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Counselling in Primary care - Make-over mania?
eIpnosis in conversation with a self-employed counsellor

Counselling in Primary Care is being moved into commissioned, contracted out commercial services. How is the transition out of the old way of running counselling services being handled?

As most of the people will know the government has decided to bring in more money into mental health and primary care through their Increasing Access to Psychological Therapies [IAPT] initiative and the money is being given to Primary Care Trusts who have to find a provider of this new service. The new service is based on a stepped care model and in most areas it seems to be based on a substantial CBT content, although in the NICE guidelines it says very clearly 'psychological therapies' plural.

In my experience what has happened is that the PCT allowed the primary care counsellors to have some voice in the specification that was drawn together, there was also some GP input to that and that specification was put out to tender. In my area that tender was awarded to a group, a consortium of three different bodies and although that provider was chosen in July we are now in October and there has been no direct contact between the provider and the GPs and only one very brief letter to the counsellors saying information would be forthcoming.

Counsellors who had been previously working for the PCT?

Counsellors who are all self-employed, on contract to the PCT and have been since 2000.

And mostly working in GP practices?

They are all working in GP practices, some of them more than one. And all have excellent relationships with their GPs and all feel that they are part of the Primary Care team. What that means in practice is that we not only take referrals from GPs, Health Visitors, Practice Nurses or whoever, we also see on occasion, members of staff from the practice. All of us have the experience of a member of staff coming and saying have you got ten minutes, even if they haven't been officially referred to us, we quite often get asked.

The new proposals are actually getting rid of the term 'counsellor' and people are to be called 'psychological therapists' and what we understand, and certainly what has happened in other areas, is that existing counsellors have been required to undergo further training, sometimes one day a week, in a university for a year in CBT, no matter how experienced they may be or no matter how well trained they may be. Which means that you are asking them to give up a lot of their skills, a lot of their experience, in order to be very very prescriptive and very narrow in the way that they work. Understandably a lot of counsellors are very unhappy about that, varying 'from what a pity that we can't use those skills and experience', to very strong and angry responses that actually we are being infantilized in some way and not given due respect.

As if what you have been doing had no great value.

Exactly. And we know that what we were doing was of value, not least because we all had waiting lists, i.e. the GPs were referring to us because they felt we were offering a good service. None of us have had complaints and the feedback to the GPs within the practice is overwhelmingly positive. It is therefore quite galling to feel that a new service will be brought in and the old service will be just thrown away without any of the good points from it being kept.

So it is not being grafted onto it or added, it's a wholesale make-over?

It appears to be. There are some areas of the country where they decided to keep some kind of counselling service alongside, but in the cases that I know of where a service has been instituted in the last year, it seems to be very prescriptive and very very limited and therefore throwing away the skill and experience that those counselors have, which seems to be foolhardy to say the least. And clearly there are implications for the counsellors but even more important there are implications I think for patients. And the government's constant desire to give patients choice I think in this instance is not going to be followed through. They will not have the kind of choice they had previously.

They'll have choice, it's this or nothing? The old Henry Ford choice, you can have any colour you like as long as it's black

Absolutely, and as counselors, again, we have huge resources at our fingertips that we use and if somebody comes for instance with a relationship problem we always have referred them to relationship therapy. Quite clearly there are other aspects to counselling which we can't all necessarily match, so we do use the resources, voluntary or other professional resources but what we do also know is that the GP's trust us to make that assessment. So again it seems that our experience in that regard is being disregarded.

So you are faced with is being coerced into retraining?

That's what it feels like.

As and when you continue to retrain as a CBT practitioner… is this a money saving exploit, how does the money play out?

The government has of course given a lump sum of money to the PCT, £500,000, which then has to be used in a certain way. One of our concerns is that the service that I've been involved with for the last eight years has run on a shoe-string. Six counselors have had self-employed contracts and we have covered 19 practices between us at no more than £150,000 a year. Full stop. Now other money is available. There is considerably more money in the pot now and there a lot of apprehension as to whether that amount of money is going to be used in offering services or whether it's going to be swallowed up by administration and management, because the management level has been very very low until now, professionals have just got on with it.

It's been self managed in effect?


And now you'd got a commercial enterprise

That's what it feels like.

It's contracted out?


What about the stories that people are in effect applying for their existing jobs and finding that they were being offered a third less money?

That is happening in some areas in the south west of England. There are some areas where there are counselors who were paid at the Agenda for Change rate of scale 6 or 7 i.e. somebody of considerable experience and capability. They will now be asked to apply for a job which has a different description and which will probably come in at scale 5.

And is that a half, or a third less, what proportion?

It will work out at something like £11-12 an hour as opposed to £16, so I suppose we are talking about a third but even so it's a demotion effectively.

And presumably lots of other people are being trained up separately to come on to the same grade.

That's exactly right.

Which is very strange. So you have experienced counselors who get demoted to be grade 5 and others who train, relatively briefly, not necessarily badly, who suddenly find they are all working with each other.

And our experience then seems to be of no real worth or value and that's not only hurtful, it seems to be rather stupid. And it doesn't sound like it's in the client's interests.

Some body's running an ideology with the practical outcomes if you want to work, you do what we tell you?

And I think it is very sad because this is actually not a government edict or directive, there are NICE guidelines which imply that each area must work out what seems best for them with their staff and their clients.

And then there is the over-arching notion that you have to have 'commissioning' which means that it becomes 'business'.

Absolutely, and in this instance we are looking at a system that has worked very well for 8 years and now is to be thrown out of the window and that seems not to be very sensible and it certainly doesn't seem to be in the patient's interests, the GP's are not happy about it because the GP's value the relationships they have with us.

The counsellor wished to remain anonymous