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Project to understand and potentially strengthen the influence in policy of applied psychologists in London

Contract reference: RH/TR 2015

Date: 8th July 2016

Report prepared by: Anne Richardson, Director Anne Richardson Consulting Ltd

Oversight: Rod Holland, Chair of London Regional

Psychology Advisory Committee, Zenobia Nadirshaw and Alison Beck (DCP chairs) Richard Pemberton, National DCP

Date of report: 15 June 2016

ANNE RICHARDSON CONSULTING LTD EXPERIENCE, KNOWLEDGE AND EXPERT ISE IN MANAGING RISK

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1. INTRODUCTION

To help to understand and potentially strengthen the influence in policy of applied psychologists in

London, the London Branch of the Division of Clinical Psychology (DCP) in consultation with the

London Regional Psychologists Advisory Committee (RPAC or LRPAC) commissioned a piece of work

during 2015 from Anne Richardson1,2. This involved a series of semi-structured interviews with

senior applied clinical and academic psychologists in London, all of whom had a strong reputation for

effectiveness in influencing policy and a record of success in service development, and two

workshops with trainees. The aim was to understand opinions and get ideas for strengthening the

resources and skills potentially available for others in London to develop their competence. This

report summarises the results of the interviews, and makes several recommendations for DCP

branch and LRPAC (now the London Strategic Network for Clinical Psychology) to consider.

2. BACKGROUND

Senior applied psychologists working as heads of department of psychology in London have been

meeting under the auspices of LRPAC since at least the late 1970s to discuss issues of common

interest for their work in health and social care. The DCP branch, along with other branches across

the country, had recently been re-structured. Planning meetings included Rod Holland (LRPAC chair),

Zenobia Nadirshaw (DCP chair) who was then replaced by Alison Beck, and Richard Pemberton chair

of the BPS UK DCP. Further information about the local and national context for the work is provided

in Section 5.

3. METHODOLOGY

A meeting in October 2015 formed the basis for taking forward work to interview a number of senior

Clinical Psychologists (`the experts’). All the names3 of those interviewed were either suggested at

the scoping meeting and/or approved by the RPAC and DCP chairs as having had a notable record of

success in influencing local or national policy. Most were, or had until relatively recently been based

in London.

A brief review of written material was undertaken, including information from the workforce review

undertaken by Alison Longwill for the BPS4 and material relating to the planning and commissioning

structures at local, regional and national level. Semi structured interviews with individuals and two

workshops with final year students (`the novices’) in London and Oxford were then undertaken to

cover the following broad categories of information:

Personal experience/examples of influencing policy (effective and ineffective).

1 Anne Richardson worked in government at the Department of Health as head of mental health policy, and in 2008 at the

Audit Commission as Head of Mental Health. Employed as a clinical psychologist in London prior to this, including as Head of Department in Newham, she also worked at UEL. In 1987 she helped to establish the new doctoral training programme at UCL, subsequently becoming joint course organiser. Since 2010 she has worked as one of a number of providers commissioned by NHS England of investigations into homicides by people with mental ill health. 2 BPS contract Reference: RH/TR 2015

3 Professor David Clark, Professor Peter Fonagy, Dr Alison Beck, Dr Rod Holland, Professor Zenobia Nadirshaw, Professor

Anthony Roth, Dr John Cape, Dr Ravi Rana, Dr Duncan Law, Dr Neil Ralph, Ms Wendy Wallace, Dr Michael Witney, Dr Lucy Marks, Professor Jamie Hacker-Hughes. 4 Available from the BPS.

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Common themes, if any (e.g., training timing, culture, organisational structure)

Personal skills (e.g., attitudes, knowledge, behaviour, listening and communication).

The origins of competence (motivation, modelling, formal learning, incentives, rewards)

Developing competence in others (training, mentoring, leadership)

Obstacles and opportunities

Theoretical underpinnings (if any) and further reading

Issues for London

Models of good practice (if any)

Role of the BPS and DCP

Limitations of time alongside the fact that the work coincided with NHS annual planning deadlines

constrained the original plans to also interview a sample of commissioners and Chief Execs from the

NHS. The views of the psychologists are therefore presented alone.

4. CONTEXT

Home to many policy hubs and national centres of excellence and the centre of national

government, London has arguably presented applied psychologists with some very particular

challenges. For example, the capital contains the centre for government, the (now much reduced in

size) Department of Health and the London office of NHS England5 and it is also home to a number

of major national centres of excellence in health-related teaching, research and care. London also

faces particular population health-related challenges6, many of which are the focus for work by the

Mayor’s office. However, issues well beyond the boundaries of London were also discussed and four

of these provide important context for the work; each has contributed to the challenge that Clinical

Psychologists face to engage with and influence policy.

4.1 Health service reorganisation

In the past, a significant level of policy support for matters of interest to psychologists was provided

by experienced psychologists7 at the Department of Health working alongside medical, nursing and

other professional colleagues, civil servants and Ministers. Now, profession-specific representation

at the centre has gone and the Department is downsizing further as NHS England’s role grows. At

the same time, the Health and Social Care Act (2011) has secured devolution of responsibility to local

level for large proportion of health service commissioning, provision and assurance. Psychologists

can no longer rely on the relatively few professional colleagues with connections at the centre to

influence policy on their behalf. Instead, regardless of their knowledge and experience, many more

psychologists are being challenged by local decisions which affect their work and many feel that they

lack relevant knowledge, confidence and skill.

5 NHS England – the national commissioning wing of the NHS – is based in four regional offices: London, Midlands and East,

North and South (27 Area teams ceased to exist w.e.f. April 2015). NHS England liaises with Clinical Commissioning Groups, local authorities, health and wellbeing boards and GPs and provides professional leadership for finance, nursing, medical, specialised commissioning, patients and information, human resources, organisational development, assurance and delivery. The London office maintains oversight of over £15bn of services for over 8 million people. 6 London contains The London Health Commission, the London Assembly Health Committee which oversees the Mayor’s

Health Inequalities Strategy, the London Health Board, the London-wide Clinical Commissioning Council (all part of the Mayor’s Office), and many leading London-based national centres for NHS treatment and care (e.g., GOS, RNH, etc). 7 May Davidson, Ed Miller, Glenys Parry.

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4.2 BPS and DCP reorganisation

In the wake of the establishment of the Health and Care Professions Council (HCPC), there has been

discussion about the structure and function of the British Psychological Society (BPS) and the DCP.

The HCPC is one of nine councils (perhaps to be further reduced in number8 in the future) carrying

responsibility for setting standards for qualifications, dealing with concerns about professional

behaviour such as fitness to practice or misconduct and maintenance of the register of individuals

approved to practice. For Clinical Psychologists, these were all areas formerly managed by the BPS.

Questions have therefore been asked about how the BPS might now be organised, and what its main

functions should be. There is clearly division of opinion about how Clinical Psychologists should be

represented and whether support for and development of policy in this area is working effectively. A

resolution at a Special General Meeting of the DCP9 expressed grave concern about the way the BPS

has provided professional leadership, direction and strategy in the past and discussion continues

about the best organisational arrangements going forward.

4.3 Austerity in the NHS

Austerity and other measures within the NHS have had a major effect10 upon the way in which

decisions about local health policy are now taken. Furthermore, the economics of care, rising care

costs, and rising demand for care has led to significant service cuts in many areas. An analysis of over

a thousand responses from Clinical Psychologists to a survey undertaken by Alison Longwill (2015)

for the BPS, showed widespread concern about the impact of austerity on recruitment and retention

to posts at the upper end (Band 9) of the pay scale. There have been reports of down-banding for

some senior posts and some evidence of an increase in fixed and short term employment contracts

and locum work. One or two very senior Clinical Psychologists11 have been made redundant. It is

possible that the absence of senior, more experienced Clinical Psychologists in management roles

has left more junior staff uncertain about how to influence policy or participate in management

decisions.

4.4 Agenda for Change

Agenda for Change12 provides the background to changes in the way that Clinical Psychologists are

graded and its impact has been quite significant. It is a fundamental tenet of Agenda for Change that

remuneration and grading for jobs is based not upon the qualifications of the individual employee

but rather upon the nature of the job. Not only are comparisons between professions much easier to

make, but there is more competition. For example, when Agenda for Change was initially

implemented, salaried trainee Clinical Psychologists (unlike nurse trainees in receipt of bursaries)

8 Regulation of Health Care Professionals. Regulation of Social Care Professionals in England (April 2014) Cmd 8839

presented to Parliament by the Law Commission (345), Scottish Law Commission (237) and N.I. Law Commission (18). ISBN 9781474101837. http://lawcommission.justice.gov.uk/areas/Healthcare_professions.htm 9 Motion proposed by Prof Mike Wang and Dr Bernard Kat at a SGM of the DCP May 2016, supported by the majority of

those present, that the BPS was failing to meet the professional needs of Clinical Psychologists. More information is available from mw125@le.ac.uk 10

Kings Fund Briefing (2015) Gilbert, H. `Mental Health Under Pressure’ http://www.kingsfund.org.uk/ 11

Doncaster. 12

Agenda for Change (2004) is a framework for remuneration based upon assessment of job responsibilities rather than individual qualifications which brought together into a single structure all salaried non-medical or dental NHS staff and all (except the most senior) managers.

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who transferred to the new arrangements received significant increases in their pay13. This meant

that more experienced nurses competing at the same pay grade often appeared to offer much

better value for money. In addition, although perhaps not as a direct consequence of Agenda for

Change, more Clinical Psychologists are now working in multi-disciplinary teams alongside other

professionals and many more are taking on generic roles as managers of therapy services. It is

difficult to see this as anything other than a positive development for the NHS as a whole and the

individuals concerned say it has opened new career opportunities for them. However, they were

doubtful about the reaction of the profession as whole. Together with widespread variation in

access to therapy services, staff shortages and problems of low morale, it seems clear that the need

to get more rather than less involved in policy issues is challenging.

5. THEMES EMERGING FROM INTERVIEWS

5.1 Theory

5.1.1 The theory, such as it is, concerned with developing influence over NHS policy or other decision

making has a long if not always very respectable history14. Like Dale Carnegie who achieved huge

popular success with his book `How to win friends and influence people’ there has been a reluctance

to consider advocates of models of organisational change as part of mainstream Clinical Psychology,

even though their writing is popular. To some extent, this is not surprising. It has been developed in

large part alongside support for management and organisational change in the NHS15; it is

characterised by language and terminology which owes more to campaigning and political

imperatives than to recognisable theory (e.g., “the helicopter view for doing things better”; “Project

management in policy” “linear delivery cycles” “Achieving dynamic stability”, etc). Whilst there are a

number of very reputable consultancies providing support for organisational change whose work is

very soundly embedded in evidence (e.g., Philip Stokoe16 or The Tavistock17 courses on leadership,

Board and team functioning) it is not unusual for much of the work to mix personal, social and

communication skills with advice on personality, personal learning styles, team structure and

management methods and it arguably lacks theoretical coherence.

5.1.2 It is therefore possible that success in influencing policy, or of leadership and management

with which policy success is commonly linked, fails to hold the same attraction for Clinical

Psychologists as clinical work, research or teaching because it also lacks academic value. If so, Clinical

Psychologists could be counted alongside doctors (although perhaps not nurses) about whom the

same general conclusion could be drawn. For example, a doctor working in management is not as

well respected by his/her profession as a surgeon or a researcher. For Clinical Psychologists, this may

have implications for the way that they think, train and write about the profession. It may also have

13

Turpin, G and Llewellyn, S (2009) Chapter 29 `Development, Organisation and Dilemnas’. In Clinical Psychology in Practice Beinart, H., Kennedy P., and Llewellyn S (eds). The British Psychological Society and Blackwell Publishing Ltd. ISBN 978-1-4051-6767-3. 14

Dale Carnegie (1937) `How to Win Friends and Influence People’ Simon and Shuster. ISBN 1-4391-6734-6 15

NHS Leadership Academy www.leadershipacademy.nhs.uk Leadership and organisational development at the King’s Fund: www.kingsfund.org.uk NHS Institute for Innovation and Improvement www.institute.nhs.uk (now closed) Commissioning Support Units (CSUs) www.england.nhs.uk/commissioning and other independent providers of teaching and training such as the Work Foundation at www.workfoundation.com and NHS Employers at www.nhsemployers.org 16

http://www.philipstokoeconsultancy.co.uk/ 17

http://www.tavistockconsulting.co.uk/

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implications for the way that the professional body, the BPS, represents the breadth and depth of

work undertaken by its practitioner members.

5.1.3 Some exceptional examples of how theory can be helpful are provided by Susan Michie18 and

colleagues who write cogently about impediments to the implementation in practice of policy

guidelines. Pendleton and Furnham’s book was also recommended19 by several experts, as was the

work of Graham Thornicroft20 and Michele Tansella who describe translational roadblocks that delay

the transfer of knowledge `from lab to life’ or from `bench to bedside’. They identify obstacles such

as the degree of flexibility in how policy information is drafted; its brevity; the reputation of those

promoting it; the time requirements; the determination of the `change agent’ to repeatedly urge its

use, and the rewards and recognition that may accrue. These are all issues with which those wanting

to effect policy and practice change must be concerned.

5.1.4. It is beyond the scope of a short report to do justice to a review of the theories that might

provide helpful underpinnings to policy development for psychologists. Suffice to say, most experts

acknowledged a significant impact of their preferred clinical or psychological therapies model

including, in particular, psychoanalytic and systems theories. Most commonly, they referred to the

importance of so-called non-specific clinical skills such as listening, empathising, and formulating.

Several spoke of the importance of `nudging’ rather than `shoving’ colleagues towards beliefs or

behaviours that would assist them in the realisation of their (not the expert’s) goals. More

information about this is provided in Section 5.4.

5.2 Practice

5.2.1. Relatively few qualified senior level Clinical Psychologists attending London DCP and LRPAC

meetings thought that the views of the profession were being heard in their workplaces. Some are

clearly struggling actively in an effort to participate in decisions being taken by management teams

which appear, at least on the surface, to be dominated by a more powerful (and certainly more

numerous) medical and nursing hierarchy.

5.2.2. Part of this seems to relate to the environment. Like other NHS employees, Clinical

Psychologists have had to deal with an ever-changing organisational landscape21. For example, in

2006, local Health Authorities were replaced by 150 Primary Care Trusts (PCTs) and 152 local (social

services) authorities, and eight regional offices became 10 Strategic Health Authorities (SHAs). In

2011 the Health and Social Care Act led to further reforms that David Nicholson famously said were

‘so big you can see them from space’ (see Figure 1 below). PCTs were replaced by Clinical

Commissioning Groups (CCGs); ten SHAs became five, and the Department of Health separated from

the NHS Commissioning Board (now NHS England). Local Health and Wellbeing Boards (HWBs) now

18

Michie, S., Webb TL and Sniehotta FF. (2010). The importance of making explicit links between theoretical constructs and behaviour change techniques. Addiction 105 1897-1898 19

Pendleton, D. and Furham A. (2012) Leadership: All you need to know’ ISBN 970-0-230-35442-5 www.palgrave.acmillan.com 20

Tansella, M. and Thornicroft, G (2009) `Implementation science: understanding the translation of evidence into practice.’ The British Journal of Psychiatry. 195. 283-285 and Thornicroft, G. Lempp, H and Tansella, M (2011) `The place of implementation science in the translational medicine continuum’ Psychological Medicine. 41 2015-2021. 21

Richardson, A. (2015) ‘The historical political and NHS Context’. Chapter 6 in `Clinical Psychology in Britain: Historical Perspectives.’ HoPC Monograph No. 2 Hall, J. Pilgrim, D. Turpin, G. (eds) www.bps.org/hopc

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draw up local `Joint Strategic Needs Assessments’ (JSNAs) to inform the development of `Health and

Wellbeing Plans’ (HWPs) and new Clinical Commissioning Groups (CCGs) carry responsibility to

secure an appropriate level of service.

Figure 1. Structure of the NHS following the Health and Social Care Act, 2011

The Health and Social Care Act, 2011

Public health

Local Authorities

Public health providers

NHS

NHS EnglandMonitor

NHS Trust Development AuthorityCare Quality Commission

Clinical Commissioning GroupsHealth and wellbeing BoardsLocal Healthwatch (old LINks)

NHS providers

Adult social care

Local Authorities

Social care providers

National Institute for Health and Care ExcellenceHealth and Social Care Information Centre

Ministers and the Department of Health

5.2.3. Those involved (including myself) in the development of the National Service Framework for

Mental Health (1999) found these changes challenging as scope was widened not only to develop a

market in health care, but also to allow greater local flexibility in how national policy22 could be

interpreted (see report by Chris Ham and colleagues for the King’s Fund (op cit). The pressures were

significant for commissioners, yet even before the 2011 reforms, the environment was challenging

for them. For example, a report by the Audit Commission (2006)23 had shown that commissioning

decisions owed less to population need than to long-term historical pattern of spend. Although there

are now signs of benefit arising from an approach that is more `joined up’ between health and social

care, the early signs suggest that there is a long way to go before the current need for cost savings

cease to be commissioners’ leading motivation. This presents difficulties for all those working in the

NHS but as the Clinical Psychologists are fewer on the ground and not all of them very experienced

in this area, it is arguably more difficult.

22

The Kings Fund (2015) `The NHS under the coalition government’ Ham, C et al. 23

The Audit Commission (2006) `Managing Finances in Mental Health: a review to support improvement in best practice’. ISBN 1 86240 521 2 Richardson, A.

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5.3 Training

5.3.1. The experts were asked about the origins of their competence in the policy area and a number

of common themes emerged. Almost all the experts were doubtful that their competence could be

attributed to their training. None had completed formal post-registration courses in policy,

leadership or management. However, some were very complimentary about skills in the policy

domain that were exhibited by supervisors and/or Course leaders and they identified an early wish

to emulate this.

5.3.2. Few (possibly no more than four or five out of about sixty) of the almost-trained psychologists

(the novices) who participated in the workshops expressed confidence in their abilities in relation to

influencing policy in the re-organised environment. Very few knew how to read a budget sheet;

hardly any were familiar with the annual planning cycle, or the organisational structures with which

the latest NHS reforms are associated. None knew the name of the Chief Executives in the Trusts

where they worked and none knew names of any non-Executive Directors.

5.3.3. At one level, this is not surprising. CP trainees are, after all, the most junior members of the

profession. However, most come into training with exceptional levels of very diverse pre-training

work and relevant experience. Many have worked in the NHS and many have experience of

managing people. For some therefore, their lack of confidence in being able to contribute to the

policy environment once they qualify appears to relate to the degree to which their experience is

legitimised, developed and valued during their Clinical Psychology training: they aren’t sure that

their knowledge and experience `counts’. One or two experts agreed; they thought training could

potentially be limiting trainees’ scope. Others suggested that trainees’ ambivalence or lack of

confidence reflected a conflict of identity in the profession as a whole about whether Clinical

Psychologists should be scientists, therapists or change agents working to intervene with individuals,

families, organisations and communities24. Whatever the case, most experts were keen to encourage

trainees to get more involved in policy matters and most trainees themselves expressed a wish to

learn more.

“There’s no magic bullet or special knowledge that they [the trainees] haven’t

got – it’s all about being prepared to have a go. I don’t see that in our trainees.

They’re too cautious and too ready to stand aside.”

5.3.4. Some training courses do provide teaching (e.g., RHBNC, University of Hertfordshire, UCL and

UEL) where varying levels of input on policy issues is provided and is positively received. However,

training is mainly course-based rather than based in placements. Although one expert25 took her

final year Trainees to a Service Delivery Board, an experience which he found exciting and

illuminating, few trainees questioned about their clinical placements reported a very positive

experience. Their supervisors apparently say that policy is more reasonably something that trainees

24

Turpin, G. Hall, J. (2015) Chapter 25 in `Clinical Psychology in Britain: Historical Perspectives.’ HoPC Monograph No. 2

Hall, J. Pilgrim, D. Turpin, G. (eds) www.bps.org/hopc 25

Dr Rana did this following an example set by her Chief of Operations who routinely does the same thing for medical trainees.

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should focus on later as part of their continuing professional development, and many were aware

that the BPS does provide support here26. However, supervisors were apparently likely to say that

their own time for supervision was more appropriately taken up with therapy skills training, about

which they were careful, protective and thorough. This may be short sighted in a reorganised and

decentralised NHS where there is no guarantee of a more senior CP in post from whom support,

guidance or policy skills can be obtained. There may therefore be merit in including more coverage

of leadership, policy development and organisational change in pre-registration clinical psychology

training (theory and practice) to better equip trainees who will compete for jobs with nurses who

appear to have more confidence and competence.

5.3.5. As indicated above, the experts tended to see the acquisition of their skills in more personal

than professional terms. They learned from their experiences of success and failure; by working

alongside non-Clinical Psychologists and, notably, by making close connections with their clients and

managerial colleagues at work. Most denied any connection between their own views and those

expressed publically by the BPS or DCP. Indeed, on more than one occasion, an expert reported

feeling somewhat `rogue’ in relation to the professional body. Unfortunately, most were also unable

to identify examples when the BPS provided them with effective support, leadership or modelling.

Indeed, several gave examples of occasions when they had been very disappointed in decisions

taken or statements made by the BPS. Several said that they would like the Society to be much more

inclusive and outwardly supportive of patients’ interests and population health, rather than simply

support what appeared to be members’ self interests.

5. 4 Knowledge, attitudes and behaviours associated with effectiveness in policy

5.4.1. The experts tended to concur that motivation was an essential pre-requisite for engagement

in policy and it was generally acknowledged that work in this area is not to everyone’s taste, even

though Clinical Psychologists should be good at it. Some referred to the way that departments of

Clinical Psychology used to be organised with a much greater division of tasks than is generally now

possible. In the past, a more senior person might carry responsibility for policy through membership

of, for example, a District Health Board or a top management team.

“Now, it isn’t possible for Clinical Psychologists to avoid the issue by saying `I’m

just here for the patients I see, not for anything else.’”

5.4.2. National planning guidance27 is essential background reading. This sets out ` the steps to help

local organisations deliver a sustainable, transformed health service and improve the quality of care,

wellbeing and NHS finances’. It is published by NHS England in partnership with the bodies that

developed the Five Year Forward View (October 2014) and sets out how, this year, localities must

develop `Sustainability and Transformation Plans’ or STPs. Additional funding (a Sustainability and

Transformation Fund or STF) to support implementation is also available.

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Leadership modules now form part of several pre-registration training programmes (e.g., at RHBNC). In 2010 the BPS/DCP established a Clinical Psychology Leadership Development Framework http://www.bps.org.uk/ and in 2002 the Leadership and Management Faculty was established to support psychologists exchange information and opinion. 27

NHS Providers: shared planning guidance for 2016/17 to 2020/21 www.gov.uk/guidance/delivering-the-forward-view-nhs-planning-guidance-for-201617-to-202021

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5.4.3. Experts agreed that it was essential to know the environment in which decisions are taken.

They emphasised the importance of `mapping the territory’, and of `knowing the people’. This

means understanding where, as well as how, and by whom decisions are taken in the wider system

of health and social care; for example, whether commissioning for particular services is local,

regional or national; which are the decision making teams and what are their needs - for example, to

make efficiency savings or meet local imperatives for safer services.

5.4.4. There is a large volume of web-based guidance on commissioning and the planning cycle and

most Clinical Psychologists will be able to find this as it relates to their localities. However, it is also

worth checking local Board papers which are public documents. Mapping the territory also means

understanding more about features of the local population epidemiology (age and socioeconomic

profile, housing and education issues, health issues) likely to have a bearing upon health needs

assessments and hence upon Joint Strategic Needs Assessments which are used to inform service

plans.

5.4.5. It also means understanding the financial context and the pressures on local services to make

efficiency savings and the associated timeframes. In this way health needs, financial pressures and

evidence can be `triangulated’ to develop proposals for effective interventions. There are several

illustrations of the way that work by Clinical Psychologists has made a powerful impact in some

relatively novel areas including work to reduce the use of expensive `Out of Area Treatments’ in

mental health28; work to reduce inpatient admissions; meet A & E Waiting Times targets, or improve

patient experience. Other examples mentioned by the experts relate to evidence for psychological

interventions to promote better workplaces29 based in work (the `Whitehall Studies’) led by

Professor Michael Marmot30,31 and work by West et al (2002)32 showing a correlation between HR

practices in acute hospitals and patient mortality.

5.4.6. Knowing the people involves identifying decision makers, meeting them, and perhaps reducing

social distance perhaps by lunching together or meeting to discuss common interests. Several

experts commented on the perceptible difference between Clinical Psychologists and medical or

nursing staff in this regard with the former much more likely to hold back from work based social

engagement. However, engagement involving face to face contact, sharing ideas in advance of a

proposal, helps to promote allegiances and it reduce the hesitation which can be associated with

unfamiliarity. One expert summed up effective networking as the process of ensuring that ideas and

views are “socialised”.

5.4.7. Among the behaviours most often mentioned by experts, there is an attitude or a stance

which many experts went to lengths to explain. It is perhaps best summarised by the advice given by

28

More information about this is available from Dr John Cape. 29

Sainsbury Centre for Mental Health (2007), Mental Health at Work. 30

www.ucl.ac.uk/gheg/marmotreview 31

Siegrist, J et al (2009) `Employment arrangements, work conditions and health inequalities: report on new evidence on health inequality reduction produced by Task Group 2 for the Strategic Review of Health Inequalities post 2010.’ www.ucl.ac.uk/gheg/marmotreview/ 32

Wells M et al (2002). `The link between the management of employees and patient mortality in acute hospitals.’ The International Journal of Personnel and Human Resource Management 13 (8) 1299-1310.

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Duncan Law to `Be useful first and a psychologist second’. This is about Clinical Psychologists

aligning themselves in public with the values underpinning the NHS system of care within which they

work, and about the importance of prioritising patients’ interests over self-interest. Wendy Wallace,

formerly a CP and now an NHS Chief Executive in London spoke very coherently on this point; she

said:

“It should never, ever, ever, be about the profession; it should always be about

care quality.”

5.4.8. For Dr Rana, this was partly about Clinical Psychologists learning to take risks, to commit to

assisting the organisation to deliver its goals rather than stand on the fence or stay isolated from the

mainstream. “There’s a perfectionist streak in us”, she said. “We’re not risk takers” and “We don’t

like to compromise.” Another expert said “We are paralysed by a need for consensus”’ and “You

don’t see the psychiatrists worrying about that.” Of course, this is not meant to imply that no Clinical

Psychologist should ever oppose policy; rather it is a recommendation about the strategies that are

most likely to be effective at the point when policy is developing.

Figure 2. Quotes from the experts about the early stages of influencing policy

`Know the ground and the environment you’re working in.’

`Be useful first and a psychologist second.’

`Collaborate. Work in partnership. Find common ground.’

`Talk, listen, meet, share.’

It does help if you can lunch, drink and network.’

`Make relationships personal.’

`It’s vital if you want an idea to be taken forward, you have to socialise it first’

`No-one should be surprised at a meeting to hear an idea for the first time,’

`It is absolutely essential to be prepared to take responsibility although some of

those roles are incredibly demanding.’

Patience and resilience `Choose your battles carefully. There are some you’ll

never win.’

5.4.9. Figure 2 contains some of the quotes from the experts about the important things to think

about in the early stages of influencing policy, including: `choose your moment’ and `keep it simple’

The experts agree that a short narrative will almost always be better than a long academic paper,

but..

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“Never underestimate the ignorance of your audience. Always show respect;

they are often very able”.

5.4.10. A distinction between the personal interests of Clinical Psychologists and the interests of

those on the receiving end of their advice was also drawn by Professor Fonagy. He contrasted what

he called public and private competence. For him, clinical skill lies at the heart of policy

competence, and some of the key features include listening, `mentalising’ or empathising with the

other’s perspective; and helping to solve their (not your) problems. He also commented on the skill

of `nudging’ slightly in the desired direction at the point when solutions start to be sought, rather

than pushing or shoving. Importantly, competence involves being careful to avoid the defensiveness,

alienation and criticism which may promote social distance. It also involves effective personal

emotional management as policy competence is seldom associated with behaviour that is angry,

indignant or self-justificatory.

5.4.11. The importance of timing was also reinforced by Professor Clark whose work with Lord

Richard Layard33 to develop the Improving Access to Psychological Therapies (IAPT) programme34.

“In Britain there are two key moments when you can inject new ideas into

public policy – one is before a general election and other is before the

Government’s periodic spending reviews”.

For Professor Clark, there was an important message about the moment when partners and those

with influence were keen to pull in the same direction. He also talked about the importance of

knowing when to back down; to bide your time, and save your plans for another day. Of course, few

psychologists are likely to achieve change of the magnitude of IAPT or have the influence that

Professors Clark or Fonagy have, but the message about timing of decision-making and of dates for

local commissioning and planning cycles are no less important.

5.4.12. Many experts talked about the importance of personal resilience and of the need to take

`the long view’. However, it is clear that unexpected opportunities to realise a vision cannot be

grasped if the vision and reasons for it are not readily brought to hand. This requires preparation,

reflection and planning. This reinforces a message for other Clinical Psychologists about risk taking

and about what some called `just sticking your neck out’ if you believe that an approach is the right

one to take. It reinforces the importance of patience, readiness and resilience.

5.4.13. Figure 3 summarises some of the points made by experts that chime with Professor Fonagy’s

helpful distinction between `public’ and `private’ although, inevitably, people vary in the words they

use. For Professor Hacker-Hughes the essential skills are summed up as needing to achieve

`Presence, Voice, Visability and Impact’. For him, too, there is clear focus on preparing the ground,

understanding the organisational framework, meeting and getting to know the people, and being

33

Professor David Clark was responsible for a number of major developments of health policy, most notably with Lord Richard Layard for the Improving Access to Psychological Therapies (IAPT) programme developed in the NHS in 2012. 34

Layard, R. and Clarke, DM (2014) `Thrive: the power of Psychological Therapies’ Penguin Books ISBN 978 1 846 14605 3.

13

clear about their (as against your own) priorities, not least because of widespread suspicion amongst

some managers in the NHS about the professional protectionism which has characterised some of

the more public negotiations between professional bodies and government.

5.4.14. For many others, including Dr Ralph, once an initial assessment of the environment for

change has been undertaken, therapy skills (potentially from a number of different perspectives) are

the ones they tend to draw upon. For them, the task is about listening, formulating, asking

questions, and understanding what they called the `sub-text’ of, for example, Board and team

meetings.

Figure 3. Public and private competencies associated with influencing policy

PUBLIC

• Empathy

• Understanding

• Partnership

• Alignment

• Communication

• Helpfulness not opposition

• Inquisitive stance

• Know context and time frames

PRIVATE

• Resilience• Tenacity• Reflection• Personal emotional

management• How to triangulate your

view, their view and the evidence.

• When to `nudge’ rather than push.

“Competencies fall into two types: public and private...”

5.4.15. All the experts referred to the importance of measuring outcomes. Professor Clark was clear

that without clear evidence of good outcomes for CBT, IAPT would have failed to gain initial support

from government. Furthermore, he said, it was only the evidence of the impact of the programme

that led to its continued and ring-fenced funding by the Coalition government at a time of austerity.

Several experts spoke about the importance of outcomes measurement. Several also expressed

surprise and regret that there appears still to be resistance amongst some psychologists not only to

the package of outcome measures associated with IAPT but also to the use of routine measures of

outcome in their own work. Several mentioned psychodynamically oriented Clinical Psychologists in

particular here (something that Professor Fonagy has worked to address).

5.4.16. All the experts also agreed on the absolutely essential need to work in partnership with

representatives from other professions, particularly psychiatrists and senior nurses who are so often

in senior management roles. One expert, for example, attended the recent annual conference for

Allied Health Professionals (AHPs)35 and was surprised to see no other Clinical Psychologists present.

Many felt it important for the BPS to work more closely with other professional bodies (e.g., Royal

35

NHS England Chief Allied Health Professions Officer Conference. London 23rd

June 2016. Focused on the solutions

AHPs can deliver to the challenges faced in New Care Models and outlined in the Five Year Forward View.

14

College of Psychiatrists, Royal College of Nursing, the Royal College of General Practitioners,

voluntary and charitable groups, and service users and carers). It was also thought important for the

BPS to make stronger partnerships with groups representing AHPs who work across a variety of

specialisms in health, including acute medicine.

5.4.17. Collaboration and partnership is a particularly powerful way to strengthen engagement with

and influence over policy and experts gave a number of different examples36. Clinical Psychologists

are also now managed alongside and/or by staff from other professional groups; they also manage

other professionals. This, along with the fact that other professionals are also actively engaged in the

delivery of psychological therapies, means that closer relationships between Clinical Psychologists

and others are very important to cultivate.

5.4.18. A number of policy papers now reinforce the importance of partnerships with service users

as a way to deliver better outcomes in health care. Many would argue that arguments for changes in

policy can no longer be successful without this. The NHS Outcomes Framework37, for example,

enshrines user-focused Patient Reported Outcome Measures (PROMS) and Patient Reported

Experience Measures (PREMS) as one basis for reporting on the effectiveness of NHS care. Other

examples of patient involvement includes the move towards recovery-oriented models of care which

emphasise user-defined outcomes and shared decision-making about treatment, or the formal

engagement of patients as stakeholders on Health and Wellbeing Boards where they now have

power to refer CCGs to NHS England if their commissioning plans fail to be aligned with the local

health strategy.

5.4.19. Last but not least, expert Clinical Psychologists, mention luck as an important feature of

policy competence. Although at least two of the experts interviewed were represented on Strategic

Clinical Networks, both attributed their involvement to a mixture of good timing and serendipity, as

did Professor Clark in relation to other national work with which he has been engaged. However,

prior to their involvement, all these individuals all had a notable record of success in working in close

partnership with precisely the key groups and service users with whom NHS England or the

Department of Health wanted to engage and in at least one case, the working partnerships that DH

wanted to support had already been established. It is therefore tempting to say that these

individuals, to some degree, made their own luck rather than waiting for it to arrive.

6. Special issues for London

6.1 Most experts were not of the view that London presented an exceptional challenge, although

they were all clear that the presence of large centres of excellence in research, teaching and clinical

practice meant competition was steep for places on London-based policy forums.

36

`MindEd’ is a free educational resource on children and young people’s mental health for adults developed in a partnership with NHS England, the medical and nursing royal colleges, the BPS, BACP and Young Minds funded by DH and the DoE with which Duncan Law was involved in helping to establish. 37

Department of Health (2010). The NHS Outcomes Framework 2011-2012, London: Department of Health and Office for

National Statistics (July 2011), Measuring National Well-being: Measuring What Matters, Office for National Statistics. Available online at: <http://www.ons.gov.uk/ons/guide-method/user-guidance/well-being/index.html>

15

6.2 Most concurred that it would be important for all local Clinical Psychologists in London to read

the report of the National Transformation Board for London38 created by London CCGs in

partnership with NHS England to implement the NHS Five Year Forward View (October 2014) . This

set out plans to:

Do more to tackle the root causes of ill-health

Give patients more control of their own care including the option of combining health and

social care

Change to meet the needs of a population that lives longer

Develop and deliver new models of care

6.3 Priorities for London’s mental health in particular can be found in the report from NHS England39

summarised in Figure 4. This sets out a number of issues distinguishing London from other parts of

the country. For example, in London “...child poverty is a third higher than elsewhere in England and

the obesity rate is the highest of any other region”. In London, mental illness and homelessness are

“more prominent than elsewhere....” The report points out that people with mental ill health die

10-15 years before others, and only 14% get the help they need in a crisis. It also discusses

challenges in training and support for GPs; and early intervention for children. The Children’s

Strategic Clinical Network40 has also highlighted major gaps here. London apparently has the highest

demand for child and adult mental health services of the whole country, yet it also has poor rates of

access to crucial services, such as IAPT, and the lowest rates of recovery and improvement in

England. These areas provide potential opportunities for psychologists to strengthen their influence.

Figure 4. Priorities for the development of London’s Mental Health Services (NHS England, 2015)

The NHS in London has come together to agree five joint priorities for mental health for 2015/16 and beyond to address these demands and issues for the benefit of our patients:

1. Address the gap in life expectancy ‘the stolen years’ between those with SEMI and the rest of the adult population

2. Reduce the variation and improve quality, access and co-ordination for people in crisis and meet the crisis care concordat

3. Strengthen mental health in primary care to meet the challenges

4. Improve access to meet new standards for mental health services as outlined in the FYFV, focusing on; early identification and access to psychosis services; perinatal mental health and IAPT

5. Improve the use and sharing of data and information

38

NHS England (2015) `Transforming London’s Health and Care Together’ www.england.nhs.uk/london/wp-content 39

Achieving Better Access to Mental Health Services by 2020 (2014) NHS England www.gov.uk/government/uploads/system/uploads/attachment_data/file/361648/mental-health-access.pdf 40

Strategic Clinical or Care Networks were established by NHS England in 2012 in key areas of challenge for health and

wellbeing. They work on cross-cutting themes aligned to the NHS Outcomes Framework. The two likely to be the most relevant to CPs are 1. Mental health, dementia and neurological conditions. 2. Maternity, Children and Young People.

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6.4. Improving policy competence

6.4.1 Table 1 summarises the comments that those contributing this work made concerning the

strengths, weaknesses, opportunities and threats (SWOT) that currently affect the policy

competence of Clinical Psychologists which could potentially form the basis for a framework to

strengthen policy competence amongst London Clinical Psychologists.

Table 1. A `SWOT’ analysis of factors affecting policy competence

STRENGTHS

WEAKNESSES

OPPORTUNITIES

THREATS

Intellectual capital Ignorance of the system, budgets and funding flows; decision making processes, people and time-frames

Outcome measurement and impact assessment

Rising care costs

Understanding of systems and processes

A lack of public alignment with NHS values.

Work in safety, system governance and risk management

Increasing transparency of activity and outcomes

Social and communication skills

Professional Protectionism and special pleading

Diminishing resources and how to achieve value during austerity

Small numbers and competition from others

Persistence and resilience

Isolation: a failure to work in partnership or make allegiances

Integration and partnership (physical and mental health41, acute medicine, MI and PD).

Poor morale and confidence

People management skills

Unwillingness - to share, bend, compromise, take risks

Workforce issues: low productivity, staff morale and sickness absence42

Failure to prioritise or afford status to policy work

A broad-based theoretical understanding

Reluctance to research in practice and measure outcomes

Primary care and early intervention

High cost of CPD and training

A very good training

A lack of leadership

Public demand Impact of austerity

Clinical and research skills

A lack of assertiveness

Technological (digital) development43 e.g., CCBT?

Low public profile

41

Stopping Over-Medication of People with a Learning Disability (STOMPLD) pledge New guidance published as part of the

pledge supports prescribing healthcare professionals to review inappropriate prescriptions for people with a learning disability and/or autism. 42

NHS England (2016) `NHS Staff health and wellbeing: CQUIN guidance’ Gateway ref. 05221 offering financial incentives to improve the health and wellbeing of NHS staff in England, as part of the Healthy Workplaces scheme. www.nhs 43

national reimbursement route for new medtech innovations to accelerate uptake of new medtech devices and apps for patients with diabetes, heart conditions, asthma, sleep disorders, and other chronic health conditions announced June 16.

17

6.4.2 First, several experts agreed that there would be value in building on work that has already

started at national level within the BPS44 for the development of competence in leadership, policy

development and organisational change. Several commented that, during his term as President,

Professor Hacker-Hughes had set out a clear vision for the BPS Divisions, Faculties and Sections as

part of an internal re-structuring which, if this work is continued, should help further. One or two

experts also pointed to the importance of the professional body taking a less centralised or

`command and control’ approach by providing support for individuals who have become influential

outwith the auspices of the BPS45.

6.4.3. Detailed questions about resources did not form part of the interviews with experts and there

was widespread recognition that provision of CPD in the policy area would potentially be expensive -

BPS membership fees are currently considerably lower than those charged by the BMA and it would

appear that there is no surplus of funds. However, experts felt that the BPS and national DCP could

potentially help to promote interest and enthusiasm to participate and learn more amongst Clinical

Psychologists and their trainers, and re-balance interest amongst trainees to work in areas other

than psychological therapy by ensuring that the profile for policy work was raised in the The

Psychologist and Clinical Psychology Forum.

6.4.4. Strong and positive comments were made about the breadth and depth of Clinical Psychology

trainees and the qualities that they bring. A focus within CTiCP might legitimise their use and help

more junior members of the profession who, it seems, are currently at risk of undermining

themselves in the face of competition. Some thought that trainers might work together through the

national Committee on Training in Clinical Psychology (CTiCP) to identify and share models of good

practice in teaching and supervised practice. This would help those on pre-registration training

courses with relatively low levels of input to potentially raise their game. This is also an approach

that could be supported by the London courses alone.

6.4.5. Some thought it might be helpful for Clinical Psychologists with particular expertise in

localities to develop short policy briefings as an aide to planning and involvement by Clinical

Psychologists who feel that they lack expertise. These, it was agreed, should be practical, short,

written in plain English and managed by the DCP branch which could potentially broker

development, distribution and extension in the form of workshops or conferences.

6.4.6. Third, there may be scope to develop support on an individual or small group basis for

qualified Clinical Psychologists in London who do not currently feel that their voices are being heard.

As already indicated, there are private providers of consultancy (e.g., The Tavistock) where support

and training are available and there is one model of good practice in the delivery of formalised

Continuing Professional Development for Clinical Psychologists operating in London46 based at UCL,

albeit with uncertain future funding. However, the diversity of the policy challenge in London,

coupled with the individual needs and personal experiences of those involved, suggest that a more

bespoke approach might also be helpful.

44

DCP Leadership and Management Faculty http://www.bps.org.uk/networks-and-communities 45

Dr Law highlighted Julia Faulconbridge outgoing chair of the DCP CYPF faculty as exemplifying very good practice

here. 46

Dr Kat Alcock UCL, Executive Lead, DCP mentoring scheme organised between the 6 London courses to increase ethnic diversity of CPs k.alcock@ucl.ac.uk

18

6.4.7. Several experts said that they would be prepared to offer supervised placements and/or

mentoring for qualified staff wanting to strengthen their competence. This might consist of

orientation and learning about local systems and structures, direct observation of and/or

participation in planning meetings, modelling, reflection and discussion of relevant theory and

practice. London contains some of the country’s leading experts in a variety of fields who may be

prepared to help. Two experts suggested that the London DCP Branch might helpfully develop a

Resource Directory to support potential learners. Some experts were very puzzled by the lack of

apparent uptake of new(ish) digital technologies like Skype which would make distance learning

easier.

6.4.8. Several experts referred to the scope for individual Clinical Psychologists to take on work

outside their traditional sphere of competence in a temporary role within their Trusts. Many

referred to their own experience of effectively `volunteering’ to help a Board or a manager to solve a

problem. Examples included help for commissioners to understand statistical data on outcomes and

performance; help for HR teams to tackle sickness absence in the NHS workforce; reflective practice

to improve team functioning; and work to strengthen clinical governance and patient safety. In each

case, work undertaken by the Clinical Psychologist was essentially `extra-curricular’; it was not

formally part of the job description. However, the results were generally well regarded by all

concerned and provided a key opportunity for learning and influence.

7. Conclusions and recommendations

7.1 To help to understand and potentially strengthen the influence in policy of applied psychologists

in London, a series of semi-structured interviews with senior applied clinical and academic

psychologists in London and two workshops with trainees were undertaken. All the names of the

`experts’ were identified as a result of their having either a strong national or local profile (or both)

and a record of success in influencing policy and promoting organisational change. This report

summarises the results of those interviews, and it makes recommendations for the DCP branch and

LRPAC to consider.

7.2 There was a high level of consistency amongst those interviewed in terms of the themes and

opinions that they shared about the development of policy competence. Most notably, the experts

failed to attribute their personal success either to their training or to connections with the

professional body.

7.3. They were united in thinking that the current organisational context coupled with changes in the

way that Clinical Psychologists work are challenging practitioners in new ways. Rising demand for

Clinical Psychologists, low levels of supply, some shrinkage in the availability of more senior qualified

staff to provide policy support, and competition from other professions together lead to some

Clinical Psychologists feeling isolated and in need of support.

7.4 Potential solutions are not complicated or difficult to find and follow logically from a review of

the underlying potential causes – in other words, there is no `magic bullet’. Recommendations at

three levels are made for the DCP and London Regional Psychology Advisory Committee to consider.

19

National

7.5 Build on work that has already started at national level within the Leadership and Management

Faculty of the BPS to support the development of policy competence. Initially, this might be helped

by further discussion between the London Branch of the DCP and the Head of the Faculty.

7.6. The Group of Trainers in Clinical Psychology might helpfully gather models of good practice and

disseminate this information to the courses as a way to promote best practice in the development of

policy competence in pre-registration training.

7.7. The DCP could potentially help to create interest and enthusiasm amongst Clinical Psychologists

and their trainers to participate and learn more, and re-balance interest amongst trainees to work in

policy or areas other than psychological therapy by profiling articles about policy success in Clinical

Psychology Forum and the Psychologist. The aim here is to try to elevate the status of such work

within the profession.

Local

7.8. The London DCP Branch might consider developing a Directory or list of those prepared to offer

support and supervision to Clinical Psychologists in London whose problems warrant a more

`bespoke’ approach designed to address their individual needs and circumstances.

7.9. The London DCP branch could support this work in areas of common interest with the LRPAC by

hosting workshops and meetings; by commissioning short briefing papers or speakers (e.g., about

the work of the Mayor’s office, activities of the London based Strategic Networks, London office of

NHS England, etc).

Individual

7.10. Clinical Psychologists wanting to strengthen their influence in policy might usefully approach

colleagues with expertise for support, mentoring and/or supervision.

7.11. Clinical Psychologists might consider developing an individual SWOT analysis and personal

development plans to strengthen their policy knowledge and competence. Ideally, these would be

developed with line managers so that delivery of local priorities could also be supported.

AKNOWLEDGEMENTS

I am very grateful to all those who were interviewed for their time and help to identify the themes

and their competencies with which they judged their effectiveness to have been associated and to

the members of the Steering Group and the DCP branch for their contribution. The mistakes in

summarising some very interesting conversations are mine.