Greater investment in psychology, social workers, therapists
Central to my proposal is the recommendation that we significantly increase the number of people skilled in psychosocial interventions and, vitally, psychosocial approaches to mental health and well-being. This is very much the province of the IAPT - Improving Access to Psychological Therapies - programme that I discussed in Chapter 4. I discussed, earlier, how my proposals differ from the IAPT programme in significant ways. But some lessons can be learned from their health economic arguments. I agree with Lord Richard Layard that a reasonable target for the UK should be to increase the number of people capable of offering psychological and psychosocial help by an extra 10,000.6 However, in the vision I am offering here, I would not expect all 10,000 to be new employees of the health and social care system. Many would be people who had worked in the old system and then re-trained in the approach outlined here. We need to separate the costs of employing new, additional, staff from the costs of re-training existing staff.
Although we need more people qualified and available to deliver the range and scope of evidence-based psychosocial interventions discussed in the previous chapter, this does not mean simply employing many more people in addition to the existing staff (which would be very expensive indeed) or laying-off large numbers of people in order to change the staffing profile. In our vision, we would take a large current workforce of medical and nursing colleagues, and transform them to a large, effective, humane workforce working in genuinely multidisciplinary teams. This should happen in the context of a major change in ethos. We are not only proposing transferring people from NHS employment to local authority employment (from governance by the CCGs, the clinical commissioning groups, to HWBs, health and well-being boards, in arcane UK governance speak) but also explicitly re-orienting their work and retraining. The current focus on medical ideology, the 'disease model', diagnosis, and medical treatment is part of the problem. In the current, 'disease-model' framework, it seems to make sense to spend a very great deal of money on people employed to deliver medical care. But we are suggesting something very different. Instead of 'nursing' or 'medical' staff, we would see a great deal of the day-to-day care delivered by staff trained primarily in psychological and social care. That would mean re-training existing staff (particularly nurses) as CBT therapists, social pedagogues, and (properly trained, properly supervised) experts in the wider range of interventions discussed earlier. We would like to see residential centres ('in-patient units') being places of safety and calm; drawing much less on the tradition of medical wards. In particular, any reduced reliance on coercion in mental health is likely to result in significant cost savings - it is very expensive to provide coercive care, with the heavy reliance on high staffing levels and physical security. But in the vision of care we are proposing here, medical doctors would still be available for consultation about prescribing, as would pharmacist colleagues - whom I've always regarded as crucial members of any team that involves prescribing decisions; pharmacists are (excuse the pun) indispensible!
That would take some training resource, but it wouldn't mean more staff. It is clear that there are opportunities for leadership by clinical psychologists in these proposals. But the proposal is not in fact that everybody should have one-to-one psychotherapy from a large new cohort of clinical psychologists. We are, at most, suggesting that psychologists help to coordinate care - with social workers as well as clinical psychologists taking a very clear lead on these issues. We are not suggesting that we need clinical psychologists to deliver every aspect of the social and psychological care described earlier. Many of my colleagues would like to see clinical psychologists leading these changes - offering clinical leadership in community teams, developing multi-factorial, multi-agency formulations, and in leading, training and supervising CBT therapists. This would apply, of course, in residential units, where again our skills in formulation should come to the fore. This, in my opinion, would also apply to care offered under a Mental Health Act (so long as this was predicated, as I have argued earlier, on the principles of autonomy, decision-making capacity and legal oversight) and where clinical psychologists and nurses already have the responsibility to coordinate care.
Nevertheless, there are training costs, and it would be remiss to ignore the benefits of greater investment in properly qualified staff.