PMS0007
Written evidence submitted by The National Counselling & Psychotherapy Society
Thank you for the opportunity to respond to the UK Government's consultation about Progress Improving Mental Health Services. The Society appreciates the chance to contribute to the ongoing discussion on this critical issue.
One of the most significant challenges facing mental health services in the UK is the lack of integration of the counselling and psychotherapy workforce within the NHS. Despite the critical role that these professionals play in helping individuals with mental health issues, the NHS has failed to draw on and incorporate this workforce to date.
It is essential that we address this issue and work towards a more integrated mental health service in the UK. The counselling and psychotherapy workforce has the expertise and training to support individuals with a range of mental health issues, from mild to severe. These professionals are also well-placed to work with individuals who may not be suitable for traditional medical-model interventions or who prefer non-medical approaches.
The lack of integration of counselling and psychotherapy services has resulted in significant gaps in mental health provision, particularly for those who may not be able to access or afford private therapy. This is contributing to a significant mental health inequalities issue. Furthermore, given the current mental health crisis facing the UK, it is imperative that we make use of all available resources to support individuals in need.
We strongly recommend that the UK Government takes steps to integrate the counselling and psychotherapy workforce into the NHS's mental health services. This integration should involve collaboration between mental health professionals, including counsellors and psychotherapists, to provide comprehensive and effective care for those in need.
The following is a proposal put together by the National Counselling Society that looks at one way in which the whole mental health workforce could be integrated into the NHS with little additional effort.
Contents
What’s causing the issues with mental health provision?
Limited Access to the Right Support
How can we solve these issues?
Cut Waiting Lists to 1-2 Weeks
Offer Each Person Autonomy and Choice
Provide Access to the Right Support for All
Why Counselling & Psychotherapy?
Accredited Registers Programme
Decades of Research Support Efficacy
Summary
- Mental Health provision in the UK has long waiting lists and poor outcomes due to lack of autonomy and limited access to the right support.
- Short-term cost-effectiveness leads to limited funding for appropriate therapies, despite the long-term costs of untreated or poorly treated mental health issues to the NHS and society.
- Empowering patients to choose their own therapy and therapist from a pool of 60,000+ trained, experienced, and ethical practitioners via the Accredited Register programme would address these issues.
- This approach would cost the NHS solely for each counselling session provided, with no requirement to train, employ, or manage practitioners.
- A ‘right first time’ approach to mental health care could diminish ongoing costs to the NHS and wider society.
The current system for providing psychological/mental health support in the UK is suffering from long waiting lists, a lack of autonomy (leading to poor outcomes for patients completing their course of mental health treatment), and limited access to the right support depending on your presenting issue and location.
The short-term view of cost-effectiveness leading to limited funding for appropriate therapies doesn’t take into account the costs to the NHS that derive from untreated or poorly treated mental health issues such as an increased risk of cardiovascular disease, digestive issues, or certain types of cancer[1][2]; nor does it take into account the societal impact, for example in terms of employment and education opportunities, especially affecting those with low social capital[3][4].
The solution to all of these issues is to empower patients to choose their own therapy and therapist from a 60,000+ strong pool of practitioners who are already trained, experienced, subject to a Code of Ethical Practice, subject to a robust complaints procedure, and who will cost the NHS solely for each counselling session provided (there would be no requirement to train, employ, and manage these practitioners). The ongoing costs to the NHS and wider society would be diminished through utilising a ‘right first time’ approach to mental health care.
What’s causing the issues with mental health provision?
Long Waiting Lists
Long waiting lists are a result of an inability to recruit the huge number of staff needed to address the volume of patients needing support for their mental health. The reasons for this inability to recruit the necessary staff are as follows:
- Having to see a GP First: Pressures on the availability of GP appointments are well known. The current system relies upon a GP acting as a gateway to obtaining mental health services by referrals. An alternative system could bypass the need for GP involvement in many, though not all cases, with the added benefit of freeing up GP time for other medical issues.
- Training and qualifications: Providing psychological therapy requires specialised training and qualifications, such as a postgraduate degree in psychology, or professional qualifications in counselling, or psychotherapy. It can take several years to complete this training, which can create a shortage of qualified therapists.
- Recruitment and retention: Recruiting and retaining qualified staff can be a challenge for NHS Talking Therapies (was IAPT) services. Many therapists may prefer to work in private practice or in other areas of mental health that offer better pay or working conditions.
- Workload and burnout: Providing psychological therapy can be emotionally and mentally demanding work, and therapists may experience burnout if they are overworked or have high caseloads. This can lead to staff turnover and shortages.
- Regional variation: There may be regional variation in the availability of qualified staff. For example, some regions may have more universities offering relevant training programs, or may have more established private practices that compete for qualified staff.
- Funding and resources: NHS Talking Therapies services may not always have sufficient funding and resources to recruit and retain the number of staff needed to meet demand.
Lack of Autonomy / Choice
This is driven by a desire for quantitative data that doesn’t reflect the human experience; a culture of directing individuals down one-size-fits-all treatment routes with no acknowledgement of their preferences or unique needs: specifically, offering predominantly CBT or Guided Self-Help to individuals who are looking for psychological support.
Autonomy and choice are important aspects of patient-centred care in psychological therapy, and a lack of autonomy and choice can have a negative impact on the therapeutic outcome.
When patients feel that they lack autonomy and choice in their therapy, they may be less engaged and motivated in the therapeutic process. This can lead to a lack of trust in the therapist or the therapy itself, which can negatively affect treatment outcomes.
Additionally, when patients do not have a say in their treatment, they may feel that their individual needs and preferences are not being considered. This can lead to a sense of disempowerment and frustration, which again can negatively affect the therapeutic relationship and treatment outcomes.
Research has shown that offering patients more choice and control in their therapy can lead to better treatment outcomes. For example, patients who are involved in shared decision-making with their therapist have been found to have better treatment adherence and improved outcomes in depression treatment. Similarly, giving patients more autonomy and control over their treatment plan has been found to lead to better outcomes in anxiety treatment.
Research clearly demonstrates that the key factors for ensuring positive treatment outcomes are the relationship between the therapist and the client[5], their motivation to work with the therapy[6], and their understanding of the therapy and how it will help them[7].
These findings have strong parallels with the recent approach taken by the Royal College of General Practice, who have published a Person-Centred Care Toolkit alongside NHS England to support GPs and primary care teams to deliver person-centred care[8].
Limited Access to the Right Support
A lack of access to sufficient mental health support can lead to not just worsening mental health, but also worsening physical health, which puts further pressure on the NHS and other areas of society.
The access to high quality mental health care solely for those who can afford to pay privately or are able to access the limited amount of free/low cost mental health provision has led to significant mental health inequalities.
The key factors for limited access to the right support are as follows:
- Barriers to access: There can be a number of barriers to accessing NHS Talking Therapies services, such as long waiting lists, difficulties with referral processes, or a lack of awareness of the services that are available. This can make it challenging for people to access the right support when they need it.
- Limited availability of certain types of therapy: NHS Talking Therapies services may not always have the capacity to provide certain types of therapy that are needed by particular patient groups. For example, there may be a shortage of therapists who are trained in providing specialised therapies for people with complex mental health needs, such as those with severe and enduring mental illness.
- Variations in service provision: There can be variations in how NHS Talking Therapies services are provided across different regions and localities. This can lead to differences in the availability of certain types of therapy or in the quality of care that is provided, which can impact access to the right support.
- Stigma and cultural barriers: Stigma and cultural barriers can make it challenging for some people to access the right support through NHS Talking Therapies services. For example, people from certain cultural backgrounds may be hesitant to seek help for mental health problems due to cultural taboos or beliefs about mental illness.
- Socioeconomic factors: People from lower socioeconomic backgrounds may face additional challenges in accessing the right support through IAPT services, such as a lack of access to transportation to attend appointments.
The current NHS Talking Therapies service alone is evidently not able to provide the support patients need, with 33.7% of patients finishing a course of treatment having shown no reliable improvement[9]. NHS Talking Therapies data shows that 89.1% of patients access their service within 6 weeks of referral, however the data is misleading: they are referencing the initial assessment, which is an approximately 30 minute call with a therapist that allows the patient to outline their issues. It is not a therapy session. The data shows that accessing therapy itself, and the gaps between the first and second sessions of therapy, can in fact be much longer, with 112,026 people looking at delays of over 18 weeks as of November 2022[10].
The recent report on Progress in improving mental health services in England by the National Audit Office on the 9th of February 2023 provides further evidence of the issues outlined here.
How can we solve these issues?
Cut Waiting Lists to 1-2 Weeks
By allowing direct referrals to the 60,000+ counsellors and psychotherapists currently listed on Accredited Registers throughout the UK, 82% of which have a waiting time to first appointment of 1-2 weeks, you would drastically cut waiting times for psychological help. There would be significantly less pressure on the NHS Talking Therapies department to recruit and train Psychological Wellbeing Practitioners – further removing the financial burden on the NHS, as counsellors and psychotherapists pay for their own training.
Figure 1 Data from National Counselling Society survey February 2023
Freeing GP Time and reducing waiting by ceasing a percentage of GP referral gateways
Direct access has the additional significant benefit of freeing GP time and reducing waiting times by meaning that a patient can start the waiting process for talking therapy immediately, rather than starting the process by waiting for a GP appointment first.
Offer Each Person Autonomy and Choice
There is significant variety in the modalities practiced by Registrants on Accredited Registers. For example, our recent survey (February 2023) shows that our members are working with a wide variety of modalities, including person-centred therapy, the humanistic approach, psychodynamic therapy, children & young people work, mindfulness-based therapy, Gestalt therapy, Cognitive therapy, Emotion-focused therapy, Acceptance & Commitment therapy (ACT), Outdoor/Eco therapy, Play therapy, Dialectical Behaviour therapy (DBT), psychoanalysis, Multimodal therapy, Art therapy, Feminist therapy, Rational Emotive Behavioural Therapy (REBT), EMDR, Grief counselling, Addiction counselling, trauma therapy, and so on.
Patients would be able to choose the way of working that best suits them, rather than from a very limited list of therapeutic practices.
It is important to offer people a choice in the kind of mental health support they receive because every person is unique and has different needs and preferences. Providing a choice in mental health support allows individuals to select the type of support that is most likely to be effective and beneficial for their specific needs and circumstances.
Some of the key reasons why offering a choice in mental health support is important include:
Personal empowerment: When individuals have a choice in their mental health support, they feel more in control of their care and have a greater sense of ownership over their mental health and well-being.
Increased engagement: Individuals who have a choice in their mental health support are more likely to be engaged and motivated to participate in their care, which can lead to better outcomes.
Better fit: Different types of mental health support are suited to different individuals and different mental health conditions, so offering a choice helps to ensure that the person receives the best possible support for their specific needs.
Increased access: Offering a choice in mental health support helps to increase access to care, as individuals are more likely to seek out support that they believe will be effective and beneficial.
By offering a choice in mental health support, individuals are empowered to make decisions about their own care, which can lead to better outcomes, increased engagement, and improved mental health and well-being.
Provide Access to the Right Support for All
A personal health budget/social prescribing style of programme would allow people to work with their GP/Link worker etc to determine the best course of therapy for them. They would be provided with the information needed to make a choice, and empowered to choose what is best for them. They could also be empowered to self-refer.
Patients would be able to choose both the practitioner and the type of therapy that would work best.
By using practitioners who already have access to working therapeutically online, the issue of location is removed – a practitioner of your choice will likely be able to provide therapy via remote video or telephone services. Our February 2023 survey shows that 90.5% of therapists now offer counselling and psychotherapy online, alongside other methods such as face-to-face (82.1%) or telephone (60.2%).
This also includes more variety in practitioners who come from a variety of backgrounds, such as Muslim communities, or LGBTQ+ communities – sections of society that can be difficult to attract into NHS programmes, but have undertaken training elsewhere that means they are qualified and eligible for admittance onto an Accredited Register.
Why Counselling & Psychotherapy?
Accredited Registers Programme
Counselling & Psychotherapy in the UK are subject to the Accredited Registers programme – a voluntary programme set up by the Department of Health in 2012 and administered by the Professional Standards Authority (who also oversee statutory registers). The programme has now been running for more than a decade and has become the de facto minimum standard for the profession. Accredited Registers are an excellent benchmark for practice in counselling & psychotherapy, as they enforce strict minimum standards of training, public protection, and ethics, whilst also allowing diversity and creativity to thrive.
Decades of Research Support Efficacy
Unlike the newer psychological professions such as PWPs and CWPs, the professions of counselling and psychotherapy have been supporting the nation’s mental health for decades, and have been considered mainstream practice since the 1950s and 60s. There is a significant amount of research that has gone into proving the efficacy of counselling & psychotherapy. Moreover, recent research shows the pitfalls of the current NHS Talking Therapies provision and how any issues might be ameliorated.
Meta Analysis of Psychotherapy Outcome Studies – Smith & Glass, 1977
The effectiveness of psychotherapy. The Consumer Reports study – Seligman, 1995
Will Publicly Funded Psychotherapy in Canada Be Evidence Based? A Review of What Makes Psychotherapy Work and a Proposal – Tasca et al, 2018
Examining the Relationship between Choice, Therapeutic Alliance and Outcomes in Mental Health Services – Stanhope et al, 2013
Depression in adults: treatment and management - NICE guideline [NG222]
Factors Influencing Successful Psychotherapy Outcomes – Lynch, 2012
What are the next steps?
Adopting a policy based upon the research above would have a hugely positive impact on many different areas of society – not only can it save much needed money at a time of increasing costs, but it can provide a significantly improved service in terms of waiting times, choice, and autonomy to patients in need of mental health support.
- Use the Accredited Register programme combined with a model such as Personal Health Budgets/Social Prescribing to increase access to mental health support
- Reduce training/employment burden on the NHS
- Reduce waiting times to 1-2 weeks
- Increase access to therapeutic modalities, based on patient preference
- Increase patient empowerment, motivation, and engagement in their own care
- Support patient-centred care initiatives
- Reduce spending in short, medium and long terms
April 2023