Written evidence submitted by the British Psychological Society (RTR0135)

This submission sets out the British Psychological Society’s (BPS) key recommendations to the Health and Social Care Select Committee’s inquiry on Workforce: recruitment, training and retention in health and social care. The BPS is the representative body for psychology and psychologists in the UK, and is responsible for the promotion of excellence and ethical practice in the science, education, and application of the discipline.

As a society we support and enhance the development and application of psychology for the greater public good, setting high standards for research, education, training and knowledge generation, and disseminating our knowledge to increase public awareness.

For enquiries regarding this submission, please contact:

Hannah Randle

Public Affairs Manager

British Psychological Society

Introduction

1. Expansion of the psychological workforce is key to the delivery of the NHS Long Term Plan, in which it was made clear that the expansion of the psychological workforce within the NHS is imperative to the continued effective provision of services.[1] A key element of meeting service demand is workforce investment, with psychologists and the other psychological professions playing a pivotal role in the provision of services both in the NHS and in the wider workforce. A properly funded and resourced workforce is integral across both mental and physical health services.

2. The challenges facing the health and social care sectors have been undoubtedly exacerbated by the pandemic. Society as a whole has suffered the impact of lockdown, many have experienced trauma and loss, and the already significant pressure on NHS and other frontline staff has further increased. The importance of the role of psychologists and the psychological workforce, particularly in relation to Covid-19 and the recovery, is more apparent than ever.

3. Through the course of this submission, we are considering two key areas: the recruitment and retention of psychologists, and the role of psychologists in supporting the retention of the wider NHS workforce. We make a number of recommendations to the Committee that we believe would improve the recruitment, training and retention of the psychological workforce within the health sector. These recommendations include that:

• all practitioner psychologist routes should have funded options available for postgraduate training;
• funding decisions for training places are made much further in advance, whilst still leaving some scope to amend numbers depending on evidence-based need;
• there needs to be further opportunities for growth in the wider psychological workforce to support and deliver services;
• the down banding of practitioner psychology posts should cease and opportunities for appropriate re-banding of roles made available to help with the retention of staff;
• all trust boards should have psychological representation, with the introduction of a Director of Psychological Therapies position at board level; and
• an England-wide wellbeing strategy should be implemented as a matter of urgency to ensure a thorough and consistent approach to the provision of support to staff.

Recruitment

4. Staffing services has, to date, proved challenging. Psychology is one of the most popular subjects to study at degree level: over 24,000 students were accepted onto UK undergraduate courses alone in 2019, accounting for one in 20 students.[2]  However, while demand for their skills is increasing, there have been difficulties in ensuring a sufficiently diverse and adequately supplied workforce. Postgraduate qualifications are required and are often self-funded, and therefore less accessible to those from a lower socioeconomic group.[3] It is important to recognise the distinctive and complementary functions and responsibilities of different practitioner psychologist roles. To reduce gaps in the workforce, we recommend that all practitioner psychologist routes should have funded options available for postgraduate training.[4]

5. It follows on that recruitment is difficult largely due to a lack of trained people available. In recent years there has been a significant expansion of psychology posts but difficulty in recruiting with one in seven posts unfilled.[5] We know from the experiences of our members that there are areas where there are particular concerns regarding recruitment and the subsequent ‘unrealistic expectations on staff.’ For example, these issues are particularly acute in, although not unique to, children and young people’s services. Children’s mental health services can often only take the most severe cases, meaning that staff are under pressure to take a high volume of complex patients and without time to allow for other aspects of the role. Children in England have some of the worst health outcomes in Europe.[6] Pre-pandemic the number of 5-16 year-olds with a mental health problem had already increased to an estimated at 1 in 6.[7] Despite greater investment, NHS services are worryingly overstretched, and due to consistent cuts over the last ten years early intervention services have been eroded. Overstretched services tend to lead to staff burnout, which ultimately has a negative impact on the number of vacant posts. The pandemic has worsened a system that was already under great strain. A recent survey has shown that more than 33% of children and young people aged 11 – 18 feel their mental wellbeing has worsened since the pandemic.[8] 

6. Given that half of all mental health problems manifest by the age of 14, and 75% by the age of 24[9], a failure to provide and invest in high-quality mental health interventions before age 25 creates significant risks for long term social and health outcomes, creating a subsequent economic impact. Additional funding announcements dedicated to children’s and young people’s services made by NHS England this year have been welcome. There is however still a significant gap that needs to be filled in order to ensure that the services and resources, including the workforce are there to ensure that children and young people can access the help that they need. Additionally, the workforce will require support through training, supervision and facilitation of peer support networks.

7. This expansion of roles in the psychological workforce is very much representative of the need for psychological skills across the health sector. However, we are concerned that these new roles may not fit the limited range of post titles used historically and this therefore requires a more careful consideration of the necessary skills to open up the pool of candidates who could best meet the requirements of the post. An audit of psychology job adverts[10] conducted for the BPS showed that 66 per cent of jobs in the NHS were advertised for clinical psychologists. Clinical psychologists make up 57 per cent of HCPC regulated psychologists. Only 13 per cent of jobs were advertised so that psychologists of any domain could apply. Further to this, in almost a third of advertisements, the job title did not match the essential criteria on the person specification. The principal and most effective ways to meet workforce demands are increasing training numbers and funding, and advertising job roles in a different way does not offer a single solution. However, we believe it could have some impact as part of the bigger picture. As such, we recommend that advertisements for psychologists are competency-based, using the appropriate title(s), based on the competences required to deliver the duties of the post. This will normally be an inclusive title such as applied psychologist/practitioner psychologist/registered psychologist; that the advertised job specifies the context of the role (e.g. Child Mental Health, Diabetes Service, etc.) and; that the recruitment process includes a review of the essential and desirable criteria in Person Specifications to ensure they do not inadvertently exclude HCPC registered practitioner psychologists whose skills, knowledge and training would be appropriate for the advertised job role/s.

Training

8. The NHS Long Term Plan made it clear that there is a need to increase the number of places for 2021 entry, and increase further for 2022 entry[11]. We welcome that Health Education England (HEE) has increased Clinical Psychology training places to meet the demand outlined in the NHS Long-Term Plan.[12] At the time of writing, HEE has not yet been given a settlement for the 2022 intake, so the number of training places available and the impact of those potential trainees moving up through the workforce pipeline isn’t yet clear. We recommend that the funding is released to meet training numbers and that in order to improve service planning, funding decisions for training places are made much further in advance, whilst still leaving some scope to amend numbers depending on evidence-based need.

9. In addition, there does not appear to be clear guidance around the numbers of Practitioner Psychologists in posts per size of the local population. Given that different services use their budgets in different ways, without an overall England-wide strategy, there are discrepancies in how psychology services are resourced: in some areas psychology is adequately resourced, and in others it is not.[13] An example of this can be seen in physical health. We believe from speaking to our members that some of the psychological needs in physical health, such as in renal and cancer care, are not considered fully in the Long-Term Plan and the need for care is in all likelihood underestimated.  This is particularly true for integrated psychology services, which complement Improving Access to Psychological Therapies (IAPT) services. Subsequently, there are gaps in services. We recommend that there needs to be more guidance as to the numbers of Practitioner Psychologists required in posts in each area. Benchmarking already exists for some conditions. This should be expanded to a wider range of areas and co-created by psychologists, medical colleagues and service users.

10. The NHS Long Term Plan is driving many of the changes required in the wider psychological workforce, with its focus on increasing access to mental health services. The BPS is developing apprenticeship routes into the wider psychological workforce both to fill workforce gaps and open up opportunities to work in the NHS to a broader range of people. For those areas that we know have had difficulties in attracting workforce, such as the intellectual disability specialism, it would be helpful to explore the expansion of roles including the Clinical Associate Psychology (CAPs) in order to attract a greater number of candidates. These roles need to be supported and supervised by appropriately qualified senior colleagues. As well as a greater number of funded routes in to the profession, in order to increase workforce diversity, we would like to see further opportunities for growth in the wider psychological workforce to support and deliver services.

11. The recruitment of psychologists from diverse backgrounds is an area where we need to see significant improvement. We know that certain minority ethnic groups are less likely to progress in a psychology career than others. For example, those with Black or Asian ethnicity going to university are similarly as likely as those with White ethnicity to study psychology and work in NHS psychological professions. However, they are far less likely to be more senior NHS roles and be accepted onto a clinical psychology training course.[14] This is clearly at a detriment to the profession representing the communities it services.

12. We believe it is important that the curriculum on all training courses is regularly reviewed to ensure that it evolves to meet new demands, and that this requirement should be part of the accreditation process where possible. As part of this process, trainee psychologists should gain experience in working in a variety of areas, including those where there are greater difficulties in recruitment, to dispel myths and promote choice in speciality on qualification. It is important to note however, that a key issue in training is the availability of placements due to a lack of potential supervisors is some areas.

13. Covid-19 has produced a profound shift in practice, with an increased number of services being delivered remotely. Services have had to adapt, and we have examples from our members where services have, for example, sought to use apps and online resources to support patients. However, we believe there needs to be further training available to support psychologists to use technology effectively and to the best advantage of patients. Despite this, there is very little training to support psychologists in using technology.  Similarly, many patients need support with technology to be able to properly access available services. In order to improve digital inclusion, we believe investment in ‘IT enablers’ would benefit both staff and patients to make the most effective and efficient use of technology to the wider benefit of the provision of services. We welcome the opportunities for patient choice and flexible working that come with the advancement in the use of technology in the profession.

Retention

14. According to Clearing House for Postgraduate Studies in Psychology, for the clinical psychology postgraduate course specifically, retention is incredibly high. The national non-completion rate for NHS clinical psychology trainees for the academic year 2019/2020 was only 0.4%, which includes both people who withdrew and people who failed. This is slightly lower than the rates for the previous 10 years of between 0.5% and 1%.[15] Not only is retention high on the programme, retention in to the NHS is also high. For people completing NHS training in 2020, (of those who returned data) 95.3% took up employment as a clinical psychologist (or in an equivalent post) within 12 months of graduating. This is in line with the rates for the previous 7 years which were between 92.0% and 96.8%. Of those working as clinical psychologists (or in an equivalent post) 98.0% were working in the NHS or in other public sector funded posts. This is slightly higher than the rates for the previous 7 years which were between 92.3% and 97.0%.[16]

15. We have heard from a number of our members however that anecdotally, more recently across NHS Trusts in England, we are seeing a greater number of practitioners leaving the NHS for development and promotion opportunities once they are further on in their careers. Due to a flattening of hierarchies, ‘downgrading’ across the Band 8 grades, and the virtual disappearance of band 9 posts[17], we are seeing people ‘get stuck’ with little opportunity to further develop their careers within the structures of the NHS. This ‘downgrading’ of bands – where the Agenda for Change pay band for a post is reduced – has led to practitioners needing to leave the NHS in order to progress. This is not a new problem and is an issue that the trade union Unite has raised extensively over the past ten years.[18] We recommend that halting the ‘downgrading’ of posts and creating a greater number of opportunities for the re-banding of roles in order to help with the retention of staff, particularly as they progress through their careers. Softer work rewards such as protected time and additional funding for training and CPD, clear job plans to maximise impact and ensure balance, and adopting flexible working policies are ways that the NHS can offer more favourable conditions. 

16. It is also essential that the skillset and experience set for specific roles is at the correct Agenda for Change band. We have heard from our members of instances whereby standalone psychological roles in medical settings, whilst commissioned with the best of intentions, are sometimes employed at a lower band than appropriate without an adequate structure in place, such as supervision, management or professional network.[19]

17. Long-term retention is, we believe, less dependent on the postgraduate course undertaken by practitioners, and more dependent on the structure of the NHS. In order to ensure that the needs of psychology services and the psychological workforce are properly considered in strategic service decisions, we recommend that all trust boards should have psychological representation, with the introduction of a Director of Psychological Therapies position at board level.

Staff wellbeing and support

18. Stress-related sickness absence is already at a higher-than-average level in the NHS when compared to all job sectors across the country. Stress, alongside anxiety and other psychiatric illnesses, is consistently the most reported reason for sickness absence in the NHS, accounting for over 511,000 full time equivalent days lost[20] costing the NHS up to £400 million per annum.[21]

19. For health service staff and those working in other frontline services, psychological welfare needs to be a high priority, with the required funding in place to ensure that support can be given. A rise in the number of staff experiencing stress is understandable as the NHS has worked in emergency mode during the Covid-19 pandemic, but the further increase from 40.3 to 44 per cent of staff experiencing work-related stress is the continuation of a long-term trend.  The likelihood of staff burnout will only increase as the effects of working through a pandemic become more apparent, and there is a particular risk of psychological difficulties for the 40.3 per cent who were experiencing stress before the pandemic.

20. As the country moves towards a reduction in Covid measures, it must be recognised that this will not equate to a reduction on the intense – and unsustainable - pressure on those working in the health service, many of whom have been working in emergency mode since the beginning of the pandemic. We are particularly concerned to hear from some of our members working within the NHS about the cancellation of annual leave requests over the past two years, as well as a lack of access to basic services during the working day, such as access to rest areas. We recommend that an England-wide wellbeing strategy should be implemented as a matter of urgency to ensure a thorough and consistent approach to the provision of support to staff. Psychologists have a key role to play in the provision of an integrated system of support, alongside colleagues from other disciplines, such as HR, and their involvement will reinforce the retention of the psychology workforce, as well as the wider NHS workforce.

21. Psychologists have played a vital role in setting up and delivering psychological support to individuals and teams. However one of the problems is that these services have been set up with staff on short term contracts which has made recruitment and retention problematic. This support will be required on a long term basis and the posts should be made permanent and where they have been the recruitment and retention problems have been resolved. To protect the future psychological wellbeing of frontline staff and access to services for those who need it most, psychologists should be involved at all levels.

Conclusion

22. At such a critical time for the health service as a whole, it is essential that the focus remains on delivering the workforce that has been well-planned. As new organisations are formed within the NHS, it is vital that these fundamental changes do not interfere with the workforce plans already in place. In these changes, consideration must also be given to the organisational position of psychology in leadership, for the benefit of the wider NHS workforce. 

Jan 2022