The Professional Standards Authority (PSA) is carrying out a review of the effectiveness of the Accredited Registers programme, of which our register is part. UKCP has prepared and sent the following response.
Question 1: Do you agree that a system of voluntary registration of health and social care practitioners can be effective in protecting the public?
We have been proud to work with the Professional Standards Authority as a member of the Accredited Registers scheme. The scheme has benefited the public by raising the standards of individual registers. This is an important and positive opportunity to review the scheme and co-design a way forward that is future-proofed so as to deliver the best possible public protection accompanied by excellent public promotion. We believe a system of voluntary registration can be effective as long as the public are aware of it and fully understand its scope and its limits.
The critical limit currently is that anyone suspended or struck off our register is entirely free to continue to offer psychotherapy to unwitting clients. Without a wide-reaching public communications campaign, the public are neither aware nor informed of the scheme and the risks of using unaccredited practitioners. We welcome your acknowledgement that this is an urgently needed project.
Since the pandemic, new waves of unregulated and sometimes untrained online practitioners are emerging from other international jurisdictions. Without tighter rules this means that effectively anyone from anywhere can now work legitimately in the UK. While regulatory bodies such as ours can strike off practitioners from our registers, unregulated therapists can never lose their title.
We are particularly proud of the working alliances we have forged with other accredited registers, albeit highlighting the variance in practices and standards of organisations within the same profession and the same scheme. We agree that a lack of consistency in education and training is hampering efforts to gain recognition by employers and commissioners, which was a driving force in UKCP joining the programme. For UKCP, it is an urgent priority to overcome this blocker to the recognition of our members’ high level of training, experience and expertise.
Question 2: How do you think the Authority should determine which occupations should be included within the scope of the programme? Is there anything further you would like us to consider in relation to assessing applications for new registers?
It is of concern to us that psychotherapy, as currently understood and offered within the NHS, offers little patient choice. Our members working in the NHS provide huge value to patients and we wish to see greater availability of a plurality of psychotherapies to patients and service users. As such we agree that who should feature on the register should not purely be the purview of the NHS and similar bodies. The number of our registrants working in the NHS has actually fallen in the past decade despite our member surveys showing that the majority of our members wish to be offering their expertise to the NHS in full or part-time roles. Currently, many NHS psychotherapy services are outsourced, with less favourable pay and working conditions for those working in them.
There is clear cost benefit in prevention as well as treatment, and this is where an accredited register scheme promoting the value and expertise of highly trained and rigorously regulated practitioners, who meet an appropriate baseline of standards of education and training, offers immense value to patient choice and safety. We agree with the need for professional bodies to work together on agreeing those standards. For example, we strictly uphold our ethics code and any registrant who is found to have breached this is removed from our register. We expect similar standards and processes to be reflected in any other register that proposes to join the scheme. As such, we agree with the need to take a risk-informed approach to determining which registers should be admitted.
Question 3: Do you think that moving from an annual to a longer cycle of renewal of accreditation, proportionate to risk, will enable the Authority to take a targeted, proportionate and agile approach to assessment? Do you think our proposals for new registers in terms of minimum requirements are reasonable?
This very much depends on the organisation and the evidence they can provide as to the stringent efficacy of their regulatory procedures over time. Any decision must prioritise public protection as opposed to the business interests of any professional body.
Re-accreditation should certainly be a positive, reflexive and developmental process for each organisation and a longer cycle might afford established organisations more scope to engage in a sophisticated and holistic process of continuous review and enhancement.
Minimum standards for new registers are reasonable in principle but it is unclear in the current articulation how these will afford better public protection.
Question 4: Do you think accreditation has been interpreted as implying endorsement of the occupations it registers? Is this problematic? If so, how might this be mitigated for the future?
If the PSA accredits registers for an occupation without any public information campaign, it might reasonably be assumed that the PSA recognises those occupations as legitimate. If you were to state ‘’we accredit these organisations but we do not recommend them” would the public feel that you have fulfilled your duty to protect them? There is the potential for reputational risk for our register by virtue of juxtaposition with professions that the PSA may or may not deem legitimate. The public may wish to use non evidence-based services and it could be seen as being appropriate to at least hold them to account via a reputable accredited register scheme. But this runs the risk of harming professional and public perception of other registers within or outside the profession. Within the talking therapies alone, there is to date still no agreement on training and competences with a knock-on effect on public awareness and policymakers’ and employers’ understanding. Within the accredited registers scheme as a whole, there is still no consensus on the meanings of terms such as ‘accredited’, which may mean different things in different organisations.
Question 5: Do you think the Authority should take account of evidence of effectiveness of occupations in its accreditation decisions, and if so, what is the best way to achieve this?
We agree that professions should have an accessible, demonstrable, collated knowledge base on the efficacy of their practice. Occupations without this should not be accredited by the PSA.
We do not concur that the NHS approach to measuring evidence should be the only admissible route. We have worked in coalition with allied professional bodies to demonstrate to NICE that their very limited empirical definition of evidence is inappropriate and flawed in regard to the context and practice of the plurality of psychotherapeutic modalities within our organisation.
Indeed, many psychotherapeutic professionals have been supporting the mental health of doctors, nurses and other NHS staff over the last year (often for no charge). This work has delivered clear and obvious benefits to the frontline workforce and yet many of these professionals use therapeutic models that are nominally excluded from most NHS mental health services.
Similarly, for the past 30 years our trainees have provided the workforce for Britain’s major mental health charities and are used in the NHS (again, very often for little or no pay). Our 9,000 qualified members have between them donated more than 4,000,000 hours of work within the charity sector, before even becoming qualified. If this were to stop, the capacity of mental health charities would be dramatically reduced.
Psychotherapies are practiced in innumerable contexts with adults, children, couples, families and groups and therefore qualitative as well as quantitative evidence should be admissible, including practice-led and reflexive analyses.
In assessing the efficacy and effectiveness of occupations, the PSA should consider the diverse range of evidence that exists, including internationally.
It must also be borne in mind that funding for psychotherapy research, indeed for most mental health research, pales in comparison with research funding for physical health. This makes it acutely challenging to embark on studies both individually or collaboratively.
In summary, we would welcome any expectation of the need for an evidence base as long as definitions of admissible evidence are not restricted to those cited by the NHS, which have clear limitations.
Question 6: Do you think that changing the funding model to a ‘per-registrant’ fee is reasonable? Are there any other models you would like us to consider?
The timing of the consultation has not permitted us the opportunity to do a full and proper consultation with members on passing the additional cost onto them via their annual membership fee. The per registrant proposal could therefore require us to make significant savings elsewhere, which may be in conflict with our position as a charity. This is especially so given that the fee would be considerably in excess of those levied by statutory regulators. The timeline proposed gives no indication of what additional value we would receive for an immediate almost 400% increase in fees. Given that any PSA public information programme would benefit all PSA registers equally, it is hard to see why some bodies should pay considerably more for that benefit than others. There is some benefit to retaining a minimum fee to protect against an influx of applications and entry from small registers, potentially confusing the public and employers even further.
The context of the pandemic and financial hardship faced by many people also makes this a challenging time to ask our registrants to pay more.
Question 7: Do you think that our proposals for the future vision would achieve greater use and recognition of the programme by patients, the public, and employers? Are there any further changes you would like us to consider?
Therapists accept that their clients need a robust form of protection from inadequate and unethical practitioners. No therapy organisation or individual has argued against this principle. Indeed, therapists have consistently been open and active to strengthen the effectiveness of their current systems by all reasonable means. We would welcome the PSA leading a managed strategic process with stakeholders potentially towards agreed standards for training and competences. In our efforts to support the response to the COVID-19 pandemic, it has been visible how much confusion still reigns within public bodies and third sector organisations about employing our registrants in spite of the urgent need for highly trained, highly competent and experienced practitioners. As a founding member of the SCoPEd project established to build awareness and confidence in the psychotherapy and counselling registers, we agree that consistency in standards of education and training is urgent and necessary. This collaboration has now extended to four further partner organisations, demonstrating the widely felt support for a representative framework in the public interest. The public good must be at the absolute heart of any reform.
We would like to know more about the PSA’s vision for an overarching body representing the whole profession. This could only be a longer-term vision. As you will be aware, the long-held view of the psychotherapy professions is that any framework should be rooted in the profession to afford responsive and appropriate adaptation to dynamic societal shifts impacting upon practice. For example, during the pandemic we flagged to you the issues of unregulated practitioners from outside UK systems accessing vulnerable clients as they took advantage of the shift to remote therapy. Our organisation is but one body that had to revise regulatory provisions extremely quickly to afford practitioners continuity with their clients, service users and patients. We invested heavily in creating guidelines and facilitating webinars, podcasts and online resources in an agile and responsive way, alongside regular pulse surveys to capture urgent needs.
In terms of the constitution and membership of any umbrella body, the PSA will be cognisant of the parallel recent history of press regulation. The former Press Complaints Commission did not build public confidence in a system of self-regulation. There would need to be much thought applied to the composition and scrutiny of any such body to assure the public that it was working wholly in the public interest. We would be keen to explore further with you how such a model would honour the plurality of practice, and what the logistical implications might be of a single umbrella body. At a disciplinary level, do the PSA’s comments signal that you are envisioning a single Code of Ethics and professional practice and a singular complaints system? How agile and responsive will that be to social and cultural change, such as the exponential growth of digital technologies alongside the transformative impact of worldwide protests against racial injustice?
We would certainly favour an approach that allows the completion of the SCoPEd framework prior to any creation of a new singular body.
We also note that VAT exemption is available to arts psychotherapists and psychologists, who fall under the statutory regulatory function of the PSA, but not to psychotherapists. This serves as an additional cost barrier to accessing services for clients who may need them. The intent of this policy is to exempt healthcare services from VAT. However, the regulatory distinctions between different health professions have a substantial detrimental impact on psychotherapists and counsellors. This often prevents the formation group practices, which further protect both the public and the practitioners from harm, as well as causing higher earning therapists to turn clients away to avoid reaching the threshold. Parity with statutory regulated colleagues in allied professions would only enhance the recognition of the accredited scheme with employers and public bodies invested in public protection.
HMRC’s current policy is dictated by the PSA’s regulatory hierarchy. We therefore urge the PSA to work with accredited registers such as ours – whose registrants’ work closely aligns with statutory regulated professions such as psychology – to make the case for VAT exemption to HMRC. We would expect one of the benefits of a better-funded accredited registers scheme to be a more collaborative working relationship around issues such as VAT inequality.
Question 8: Do you agree that to protect the public, the Accredited Registers should be allowed to access information about relevant spent convictions?
We have previously raised with you our concern at the anomalies that mean the public is insufficiently protected. Our registrants are not afforded the same rights as fellow practitioners in statutory schemes which is a barrier to public trust in the accredited registers.
All cautions and convictions (except those resulting in prison sentences of over 30 months) after a period of time are regarded as ‘spent’. As a result, the offender is regarded as rehabilitated. The Rehabilitation and Offenders Act 1974 for most purposes treats a rehabilitated person as if they had never committed an offence and, as such, they are not obliged to declare their caution(s) or conviction(s), for example, when applying for employment or insurance. Members may therefore argue that it is disproportionate or prejudicial for us to have access to spent convictions. If we want to ask for access to spent convictions, then our organisational members should also have the right to them as they are responsible for putting forward and recommending members for our register.
What is paramount is the access to unspent convictions (which are live). At present, we rely on our members to notify us of if they have been charged with a criminal offence, convicted of a criminal offence, receive a conditional discharge for an offence, or accept a police caution. It is a system based on trust. On rare occasions we have been contacted by the police directly when a member has been arrested and charged. It would be ideal if it were mandatory for the police to contact us and provide this information.
We should also be able to require DBS certificates from current and prospective members to establish that they are not barred from working with children and vulnerable patients and clients.
Question 9: Are there any aspects of these proposals that you feel could result in differential treatment of, or impact on, groups or individuals with characteristics protected by the Equality Act 2010?
It is in the public interest that the profession is diverse in order to meet the needs of patients, clients and service users in an array of contexts. We know that members of certain demographic groups are less likely to access support when they need it and may be deterred by a perception of a lack of cultural awareness. It is vital to ensure that entering the profession is attractive and sustainable to new trainees, especially those from structurally disadvantaged backgrounds. One aspect is ensuring that, after a minimum of four years’ training, their professionalism and rigorous education will be recognised and that they are employable alongside their counterparts from allied professions in the statutory registers. It remains of acute concern to us that we have no real recognition as healthcare workers (for those registrants seeking to work in those settings) and, despite providing free support for NHS staff, most of our registrants are not considered key workers.
We very much welcome further discussion with you on the future shape of the scheme, and very much look forward to the opportunity to co-create an exciting vision and system for greater recognition and public protection.