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October 24th 2001text

Anne Richardson
Senior Advsior at the
Department of Health

Selected Quotation from a presentation on 'Statutory Regulation of Psychotherapy and Counselling: The Way Forward', given to IPN London Gathering 13th October 2001
text text
A CD of Anne Richardson's presentation may be available in early November.

Details: denis@postle.net


... it is very important that people don't run away with the idea that this is going to be a quick or easy process or even that it will certainly, this initiative, that it will certainly lead to regulation and registration of psychotherapists. It may or it may not

... you set clear standards, you have processes to help you deliver them and then you monitor those standards... but like I say, there is one message to take from it... and that is that the law is only one way that you might improve quality, there are lots of other ways too...

the Health Act Order-making power which is what's used to set up the Health Professions Council or HPC, as I said before, has also been used to reform some of these systems. So it's been used for the nursing and midwifery council. These were all changes that that profession wanted to make. And the order-making power is... as I said... the order-making power is...I said it's powerful but it's good because it's quick. There have been bits of proposal waiting in the wings for years and years and years, especially around the GMC, which simply there hasn't been Parliamentary time to do. But this order-making power enables you to do things relatively quickly once you've decided what you want, which is a key feature.

...Now there are lots of new groups waiting in the wings who want registration... and these are some of them...

Operating department practitioners.

Well they are not a very big group but this is one of those areas where size doesn't matter because they are a small group but they could be quite dangerous...

Clinical perfusionists.

Complementary and alternative medicines.
Well you may have seen the house of Lords debate on complementary and alternative medicines and seen the government response you can read more about on the web site if you want to.
But there a very strong argument was made in the debate that for example acupuncture and other complementary and alternative practitioners should be regulated because of the risks unprofessional practice poses, or because of the risks that practice delivered by untrained people presents to the public and of course psychotherapists, psychologists and counsellors are potentially waiting in the wings.

The psychologists in particular have a long history of interest in statutory registration Their arguments go back some 20/25 years now and over time they've got quite close to it, then pulled back. And relatively recently, it is said this, is just rumour mind you, I don't know if it is true, but it's said that they had two peers in the House of Lords quite keen to take forward a Private Members Bill on their behalf And of course they drafted their own Bill there was there a lot of support for the idea from the government, from other departments and from the Privy Council and other professional bodies, and from the public and from practitioners and so on. But the proposers stepped back because the Health Act was there and because the Health Act offers the opportunity to do it, to do registration for a number of people, and to do it in an economic way...

So they are close to being ready.

Psychotherapists? well you can tell me. I've been talking with representatives and interested individuals and professional bodies and organisations and really anybody who wants to have... has something to say... about this issue for psychotherapists and counselors. It's my impression is that counselors are reasonably keen to pursue statutory registration. My sense is that... we haven't done a formal consultation... this is all part and parcel of just gathering views at this stage... my sense is that the psychotherapists are bit more mixed.
But as I say we can talk about this... you can tell me.

...some general principles behind the development of statutory registration for such groups. The first and most important driver for this so far as the government is concerned is public safety.

I don't think that civil servants any longer need any convincing that psychotherapy can be dangerous.

...I think that whereas once upon a time some time ago it wouldn't have been too surprising to hear somebody say... oh well psychotherapy... why would you want to register that... Psychotherapists can't do any harm. It is clearly not true and it is not a view that is held by anybody dealing with this issue now.

I think it's also clear that when you follow those individual's stories it's common that they can't get redress. It's common that a professional body doesn't actually even have a clear... I mean some of them do... some of them do very, very well and they have proper, robust, open, transparent disciplinary procedures and procedures for investigating complaints. But actually a lot of them don't and to be fair, some of them are... appear to be more interested in protecting their members rather than they are in protecting members of the public who have been on the receiving end.

So it's not untypical for a service user, for a psychotherapy patient to have felt that there was a cause for complaint... to take that complaint to a professional body and not to have any information about what happens next... their letter goes into a black hole and months and months go by... So somebody might take up... if they know about POPAN... might go to POPAN and Popan do a really good job in providing advocacy and information for people who are wanting to take up complaints.

But even the structure of some of the committees are not balanced... precisely the individuals who are on the committees making judgments about the practitioners who are guilty, perhaps allegedly, of unprofessional practice are those individuals, or are connected to those individuals who have been practicing... they are not independent... is what I'm trying to say.

We know that the systems aren't great.
...professionals can also be victimised and they also need their interests to be guarded...you also as therapists need to find ways within your structures to make sure that you are not unreasonably criticized, or unfairly criticised and that matters just as much, but that balance of interests hasn't always been right. It has been much more in favour of the therapist up to now.

So the balance of interest between the patient the therapist and the employer ....it's certainly true within the NHS that NHS managers and employers need to know more about what to expect from a competent psychotherapist... what does it mean to fund, support, supervision or continuing professional development.

One of the things that has been set out in the statutes, or in the arrangements that follow on from the statutes, is that those expectation are clear.

That there are standards that are open and obvious.

This initiative is driven by the needs of service users but it does have professional ownership
The reason I say that is that Ministers and civil servants do recognise that the only people who are best qualified to judge whether someone is qualified to practice is somebody who has that qualification...

Although the committees on the health professions Council...have a majority of only one... in terms of profession's representation... all the rest are lay members... it is nonetheless true that things like the training committees and the committees that deal with standards of education and who should be registered and who shouldn't be... are mainly made up of those people who you would expect to know what a good qualification looks like.

So general principles...
...to be compatible with the needs of the NHS, because the NHS is still in fact I think...we don't have good data held centrally on this... is the biggest provider across the UK, of talking treatments..... Now some people hate that expression so I apologise to you if you do but it?s a quick shorthand for me to summarise all the different approaches that get offered that are not drug?that might include psychotherapy, IPT, CBT whatever, whatever.

Most talking treatments are delivered within the NHS...which is not to say that most specialised psychotherapy is provided there...There is a lot of specialised psychotherapy provided in the private sector, a lot of counseling provided in the private sector but adding up all of it... lots is in the NHS.
And therefore it is appropriate that the NHS is one of the stakeholders, one of the interests here, and we need to think about that? so one aspect of the work involves trying to encourage psychotherapists psychologists and counsellors to develop procedures and practices that are consistent with what is going on in the NHS, for example around clinical governance, or for example, around supervision and support.

Now I'm going to say a bit about the Council for the Regulation of Health Professionals, HPC The one that replaces the Professions Supplementary to Medicine Act. I'm going to talk a little bit about it for two reasons

One, because it offers the best example out there at the moment for you to look at if you are interested to see what a model might look like that would register psychotherapists. That's one reason. So the shape of the HPC is the best example... if you are trying to invent a machine that will fly...we have got one aeroplane just about to take off over there which is worth your while looking at in order to give you an idea of what shape it is, how fast it goes, and whether it is likely to fall down.

There's a second reason for why I want to mention the HPC ...and it is because it also leaves open the possibility that new groups... beyond speech and language therapists could join the HPC if they wanted to and if they were ready.

The HPC actually offers one model to register psychotherapists counselors and psychologists. I'm not saying it is the best model... there are some things that it might not do that you might want but anyway...

What would make a group eligible? Assuming you wanted to be eligible for registration...

Well... size is important but it's not the only issue because as I've said, operating department practitioners are quite a small group but they are potentially quite dangerous... the degree of risk is also a factor... so size plus a clear case of public protection...Well on both those counts psychotherapists, counsellors and psychologists fit the bill... there are enough to make it a concern... there is sufficient of a case on public protection to make ministers concerned about practice.

There would need to be understanding on the part of all those practitioners who would be affected... of what was going on... so people would need to understand what it meant. Now that's why as I said at the beginning this isn't going to be quick... because it is going to take us a really long time to scope the issues, to talk to people, to get information out there about what the issues really are. And there is no way at all that the government will be running away with an order, or a piece of legislation to enforce registration on a group of professionals that don't want it. It's as simple as that. ..........

So in addition to understanding the issues it's important that the group if it is a group... which is another question... that there is unanimity... that there is agreement about the right way forward... and that isn't easy.... I think that's very unlikely... it's impossible right now... completely impossible right now but maybe in the future it won't be.

In order to be eligible for statutory regulation, a group has to have agreed standards for selection. Who should get in to the profession? Who should qualify and be registered? Who should actually get into training? And here you'd ask yourselves... well do you have any kind of agreement as a group, or as a collection of groups, or as a federation, about who is unsuitable to train as a psychotherapist. I mean are there people you'd exclude from training?

Standards for selection do matter. You have to agree what the content of training was. Now, you only have to think about the difference between a training in say...psychoanalytic psychotherapy, or psychoanalysis and CBT, or some trainings in counselling, to see that this is like the difference between well... the difference between those is vast. This doesn't perhaps matter too much provided that all the groups who call themselves counsellor agree that about what it is that constitutes a training to be a counsellor, and if it is different from what constitutes a training to be a psychotherapist that's fine, it doesn't matter as long as the counselors and the psychotherapists agree.

Last but not least, we would need to agree what we meant or what we should do when somebody complained. Maybe this one is slightly easier because I think that for the most part, although we wouldn't always agree what did constitute a breach of professional practice, in some of the minute details of training, we probably would agree, all of us about the things that are wrong.
I think across all the psychologies, psychotherapy, counseling you don't have sex with your patients, you don't abuse them financially, you don't mislead them, etc We'd probably all be able to sign up to some common ground there.

And that actually is the major driver for this legislation anyway... public safety.

So what you can do is write into the legislation some of those things that everybody does agree and then set up sub-committees and advisory committees to help you develop the rest.

Minister's priorities. We've had a Labour government since... come in for a second term and that's meant that this interest in service quality... which is not to say that an alternative government wouldn't also be interested in service quality... but it does mean that this agenda on the Health Act and on developing the means to strengthen professional self regulation... has had a longer go than it otherwise might have done but you know there will be another election, ministers may change... they may change their minds... Although this government has given a commitment to taking action in due course on statutory registration for psychotherapists psychologists and counselors, very wisely there's been no commitment about when that would be done or how that will be done and the only undertaking at the moment is to talk it through.

If an order were to be developed then there are protections even on the face of the Act which have to be thought about. An order has to be published three months before it is laid before parliament. It has to be debated in both Houses... and what else?... It can't be amended in the House but it can be voted out.

So what that means is that there has to be absolutely full consultation in advance of any order. You have to have a pretty certain run for a thing before you even write an order. And that is an important safeguard for those of you that opposed in principle to statutory registration...a view which I respect... but that's an important safeguard for you because it means that there would be an opportunity to debate the philosophical issues. And the issues of principle that underpin the question of whether a law is the right way to do it, or whether some of those other ways are more important to do first. Which I think we'd all agree, these other ways are also important and we should be getting with them now. .

Resources are an issue as well. I'm the only person at the department who has a particular background in this area of psychology, psychotherapy, and I work closely with Ros Meade who is the head of non-medical regulation and she has her hands very full at the moment with the HPC and with the nursing groups, we're also amending the statutes concerning them. So that's another reason why this isn't going to happen fast.

And as I say we need agreement on those things.

There are a number of possible structures though that we might be thinking about in due course and one is these are based on what is there in the HPC right now We could be looking at a small strategic council that's set out broad principles for the talking therapies, maybe something, a council that would register psychologists, counselors and psychotherapists, or perhaps for some of the groups we could be looking to the health Professions Council in due course... there might be some groups that would want to attach themselves to the cluster being regulated/registered through the HPC.

I'm absolutely neutral about this personally, as long as those other conditions are met and everybody knows what they are doing and is clear, I think you design the vehicle that's going to get you where everyone wants to go. There's no drive to take you in one direction rather than another in terms of the structure.

What is clear is that whatever the structure, whether it's a structure that connects counselling psychotherapy, psychology, it would have statutory committees for the common ground. So it would have a statutory committee on education, conduct, health and fitness to practice. Those are the standard ones that you always have.

Accreditation criteria
Well that's an issue to resolve. That's basically about who should be on the register and how do you decide what methods to use to accredit the training courses that do exist because there are a great many out there. You only have to look in the back of Time Out or any newspaper and you'll find courses offering therapy training... which at the moment it's possible at the moment for anybody to take, and then anybody can call himself or herself a therapist, a psychotherapist and offer services to the public. And that is essentially what this is all about it's all about...trying to do something about that.

Fitness to practice now this is an important one ...because we are not exempt from psychological problems ourselves, we're not exempt from mental ill-health ourselves. None of us I suspect as a psychotherapist or as a therapist of any kind would argue that it's appropriate to be delivering practice if you yourself aren't functioning as you should be. Either if you are physically ill, or if you are mentally ill. It's normal to stop working if you are physically ill, how normal is it to stop working if you are feeling anxious, stressed, depressed? Should you be counseling people going through a divorce if that's what just happened to you? Maybe it makes you better at it. That's an open question...

What would success look like?
I do think it's a long way away (and I'm nearly finished so now please be reassured...)
It would mean clearer identities for the talking therapists. I think it would mean a clearer distinction than perhaps exists now between the use of therapeutic technique and the professional practice. Or use of that technique in the service of the public, or in a job. So I'm not saying that we are, or should be, in the business of registering people who deliver counseling skills. If I go to my GP I expect my GP to be a good communicator. I expect him or her to be able to use effective communication skills in relating to me. That is not the same as being a counsellor. If I go to a priest, I expect him, I guess it would be a him, if its a priest, certainly given my background it would be. I would expect someone with that background to have effective communication skills. The delivery of their practice might well be helped if they had done a counselling course. No problem. They still wouldn't register as a counselor, and we wouldn't be interested in regulating their practice as counsellors or as psychotherapists because they are not calling themselves counselors, or psychotherapists? they are delivering something else. A GP is delivering medicine and so on.

So it would make it clear...that there was a distinction between the professional offering of therapy and the use of those skills.

...some of you may know osteopaths or the general osteopathic council that was actually set up by a Private Members Bill some years ago was an example of an approach that was a sort of stand-alone approach, they took a Private Members Bill just for osteopaths, which contrasts with the approach which is more federal for the professions under the HPC. The costs to osteopaths of registering are really high. I think they are in the region of £700-900 a year. Quite a lot of money. Taking this approach is cheap. Because it is supported by government. It's.... a system that... the more you have in the group, the lower the costs are kept.
You get more objective performance assessment because you have systems in place, as I said for supervision and support and CPD and so on, you can target your CPD more appropriately.

Ok, so that's pretty much what in due course success might look like.

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