The House Of Lords
The most obvious government response would be to turn to the Health Professions Council established under the Health Act 1999. However, that would not be satisfactory and, after due consideration, was rejected by all the major elements of the professions. The president of the British Psychological Society recently made clear to me that, regardless of the society's position some years ago when it accepted HMG's invitation to explore the HPC as an instrument for statutory regulation, it is, in hiswords, not fit for that purpose. Along with theUKCP, the British Association for Counselling and Psychotherapy, the British Association for Behavioural and Cognitive Psychotherapies and others, the society has produced detailed proposals for a psychological professions council. While not part of this consortium, the British Psychoanalytic Council came to the same conclusion—that the HPC was not an appropriate body, but that one which brought together the three professions would be suitable.
Why this dissatisfaction with the HPC? The membership of the HPC is primarily concerned with those who treat physical illnesses, and the way that they deal with training and skills is much less variable. In general terms— and I know that I am not doing justice here—while there is largely a right way of doing physiotherapy, chiropody or microbiological or histopathological tests, there is much wider variation in psychological treatments. The HPC professions are also much more able to set out their skills in the form of protocols which can be followed by people of a range of personalities. It matters relatively little if one technician or physiotherapist has to be replacedwith another. The personality of the therapist andthe relationship with the client is, however, crucial—indeed sometimes central—to psychological treatments. Therefore, the training, assessing and monitoring of psychologists, psychotherapists and counsellors needs to be quite different. A separate regulatory body is the best way to do that. Frankly, it is also difficult to conceive how such a wide range of psychotherapies, schools of psychology and counselling could be represented under the current HPC mechanisms.
I should emphasise that nothing that I have said about concern for patient welfare and anxiety about rogue therapists should be taken to suggest that the professional standards developed by the various professional bodies in these fields are not excellent. Indeed, another reason for their antipathy towards the HPC is that it is perceived to have a lower threshold than the majority of voluntary codes. The concern is that these do not have a statutory basis and anyone can practise without membership of a professional body or reference to their professional codes.
The Minister's responses to the amendments in Committee in 2001 indicated that he realised this, when he said that HMG might be prepared to consider new arrangements enabling psychotherapy, psychology and counselling to be managed together in a new council set up under the Health Act 1999. Sadly, however, the Government were not willing to amend or widen the terms of that Bill; nor were they willing to proceed with their own version based on the Minister's response.
In my closing comments during the Second Reading debate in 2001, I noted that in respect of Northern Ireland, Her Majesty's Government had decided that 30 years was long enough and had set their mind to addressing those complex problems—with which I am also somewhat familiar. It would appear that in the intervening six years even the historic problems of Ireland have made more progress towards resolution than the problems of the statutory regulation of psychology, psychotherapy and counselling. I hope that, now the Minister has returned to the Department of Health and again shouldered responsibility for better regulation, he will encourage us by preparing to build on the thoughtful proposition that he made in Committee on my Bill all those years ago, by establishing a body that will bring together into one body what he described as the talking therapies. As he said, that could be done by an Order in Council process, under the Health Act 1999. Is he prepared to do this with due consultation with the stakeholders involved? If he is, my colleagues and I stand ready to assist him in this important matter.
I and others use the word "profession" but thatis in itself a misnomer. Profession implies a recognised qualification, proper standards, registration, monitoring and, in extremes, striking off. But nothing like that exists for many of the people who practise talking therapies. The British Association of Counselling and Psychotherapy and other bodies do their best. As the noble Lord, Lord Alderdice, reminded us, some of their standards are higher than those that might be imposed by legislation. However, there is no necessity for anyone to register with them. As we have heard many times, anyone can put up a brass plate and practise as a psychotherapist. While we can say to a potential client or patient, "Always be sure that the person you are seeing is approved", how many people would even begin to know what that was? The plain fact is that we begin to think about seeing such a therapist only when we are in some kind of distress; for example, in bereavement, when our marriage ends or when our most intimate relationships are going wrong. That is when we are at our most vulnerable, most suggestible and when we are least able to make rational judgments.
Sadly, that makes us prey to practitioners who are incompetent or even malevolent. We have all heard of therapists sexually or financially abusing clients. I believe that these cases are rare, but even one is too many. But still too many people find—by chance, by recommendation or through desperation—a therapist who exploits them in some way or who does not help them to cope with the problem they are presented with. This exploitation takes many forms: for example, people may be kept hooked for too long in a therapeutic cycle; people may be caused financial distress because therapy is not cheap and is rarely available on the NHS; or, perhaps worse, therapy does not help them to become strong enough to deal with their own life for themselves.
Your Lordships may be familiar with that old Woody Allen joke: "I have been seeing my shrink twice a week for seven years now and don't feel any better. I am going to give him one more year and then I'm going to go to Lourdes". It may be amusing, but to see people spend their life savings on 10 years of therapy and never move on, or even begin to come to terms with their difficulties, certainly is not. Of course, some problems are so difficult and so deep seated that they may take 10 years, but most people can be helped to find a means of operating which enables them to grow and not be kept in thrall to therapists. Surely, that says more about the therapists than the client.
As Dr Chris Allen said in yesterday's Observer:
That is why most reputable therapists, as we have heard from the noble Lord, Lord Alderdice, welcome the idea of more regulation and that it should be statutory. I believe that it should also be necessary to ensure that therapists are in therapy or some kind of continuing counselling relationship.
We also have to acknowledge that it will not be easy to regulate such therapies. By definition, they are carried out on a one-to-one basis where a relationship of trust is established between the professional and the client. But there is no doubt that effective training, assessment and supervision of people in such professions will certainly go some way towards identifying those most likely to abuse power.
I have been involved in this debate for many years, originally working in association with the Maudsley hospital and with child guidance clinics in Brixton and Peckham. I was chairman of the juvenile court in Lambeth for many years. One could see those troubled, disturbed young people and believe that the answer for them was a physical, pharmaceutical, medical response. They needed support, encouragement and education, but they and their families also needed talking therapies. As Health Minister, I certainly did not make the progress that I hope future generations of health Ministers will make. We had the Professions Supplementary to Medicine. We have moved on to the Health Professions Council. But I am very much with those who believe that the talking therapies need a different structure.
Since I last visited the subject, the progress has been great. I was brought in again in 2000-01 by a wonderful man, Peter Hildebrand, who had been on the Sieghart committee. He was in charge of adult therapy at the Tavistock. In his last year of life, he called and said, "I will not see the year out, but before the year is through I want progress to be made on the statutory regulation of talking therapies". I spoke to his widow today and said, "There has been further progress, but we still haven't got there yet".
I believe that we have a real opportunity but we must not allow simplicity to cloud the complexity of introducing statutory backing that is sensitive to these therapies. The crucial element is that for many people with mental health problems it is the medical model that they most dislike. They do not want to use a pharmaceutical approach. They find hospitals and the medical culture alien. For them, there is a great demand for talking therapies. I spoke today to Barbara Herts who runs YoungMinds, which has a campaign to mainstream mental health issues for young people—in schools and youth clubs—and be a voice for children and young people. It wants talking therapies. It does not want to go on a pharmaceutical route unless it really has to. Of course, if people have a psychotic condition, that may be the best option. But there is a real demand for talking therapies.
What do these young people want? They want robust regulation, transparency and to know about outcomes. They want less jargon and more openness, and regulation with an independent element. Of course, all the talking therapies have received a great boost from that wonderful report, The Depression Report, by the noble Lord, Lord Layard, which I am sure was greatly inspired by the noble Baroness, Lady Meacher, and all her work at the Mental Health Foundation. As a distinguished economist at the LSE, at its centre for economic performance—I declare my interest as a governor of the London School of Economics—he gave great priority to the importance of talking therapies and greatly promoted cognitive behaviour therapy. We know his argument; namely, that 16 treatments would cost £750, the equivalent of one month's incapacity benefit and lost tax. His wonderful argument is that it makes economic good sense to take cognitive behaviour therapy seriously. His report argues persuasively and disturbingly that those NICE guidelines simply cannot be implemented. There are not enough therapists. Only one person in four is receiving any kind of treatment. Three-quarters of those affected live in their unhappiness individually. They are economically inactive and, of course, there is associated family misery. We all know that the effect of a depressed mother in terms of children's disturbed, hyperactive behaviour and so on has been evidenced for a long while. People wait nine months to receive help. We need another 10,000 therapists and 250 local services to be achieved by 2013. The decent regulation of people involved in talking therapies would make a significant contribution. I referred in an earlier debate to the Charlie Waller Memorial Trust. It funded a chair at Reading University in CBT, which was a practical contribution to this movement.
This is a remarkable charity employing 300 psychotherapists. It cares for the damaged children of the industrial schools in Ireland and provides support and care for many Irish migrants to this country, a group that is often overlooked and misunderstood. Many of them faced great personal distress during the Troubles and in some of the incidents in this country. The charity's psychotherapists are regulated by the British Association for Counselling and Psychotherapy and the UK Council for Psychotherapy. It applies high standards with good supervision; indeed, many of its standards are higher than could be expected of a statutory body. Along with all the others involved in practice, it is anxious about the damage that could be done if the Government take what may seem like the simplest and shortest-term option rather than look at the complexity of the position.
I am grateful to Professor Jennifer Brown, head of the Department of Psychology at Surrey University, where I am a Pro-Chancellor. Along with the University of Hull, where I am Chancellor—I should mention that to provide balance—it does a lot of work in training psychologists and counsellors. Professor Brown articulates the position clearly:
"The HPC procedures are designed to encompass a very broad range of health and allied professions, and as such are neither rigorous enough nor are their standards sufficient to regulate the professional practice of psychology effectively".
Some 60 per cent of psychologists do not work in the NHS, but in other settings. Some work for charities such as those I have mentioned. I have talked about Young Minds and ICAP. They work with Cruse, Relate, the Samaritans, and on helplines. It is not appropriate to regulate these people in that way. What is more, the perverse aspect of this is that in many cases there is a degree of co-payment, so if the Minister effectively nationalises all these therapists, with that he will pick up a considerable hidden cost. Regrettable as it may be, many charities work through contributions made by patients. That is a further argument. Many work in education and the Prison Service, which is much debated in this House. For them, the sensitivities required in their field of engagement are extremely important.
Baroness, Lady O'Neill of Bengarve. In her wonderful book, A Question of Trust, she wrote:
Baroness Barker (Liberal Democrat) Link to this | Hansard source
Looking back to the debates in 2001 on my noble friend's Bill, what he managed to do then was to crystallise the main issues. I would say that the only difference between then and now is that the demand for talking therapies has increased dramatically. Thirty-five years ago, no one had heard of chronic fatigue syndrome or ME, but people are now regularly given those diagnoses and sent for talking therapies. Further, Members of this House know only too well that the demands for the child and adolescent mental health services cannot all be met.
A key issue of the time was whether the inclusion of counselling in a regulatory body was desirable. Counselling is now recognised as one of the most cost-effective low level interventions in health, but it is one which people often do not seek for themselves. They are frequently referred by, for example, their GP, and innovative GP practices now provide counselling services. People take counselling on trust and at one remove, and so have no way of establishing the quality of the service for themselves. Another issue was how to include the different modalities of psychological and psychotherapeutic intervention.
A further issue was how to regulate most effectively a range of people working either privately or within the NHS with a myriad of job titles, and some of whom may be subject to different and separate regulation. For example, GPs are already subject to regulation by the GMC, but may provide some form of psychological or psychotherapeutic service although that is not their primary role. Questions were asked about how to establish the most effective and efficient regulatory framework. Back in those days Ministers argued for therapists to be included in a health professionals' council under the Health Act 1999 while others pursued the route of a stand-alone body, a form of psychological professions' council as outlined by my noble friend. Six years on, I suggest that it is a good time to look at where we are and where we need to be.
One of the things my noble friend deserves most credit for is bringing about a degree of consensus among the professions, which was not the case back in 2001. I do not say that there is now complete unanimity, but there is a far greater degree of agreement than was the case then. For example, the inclusion of counselling and psychology is now by and large agreed. That is no mean achievement given the range and strength of views held. An additional key issue was the agreement that it is not right to include psychological and talking therapy professions in with other health professionals. It simply doesnot make sense either to patients, users or the professionals themselves to be lumped in with those treating physical illnesses because they simply do not have a sufficient commonality of approach. My noble friend Lord Alderdice set out the reasons for that extremely clearly.
That mirrors something which is going on in another area of the health field: the proposal by the Government to merge CSCI with the Healthcare Commission and the Mental Health Act Commission. There are similar reservations on the part of mental health professionals who feel that putting these bodies into the same inspectorate framework is misguided. I know we are going to have other discussions about mental health in this House—indeed, we are in the middle of them—but it is important to make the point that when the professions themselves are talking in that way about regulation, the Government ought to listen. The question is whether one has a regulatory framework that is sufficiently broad to enable it to include a wide range of people, or, if you seek to go down that road, whether you then lose quality and professional standards. I suggest that one of the lessons we can learn from this is that we do.
I wish to pick up the point about the composition of any regulatory body, about which there was a big discussion during consideration of my noble friend's Bill. At that time the Government talked about the need to have lay involvement. No one these days would suggest that not having some degree of user involvement on a regulatory body was anything but acceptable, but the Government were talking then about something in the order of 50 per cent lay people. When one considers the range of disciplines within the fields of psychology, psychotherapy and counselling that have to be included, one is talking about quite an extensive body. I wonder, when the Government get around to discussing the nature of the body with us, whether they might consider that matter.
Finally, back in 2001 the Government made an argument about the need to avoid as far as possible dual regulation of people who are already regulated because they have another medical profession; for example, GPs being regulated by the GMC. It is fair to say that it is not that unusual, within the health service alone, for people to be subject to different forms of regulation. There is a general level of patient care that one would expect in any of the caring professions; that is a given. If someone were to present themselves to a patient as having a degree of expertise above and beyond that—I am thinking,for example, of a nurse who becomes a specialist bereavement counsellor—we would expect them to have that qualification, and I think they would expect that too.
I wish to make two final points. There is an urgency about this issue. At other times we have been discussing the Mental Health Bill. The increased role envisaged in that Bill for psychologists and associated mental health professionals cannot but mean that there is going to be greater involvement of these sorts of professionals in the mental health world. There seems therefore to be an urgent need to make sure that there are standards and a quality of regulation to which they are not subject now.
We start, as the noble Lord rightly said, froman agreed position of principle. We know thatthe Government, as much as the psychological professions themselves, are desirous of achieving a workable system of professional regulation. Indeed, we have known that for some years. It is, frankly, disappointing that six years after the noble Lord introduced his Private Member's Bill, the expressions of commitment from the noble Lord, Lord Hunt, to help bring about that system of regulation have still not reached fruition. At that time we received a clear message from the Government that their preferred route for achieving regulation was to use the powers set down in the Health Act for a quick and flexible solution; namely, a Section 60 order.
It was not quite clear to me at the time whether they were suggesting that the psychological professions should be subsumed under the umbrella of what is now the Health Professions Council, or whether in their view there was a case for establishing by order a separate dedicated body for the talking therapies. Reading those debates again, I am inclined to think that they were deliberately leaving their options open on that point. Until the forthcoming White Paper is published we will not know for certain what the Government's final proposals are, but judging by the tenor of the Foster and Donaldson reports it seems clear to most of us which way the wind is blowing. That is why I believe this debate is timely.
That statement has the distinct ring about it of a prejudged conclusion. I have to say that the vagueness of the word "probably" in that sentence underscores my belief that there really is very little in the way of logical argument underpinning the recommendation. To argue that having one umbrella regulator is neater and tidier, which is what his position amounts to, is to adopt an a priori position that has nothing whatever to do with the needs and circumstances of individual professions or of those in receipt of treatment from people practising in the name of those professions.
If, as I fear, the Government are set on making the Health Professions Council responsible for regulating psychologists and psychotherapists, we are heading for real trouble. What unites those professions currently regulated by the HPC is that, as a generality, they work within a context of delivering healthcare on behalf of employers whose function it is to do that. The focus of the HPC is therefore on healthcare. As we have heard from my noble friend, only a minority of psychologists work in a healthcare environment. Many work in industry and commerce. Many do not provide one-to-one therapy as the main part of their job, or indeed at all. Many of them work independently and unsupervised. Certainly, there are important aspects of the work done by some psychologists that are related to people's health and well-being, but it is for good reason that psychologists do not call themselves healthcare professionals.
To shoehorn psychologists, psychotherapists and counsellors, with all their very different modalities, into the Health Professions Council would be to blur the distinct and individual interests represented within those professions. That would not only do those professions an injustice; it would also be to the detriment of the clients whom they serve. It is very difficult to see how, under its present modus operandi, the HPC could accommodate and champion issues that may be very profession-specific and often very subtle. One person sitting on the council representing a multitude of disparate professional interests is a formula for poor regulation.
The British Psychological Society, in presentingits proposals for a free-standing psychological professions council, points to a whole host of considerations which, to my mind, confirm that fear: the relatively weak provisions within the HPC for revalidation; the near-impossibility of transposing that revalidation system on to work settings outside the NHS in a way that was consistent and fair; the lack of relevance to psychology and psychotherapy in much of what the HPC calls its standards of proficiency; its inability to accommodate the key standards expected of professionals within all those disciplines without a major change in the way the council operates; the huge difficulty of trying to set up a complaints system that would work fairly inside and outside the NHS; and the inability of the HPC to recognise trainees.
Why, therefore, resist the idea of a separate and dedicated regulatory body for the psychological professions? It would be quite possible, and indeed desirable, to replicate within such a body those features of professional regulation which are or should be universal. But it would also enable the distinct and important differences between the psychological professions on the one hand and most healthcare professions on the other to be captured.
The Minister said on 21 February 2001:
Lord Hunt of Kings Heath (Parliamentary Under-Secretary, Department for Work and Pensions) Link to this | Hansard source
In response to the noble Earl, Lord Howe, six years does seem a long time and it is a great pity that further progress has not been made, but it has not been for the want of trying of many people—the noble Lord, Lord Alderdice, the professions and officials in my department. I want to pay tribute to all those who have worked so hard to try to find a solution. It is disappointing, but we must not let that deter us from doing everything we can to produce a solution in the future.
As my noble friend Lady Pitkeathley pointed out, we are due to publish a White Paper shortly. That inevitably precludes me from responding in some detail to one or two of the more contentious points made in tonight's debate, but no doubt there will be a time when we can debate these matters in the future. I also say to the noble Lord, Lord Alderdice, that he is right to point out the risks to the public of a variable quality in the performance of people who come under the titles that we have been talking about. On the other hand, I echo the remarks of my noble friend Lady Pitkeathley in saying that many of the people concerned have given huge benefit to the people who have come to them. I count myself as one of those people. Just as we are clearly agreed that we wish to have statutory regulation and want to outlaw people who should not be in a position to offer poor and sometimes dangerous services to individuals, let us pay tribute to the great majority of people within the umbrella of the talking therapies who have done so much to help people.
I was very interested in the remarks of the noble Baroness, Lady Bottomley, about the benefits of talking therapies. She referred to the work done by the noble Lord, Lord Layard, on cognitive behavioural therapy. Wearing my old hat at the DWP we were very interested in that work. She is right to refer to the number of people on incapacity benefit. The fact is that their life outcomes are very poor and the longer you are on IB the harder it is to get off. If you have been on it for two years, you are more likely to die or retire than ever to get back into work. Discussions are going on in the Government in relation to that report and to the benefits of cognitive behavioural therapy.
Many professional bodies active in the field of psychotherapy and counselling have developed different theoretical models, as we have heard. My officials have worked with those bodies since 2001. It is noticeable that many of these bodies have very different ideas about what constitutes good practice. Therefore, it is very difficult to get any acceptance of leadership from within the field, on the grounds either of lack of knowledge or appreciation of each other's approach.
As a result of the competence-based role identification, we may find that some practitioners who are currently called counsellors do the same job as psychotherapists and should be regulated as such. We may also find that there are roles at other levels, and some may work in managed and supported environments which may not need statutory regulation.
My officials began talks on a draft order with the British Psychological Society in 2003. The talks lasted two years and produced an order which was issued for consultation in March 2005. Noble Lords will know that the BPS rejected those proposals, first, because it wanted a separate psychology council and, secondly, because it rejected its previous position, which was that only those working in applied fields of psychology would be regulated. The Government's position is that we need regulate only those whose practice warrants it because of the risk to the public if their practice goes wrong. The BPS called for other types of academic and research psychologists with theoretical training only to be registered. Thirdly, the BPS wishes to protect the generic title "psychologist" and set generic standards which could not be met by those without practical training. However, if we legally restrict the title "psychologist" to those who can demonstrate practical and theoretical competence, we would unfairly criminalise many with a legitimate claim to use the title.
There is an analogy here with the legal profession. Many eminent academic lawyers have every right to call themselves lawyers but because they have not had vocational training they cannot call themselves solicitors or barristers. I raise those as some of the issues that still need to be confronted.
In conclusion, this has been an excellent short debate. We are all agreed that regulation of the talking therapies is a very important matter; I regard it as very important indeed. There will be issues to discuss on what is in the White Paper. I understand the issue about the Health Professions Council and the desire of some to have a separate council. That will have to await further discussion. What is not in doubt is the department's willingness to engage with the professions as much as possible or our debt to the noble Lord, Lord Alderdice, for all the work that he has done in the past, and in anticipation of the work that I hope he will do in the future.Add your comment