One of the hidden factors driving the UK’s mental health services to its current tipping point is the working conditions of the people who deliver them. Mental health services have always been the poor cousin of the health family but with our health bodies, NHS England and Monitor, proposing that mental health services should face an additional 20% cut in funding those of us working in mental health should officially be concerned about our individual and collective states of mind. From Psychological Wellbeing Practitioners, Employment Advisors to community health workers, working in mental health care settings might be posing significant health risks to both clients and clinicians.
Psychotherapists offer us a graphic case study in the precarious work of the UK’s mental health services. An estimated 6,000 people a year qualify as counsellors and therapists and approximately 4000 clinicians have been trained to deliver Increased Access to Psychological Therapies (IAPT) services through the NHS. However we do not know how many people now work as psychotherapists, who their employers are and what their working conditions are like. According to the Health and Social Care Information Centre (HSCIC) there is no data on psychotherapists who work for agencies and information on Bank staff (the NHS’s own agency) is only this year being collated, due to be available at the end of 2014.
The confusion and ignorance about the employment relations system of psychotherapists is very much about the continuous privatization and restructuring of the NHS and the 2013 shift of commissioning powers to local level. However it also exposes a range of systemic problems faced by psychotherapists, including the growth of agency work, the use of unwaged labour and the insecurity of ‘permanent’ psychotherapists in the NHS. We will look at each problem in turn.
The debate about precarious work is a defining one in the field of employment relations attempting to map and navigate new ‘externalized’ employment relationships, from zero hours to contract and agency labour. Along with these changes in the employment relationship come profound changes in the duty of care towards patients, including projecting risks and duties away from the principal employer onto service providers and labour agencies. In the UK, this process of externalization is seen graphically in the use of private employment agencies (PrEAs), an industry with an annual global turnover of US$200 billion with Adecco, Randstad and Manpower representing some of the largest multinational companies in the world.
Agency work is not just about who cleans our clinics but it is also now a reality for psychotherapists. The advent of agencies is nothing new in healthcare but with the massive rise in demand for IAPT services, NHS cuts and waiting lists of between 6-18 months we are now seeing the creation and expansion of private employment agencies for therapists. Because of the intense insecurity of agency work and the fear of blacklisting of individual therapists, nobody wants to talk about this growth of third parties in mental health. There is no comprehensive data about how many therapists now work for PrEAs. We do not know how many Private Employment Agencies and contractors, including charities and clinical training centres, now deliver IAPT services. Most of the psychotherapists employed by them are on short term and insecure contracts raising questions about the how employment insecurity might impact the quality of services provided.
We also know that the big PrEAs including Reed and Manpower, yet to specialize in clinical services, are however providing labour for the call centres and online services that clients are fed through in order to access NHS services. It means that the people acting as the first point of contact for patients trying to access mental health services are unlikely to have any clinical training, or to be able to offer the clinical support needed by anyone dealing with people in distress and crisis. This raises questions about the duty of care of agencies dealing with vulnerable people, which is a growing reality given the length of NHS waiting lists and the inevitable rise in patient distress this creates.
As with all externalised employment relations, it is not just the contract of employment that gets passed over to third parties, it is also the responsibilities of employers. Many people working in the NHS via agencies receive no training or supervision. This is particularly true for therapists who can find themselves providing therapy without any idea as to who their employer is and without any clear duty of care.
An example: Under IAPT the main bulk of services are low intensity ‘wellbeing’ programmes delivered by Psychological Wellbeing Practitioners. PWPs’ work is formalised and standardised to the extent that if a patient does not pick up the phone for an initial assessment within the allotted 15-minute time period they are referred back to their GP, presumably to wait for a further 6 months. Within these services it is all too easy to develop a hatred for the patient who keeps clinicians on the phone for too long, making it impossible to meet the quota of 8 satisfied clients a day. Under these conditions the only way to responsibly help patients is to refer them on to other more intensive services. PWPs that offer more support, mainly through giving more time and going off script, are forced to keep this secret from employers because it breaks their contract of employment, leaving them to carry the full ethical and clinical consequences of their interventions. This situation exposes therapists to potentially precarious states of mind, from increased anxiety to vulnerability to bullying, a systemic problem within the NHS. This systemic precarity for mental health workers is completely counterproductive for people employed to contain the anxieties of others.
The second systemic problem in psychotherapy relates to internships, or the widespread use of honorary psychotherapists. Adult psychotherapy training involves a minimum of 4-6 years of part-time training. During that period the most important part, along with your own personal therapy, is to carry out clinical work. In the case of adult therapy, this work is carried out under supervision with the support of high-quality training and qualified practitioners. The problem is that the trainee is not paid. This means that in order to train as an adult psychotherapist you have to work part-time (usually 1-3 days a week) for nothing for between 4-6 years. There is currently no up to date data on how many psychotherapists work unwaged as honoraries, but a conservative estimate is that 6,000 psychotherapists are being trained every year in the UK, which is the equivalent of approximately 2,000 full time jobs every year covered by unwaged trainees. This includes a substantial percentage of the psychotherapists working for the NHS, Mind and many local mental health charities providing clinical services in the UK.
The professional bodies such as the Tavistock Clinic are complicit in this system of unwaged work; in effect the bodies which provide clinical training receive state funding for providing trainee and therefore unwaged psychotherapists to the NHS. This leads to the curious situation that the professional bodies charged with building a sustainable profession are fundamentally unable and unwilling to do that. To demand wages for the people who provide a large chunk of NHS services is not in their financial interest.
As a result this is a profession open primarily to people from families rich enough to support them. There are some who work full time and do the training on top, but with work intensification and a rise in command and control management in the NHS, there is a real risk that (as in other fields such as the media and the arts) the great majority of practising therapists will eventually be people from relatively affluent backgrounds. That is not to say that rich people make worse therapists than poor people, but it does raise important questions about class and power both clinically and within the profession.
The third systemic problem relates to therapists within the NHS, both directly and indirectly employed. There is an increasingly rare breed of psychotherapists who still work directly for the NHS as well as indirectly via the big mental health charities and professional bodies. In most cases the days of ‘permanent’ contracts are over, with annual commissioning of services and rise in short term contracts. With cuts in funding and increasingly insecure and short funding cycles many of the jobs in mental health services are fixed and short term. This insecurity has profound implications for ‘workplace fear’ and cultures where clinicians are reluctant to raise concerns about employment relations and patient care. Despite the important debate about raising concerns in the NHS the reality is that precarious workers are unlikely to speak up for fear of victimization and job loss.
The Francis reports clearly state that systemic bullying of the NHS workers by the managers was an important factor behind the failure of care in Mid Staffs. Do this or lose your job, where targets can only be managed through systems of command and control. It is a stomach-churning reality that the NHS rests on bullying the people who are supposed to protect vulnerable service users. Often the people with the best contracts end up with the worst jobs, internalizing the guilt of a system which treats its workers as if they were ancillary to their survival and lacking the competencies needed for the job.
A few years ago a friend and I, while working on a Psychiatric Intensive Care Unit (PICU) ward in the NHS, were struck by the mental distress of the staff, rather than the patients, and tried to set up a trade union for precarious mental health workers. To try to encourage people to join up, we did this online and guaranteed anonymity for everyone who registered. Despite our contacting hundreds of mental health workers only 2 people signed up. They were too scared to disclose their situation anonymously online. From an employment relations perspective the unwaged and insecure inevitably put a downward pressure on paid employment and decent jobs. As long as psychotherapists are working quietly and diligently under precarious conditions and at times for free, the NHS as an employer will never respect the people who work for it.
The psychotherapeutic workforce is made up of three precarious groups: temps, interns and scared NHS workers. Many experienced and wonderful therapists have retreated to private practice, unable and unwilling to navigate a broken system. This means that there is some great therapy available out there, but only for those people that can afford it. It is not to say that private practice does not offer massively needed services, it does, and a careful assessment and referral can make the difference between life and death. But it also means that anyone without money is left behind, regarding therapy as available only to those who can pay.
Just because our precious mental health institutions provide good services does not mean they make good employers, a reality that can break the heart and career of any committed psychotherapist. In a context of deteriorating mental health in the UK, the fact that psychotherapists are a disorganised and chaotic group of people is a matter for both professional and personal ethical concern. The current economic argument for cheap therapy is based on the unacceptable working conditions of the thousands of dedicated therapists. There is no question we will see more failures in care, whistleblowing and burn-out if these employment relations problems are not addressed.