Below is the ACP-UK response to the Vision produced by the Psychological Professions Network and NHS England/NHS Improvement regarding the proposed expansion of the psychological workforce. It incorporates the views of those members who responded to our recent survey, and represents the consensus view of the ACP-UK Board. You can read the Vision document here.

ACP-UK Response to the Integrated Workforce Plan for the Psychological Professions in England to 2023/24 and the PPN Vision Consultation

March 2020

Summary

• ACP-UK strongly welcomes proposals for the substantial expansion of the Psychological Professions including Clinical Psychology
• We summarise some of the specific roles and competencies of clinical psychologists (over and above one-to-one and group therapy) that are essential for service development and expansion
• The implementation strategy must include consideration of service organization structures and the deployment of senior clinical psychologists in leadership, supervisory and governance roles to maximise the effectiveness of the workforce expansion
• Some of the proposed additional funding should be used to create consultant grade clinical psychologist posts and offer incentives to attract back those who have left the NHS for the private sector
• Suitable safe practice space, remote working facilities and administrative support must also be provided

Introduction

1. The NHS Mental Health Implementation Plan 2019/20 – 2023/24 outlined eleven areas of service expansion. The Integrated Workforce Plan quantifies the expansion in the psychological professions workforce required to meet various targets. Amongst the proposals, the Plan envisages increases in the number of clinical psychologists who will be needed to fulfil the needs of the expanded services.
2. ACP-UK has conducted a survey of its members and this response incorporates collective feedback as well as representing the views of the ACP-UK Board.
3. ACP-UK strongly welcomes and supports the Plan’s proposals to create new and additional posts and developing staff to fill them. In this document we aim to facilitate implementation of the Plan by describing relevant aspects of clinical psychologists’ work, skills, and career pathways. We identify and recommend steps to get the best out of the new posts when created; this guidance should be made available to employers.
4. Whilst welcoming the proposed expansion, we would like to see the rationale on which the additional numbers and types of psychological professionals proposed are based.
5. Additional posts will mean additional newly qualified clinical psychologists. Firstly, we consider the relationship between senior and junior posts, the responsibilities undertaken, and how the effectiveness of new staff can be maximised.
6. Our members have stated they would like to see governance, accountability and professional registration (of non-registered psychological professions) prioritised in the PPN strategy.
7. Our members broadly agree with points made in the PPN Vision concerning optimising training and the establishment of professional leadership across the whole healthcare system; although leaders will emerge from all the psychological professions, clinical psychology training is particularly suited to leadership roles because of its highly-specialist and multi-systems nature.
8. The Plan further relates the proposals for additional staff to services for specific kinds of patients. Secondly, we consider issues of specialisation and specialist knowledge.
9. All knowledge and theory-based professions evolve through the work of talented and experienced individuals, who innovate to meet the professional competencies of its practitioners and the changing demands of the population or organisation within which they work, and each NHS profession produces effective clinical leaders. The applied psychology training and experiences of clinical psychologists particularly prepare them for the responsibilities we identify below, ensuring that the profession as a whole constitutes a valuable resource for the NHS and the populations it serves, encompassing mental and physical health as well as wider social care needs.
10. Our survey demonstrates that ACP-UK members support the PPN principles.
11. Whilst we support the intention of maximising impact in the various and diverse clinical contexts listed, we note that these do not appear to fully correspond with the proposed areas of expansion. Moreover, there are other clinical contexts that are not listed that are desperately in need of psychological expertise (e.g. neurological disorder and clinical neuropsychology).

A. Clinical psychologists not only provide direct care services but improve the productivity and efficiency of services by facilitating and augmenting the work of those who provide psychological therapies and psychologically informed care.

12. The clinical psychologists whose work adds greatest value to healthcare and can have transformative effects, are those who undertake one or more of the following responsibilities:
    • Provide clinical leadership, management, and supervision within the services in which they work, a responsibility which often includes identifying colleagues in psychology and other professions with particular skills and abilities and supporting their professional development;
    • Provide clinical expertise in specialist areas such as neuropsychology and integrative approaches such as assessment and formulation;
    • Draw on (and contribute to) the extant evidence-base to innovate theories, therapies, techniques or procedures in response to clinical need; many clinical psychologists are national and international experts in their field;
    • Contribute to the design, creation and provision of services to provide psychological interventions and / or psychologically informed care;
    • Identify new and changing needs for teaching and training in response to developments in service provision, including those enabled by new technologies and contribute to getting those changes put into effect;
    • Publicise and disseminate innovations and service developments, and their financial benefits to the health and social care systems, through research, publications, presentations, teaching and training, locally, nationally and internationally;
13. The abilities underlying these responsibilities are:
    • The personal capacity to recognise needs for change or developments in services or systems;
    • The personal creativity and commitment to draw on clinical experience and the core discipline of psychology to identify feasible changes;
    • The personal skills and capacity to work at the level of services or systems, including the knowledge and skills to inspire other people to support and take part in the proposed changes and developments, and to support the process of continuous improvement.
14. Those psychologists create the conceptual and organisational frameworks within which other psychologists work and provide services and may also provide the frameworks within which staff from other professions also carry out their day to day work.
15. Typically, the responsibilities identified above are undertaken by clinical psychologists in more senior posts (AfC bands 8 and 9). Their work is often carried out over periods of years; by working at service and system levels they have a long-term impact on services and the practice of the profession and other practitioners (e.g. developing CBT nurse practitioners).
16. It is therefore important that the functions and responsibilities of senior staff are included in Job Plans so that they are known and accessible to management and because they are essential to the effectiveness of more junior staff.

B. Career pathways: “You can’t put an old head on young shoulders.”

17. Whilst supervision and continuing professional development contribute to the requisite developmental processes and experience in a job, they cannot turn recently qualified staff into experienced clinical psychologists overnight. That needs to be considered when planning the expansion of the workforce.
18. Typically, clinical psychologists complete their pre-qualification training (which includes an undergraduate degree in psychology, approximately two further years in a related job, then an additional three years Doctoral training) between 25 and 30 years of age. Many of them will have brought valuable prior experience and learning to their training. The pre-qualification training then equips them with the range of clinical and other professional skills that enables them to undertake advanced clinical work and work in complex situations. But the posts for newly qualified staff for which they can apply are not ends in themselves; they are first steps along a career pathway. Having qualified as clinical psychologists, they typically practice in the profession for up to 40 years or more. During that time their skills and abilities develop, becoming more valuable to their employer as their professional perspectives advance, and they take on broader and more diverse responsibilities.
19. The implications are:
    • Most of the expansion of the workforce will be achieved through additional training posts and posts for newly qualified staff. There need to be realistic expectations about the volume and complexity of the work that it is reasonable to expect newly qualified staff to undertake; in order to assure the quality of services and the quality of patient care, recently qualified clinical psychologists should be provided with access to  professional support and guidance, mentoring by senior colleagues, suitable workspaces, administrative support and other developmental opportunities;
    • Like all professions, clinical psychologists must undertake continuing professional development (CPD) in order to maintain their registration with the HCPC; because ongoing registration is essential to their employment, CPD should be undertaken during paid time. This should include time for undertaking research (similar to our medical colleagues) which helps to embed cutting-edge evidence-based care within the local system, and contributes to the improvement of services
    • The benefits to NHS employers are maximised by encouraging junior staff to gain the additional training and experience required to become eligible for more senior and more specialist posts.
    • It is crucial that additional funding is also used to create senior posts at Grade 8c and above to manage newly qualified clinical psychologists and other psychological professionals.
    • Other incentives may be needed to attract senior psychologists back into NHS services since in recent years many have left for the private sector due to an absence of promotion opportunities in the NHS.

C. Specialisms and specialisation

20. The Plan refers to 8 client group services within the field of mental health and looks forward to the development of a further 5:
    • Children and Young People’s (CYP) Mental Health; Perinatal Mental Health; Adult Common Mental Illnesses (IAPT); Adult Severe Mental Illnesses (SMI) Community Care; Mental Health Crisis Care and Liaison; Therapeutic Acute Mental Health Inpatient Care; Problem Gambling Mental Health Support; Rough Sleeping Mental Health Support
    • Dementia care and ageing well; Digitally enabled therapies; Physical health services; Prevention; Caring for NHS Staff
21. In that the Workforce Plan has been motivated by the NHS Long Term Plan, building on the Five Year Forward View for Mental Health, the focus on mental health services is entirely appropriate. Nonetheless it is important to recognise that there are other areas of healthcare which also employ clinical psychologists and create a demand for additional service and training posts. Examples include the learning disability services, general / acute hospital specialisms, primary healthcare and primary and community care, and also the charitable and independent healthcare sectors. We anticipate that the breadth of services wishing to employ or contract in clinical psychologists will increase as Integrated Care Systems are implemented.
22. Pre-qualification training in clinical psychology focuses on the depth and scope of psychological knowledge, but does not aim to produce staff for a particular specialism or area of work; it aims to produce staff with a robust grounding who are then potentially able to enter and develop in any of the areas of work in which newly qualified staff are required. The emphasis on core skills and varied clinical placement experience during training means that newly qualified clinical psychologists have knowledge and skills that are transferrable across areas of work. However, each area of work requires some knowledge and skills specific to that area, and this is gained during the years immediately after qualification, through the support of senior colleagues. Individual clinicians tend to focus their careers on specific areas of work; ultimately their value to their employer and to the NHS in general is the result of them becoming true specialists in their area of work, while maintaining highly transferable skills.
23. At present there is no definitive list of specialisms in clinical psychology; specialisms arise ad hoc as a result of an awareness of the relevance of the discipline across the spectrum of healthcare, clinical need and employer demand: clinical psychology is about meeting the psychological needs of people and these needs are ubiquitous in healthcare, including healthcare practitioners. At present the Health and Care Professions Council does not validate post-qualification qualifications or register the holders of such qualifications. Consequently, it is difficult to collect data on the number of clinical psychologists with specialist knowledge and skills in an area of work; inevitably that means that workforce planning that seeks to take account of the need for specialist knowledge and skills will be imprecise.
24. The current mechanism for determining whether a psychologist has adequate specialist knowledge and skills for an NHS post is the inclusion of external national assessors in appointment panels, particularly those for Consultant-level posts. For more junior posts, assessment of candidates is undertaken by the psychologist responsible to the employer for providing clinical leadership in the relevant area of work. This is usually sufficient.

D. Resources and facilities

25. Similarly, to get best value for money from professional staff, and from the proposed expansion of the workforce, it is important to ensure that safe consulting rooms, desk space and necessary equipment are provided. This includes proper facilities for remote working.
26. We recommend that in order to ensure that new and additional posts are used to best effect it is important that employers are offered guidance on the resources and facilities required at the stage at which budgets are being determined and allocated.
27. There are potential opportunity costs at the operational level when clinical psychologists are required to devote significant time to carrying out administrative and clerical tasks and generic care co-ordination roles which could be undertaken more economically by other staff.

E. Conclusion: steps to maximise benefit within the new posts when they are created

28. In summary:
    1. It is important that management and other key decision makers understand the roles and responsibilities of senior clinical psychologists in leading psychological services, maximising the effectiveness of less experienced clinical psychologists, and augmenting the psychological care provided by other practitioners;
    2. Clinical psychologists should be facilitated to undertake the highly-specialised level of work for which they have been trained, including leading and developing services, providing support to other practitioners, and undertaking research and related activities to embed contemporary evidence-based care within the broader system;
    3. Reasonable standards concerning the volume and complexity of the work that can be expected of recently qualified staff, both in clinical psychology and in other professional services should be developed;
    4. Ensure that recently qualified clinical psychologists have access to the professional support and guidance, mentoring from senior colleagues, and other developmental opportunities necessary to prepare them for providing the specialised services that NHS employers want to offer to their populations and commissioners;
    5. Ensure that all clinical psychologists undertake in paid time the continuing professional development necessary to maintain their registrations;
    6. Ensure that all clinical psychologists have allocated time (in line with our medical colleagues) to undertake research in order to improve the psychological provision that is available;
    7. Ensure that applicants are assessed before they are appointed by the psychologist responsible to the employer for providing clinical leadership in the relevant area of work.

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