Welcome to UKCP Bulletin 11 ( Reproduced in full with permission from UKCP ) This Bulletin is about a government command paper issued on Wednesday, 16 February and how it affects the regulation of psychotherapy and counselling. We apologise for not producing our Bulletin more quickly - we wanted to consult the Board of Trustees and gain input from Carmen Joanne Ablack. To respond to the issues raised in this Bulletin, please email email@example.com or share your views on the UKCP website forum at www.psychotherapy.org.uk/discussion_forum.html. Andrew Samuels, UKCP Chair and David Pink, UKCP Chief Executive Summary
The command paper, 'Enabling excellence: autonomy and accountability for healthcare workers, social workers and social care workers' (Cm 8008) sets out the government strategy for reforming the system for regulating healthcare workers in the UK and social workers and social care workers in England. It marks a change in direction in the government's approach to regulation which will affect us.
Put in the most succinct form: On the apparent balance of probabilities, statutory regulation by the Health Professions Council (HPC) will not proceed. The paper states that statutory regulation is to be the last resort, used in circumstances where there is a 'compelling' public safety risk. The government's preferred approach is 'assured' voluntary regulation. Where HPC has previously recommended statutory regulation for a profession, the assumption now is that assured voluntary regulation would be the preferred option. The Council for Healthcare Regulatory Excellence (CHRE) will be renamed and will have new powers to accredit existing voluntary registers such as our own. HPC (also to be renamed) has a new power to establish voluntary registers for hitherto unregulated health and social care workers following risk assessment and consultation. Legal protection of title - and all that went with it such as alternative professional accountability (APA) - is not now a pressing issue for UKCP.
What will UKCP's policy be? The changes to the regulatory scene mean we must adopt a new policy. As you will know from previous Bulletins and our recent email about regulation, our current policy is to engage constructively and firmly with HPC in order to gain the best possible final result for our members who wished to register there, while at the same time creating an accommodation for those who will not want to register with HPC. The process of refining this policy on regulation has had ethical and psychological dimensions: that the majority, who might have wanted to register with HPC, respected the position of the minority who did not want to do so. UKCP evolves a sophisticated balance and is enabled to retain its integrity and unity. Going forward, we pledge to stick to the same ethical values of doing our best to make sure that no member feels their key needs are being ignored. But, if that was hard enough before this command paper, it is even more of a challenge now. This news about a change in direction by the government will carry its own emotional charge for some members. Our reactions and discussions need to take place in an environment which is respectful and above all well-informed.
What does the government paper say? Policy direction and principle The command paper, a relatively brief document from the government, is a statement of policy direction. It contains few explicit details of changes and there is no specific statement about the future regulation of psychotherapists and counsellors in the paper. Rather the coalition sets out its principled position on regulation. It says that centralised regulation of health and social care workers by the state has been improved in recent years, and acknowledges that such regulation has considerable value to society. But the paper implies that people have adopted a lazy thinking that assumes that the highest form of centralisation and statutory enforcement is automatically the most effective or appropriate form of regulation. The new policy paper argues that professional workers do not do good things for their clients merely because of the threat of statute. We are right to trust professionals because they are good people, the paper suggests. The paper argues that statutory regulation imposes a very significant compulsory burden on society, and that it is one of the government's central policies to contain or reduce regulatory burden. So there are both philosophical and economic reasons to end the kind of thinking that assumes that all risks should be tackled through national, statutory action.
In fact, the paper pushes the argument much further: it says that the assumption should be against statutory regulation as a way of managing risks and the first response should be other approaches that are closer to the front line of services. The paper points out that there are other ways that the quality of professional care can be addressed - including the Care Quality Commission inspections of providers, and employers' responsibilities for the actions of their staff. This second issue (employers) seems to have been a very significant driver of the thinking in the paper. The paper rarely uses case studies or examples but it appears that the government feels that full statutory regulation is an inappropriate and OTT intervention for health care assistants and social care assistants. There are hundreds of thousands of 'unregulated' employed staff working within a professionally-led service under direct management and supervision and the government intends that they will not be regulated by statute. The paper is at its most potent - and most frustrating - when considering the employment status of professional workers. Clearly, as the paper acknowledges, statutory regulation has the greatest penetration in those employment settings that are already subject to the most stringent employment-based management regulation, such as the NHS. By implication, there might have been a perceived greater need for state regulation in those areas where managerial regulation is not available, such as peripatetic or self-employed sole practitioners.
But the paper does not travel in this direction. Disappointingly, the policy paper says very little about the role of professions and professional bodies in our society. The focus is on the relationship between the state and the professional worker. Voluntary systems of regulation The paper proposes that there should be new systems for voluntary registers of unregulated workers (being on a voluntary professional register such as UKCP means you are 'unregulated'). These are called 'assured' voluntary registers. There are 1.4 million people on the existing statutory registers for health and social care. And we are told there are 1.3 million more in the queue of groups that the previous government would have put into statutory regulation (including specific mentions of psychotherapists and counsellors, and 'low paid support workers').
The paper says that the assumption should be that voluntary registers are the way forward for these 1.3 million workers. The government will be taking steps to enhance the status and quality of voluntary registers. CHRE will become a national accrediting body for voluntary professional registers in health and social care (health on a UK basis, social care for England only). CHRE is not going to regulate individual workers, but it will regulate existing registers of professional workers. That means us. However, the existing statutory regulators in health and social care, including the HPC, are also given powers to set up and maintain 'voluntary' registers. If HPC were to consider setting up a 'voluntary' register of psychotherapists that would take us into completely uncharted territory. There could be two statutory regulators in competition to provide assured voluntary regulation via different means. Moreover, if the HPC established a new voluntary register, it could be a rival to our own.
The government has created a hybrid in which a statutory regulator (HPC) establishes a voluntary register. Might that be seen as unfair competition? Voluntary registers, whether 'assured' by CHRE or 'established' by HPC will not be given any privileged status in law or employment. Rather the government policy is that employers might choose to prefer those on assured registers over those professionals who are not on assured registers. National professional associations, such as UKCP, get hardly a mention even though they are clearly the traditional holders of voluntary registers of professions. We shall have to be sure that we continue to act in the best interests of our clients/patients, the profession and the public. What now? There is no direct statement about the regulation of psychotherapy and counselling in the command paper.
We have discussed the paper with our contacts, including senior people at the Department of Health, HPC, CHRE and the other professional organisations. (You may be interested in the various statements on the websites of all these organisations.) Taking a very deep breath, we think it is reasonable to conclude: While the previous government were willing to assume statutory regulation was appropriate for psychotherapists and counsellors, the coalition government is not convinced of the case. Psychotherapy and counselling are not dominating thinking; health care assistants, social care workers and Chinese herbalists have, for differing reasons, been given much more consideration. In the case of professions that have previously been recommended for statutory regulation by HPC 'the assumption would be that assured voluntary registration would be the preferred option' (emphasis added). Assured voluntary registers will be preferred over statutory regulation by this government. Assured voluntary registers should be used first, and only if they fail to provide sufficient public protection, would statutory regulation then be considered. There would need to be a 'compelling' overwhelming public protection issue to convince this government to skip the 'assured' register step and go straight to statutory regulation. Issues such as protection of title by statute, and the concomitant push towards APA, will not now be nearly as central.
In terms of what happens now: HPC and those members who are pro-statutory regulation can assess the government's thinking and can therefore decide if and how to make a case for continuing the HPC statutory regulation project for psychotherapy and counselling. Equally, people who want to work on a different national regulatory approach need to decide if and how they intend to engage with the non-statutory options that are now available. UKCP and the other professional bodies in our field could seek to have our voluntary registers given 'assured' status granted by CHRE, working together or separately. Some individual members of UKCP might be interested in a voluntary register established by HPC. Assessment: risks and possibilities We have considered this new situation and our assessment is that it will be very difficult indeed to persuade the coalition government to proceed with statutory regulation. What follows are our discursive thoughts on some of the scenarios we could encounter going forward. We could find that, against expectations, a compelling public safety risk argument was mounted such that the government agreed to place psychotherapy and counselling under statutory regulation. If this happens, then the efforts of the last year will come into their own. We have been in the lead of improving the deal at HPC, and we are ready for APA.
We could find that discussions over our heads between HPC and CHRE lead to one or other of them standing aside in terms of accrediting existing voluntary registers (CHRE) or establishing new ones (HPC). We would hope that UKCP's views would be decisive here. We could find that both the HPC route and the CHRE route are open to us. But it is important to understand - and one can do so even at this early stage - that these are somewhat different animals. HPC would be considering setting up a voluntary register for individuals to compete with those of voluntary professional bodies like UKCP. On the other hand, CHRE would be accrediting the profession-specific registers of professional bodies like UKCP. Employment - a central concern One area where we shall have to be vigilant is NHS and other public sector employment. If there is a job for a psychotherapist or counsellor, then it is likely that, over time, you would have to be on an assured voluntary register. It is not likely to matter which one you are on. And if the job is for a psychotherapist or counsellor then any UKCP member would be as eligible as they are now. But things are not so simple.
What if employers seek to expand their psychological therapies workforce on the basis of a preference for workers who are registered with statutory regulators such as psychologists and arts therapists? That is to say, what if the employers give a thumbs down to assured voluntary registers? They may use the difference between statutory and voluntary to pursue a prejudiced approach towards employing psychotherapists and counsellors. This could happen, though it clearly is not what the government intends. Hence, we will build into our thinking and policy formation a constant attention to the employment angle and to the need for full recognition of psychotherapists and psychotherapeutic counsellors on the part of NHS and public sector employers. This is where the ethos of the majority paying attention to the needs of the minority is so important. We promise to keep employment issues firmly in mind. And, in fact, we have been doing so already, with our work on a new structure for psychological therapies in the NHS and our critique of the National Institute for Clinical Excellence (NICE). Both of these will be widely circulated quite soon.
Conclusion Well, there can't be a conclusion yet, can there? We all need to give these matters the deepest possible thought and reflection, and to engage in creative and respectful dialogue. We are faced with a range of possible scenarios that we cannot really ask you to vote on because it cannot be set up like that when we are faced with government policies. But we can promise that there will be consultation every step of the way. We will keep you informed as we clarify matters and develop our policy.
By all means tell us your reaction to the government paper and this message. Please email firstname.lastname@example.org or share your views on the UKCP website forum at www.psychotherapy.org.uk/discussion_forum.html. Andrew and David UK Council for Psychotherapy (UKCP) 2nd Floor, Edward House, 2 Wakley Street, London EC1V 7LT www.ukcp.org.uk