Clinical Psychology Future: Challenges and Leadership

2. Association of Clinical Psychology Inaugural Conference: Edinburgh Thursday 28 March 2019 Clinical Psychology: Future Training, Funding, Leadership & Management Professor Tony Lavender, Salomons Centre for Applied Psychology, Canterbury Christ Church University

3. Clinical Psychology: Future Training, Funding, Leadership & Management • NHS Background: Financial Context. • Threats to CP Training Funding: History, Issues, Response and Progress. • Clinical Psychology: A Positive Story • The Challenges • Leadership & Management in the Profession • The Future

4. Background: Financial Context • 2008 Financial Crash • 2010 Election of Conservative administration policy of austerity – reducing public sector expenditure. • 2010 -17 NHS spared the worst but still significantly affected

5. Health Care Expenditure • 1997 Total health care spend £59.9 billion Public Sector £44.1 billion Private Sector £10.8 billion • 2009 Total health care spend £136.4 billion Public Sector £114.8 billion Private Sector £ 21.6 billion • 2015 Total health care spend £185 billion Public Sector £147 billion Private £38 billion • 1997 – 2008 Annual Average Rate of Growth 8.1% • 2009/10 - 2015 Annual Average Rate of Growth 2.6% (Kings Fund 1% - 09/10-18/19) • 2019/20 – 2023/24 Annual Average Rate of Growth 3.4% (3.6% in first two years) • 1948 – 1918 Annual Average Rate of Growth 3.7% Source ONS

6. Background: Changes to funding of nurse and AHP training Council of Deans • 2014/15 Proposals - move from fees paid by the NHS to loans - bursaries to loans also discussed • Rational for Change - NHS benchmark fee less than 9k undergraduate fee - Avoid annual conflict with university over fee price - Bursary not enough to live on, part time jobs required and no access to loans - Frees the cap on places (however placements still restrict expansion) - Reduce NHS expenditure - In line with other undergraduate arrangements

7. Background: Changes to funding of nurse and AHP training • Government (George Osborne) announced change in November 2015 • From August 2017 intake - Fees and bursaries replaced by loans • Early days but – 8% (11% England) drop in nurses accepting place 2016 to 2018 - 42.3% drop in applications from over 25s 2016 to 2018 - particular concern for mental health and LD nursing 2017 and 2018 – Attrition still averaging 24% (Health Foundation, 2018)

8. Implications for Clinical Psychology and other Postgraduate Entry Schemes • Oops! Didn’t think about those programmes/students • If generalise to Postgraduate programmes (e.g. CP & IAPT training) it’s problematic because: 1. Converting salaries and fees paid to a loan system creates an unbearable debt burden - Undergraduate debt £40 - £50K - Postgraduate Doctoral debt £81 - £110K - Cumulative debt - £120 - £160K - Applications and regulations will plummet 2. NHS strategy ‘ Five Year Forward’ & ‘Achieving Better Access’ require an increasing workforce – becomes undeliverable 3. Impact on diversity 4. CP trainees not supernumerary

9. Professional Response • Comprehensive Spending Review Group (CSRG) Established 2015 BPS group became a DCP group in 2016 when the BPS established a Presidential Task Force • Established as Workforce and Training Committee of DCP in January 2019 Wider remit to: To formulate advice and guidance about workforce planning matters relating to, and that impact on, the clinical psychology workforce.  To ensure clinical psychology is represented and provides input to national bodies concerned with workforce planning.  To coordinate activity within the Division and the profession and seek to influence the direction of travel of HEE, NHS (E), NHS (I), Department of Health and the Government about the development of the clinical psychology workforce and the funding of clinical psychology training.

10. Actions of the CSR Group • Lobbying key individuals and Committees at HEE to raise awareness of issues • Lobbying directly with Jeremy Hunt via David Clark & Richard Layard • Lobbying key staff at NHS England • Providing Briefing documents & updates to the Manager’s Faculty Course Directors to support them in work with commissioners • Developing papers re key issues, e.g. retention, to support a consistent approach nationally

11. Outcomes So Far • Immediate threat to 2017 and 2018 entry was addressed and fee & salary maintained • Just before Christmas it became clear that 2019 entry fee and salary will be maintained • Proposals discussed at HEE (Group’s aim is to maintain current arrangements): -Fees don’t seem to be under an immediate threat -Salary options reviewed at HEE: 1. As we are, fees and salary from HEE, good reasons to maintain 2. First year 90/10 (HEE/CCGs/Provider Trusts) Second year 70/30 (HEE/CCGs /Provider Trusts) Third year 50/50 (HEE/CCGs/Provider Trusts)

12. Clinical Psychology: A Positive Story • Attrition & Retention -attrition from courses: 0.5 – 1.03% last 5years; 0.62% in 2016/17 (nursing average 25.1%, range 9-45%; medicine average 2%) -NHS retention 96.6% in NHS in 12 months (2016/17 leavers). 92.4-94.5% previous 3 years -34 year study 78% still in NHS as CPs (wastage rate <1% annually) • Evidence Base -major contribution to generating the evidence and introducing innovations • User Engagement/Coproduction -embraced engagement/coproduction and psychological work increasingly wanted • Service Delivery -CPs trained to deliver services to a wide range of clients (e.g. only 2% work in IAPT services, although more are involved in supervision & training) and using a broad range of therapies -major contribution to developing new and established services

13. The Challenges • Financial Constraints/Austerity • Lack of formal representation at NHS high table • Perception of high salary without the responsibilities of psychiatry or the management responsibilities of the higher graded nurses in management positions • Highly medically (conceptually and staff numbers) weighted services in terms of power and culture • Although trained in a range of therapies may appear not as qualified for specific therapies following training (E.g. CBT) • The above have contributed to the sense of threat (and probably downgrading) which means maintaining morale and strong supportive relationships with colleagues is challenging (each psychologists behaviour matters)

14. What next? Collaboration: Psychology Professions Network Aims to maximise benefits of all psychological professions in NHS funded healthcare Includes full range of psychological professions (CPs, CBT therapists, cild psychotherapists, PWPs, counsellors and art, drama and play therapists, etc. A stronger voice to policy makers, workforce planners and commissioners Networks established in North West, South East and developing in the Midlands and North East (Sheffield based developments?) Products include: ‘Delivering the Expansion in the Psychological Professions’ workforce implications for delivering Stepping Forward (MH Workforce Plan) Negotiating for HEE psychology lead nationally

15. What Next? Collaboration:ACP, DCP, BPS,PPN,UNITE • We could tear ourselves apart • Need to find ways of working together • Strength and influence in cooperation and finding common agendas • Dealing with disputes and disagreements professionally • Managing the perceptions of policy makers and the public

16. What Next: Leadership and Management • An understanding and a useful model • Training/development issues - prequalification - postqualification • Taking management and leadership opportunities

17. Burke and Litwin (1992) • Transformational Change Variables - External Environment - Senior Leadership - Mission and strategy (Purpose) - Organisational Culture (Values/Norms)

18. Burke and Litwin (1992) • Transactional Change Variables - Management Practices - Structure - Systems (Policies and Procedures) - Work Unit Climate - Motivation - Task Requirements and Individual Skills/Abilities - Individual Needs and Values

19. Burke and Litwin (1992)

20. Management and Leadership: Training and Development • Prequalification -Teaching -Understanding of leadership and management (a model) -Importance of values evident in relationships -NHS Healthcare Leadership Model -Placement experience -Observations and reflections of M & L -Practice in working with individuals & teams -Using a model to understand the Trust

21. Management and Leadership: Training and Development • Postqualification -Taking opportunities to manage and lead within discipline and across disciplines -Encouraging and supporting others to do so -Taking on the complexity -Influencing the psychological trajectory of services -Confidence and resilience from training and ability

22. Management and Leadership: Training and Development • Postqualification Methods -Programmes/Courses single or multi disciplinary -Mentoring, reflecting on and developing practice -Self development • Postqualification Content -Organisational models and change -Current NHS Leadership Model -Management processes - meetings, appraisals, performance management, grievance, etc.

23. The Future • Lead, think and work strategically: -more important with fewer numbers every CP matters, -campaign for Chief Psychological Advisor (HEE and NHS England/Improvement), -secure more senior leadership and management positions in Trusts, HEE, -secure positons in Integrated Care Systems & service commissioning, -take positions in policy and workforce influencing positions (HEE, NHSE/I) -lead & contribute to networks promoting psychological services (e.g. Psychology Professions Network) -leadership and management training separate or with other professions?

24. The Future • Develop a co-produced vision for psychologically based services nationally and locally that takes account of the NHS Plan. • Formulation is key to providing a psychological alternative to diagnosis. • Value your work. The scientific and values base. Demonstrate utility to service users, providers, commissioners and policy makers. • Humility and doubt is a good thing but not if overdone. Optimism and resilience are essential.

25. The End Thank you for listening Questions