WHY ANALYTIC PRACTITIONERS SHOULD SAY NO TO THE HPC
by Ian Parker
The Health Professions Council (HPC) was, the organisation says on their website, 'set up to protect the public'. It currently, in 2008, regulates 'arts therapists', 'biomedical scientists', 'chiropodists and podiatrists', 'clinical scientists', 'dietitians', 'occupational therapists', 'operating department practitioners', 'orthoptists', 'paramedics', 'physiotherapists', 'prosthetists and orthotists', 'radiographers' and 'speech and language therapists'. It is set to take under its wing psychologists and then counsellors and psychotherapists (though the precise titles under which such practitioners will be registered are so far still unclear). The motif of 'protection' is appealing to those practitioners who do not want their colleagues, or even themselves perhaps, to do harm to others, and the call to protect the public is mirrored by HPC functionaries who reassured those about to be brought into this regulator that all practitioners need to do is pay their money and carry on much as before. The problem, however, is much deeper than this, for the HPC threatens to close down psychoanalytic practice as we understand it today.
There are many scare stories about the HPC, and about the consequences of state regulation and promised protection of the public in general, and these two issues of regulation and protection are often run together. And discussion of the role of the HPC often drifts into broader issues of regulation and protection. There is, for example, a good deal of heated discussion among spiritualists about plans to repeal the 1951 Fraudulent Mediums Act and replace it with Consumer Protection from Unfair Trading. The newly formed 'Spiritual Workers Association' (SWA) will fight this new legislation, and is scathing about the attempts by some to find loopholes by which they can carry on practising if they claim they are conducting a scientific experiment or simply entertaining the public. What, the SWA say, does this mean for those practitioners who refuse to adhere to a scientific worldview and really do believe in the afterlife? An editorial in Spiritualist News, on the other hand, says that such scare stories about consumer protection are unfounded, and that it is necessary to have a degree of legislation 'to eliminate the undesirables, the fortune tellers and con artists.'
We are on familiar territory here already in these disputes among spiritualists, and some analysts - some Jungians perhaps - will find something in common with spiritualist practice. Nevertheless, it is important now not to get drawn into some unwise alliances with other professionals and to keep focussed on the particular question of whether the HPC is right or wrong for us. Not whether it is inevitable, or whether it should be reformed, but quite simply whether it is harmful to analytic work. The best way of answering that question is to keep focussed on the material the HPC makes available on its website. One of the advantages of the rhetoric of transparency and accountability is that the functionaries now feel impelled to put everything up on the internet. For now, this to the benefit of those who want to know what they are up against, but you will see that when psychoanalysts, psychoanalytic psychotherapists, psychodynamic therapists and other analytic therapists are brought into the HPC this tangle will turn from the dream some have of complete protection into a nightmare of surveillance and perpetual insecurity. By looking closely at the website now, we will see that the norms and procedures of the HPC are antithetical to analytical practice on the following counts, ten counts:
1. Surveillance of each individual's activity against a presumed moral standard
The problem here is not only with the moral standard as such, but also with the process by which the practitioner is measured against it. This includes a notion of past infractions of the law which are recorded in criminal record bureau checks and which thereby mark the individual as being the self-same agent throughout their life. This mobilises a notion of status that is marked by title that gives the individual an identity, and also images of health which extend already contested bodily health as a metaphor to define what we are expected to understand as mental health.
The details of hearings for complaints listed on the HPC website in March 2008 are indicative. Note that those accused are already at this point named on the website before the charge has been found proven; all the specific cases mentioned in this paper publicly name the offenders. Take the case of a chiropodist whose fitness to practise was impaired because of 'a conviction for being in charge of a motor vehicle with excess alcohol' which resulted in them being 'disqualified from driving for twelve months'. The point here is not whether someone should or should not drive under the influence of alcohol - something that would not have been a criminal offence in the UK until recently and is still not an offence in many countries - but how this is then used as a benchmark to assess whether someone is 'fit to practise' when they are at work. As the HPC reminds us in their newsletter, 'When we say that a health professional is fit to practise we mean that he or she has the health and character, as well as the necessary skills and knowledge to do their job safely and effectively.'
2. A notion of moral character defined by conformity and collusion with current questionable practice
This problem is evident in the expectation that practitioners should maintain the professional reputation of organisations they may have profound doubts about, to the extent that breaking silence can be ground for complaint. And it is evident in the assumption that social norms about the private ownership of professional knowledge should be maintained, as is apparent in complaints concerned infraction of copyright. This will pose problems for those who do not believe that knowledge is something that can be owned by individuals or private companies. A complaint against a named occupational therapist, for example, was that they were selling occupational therapy assessment materials on eBay, and the accused was told that 'In selling these CDs you breached copyright restrictions'. There is, of course, already legal recourse for those wishing to protect their private property, but here we are drawn into a realm of 'intellectual property' which surely is problematic for those practitioners who see the 'individual' as a construct peculiar to the political-economic system we inhabit today.
The HPC website sets out 'Standards of conduct, performance and ethics', and it reminds registrants of a sample list of misdemeanours that can lead to them being struck off. Registrants are reminded, 'make sure that your behaviour does not damage your profession's reputation'. An example case is highlighted in the February 2008 HPC In Focus newsletter, and so we must take this as exemplifying what the HPC considers to be good practice on its part. In this case an 'operating department practitioner' was removed from the register for 'theft, assault and failing to provide a breath specimen'. These are, of course, quite serious matters, but what you should notice here is the grounds for his removal from the register. The chair of the HPC panel is reported in the newsletter as saying 'The panel is satisfied that the fact of the theft constitutes misconduct and that the registrant's fitness to practise is impaired.' So far, so good, if you accept the assumption that conviction in a criminal court should then be redoubled and reinterpreted as a case against listing on a professional register. Let us leave that aside, to move to the more worrying part of the chair's comment, which is the crux of the case against this registrant: 'He did not behave with integrity and honesty and allowed his behaviour to damage his profession's reputation'.
3. Training reduced to the logic of compliance to a programme of study
This is clear in the attempt to ensure good practice in training by monitoring attendance at courses. What is important is that the trainee is seen to learn, not that they actually learn anything at all. This buys into the worst models of education that are now increasingly rife in the university sector in the UK in which 'learning outcomes' take the place of independent thinking by the student. The goal is to be able to match preset 'standards' with a student's work, and then the institution is drawn into checking for plagiarism at the same time as it effectively penalises originality.
So, for example, in its 'Standards of education and training guidance' document, the HPC say to training organisations that 'You should show how you monitor attendance, for example, by a lecture register. You must show the systems you have in place for doing this, for example, the action you will take if students do not go to the compulsory parts of the programme'.
4. Training reduced to the progression through a course of study
A particular notion of progression clearly underpins the HPC's reference to 'modules' in training courses and the provision by organisations of the possibility of 'resitting' assessments. 'Why', training organisations will be asked, 'have you chosen the particular types of assessment for each module?' The training organisation must specify the 'number of module resits allowed within any one year'. The HPC education standards document spells this out to training organisations: They will have to answer the question 'How would you explain the overall programme and how a student progresses from day one to graduation?', and the monitoring of 'student performance' must include the organisation's 'expectations for student progression'.
The progression motif is crucial to the way the HPC monitors trainings, and its 'Standards of education and training guidance' document is insistent that there should be no ambiguity: It says 'You should make sure that your documents clearly tell students that completing the programme means they are "eligible to apply" for registration with us'. There is the option to 'award an aegrotat award', and a training organisation must then make it clear that the candidate cannot register with the HPC. In short, there is no acknowledgement that the learning process might include learning that one does not want to be an analytic practitioner.
5. Knowledge treated as something packaged and applied
Knowledge acquired in training is to be validated by the authorities and the message is that this knowledge should be taken for granted rather than questioned. Again, the problem lies not only in the kind of knowledge that is transmitted but also in the relation to knowledge that practitioners are expected to work with, here a relation in which they are passive, or perhaps at best, active consumers - but still consumers - of knowledge. The particular nature of knowledge in analytic work is treated as defined content which is then stripped out and replaced with formal adherence to recognised forums that are deemed suitable to provide knowledge. For example, this is why the HPC warns in its FAQ page, that 'falsifying CPD records' will count as 'misconduct' and will 'lead to your fitness to practise being investigated' We are in a kind of loop here, where knowledge is reduced to something that is relayed from one head to another, and 'fitness to practise' entails conformity to this model of knowledge.
6. Thresholds treated as grounding for practice then operate as limits
The threshold standards which permit entry to the register are not simple bare minimums, beyond which it is possible to develop a distinctive good practice in such a way as to respect the particularity of each subject. Rather the standards permeate each level of training and everyday work so that departure from them can be grounds for complaint. The motif of 'risk' is potent here. For example, an occupational therapist has been up for a hearing by the HPC Conduct and Competence Committee on two charges; the first is that they 'walked a patient down the stairs without first undertaking a stairs assessment, putting the patient at risk' and the second is directed to the evildoer and their own risk to themselves, and so this therapist is told that, you 'transported a wheelchair down the stairs unaided, putting yourself at risk'.
The downloadable document on 'Standards of education and training guidance' says that 'our standards are set at a "threshold" level' and qualifies this as a 'minimum standard', and this 'minimum' is often quoted by those who think there will be freedom of movement up above that standard. But, on the same page, it is clearly stated that 'we must set standards which are necessary for safe and effective practice', and that these will be 'standards for the education and training, professional skills, conduct, performance, ethics and health of registrants'. This is why the HPC recommends to training organisations that 'you do not use phrases such as "implicit through entire programme" or "throughout"; you must 'say exactly where the visitors can find evidence to show how you meet the standards'.
7. The subordination of independent trainings to the universities
There is an insidious use of academic standards as benchmarks against which training should be measured, and the implication is that universities should validate training courses. This has the effect of locking a particular notion of knowledge that is presumed to operate in analytic work with a bureaucratically formalised provision and assessment of knowledge that is becoming dominant in the university sector. For example, the 'Standards of education and training guidance' document gives example questions for training organisations to consider like 'How is the MA different from the PG dip? Is there an exit route other than BSc or MA?'
The modularisation of the learning process is clear in the assumption that training organisations should employ 'Accreditation of Prior Learning and other inclusion mechanisms': 'You must show that you have a system for accrediting prior learning'. This is why training organisations are told 'you could show the visitors how you map your placements against learning outcomes'. And this is why there are so many references to the Quality Assurance Agency for Higher Education as the relevant agency for ensuring there is a code of practice' for various aspects of the training programme.
8. Turning of analytic organisations into monitoring bodies that are compliant with regulators
The 'Standards of education and training guidance' document spells this out in a list of requirements that will include a 'criminal records check', of course, but also making sure that 'overseas applicants go through the same relevant checks', and making sure that 'students reach International English Language Testing System' levels. The HPC also insists that 'Health checks must be carried out as part of the admissions process.'
9. Destruction of existing professional spaces and replacement with individual accountability to regulatory apparatuses.
The HPC operates as a regulatory body that is perfectly adapted to conditions of deregulation in public services. Those working in the NHS have already been subjected to such deregulation by which services are privatised and distributed among various components of the organisation that then have to compete as service providers selected by different cost centres. This means that each individual is forced to operate in a context in which they must be competitive and look out for their own interests; even if they genuinely believe that they want to provide the best service, they have to configure their work into a package that can be assessed by those who will purchase that work. This internal privatisation also serves to bring about some kind of equivalence between the public sector and those operating privately, or, as they like to kid themselves and others, 'independently'. Such privatisation of services serves to individualise provision, and the HPC is an apparatus that then provides the appropriate regulatory framework to monitor individuals.
There is a logic to this privatisation and individualisation of accountability and responsibility, which is that the link between a practitioner and their own organisation must be broken. The organisation is no longer a space in which to learn about the relation between theory and practice - a continual process of learning that is now abstracted and reified by the HPC as 'CPD' - but is an obstacle to the regulators. Under these conditions of neoliberal simultaneous and complementary deregulation and regulation, each individual must be addressed directly and separated from bodies that question these conditions. The FAQ page of the HPC website makes this clear, stating 'You do not have to be a member of a professional body in order to meet the HPC's Standards for CPD'.
10. An illusion of safety guaranteed by equally illusory attempts to predict and control innovative human activity
The HPC website offers posters and window stickers which proclaim 'You're in safe hands: I'm regulated by the HPC', and the message is that once you are with a practitioner on a register you will be safe and sound. This is a dangerously misleading message. The market research documents included by the HPC on their website are quite revealing here, for they show that 'there is little awareness of HPC amongst consumers', but then suggest that 'Sight of certificates on surgery walls and letters after practitioners' names serves to instil further confidence and peace of mind amongst patients'. The research company commissioned by HPC found that the public 'certainly do not understand the concept of protected titles' in warnings on sample posters or 'the possible uses of alternative titles by non-registrants.' They argue that 'The protection of title rather than the protection of function is perceived to weaken the value of HPC registration and proposition of public protection. Titles such as Foot Health Practitioner and Sports Injury Therapist, used by non-registrants, are felt generally to be more glamorous and appealing than chiropodist, physiotherapist, etc.'
The investigating panel in the HPC complaints procedures will, when considering an 'interim order', decide whether the allegation is proven, and they are directed to say that it is 'well-founded'. Note that such orders will have immediate and direct impact on practice, and because 'the public might need some type of immediate protection', the practitioner will therefore be treated as guilty until proven innocent (and will already be publicly shamed on the HPC website before the case is heard). The judgement 'well-founded' is legally applicable to civil cases rather than criminal cases, but potentially criminal matters are here, of course, being dealt with using commonsensical procedures in which there is actually little protection for the practitioner. The HPC say they 'try to make sure the hearings are as informal as possible', a situation in which intuitive everyday face-to-face judgements replace formal rule-bound procedures, and in this lies the problem that any real legal protection is absent and there is instead insecurity for all. Many of those involved are well-meaning folk. Some of them are not, and we should not make the mistake of thinking that all the fraudulent practitioners are outside registers that promise that we will be safe.
These problems with the HPC have been carefully documented in some detail so that sceptical readers can check the interpretation themselves. Of course, there are questions of context, and a sympathetic reading of the whole project of the HPC might treat these particular issues as untypical, as anomalies, or as explicable against the particular background of a benevolent organisation. But we have to ask ourselves what the consequences are if we take these problems seriously and use our own standards of analytic practice to evaluate them. What, even, if only some of these ten points pose problems for our practice? The conclusion should then surely be that the HPC is not fit for practice, and that we should say no to it now. And, if and when we are pulled into the HPC - to anticipate the argument of those who say this process is inevitable - we should know what the problems are to be able to argue against what is wrong about it. To pretend that everything will be ok inside the HPC is to betray psychodynamic work and so also betray those who others claim to protect.