefore make some predictions and identify some steps that need to be taken to ensure that graduate psychologists do not follow a career pathway into a dead-end and that the NHS gets value for money out of its investment.

Unless training courses are created in the context of career pathways and lead to jobs which require the training that the courses provide, there is no point in setting them up because they will result in waste of graduates’ lives and NHS money.

A graduate psychologist may be trained for and initially employed in a ‘level 2’ job but as their capacity to make judgements and decisions develops, they will inevitably start seeking out more challenging opportunities and may opt out of the NHS if they do not find them (as, so it seems, some ‘early career’ clinical psychologists have been doing). Their development should not be seen as a source of regret or a sign of failure of selection; it is an enormous asset to the organisation. In the future psychological healthcare could be even more innovative and effective than it is now.

Therefore, in order to make best use of new training initiatives strategic and operational managers need to ensure that the services in which they are working are structured in a way that anticipates the natural development in their staff and uses it to best effect whilst ensuring that the work they were doing is taken over by the next cohort of graduate trainees.

A person’s capacity may develop throughout their life but it still needs to be focused on their actual and foreseeable responsibilities by education and training – ‘continuing professional development’ in the jargon. In some other professions, and there is no reason why clinical psychology should be an exception, that is structured by a sequence of qualifications and memberships of specialist bodies. That sequence needs to be in place in order to provide individuals with a reason and motivation for investing their time and effort.

The creation of service models, career pathways, and an appropriate range of training opportunities may sound like big tasks, because they are, and difficult to organise because the systems involved are decentralised and geographically dispersed. But the work has to be done. There is a responsibility to take the lead otherwise it will be Groundhog Day all over again.

Note: if you wish to contribute to the ACP-UK response to the current proposal for Clinical Associate Psychologists, please respond to our survey without delay because the closing date for the Skills for Health consultation is 20^th March. Members can access the survey by logging on to the members area of the website and clicking the consultations tab.

Bernard Kat
ACP-UK Director & Legal Lead