The experiment with providing counselling to one in 30 people – Improving Access to Psychological Therapies [IAPT] – appears to have broken the mental health of many NHS therapists themselves.
"The idea of a competent practitioner being somebody who’s invulnerable is a myth.”
With the NHS’ new ten-year plan backing expanded access to IAPT, former counsellor Philip K. Marzouk speaks to some of those involved in and impacted by an often-heralded initiative.
The latest figures from the Mental health statistics for England briefing report put the number of referrals through the Improving Access to Psychological Therapies (IAPT) programme at 1.4 million in 2016/2017. That’s three in every 100 people. Services are under immense, increasing pressure to the extent that staff are now running for cover.
Department of Health and Social Care figures from September 2018 showed that 2,000 mental health staff are leaving NHS services per month, increasing waiting times to up to 18 months for low intensity care and up to four months for high intensity cases. People at severe risk are being left without appropriate treatment because services simply don’t have the staff to cope with referrals. Things are set to get worse as, according to NHS Digital, mental health trusts have hired only 1,524 extra personnel since July 2017. The government is way behind its target of hiring 21,000 extra personnel by 2020.
Staff wellbeing in NHS mental health services
The New Savoy Partnership (NSP) are among those convinced the mass exodus is an issue of staff wellbeing. The NSP was initially set up in 2007 as an advocacy group to persuade and ensure that UK governments recognised the value of psychological therapies and increased their provision on the NHS. However it has now shifted away from advocating for therapies and towards ensuring the wellbeing of staff within NHS services, after observing the impact the weight of demand for counselling has had on therapists and supporting staff.
Since 2014, the NSP have been conducting annual surveys with mental health staff to assess national staff wellbeing within NHS services. The figures are remarkable. In their latest survey, NSP found that 43 percent reported feeling depressed in the prior week; 42 percent reported feeling like a failure in the past week; 72 percent think that the service they work in was understaffed and not fit for purpose; and 23 percent were actively considering leaving the NHS. These figures have been broadly consistent since 2014.
NSP’s founding chair, Jeremy Clarke, was a national adviser during the roll-out of IAPT services in 2007, yet he has become critical of the service and is working to limit access to it. “[Staff] were trained as professionals but they felt the whole IAPT system was reducing them to a cog in an industrialised process. That was one of the more demoralising aspects: they’re having to deliver the throughput of numbers and not really do the job they were trained to do. IAPT needs to develop a different form of quality improvement by enabling teams to come together and figure out their own ways and own solutions to these problems.”
Is NHS England receptive to restricting or reforming IAPT?
Describing IAPT as “too big to fail”, Clarke is sceptical. “We met with Claire Murdoch [NHS England’s Mental Health Director] and the senior people, but apart from just a few warm words of, ‘Yes, we take the results of your survey very seriously. We should work together’ they haven’t actually worked with us at all on it. They would rather we go away, shut up and not do the survey.”
NHS England is failing to lead and leadership issues are trickling down to trusts. Within the NSP’s latest survey, they also found that 33 percent of respondents had seen their service lose senior staff due to reorganisation in an attempt to cut costs.
Dr. Amra Rao, a clinical psychologist and one of the researchers for staff wellbeing at the NSP, told this journalist that pressures are forcing well-trained leaders out, to be replaced by more junior staff who receive no extra pay for their extra work: “Many leaders have taken redundancies or they have taken early retirement. In psychological services at the moment the leadership is quite fragile.”
This speaks to NHS England’s approach to the crisis: to them, staffing is a revolving door. Their approach is if someone is unwilling to do the job, they’ll find someone who will for less pay. People are concerned about their job security which is leading them to take on more than their pay-grade or training mandates, Dr. Rao says. “There is an increasing level of competition between people. People are really fighting for their own individual survival rather than thinking about what’s happening to the team.”
This has encultured fear of stigma in practitioners and makes them unwilling to speak out about any difficulties they’re facing. “[Therapists] think it says something about their competency and capacity and people are very fearful of being struck out, adds Dr Rao.”
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The role of clinical supervision in staff wellbeing
For many practitioners and academics, the answers lie in ensuring the NHS has adequate clinical supervision in place. “There’s a lot of people trying to do things briefly and without sufficient support,” says Dr. Terry Hanley, Senior Lecturer in Counselling Psychology at the University of Manchester. “The combination of trying to do too much, in too little time, with too little support… I think having more people supporting the supporters seems logical.”
Dr. Hanley stressed there are organisations that do have adequate support in place, but these primarily exist in the private and third sectors. One such organisation is that of Bradford-based clinical psychologist Dr. Rufus May, who ensures his private practice does what the NHS does not: “Once a week we have a support group for staff. Sometimes people just need to off-load a bit… The idea of a competent practitioner being somebody who’s invulnerable is a myth.”
Invulnerability is exactly what the majority of NHS services currently demand. Ray Woolfe, a now retired psychologist, argues that pressure and budget cuts have shifted the role of the supervisor in NHS services. “Supervision has just become case management, not about what the clients need, how best to help them.”
And this is the crux of the issue at hand: the NHS workforce is being so restricted and damaged by current practice and a lack of resources that it is impacting clients. Beyond the mass exodus of staff and ever increasing waiting times, there is a high chance that when a client finally sits down with an NHS mental health professional, that person will be carrying the stress and burden of a reticent and antagonistic system on their shoulders. The NSP will be releasing their latest survey statistics in March, but the NHS’ ten year has just been released and workforce concerns have hardly been reflected. Mental health policies need to work for staff in order to work for them to work for clients and patients.
* NHS England did not respond to an approach from Philip K. Marzouk for comment.