Vesey, R., 2012. CAT in the NHS: Changes as a result of the Health and Social Care Act 2012 and the future of CAT. Reformulation, Winter, pp.6-9.
I remember reading the Introductory CAT text by Ryle and Kerr (2002) and being inspired by their quote of the description of the NHS that was sent to demobilised servicemen in 1950. This quote emphasised universal access as well as the importance of using the resources well. The chapter from which the quote is taken is written by D Wedderburn and entitled “The superiority of collective action: the case of the NHS”. The NHS has, on the whole, worked effectively as a collective. It has provided services to patients and provided training for staff to deliver services in arguably highly cost effective and efficient ways. The NHS is a complex organisation, in part because of its size and the scope of its functioning, but also because of the human complexities of its task of providing health care. In this brief article I want to take an organisational and historical view, offering my understanding and opinions of the changes at a broad level before focusing on some practical implications as I see them. I will argue that the organisational changes that are being introduced are fundamentally altering the mechanisms for the allocation of resources and restructuring organisational priorities. The new mechanisms, based upon market principles and competition, require health-care episodes to be made into discrete entities, with as low as possible costs (perhaps impossibly low) and fundamentally change structures of accountability and governance for healthcare services.
I suggest that the impact upon health care services will be hugely diverse and dependent on the interests, understandings and alliances of those with the power to allocate resources.
The NHS was formed at a time of great economic hardship, when the national debt was much higher than the current national debt (by approximately two and a half times as a percentage of economic output, (Newman, 2010)) and in the face of strenuous opposition from the powerful medical profession. A considerable weight of social and political opinion had to be mobilised to overcome this opposition. At the broadest level, it seems that the solidarity created by the suffering, conflict and hardship of the second World War made possible the creation of the NHS in 1948, particularly in terms of the public and political will to allocate resources to such a project. In a Guardian interview, the author PD James reported that early on in the life of the NHS it was imagined that after an initial surge in need for health care, demand for healthcare resources would stabilise. In contrast, the costs of medical technology and treatment (and here we might consider psychological and psychotherapy staff to be costs of a treatment) have risen steeply. It seems that there has always been a tension between the health needs of the population, the wishes of NHS staff to respond to those needs, and the available resources. A nationalised system of regional administration allocated resources according to evaluated, estimated and projected needs, with data collected to more, or less, accurately assess this, and to allocate resources for workforce development. An ongoing government problem has been regulating spending within the health service, where budgetary control over health care decisions has been, or at least perceived to have been, limited. Of course there are criticisms of inefficiency in large organisations, but it is clear that the term “bureaucratic” often used as a synonym for inefficiency, has a moral and reasoned justification in the writing of Max Weber who introduced the term in the 1900s. Weber wanted to ensure that organisations had legitimacy within society, and structures that would effectively coordinate action, with fairness, accountability and ethical actions. His aim was that authority would be respected rather than imposed through power, nepotism or charisma. Although a very rational approach to organisations and their functioning, this historical view of bureaucracy highlights what it is that is being lost by introducing the market to coordinate action. Perhaps more pertinent to understanding organisational structures in healthcare, are the interpersonal dynamics and so-called “social defences” whereby staff become emotionally detached from challenging, even overwhelming, demands for care, in a way that can interfere with the primary task of the organisation. Whilst the scope of this article is not to address these issues, I feel they are relevant and well-articulated, for example from a psychoanalytic perspective in the classic paper by Menzies-Lyth (1959), and from a CAT perspective by Walsh (1996).
The Thatcher government began to change the mechanisms of resource allocation in the NHS. With the neoliberal political ideology of minimal state involvement and a belief that market systems promote efficiencies (as well as profit for some), the Conservative government sought to introduce a market system into the NHS in the form of “fundholding” GP practices in the 1990s, whereby GP surgeries took responsibility for their healthcare spending, and the consequences of going over-budget. The Labour Government abolished fund-holding practices upon election in 1997. However, New Labour pursued the instigation of an internal market, creating a split between groups set up as “purchasers”, and groups set up as “providers”: the purchaser-provider split. This created primary care trusts which, as it were, bought services from service provider organisations, such as hospital trusts or mental health trusts. Because of the significant resources needed to set up a hospital and the systems of care around it, there was initially one service provider (or maybe a specialist service provider out of area for exceptional cases) and usually a wide array of services would be “bought” in a “block”; for example a region purchasing mental health inpatient and community mental health nursing, and psychological therapy services all from one (usually NHS) service. Therefore the integration of the NHS and its structures meant that the reality of market competition was limited, for practical, rather than ideological reasons. Throughout the 2000s services were increasingly tendered out for delivery by new organisations, for example cleaning services became separate from hospitals and were provided by private companies; inpatient forensic services and some psychological therapy services were arranged as a distinct package of care to be provided by the preferred bidder (for example the resources for IAPT were allocated in this way). The participation of non-NHS providers, and of competition has become increasingly present and, in the market model, no distinction is made between profit-making, statutory and charitable services.
The Health and Social Care Bill, now Act, extends the use of market principles in the mechanisms for distributing resources in the NHS. The act furthers the extent to which profit can be made from providing healthcare. I suggest that these three crucial changes are particularly significant for people working in mental health (see Pollock & Price, 2011, BPS Response to the Department of Health consultation, 2011):
A system has been put in place to administer and allocate resources as if health care can be allocated per person, and therefore services can be purchased on a “one-off” basis, based upon an assumption that resources can be packaged on a per person basis, and that more competition will make health care services more efficient and even of higher quality.
GPs have been given responsibility to purchase services for their patients, giving them the power and the responsibility to allocate resources as if they are “consumers” in the market, based upon the assumption that GPs have the knowledge and time to make “consumer choices” and that this will improve services.
Responsibility for the provision of healthcare, both to those registered with GP practices and to those denied healthcare by the usual route (for example not registered with a GP surgery) is to fall to the local council social services.
Because resources will be allocated by GPs, or those they employ to allocate resources and commission services on their behalf (care commissioning groups), the first significant impact of this act is variation across regions. Whilst national guidelines are available in terms of what is expected in a particular service, often using NICE evidence-based recommendations (see Waft, 2011 for a review of the practical implications of evidence based guidance), commissioning decisions are likely to be influenced by the interests, understandings, preferences and resource-pressures of the particular local care commissioning group. This has been evidenced by the significant variety in the services offered in the IAPT programme; despite the guidelines and monitoring of IAPT service providers, in the trust regions in which I work, IAPT services vary in the therapy models that are available, the criteria for a service, the qualifications of staff employed, and the communication between primary and secondary care.
Whilst the government has claimed that national tariffs will be set so that care commissioning groups pay the same, per patient, to any organisation, the reality of service delivery means that the organisation’s overheads will need to be addressed. One such overhead is staff employment and NHS organisations which are bound to meet NHS employment arrangements are unlikely to be able to offer, for example, the same costs per face to face contact when compared with a charity employing practitioners on a sessional basis without the same employment conditions. Other overheads include buildings and rooms, assessment tools, time and money to support staff training and supervision time.
How a particular organisation chooses to allocate its resources internally may change. It might be that an organisation employs more staff who can be paid less, perhaps because they have a different professional status or fewer qualifications, but it might be that such staff are more dependent on supervision to ensure quality in their work. It might be that an organisation offers the minimum of services, and is encouraged to offer the cheapest possible version of an agreed package of care because of resource pressure. In both these examples there would be lower paid and less qualified staff offering therapeutic interventions under supervision, with fewer, more highly paid and better qualified staff, facilitating this work.
Because of these changes to decision making in the allocation of resources, and because of the way organisational decision making is determined by individual power, professional status, and networks of people in their work roles, the ways in which resources will be allocated is difficult to determine. Given the changes outlined above there seem to be constraints that may mean the following for any psychological therapy including CAT:
I have found the introduction of the Health and Social Care act hugely disturbing and been left feeling powerless, rebellious, grieving and defensive. It has been very difficult for me to articulate quite why this act has felt like such an attack, and I’m sure there are a number of factors, including those personal to me, my life history, values, and secure bases. Nevertheless I will attempt to formulate and share my concerns which are:
In such emotional and relational challenges and difficulties may lie the space that we have for influence: to hold to our integrity, our sense of what defines good relationships and our wish and ability to relate well to and within our work. Where possible, we could establish relationships with local commissioning services and with our enthusiasm spread the knowledge and understanding about CAT (letting CAT out of the bag) with the materials provided by ACAT. There is an increasing demand for psychological therapies from commissioners, service users and national bodies (for example for severe mental illness as outlined in the Schizophrenia Foundation report and the IAPT SMI agenda at the department of health). Some degree of keeping faith with each other seems crucial in order to resist the pressures from competitive business models to diminish therapeutic spaces and undermine our collective motivation to provide high quality therapy to as many as possible of those who need it.
Consultation Response Team, British Psychological Society, (2001). Response to the Department of Health consultation: Modernisation of Health and Care Listening exercise.
Hoggett, P. (2006). Conflict, ambivalence and the contested purpose of public organisations, Human Relations, 59 (2):175-194
Menzies-Lyth, I. (1959). The Functioning of Social Systems as a Defence Against Anxiety: a report on a Study of the Nursing Service of a General Hospital, Human Relations, 13:95-121
Newman, A. (2010). British Government Debt from Atlee to Cameron, Socialist Unity: Debate and Analysis for activists and trade unions. posted online August 2010: www.socialistunity.com/british-government-debt-from-attlee-to-cameron/
Pollock, A.M. & Price, D. (2011). How the secretary of state for health proposes to abolish the NHS in England. British Medical Journal, 342:d1695
Ryle, A. & Kerr, I. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester, Wiley
Waft, Y. (2011), Is CAT in danger of being squeezed out of the NHS? Reformulation 36: 18-21
Walsh, S. (1996), Adapting cognitive analytic therapy to make sense of psychologically harmful work environments. British Journal of Medical Psychology, 69: 3-20
Robyn is a Consultant Clinical Psychologist working in an adult community service in Essex in the NHS. She is currently studying management and organisational dynamics at Essex University. Robyn is a CAT practitioner and has contributed to discussions within ACAT as a trainee representative on the council of management, and as a participant of the research and communications committee.
She can be contacted at: firstname.lastname@example.org
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