The following account of the ALB Review attempts to explore these decisions about reorganization of the NHS for resonance with the ongoing disputes about civic accountability in the psychological therapies.
The first thing to be said is, if you are a counsellor psychotherapist or psychoanalyst likely to be within the remit of the HPC, don’t expect to fall into the embrace of this (independent) Arms Length Body anytime soon. Regulatory digestion of 100,000 social workers (including 16,000 students), will entail appointment of Professional Liaison Groups, and, if the psychologists are anything to go, by picking up the disciplinaries that are presently on the General Social Care Council’s books. This, along with a social worker trade union, could put sand in the HPC gears for some time.
Before we get to the Review text, we might note that the GSCC and the social workers union BASW don’t seem well pleased with the former’s demise. Neither appear to have been consulted about the transfer to the HPC.
Commenting on the DH’s announcement that the GSCC’s functions will be transferred to the Health Professions Council (HPC), Chair Rosie Varley said:
“We were surprised by this decision… discussions have yet to take place about how this will work, including the costs, benefits and wider consequences. We are seeking an early meeting with the Health Professions Council and the government.
While the social work trade union the British Association of Social Workers BASW campaigned over many years for registration for social workers, they are on record as claiming that the GSCC overplayed its role in public protection, stirring up public fears and concerns that Social Workers were incompetent and dangerous while doing little to address the myths that arose around social workers being all powerful malevolent beings promulgated by certain ‘name and shame social workers’ websites and various media outlets.
Goodbye GSCC, hello HPC, or, as it is probably to be renamed, Care Professions Council/Commission, we’ll return to them later.
Let’s taste the Government’s, or more precisely, the DH’s approach to Arms Length Bodies in general and regulation in particular. At the top of the Review document it declares its ‘target audience’ as ‘ALB Chief Executives and Chairs’, revealing, in contradiction to other parts of its vision that seek to devolve responsibility to the front-line, an apparent belief that organizational coherence and efficiency trickle down from the top.
(In what follows, I’ll put issues that might relate to the psychological therapies in bold)
In the Contents under para 4 outline the Review’s intention to ‘simplify the national landscape’ through:
• ensuring that functions related to quality and safety improvement are devolved closer to the frontline;
• creating a more coherent and resilient regulatory system with clarity of responsibilities and reduced bureaucracy around licensing and inspection;
• centralising data returns in the Health and Social Care Information Centre;
• maximising opportunities for outsourcing of functions and shared business support functions across the sector to reduce overall costs and seek to realise assets through the commercialisation of activities.
• functions will only be carried out at national level where it makes sense to do so;
• where appropriate, arm's-length bodies will be expected to exploit commercial opportunities and maximise commercial discipline across the sector.
Bringing regulation closer to the frontline paradoxically seems to mean greater administrative centralization coupled with the application of commercial intelligence. Here, as elsewhere, there seems to be an assumption that commerce is value-free and focused only on the task at hand. As though proprietors or shareholders lived in a capital-free universe.
Devolving functions related to quality closer to the front-line may well be a way of honouring diversity and choice for patients, however the Review doesn’t seem to notice that econically driven ‘simplication of the national landscape’ may mean that it is heading in the opposite direction.
However such simplication isn’t all that new:
1.8 The last review of our arm's-length bodies, which took place in 2003/04, reduced the number of organisations from 38 to 18.
This review reduces them further, from 18 to 6 (3.3)
3.10 So in future, we propose to have:
• one quality regulator;
• one economic regulator;
• one medicines and devices regulator; and
• one research regulator.
In ‘OUR STRATEGY FOR THE ARM’S LENGTH BODY SECTOR’ the review sets out its priorities. Here are a few of them:
2.4 Arm's-length bodies will be required to deliver their functions effectively and efficiently, and minimise the burden on the front-line. Our arm's-length bodies will be expected to take full advantage of commercial opportunities to improve value for money in the delivery of their services.
2.8 the desire to create a shift of power to patients and clinicians has implications for the future role of information.
2.10 provide accountability and assurance to patients, service users and taxpayers by independently establishing facts.
- real efficiencies have yet to be delivered across business support functions, including cost efficient estate utilisation.
- commercial opportunities have not been fully exploited.
As might be expected from a business oriented government, there is a repeated litany in the review of the benefits that might accrue from embracing commercial values and practices. For example after an eminently sensible point asserting that in key principles for the arm's-length bodies sector:
2.13 devolution to the frontline: functions will only be exercised at a national level where it makes sense to do so.
The text goes on to state that:
2.13 The following principles will be applied to the sector:
- business support functions will maximise economies of scale
- where appropriate, arm's-length bodies will be expected to exploit commercial opportunities, for example outsourcing or divestment, to maximise commercial discipline across the sector.
Further on we learn of two other principles the second of which might be relevant for the psychological therapies:
2.15 Less bureaucracy: Key to the effective and efficient delivery of arm’s-length bodies’ functions will be their practical demonstration of the principles of good regulation (proportionate, accountable, consistent, transparent and targeted)
2.17 Greater efficiency through contestability: For large scale central functions, alternative organisational and delivery models may exist which will deliver services in a more cost effective way.
The DoH, and the government behind it, see themselves as ‘rationalizing the regulatory landscape’:
‘regulation should be relevant, effective and proportionate’…. ‘from the perspective of those who are regulated, it is also important to minimise the bureaucratic overhead due to multiple lines of accountability, licences, inspections, data collections, and so on’.
In what appears to be a curious contradiction of the benefits of the roles of that regulatory bodies might be thought to deliver, the Review announces the establishment of:
3.18 Healthwatch England a new independent consumer champion, which will be an advocate for patients’ rights and concerns, will be located with a distinct identity within the Care Quality Commission
This summary concludes with some detail of the demise of the GSCC probably the change that has biggest implications for the psychological therapies, both in its peremptory style and the parallel dubiousness of the practicalities it entails. We might note in passing that the HPC, stalled for the moment with regulating counselling and psychotherapy let alone psychoanalysis, might doubly welcome regulation of the social workers. After all when they are in the fold and the gate is secured who else is left except the psychological therapies?
‘Arm’s length bodies’ can be seen as having two classes of virtue, a democratic one ensuring that the government is appropriately distanced from certain kinds of ethical decisions, secondly, that governments can stay distant from toxic or problematic socio-professional quagmires of which it is easy to guess, social work has lately been one.
Under the second of these, moving the difficulties of social work to a big, robust, muscular regulator like the HPC may well have been very attractive. And we might guess, apart from the obvious status gain for the HPC, due to the psychological therapies impasse it might also have been contemplating a serious shortage of work for many of its staff.
Since social work regulation in the shape of the GSCC has been anomalous as the only professional regulator answerable directly to the Secretary of State for Health.
The General Social Care Council is to be abolished:
3.38 …we intend… move the regulation of social workers out of the arm’s-length bodies sector to make it financially independent of government. We believe that in future, the most appropriate model for the ongoing regulation of the social care workforce is to transfer responsibility for these functions to the Health Professions Council, a well established and efficient regulatory body currently regulating over 200,000 registrants from fifteen professions. The Health Professions Council - which will be renamed to reflect its new remit - operates a full cost recovery scheme and currently charges an annual fee of £76 per year, which is considerably less than the likely registration fee if the General Social Care Council were to operate alone on a full-cost recovery basis.
I.e. in future, regulation will be paid for by social work registrants, thus saving a piece of money. However this might not be all that straightforward to implement:
3.40 The abolition of the General Social Care Council, the transfer of functions in relation to the regulation of the social worker workforce and related changes will require primary legislation. The timing of these changes is dependent on discussion with the Health Professions Council and the General Social Care Council to ensure an orderly transition.
This task of reading the entrails of government intentions ends with a one or two gleanings that seem to face in directions contrary to the expressed desires of the review.
The government’s desire to ‘devolve responsibility to the front line’, a laudable honouring of diversity and choice, seems to get obscured by a parallel belief that duplication is unacceptable.
3.49. …across the wider infrastructure supporting health and social care, there is a duplication of roles and responsibilities around collection, analysis and dissemination of information. This is no longer acceptable as it places a significant burden and costs on the frontline. We intend to make aggregate data widely available to patients, the public, researchers and other organisations in a standard format.
Along with occasional mention of the ‘potential for alternative delivery models (3.75) there is the very welcome assertion that regulatory organizations should:
4.7 embed the principles of good regulation (proportionate, accountable, consistent, transparent and targeted) within the culture and practice of their organisations. Paramount within this will be to act on feedback from customers to develop and utilise more innovative methods to deliver their functions effectively.
And lastly, one more repeat of the commercial litany, threaded throughout the review, of encouragement to engage with the ‘private sector’.
4.3 We will identify opportunities to raise capital and improve the commercial performance of trading activities within the arm’s-length bodies sector and the Department of Health, increasing independent sector ownership and involvement in trading activities, and outsourcing. This builds on an existing commercialisation and divestment programme within the Department.
The review expects that implementation of the proposals will be completed by 2014 in line with the wider system changes (and within the planned time-scale of the present parliament).
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