Quality in Counselling in Primary Care

Transcription

1 Quality in Counselling in Primary Care A Guide for effective Commissioning and Clinical Governance Peter Bower National Primary Care Research & Development Centre Joan Foster Counsellors and Psychotherapists in Primary Care John Mellor-Clark CORE Ims Ltd

2 uality in Counselling in Primary Care A Guide for effective Commissioning and Clinical Governance Peter Bower Joan Foster John Mellor-Clark Design: Lisa Tilsley, NPCRDC Illustrations: Fran Orford, Printed in England by: Heaton Press Ltd. Tel: The University of Manchester October 2001 ISBN: O To order extra copies of this report please phone: NPCRDC Publications Order Line: or communit@fs1.cpcr.man.ac.uk Collaborating Organisations: Counsellors and Psychotherapists in Primary Care The Psychological Therapies Research Centre CORE Information Management Systems Ltd If you require further information about NPCRDC please contact us at: NPCRDC University of Manchester 5th Floor, Williamson Building Oxford Road Manchester M13 9PL Tel: Fax:

3 CONTENTS PAGE INTRODUCTION 1 1 Does counselling work? 4 2 How should counselling services be organised? 9 3 What are the key process issues in counselling services? 35 4 How can quality be enhanced in counselling services? 41 Reference List 48 List of Contents APPENDICES Appendix 1 Useful addresses 51 Appendix 2 Grading and pay scales for counsellors 52 Appendix 3 Training criteria and standards of the major 55 professional bodies Appendix 4 Example cost breakdown for a managed 58 counselling service Appendix 5 Example counselling service letters 59 Appendix 6 Clinical outcomes in routine evaluation: 66 contents and useful supporting references ACKNOWLEDGEMENTS The team would like to pass on their gratitude to a number of people who through a combination of their time, effort and skills enabled the completion of this guide. Thanks to Lisa Tilsley for her patience, creativity and flair in producing the eye catching design of the finished report. To Laura Blake, Martin Roland, Nicki Mead, Stephen Campbell and Anne Kennedy for their constructive comments and tireless proofreading. Last but not least, a mention for Cartoonist Fran Orford, who managed to capture the main points of our work in a humorous and memorable way. The views expressed in each section of this report are those of the authors and not necessarily those of the Department of Health.

4 INTRODUCTION Why is this handbook needed? The development of Primary Care Groups and Trusts (PCG/Ts) has put primary care in the driving seat of service development. The Mental Health National Service Framework highlighted the role of primary care in the development of high quality mental health services. For example, Standard two states that any service user who contacts their primary health care team with a common mental health problem should have their mental health needs identified and assessed and be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it. 1 The Department of Health Clinical Practice Guidelines have indicated the important role to be played by psychological therapies in mental health care. 2 Counselling is the most frequently provided psychological therapy in primary care. The bulk of the handbook deals with issues surrounding the provision of counselling. However, some of the general principles are of relevance to all psychological therapies (e.g. effectiveness, quality improvement). Introduction What is this handbook for? We aim to: Describe counselling in primary care. Summarise the evidence about how well counselling works. Describe how to organise and run counselling services most effectively. Describe methods of measuring and improving the quality of counselling services. Who is this handbook for? This handbook is designed for: Commissioners and providers of counselling and psychological therapy services. PCG/T chief executives. PCG/T mental health leads. Health Authority mental health leads. Other providers such as private providers, trusts and the voluntary sector. It will also be of interest to practitioners such as GPs and psychological therapists. 1

5 introduction Where do the ideas in this handbook come from? This handbook is based on the work of four collaborating organisations: The National Primary Care Research and Development Centre (NPCRDC) is a Department of Health funded initiative based at the University of Manchester which aims to promote high quality and cost-effective primary health care. NPCRDC has published widely on the clinical and cost-effectiveness of psychological therapies in primary care. Counsellors and Psychotherapists in Primary Care (CPC) aims to represent counsellors and psychotherapists working in primary care and to lead the way in establishing national standards and guidelines for further development of professional and effective counselling throughout NHS primary health care. The Psychological Therapies Research Centre (PTRC) is a department of the University of Leeds which exists to develop evidence-based psychological treatments through multidisciplinary research into both the efficacy of psychological methods and strategic planning of psychological treatment services. CORE Information Management System Ltd has extensive expertise in relation to quality issues in psychological therapy services in the NHS, with an emphasis on primary care provision. CORE IMS is an independent organisation that has been licensed by the CORE Systems Team to provide training, support and material to users of the Clinical Outcomes In Routine Evaluation (CORE) System for the measurement of quality in psychological therapies. The addresses of these and other useful organisations can be found in Appendix 1. 2

6 Structure of the handbook Providing effective treatments in the NHS is a complex task. As well as reviewing the scientific data as to whether the treatment is effective (evidence-base), it is also necessary to ensure that the proper arrangements are in place to provide the treatment (structure), that the different parts of the system work effectively (process), and that the way in which the treatment is provided is of the highest quality, and delivers the necessary outcomes in terms of patient health and optimal use of resources (outcomes). introduction The handbook has been structured to deal with these four issues in turn, with a separate chapter on each. The handbook can be read as a whole, but each section is relatively self-contained. Chapter 1 - Evidence base Does counselling work? Is it an efficient use of resources? Chapter 2 - Structure How should services be organised? What type of staff should be employed? Chapter 3 - Process How is referral to counselling best organised? What is the relationship between the counsellor and the primary health care team? Chapter 4 - Outcomes How can quality in counselling services be assured? How can audit be conducted in counselling? 3

7 DOES COUNSELLING WORK? Peter Bower chapter 1 Mental health issues in primary care Mental health problems are common in primary care. Box 1 shows the proportion of patients presenting to GPs with particular diagnoses. Diagnoses (such as those in Box 1) are the traditional medical approach to describing mental health problems. Box 1: Prevalence of mental health problems (from International Classification of Disorder version 10) Depression 16.9% Generalised anxiety 7.1% Agoraphobia 3.8% Panic disorder 3.5% Alcohol dependence 2.2% Somatization disorder 0.4% However, patients in primary care often present with what are called undifferentiated problems i.e. a complex mix of social, psychological and physical difficulties which may be difficult to summarise under a single diagnostic label. For example, even if they are suffering from symptoms of anxiety and depression, patients often describe their difficulties in terms of the causes of these problems, such as life events. These can include relationship difficulties, bereavement, redundancy, work stress or discrimination. The development of counselling in primary care Changes in the GP contract and the advent of fundholding were key factors in the development of counselling services in primary care. GPs were able to employ professionals such as practice counsellors, community psychiatric nurses and clinical psychologists. However, the increase in numbers of counsellors and other professionals has led to concerns about their training and qualifications, supervision arrangements and the cost-effectiveness of services provided. The advent of PCG/Ts means that commissioners are again facing issues concerning the effectiveness and quality of counselling services in primary care. This handbook aims to provide the most up-to-date information available on these issues. How is counselling and psychological therapy in primary care defined? Counsellors are the most common psychological therapists working in primary care. The exact definition of counselling, and the differences between counselling and other psychological therapy approaches, are somewhat controversial. Throughout the handbook, the term psychological therapy will be used to describe treatments where a professional therapist provides a series of sessions to a patient in order to discuss their problems and develop solutions. The more specific terms relating to individual therapies will be used where appropriate. It is important to note that counselling is something more than just the use of counselling skills (such as listening, reflecting and demonstrating empathy). All health professionals should have some counselling skills to communicate effectively with patients, but this does not mean that they are providing counselling as a distinct service. Counsellors tend to have different training and theoretical approaches to other professionals (such as clinical psychologists and psychotherapists) although some skills are shared. Although concerns have been raised about the training and supervision of counsellors in primary care, a recent survey suggested that the vast majority had appropriate training and were receiving regular supervision for their work. 3 4

8 The Department of Health Clinical Practice Guidelines define counselling as: a systematic process which gives individuals an opportunity to explore, discover and clarify ways of living more resourcefully, with a greater sense of well-being. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict, or improving relationships with others. Counsellors therefore focus on patient choices in their life circumstances, as a basis for their work. Counsellors may practice within any of the therapeutic approaches listed here, using psychodynamic counselling, cognitive-behavioural counselling, systematic counselling and so on. However, most are influenced by humanistic, processexperiential and psychodynamic principles. 2 does counselling work? Thus a number of approaches may be considered under the broad label of primary care counselling. Although counsellors often use a number of approaches in their clinical practice, studies of the effectiveness of counselling (which will be described later) often concentrate on a specific form of therapy. Box 2 shows other psychological therapies that may be used in primary care. Box 2: Other psychological therapies Behaviour therapy and cognitive-behaviour therapy (CBT) are treatments that are concerned to modify thoughts and behaviours that lead to problems in functioning. Therapy is structured, with clear and definable goals. This treatment is most often associated with clinical psychologists and nurse therapists. Psychodynamic therapy developed from classical psychoanalysis, but is far briefer. The focus is on difficult emotions and relationships with significant people in the patient's life. These problems are understood in the context of the relationship between therapist and patient. Interpersonal therapy is not well known in the UK. The treatment involves linking current interpersonal problems with current symptoms, usually depression. Problem-solving therapy has been developed in the UK and evaluated in the primary care setting. The treatment is brief, structured, and seeks to teach patients general procedures for dealing with life events and difficulties. There are many other therapies available in the UK. Descriptions can be found in the Department of Health Clinical Practice Guidelines. All therapies share some characteristics, such as the development of a therapeutic alliance between professional and patient, and the need for the therapist to display communication skills and empathy. They differ in terms of their theoretical underpinning and technical procedures. Does counselling work? Evaluating counselling - the importance of randomised controlled trials Evaluating treatments has generally involved the use of randomised controlled trials (RCTs). The main reason for this is that some psychological problems improve over time without any treatment (what is known as spontaneous remission ). Without a randomised control group, it is easy to confuse these changes with those caused by treatment. In primary care, the control group is frequently usual GP care, which is the care patients would normally receive. This might involve support from the GP, medication and referral to specialist or voluntary services. 5

9 does counselling work? How are the effects of counselling measured? Usually, this involves standardised measures of psychological symptoms such as depression and anxiety. Other measures may include quality of life, or social functioning (such as personal and work relationships). Patient satisfaction with treatment is increasingly seen as an important issue. Economic analyses test whether the clinical advantages of one treatment over another are justified given the additional costs. For example, if counselling cures 10% more people than usual GP care, but costs twice as much, the additional clinical benefits may not be worth the additional costs associated with its use. Evidence-based practice and practice-based evidence Showing that a treatment works in an RCT is known as demonstrating efficacy. This is the basis of evidence-based practice - the use of the best evidence to inform clinical decisionmaking. However, there are always concerns about whether the results from RCTs are relevant to the context of everyday clinical care. Therefore, data from RCTs may have to be complemented by data from everyday clinical work - what is known as practice-based evidence. 4 Chapter 4 provides details of such approaches. The Department of Health Clinical Practice Guidelines 2 The Department of Health has recently published clinical practice guidelines for psychological therapies (available from These guidelines refer to therapies conducted in primary care and those within community mental health teams and psychotherapy departments, and draws on different sources of evidence (such as results of studies from secondary care). This handbook only considers studies involving patients recruited and treated in primary care, and thus draws on a slightly different evidence-base. The efficacy of counselling In this section we summarise the evidence concerning the efficacy of counselling in comparison with: usual GP care; antidepressant medication; other psychological therapies. The effectiveness of other psychological therapies will also be examined. A recent systematic review identified a number of RCTs which examined counselling in primary care All the RCTs were from the UK, and involved counsellors with the necessary qualifications and experience to be accredited by the British Association for Counselling and Psychotherapy (BACP - see Appendix 3). In most of the studies, counselling was compared with usual GP care. 6

10 A statistical summary (or meta-analysis) of the results found that: Counselling reduced psychological distress more than usual GP care in the short-term (six weeks to 6 months). The overall benefits were modest in size. Counselling was no better than usual GP care in the long-term (over 8-12 months). The size of the benefits associated with counselling are modest. As with any treatment, some patients do very well, some do poorly, and most benefit to a degree. The data suggest that the average counselled patient is better off than approximately 60% of those receiving usual GP care. If counselling were no better than usual GP care, the figure would be 50%. does counselling work? One study compared counselling and usual GP care in the management of chronic depression (i.e. symptoms of six months duration or more). 12 A mix of psychodynamic and cognitivebehavioural counselling was used. Results indicated no benefits associated with counselling at six or twelve month follow-up. Counselling compared with antidepressants and other psychological therapies One RCT 9-11 also compared cognitive-behaviour therapy provided by psychologists with counselling and usual GP care. The results indicated that both cognitive-behaviour therapy and counselling were superior to usual GP care at 4 months, and that there were no differences between cognitive-behaviour therapy and counselling in their effectiveness. There were no differences between the three treatments at 12 months; i.e. neither psychological therapy was superior to usual GP care in the long-term. A second RCT 13,14 compared counselling with antidepressant treatment provided by GPs. The antidepressant treatment was designed to mirror the sort of medication treatment that GPs provide. Results indicated no differences in clinical outcomes between the two groups at eight week and 12 month follow-ups. Counselling may be as effective as either cognitive-behaviour therapy or antidepressant medication as routinely prescribed by the GP. The cost-effectiveness of counselling Four RCTs have reported economic analyses. 6,7,9-12,15 These analyses aim to determine the costs of treatment and the relationship between benefits and costs. For example, if counselling a patient is more expensive, is the additional cost worthwhile in terms of the benefits to the patient? None of the RCTs found that the costs of counselling were markedly different from those associated with patients under usual GP care. However, the economic evidence from these studies is preliminary because the relatively small numbers of patients involved in these RCTs means that the results may not be totally reliable. It has been suggested that adding a counsellor to a practice may change GP behaviour towards the entire practice population, resulting in widespread savings in costs, but the published studies suggest that this is not the case, and that the effects on prescribing and referral behaviour are relatively restricted. 16 The evidence concerning counselling is summarised in Box 3. 7

11 does counselling work? The efficacy of other psychological therapies The other therapies that have been evaluated in primary care are cognitive-behaviour therapy (or simply behaviour therapy), problem-solving therapy, interpersonal therapy and psychodynamic therapy. Unfortunately, none of these treatments has been the subject of a systematic review based solely in primary care populations. The Department of Health Clinical Practice Guidelines describe the evidence concerning these therapies, but this is not specific to primary care. The primary care evidence concerning each therapy is briefly detailed below. Cognitive-behaviour therapy is well-validated outside the primary care setting, and was highlighted as the treatment of choice for a number of conditions in the Department of Health Clinical Practice Guidelines. Evaluations in primary care suggest that this treatment is effective when provided by psychologists and nurse therapists, with the majority of studies reporting some positive results. 9,10,17-23 Like counselling, there is little evidence that the benefits of CBT endure in the long-term in primary care populations. One study (described above) suggested that the effectiveness of CBT was similar to that of counselling Most evaluations of problem-solving therapy have reported positive results, suggesting that it is as effective as antidepressant medication, at least in the treatment of major depression However its efficacy in treating more minor problems is unclear, and it has not been determined whether all primary care professionals can be taught to use the treatment effectively. 27 There are few professionals available who have been trained in these techniques, although the training requirements are relatively modest. There is little cost-effectiveness evidence available. There have been only two evaluations of interpersonal therapy (both in the United States), but it was found to be as effective as medication and more effective (and cost-effective) than usual primary care. 31,32 However, there are few trained professionals able to use this treatment. Psychodynamic therapy has only been evaluated in one study, which did not find it more effective than care from the GP. 33 Does counselling work in routine primary care? As stated above, efficacy data from controlled trials need to be complemented by data from routine practice to ensure that the outcomes measured in trials are being delivered in routine settings. This is the use of practice-based evidence to support evidence-based practice. A recent survey examined the outcomes of counselling as routinely provided in primary care using the Clinical Outcomes in Routine Evaluation (CORE) system. 34 This is described in detail in chapter 4. Box 3: Summary of the evidence Counselling reduces psychological distress more than usual GP care in the short-term (six weeks to 6 months). The overall benefits are modest in size. Counselling is no better than usual GP care in the long-term (8-12 months) Chronically ill patients may benefit less than those with acute, short-term problems. Counselling may be as effective as either cognitive-behaviour therapy or antidepressant medication as routinely prescribed by the GP. Economic studies suggest that the overall cost of counselling may not be more than the costs of usual GP care. 8

12 HOW SHOULD COUNSELLING SERVICES BE ORGANISED? Joan Foster Whatever the evidence concerning the efficacy of psychological therapies, it is unlikely that an efficient service can be provided without the proper organisational and structural arrangements. chapter 2 There are four main models of organisation for counselling services (Box 4). Each model is dealt with in a separate section. However, certain issues are common to all models. The description of each model can be read as a self-contained section, and there is considerable overlap between the four sections because of these shared issues. Managed Counselling Services - Managed in Primary or Secondary Care? Primary care counselling emerged through the 1990 s, mostly provided by individual practitioners on a self-employed basis. Some services were managed by Health Authorities, Mental Health Trusts or Community Trusts. With primary care commissioning and increased Government focus on mental health, establishing counselling services may cause tension between primary and secondary care concerning the management and funding of primary care counselling. One strength of primary care counselling has been the incorporation of the counsellor into the primary health care team. The counsellor may be able to offer services similar to the cradle to grave philosophy of the GP. Patients are often referred to counsellors for a life crisis, and useful work can be done a few years later when another life event causes problems. Seeing the same counsellor can be of immense benefit. More importantly, counsellors based in the primary health care team can work closely with the referring GP. This will result in good team-working, providing co-ordinated physical and emotional care to the patient. The Association of Counsellors and Psychotherapists in Primary Care (CPC) has provided guidance to PCG/Ts around the country in setting up managed counselling services. 35 This work supports a managed approach providing accountability, team-working, cross-referral opportunities and economies of scale. Primary care counselling can be managed through a Psychology Department in Secondary Care, through a private provider or through a PCT-based managed service. What is important is that the management should recognise and understand the distinctness of primary care counselling, which is a discipline in its own right. It is not helpful to re-produce secondary care services in primary care and lose the unique contribution primary care counselling services can make. This uniqueness involves the generalist approach, the use of brief, focused methods, dealing with a very wide range of presenting problems, working as part of a primary health care team, and the ability to offer continuing care to patients over a number of years. The Final Report of the Primary Care Key Group to the Workforce Action Team of the Department of Health states in Appendix C, under Primary Care Counsellors : However, we do consider that terms and conditions of employment, salary and management arrangements should be implemented for counsellors in primary care consistent with the guidance on general NHS employment arrangements. (The final report is available on the web at: Four models are emerging as PCG/Ts make decisions to establish primary care counselling services (Box 4): 9

13 how should counselling services be organised? Box 4: Models of counselling service provision As part of statutory provision: this means that a managed counselling service is established within a Mental Health Trust, often located within the psychology department, or as a service established within a PCT. For information on issues relating to this model, go to page 11. As an independent/private provider: this may be an existing counselling agency tendering for the contract to provide a PCG/T-wide counselling service. The agency may or may not have contacts with existing, independent primary care counsellors. For information on issues relating to this model, go to page 17. Existing independent counsellors working as a group: The provider could also be a group of existing, independent, primary care counsellors who form themselves into a structure (such as a limited company) and tender to provide the service. For information on issues relating to this model, go to page 23. Individual counsellors employed by a PCT or individual GP surgeries: In this model the counsellors could be individually employed by a designated surgery for a PCG/T or directly employed by a PCG/T. For information on issues relating to this model, go to page

14 Counselling services as part of statutory provision This usually means that a managed counselling service is being established within a Mental Health Trust, often located within the psychology department. There are also models whereby the Counselling Service has been managed through an NHS Trust but the counsellors are on self-employed contracts and some of the provision is sub-contracted to Relate and the Psychology Department, or where the service is managed by a Health Authority manager using individual counsellors on self-employed contracts. With the establishment of Primary Care Trusts, services are moving towards being managed at a PCT level. Key issues: Where should the management be located? This is possibly the most important decision that commissioners will have to make. Do they want the primary care counselling service to be a true primary care service or to become a part of secondary provision? If it is part of secondary provision, there are management and organisational structures to encompass it. However, if it is to stay in primary care, then management structures have to be put in place to provide effective links with secondary services. how should counselling services be organised? Statutory provision of primary care counselling (as opposed to private or voluntary provision) has one enormous strength, which is that the management can then be automatically involved in strategic thinking and implementation of the National Service Framework for Mental Health and other initiatives. Historically, primary care counselling has been on the periphery and has not been considered when policy decisions are being made. Counsellors have lived with uncertainty as to their future over the past three years. For the majority who have not worked in a managed service, this uncertainty may generate anxiety. There is concern that counselling is not understood and there may be a lack of recognition and respect for counselling within secondary services. The opportunity to establish a new primary care counselling service, managed within a PCT, could result in a more focused management structure. Employment Issues The majority of counsellors have been on self-employed, individual contracts paid from a variety of sources. Appointing a counsellor for a fixed number of hours per week, in a defined location, at a fixed salary, does not meet the Inland Revenue s definition of self-employed status. The Inland Revenue has a number of badges of criteria, which have to be met to establish self-employed status. 36 Whilst a perception has been that part-time staff can be selfemployed, it is not the legal reality. This is a grey area. In some practices, counsellors have been self-employed and have paid room rental, which would contribute to self-employed status. However, advice taken by CPC indicates that self-employment of counsellors would not meet the Inland Revenue s criteria. If the Inland Revenue decide an individual should have been employed instead of self-employed, the employer is fined and liable for the relevant back tax. Counsellors will eventually have to be on employed contracts, but the question is, employed by whom? This has financial implications for PCG/Ts and for independent providers of counselling services. For example, if a provider of counselling uses counsellors on self-employed contracts, that provider would then be responsible. This is an important issue when contracts are being put in place. 11

15 how should counselling services be organised? Counsellors in primary care have been working in very uncertain circumstances. They have not known whether they will still have a job, or how they will be paid. This is, of course, not a unique phenomenon in the NHS. However, as changes in commissioning are undertaken, sensitivity to the implications for primary care counsellors is desirable. Grading Criteria and Pay Scales There is no statutory guidance as to pay scales for counsellors. CPC in conjunction with the British Association for Counselling and Psychotherapy (BACP) and UNISON have produced guidelines on pay and grading structure (Appendix 2). Whilst there is a wide variance in pay around the UK, the average range is 20,000-25,000 per annum (full-time equivalent). Indications are that the Department of Health will establish pay scales for counsellors in due course. It is important to recognise that the fact that counsellors are supervised does not mean that they are trainees or incompetent: supervision is a clinical and ethical requirement for the safety of both patient and counsellor. Management For effective accountability, use of resources, audit and evaluation, a counselling service requires managing. This is distinct from clinical supervision. Manager and clinical supervisor have different roles and require different professional skills, training and experience. Management is a non-clinical role. Supervision is entirely clinical. Key issues are both the lack of structure for this post and the lack of management experience of counsellors. The lack of structure applies whether the counselling service is based in primary or secondary care. Any service is more effective if properly managed. Who is identified as manager and where they are located has major implications for how the service will perform. If the service is being run by an NHS Trust, then it is possible the manager will be an existing member of the Trust staff - possibly in the Psychology Department. This is understandable as there may be anxieties about whether anyone in the counselling team has management skills and how this would fit into the current structure. However, locating the manager in secondary care may mean that management is not sensitive to the particular nature of primary care. Normal practice is that managers are of the same professional group as those they manage. At present, clinical psychologists may manage counsellors, and in the future, a manager who is a counsellor by background may manage a range of professionals, including psychologists and psychotherapists. There are benefits to appointing a manager who is a counsellor, in terms of their clinical understanding of the nature of the work and the issues that affect counsellors, such as supervision, audit and evaluation, training etc. The following describes the different responsibilities of manager and supervisor: Manager 1. Manage the service. 2. Interview and recommend appointment of counsellors and supervisors. 3. Establish service guidelines and protocols. 4. Allocate counsellors to GP surgeries. 5. Introduce the service to GPs, liaise and advise on referrals. 6. Meet with the supervision team. 7. Provide initial training for counsellors (if applicable). 8. Provide on-going review meetings with counsellors. 12

16 9. Monitor effectiveness of the service. 10. Evaluate outcomes. 11. Provide telephone, ad hoc meetings/support as required. 12. Arrange administrative/clerical support. Supervisor 1. Supervise a group of counsellors (or individuals) for a number of hours per week. 2. Work to a Code of Ethics for Supervisors. 3. Provide effective clinical supervision. 4. Be aware of possible legal issues, e.g. The Children Act. 5. Keep adequate records of attendance, counsellor case load etc. 6. Have Professional Liability Insurance. 7. Be available by telephone between sessions for emergency support. 8. Be available for ad hoc meetings with the Consultant or supervisees if required.. 9. Attend meetings with the Manager. how should counselling services be organised? Counsellor Qualifications and Training Counselling is an unregulated profession. Practitioners of counselling working in primary care can be counsellors, psychotherapists or counselling psychologists. Understanding the different training routes is complex, as there are no nationally agreed standards available. For example a diploma in counselling could constitute 10 weeks training or three years. Appendix 3 gives a list of training criteria, and the standards required by the major professional organisations. To make this more straightforward, CPC acts as a self-regulating professional body, recognising and understanding all the varied training criteria. A Registered or Intermediate Member of CPC can be viewed by an employer as having the necessary qualifications and experience. This would enable a PCG/T to demonstrate in its Clinical Governance Report that counsellors on the CPC register meet training requirements. The CPC register is in the public domain and random checks of members are undertaken. With any profession, continuing professional development is essential. In addition, there is now recognition that specific training is required for primary care counselling. Work is underway to identify competencies and continuing professional development needs. Particular areas of focus are: Assessment and Risk Assessment. Psychotropic medication. Legal Issues - e.g. Children Act. Severe and enduring mental illness. Working to a focus and to a time limit. Working in a Primary Health Care Team. Structures of the NHS. Relationships with secondary services - referral pathways. It is important that commissioners and employers are aware of the issues involved in counselling and psychotherapy training and are appropriately advised (individual membership of CPC would satisfy this requirement and meet clinical governance requirements). 13

17 how should counselling services be organised? Supervision Requirements Primary care counsellors require supervision. Supervision is clinical case consultation and can be either conducted on a one-to-one basis or in a group. Effective supervision is required for the well-being of the patient, as well as the counsellor. Supervision is required as counselling involves intense one-to-one working, which can be distressing, difficult and challenging. Both the counsellor and patient need to feel safe. An experienced, trained supervisor is able to explore what takes place in the counselling process and ensure that the patient receives the most appropriate treatment. An important issue is whether the supervisor s theoretical orientation should be similar to the counsellor s. Counselling and psychotherapy training entails working with the therapeutic relationship between the counsellor and the patient and interpreting it as appropriate. It is also important that the supervisor has experience of brief, focused primary care counselling. Levels of supervision required of a counsellor vary according to experience and caseload. CPC has defined these as one hour supervision pro rata for every twenty-five patient contact hours. Trainees should receive supervision at a ratio of one hour for every six patient contact hours. The supervisor/counsellor relationship is an extremely important one for all counsellors. Many independent self-employed counsellors will have a private supervisor and having to move into a structure where the supervisor is imposed upon them can cause difficulties. It is very important that any service employs appropriate counselling supervisors who would be aware of these issues. Economies of scale suggest that group supervision is a good model, but there should also be the opportunity for individual supervision. A good working model is two 1.5 hour group sessions a month with an additional one hour individual session each month. For a complete and accountable service it is important that supervisors should be employed within the counselling service structure. It is also important that the supervision arrangements are sensitive to the differences between counselling and clinical psychology. Counsellors are in breach of their Code of Ethical Principles if they are inappropriately supervised. Counselling is a distinct discipline and requires supervisors who are trained as counsellors, psychotherapists or counselling psychologists. This will ensure supervision is congruent to the theoretical skills of the counsellor. There has been a history of employed counsellors also seeking external supervision, for which they sometimes pay themselves. This was to meet their needs as a practitioner but can be problematic if the manager of the service is not aware of the supervisor s training and experience. It also raises the question of accountability and the service manager s ability to demonstrate clinical governance. 14

18 Legal Issues Counsellors need to be aware of relevant legislation, in particular the Children Act. There is an interesting anomaly in this piece of legislation in that organisations or individuals have to sign up to the Act rather than the Act covering everyone. This means that an employed counsellor would be bound by the Act, but a private practitioner would not. It is another grey area as to how this applies to a self-employed counsellor working in the NHS. Again these issues would need to be covered in any contractual arrangements. Insurance Counsellors require professional indemnity insurance. A key issue is whether an organisational insurance is adequate for employed counsellors. Self-employed counsellors must have their own insurance. It would be important to establish whether NHS Insurance cover is adequate or whether counsellors should retain their own individual Professional Indemnity Insurance. how should counselling services be organised? Budgets An example of the budget for a counselling service for a PCG/T with a 100,000 adult patient list is shown in Appendix 4. This is not a recommended level of provision. The funding for primary care counselling is usually for adult patients. There are legitimate issues as to provision of counselling for the elderly and many practices choose to ignore the upper age limit when referring. The result of this is that waiting lists become longer. As many counsellors have been selfemployed and are paid for their clinical hours only, there is no tradition of funding for administration, supervision and ongoing training. This is a difficult transition period for commissioners with very tight budgets. It is important to recognise that setting up a counselling service with inadequate funding will result in a failing service. It could be worth exploring whether rolling out services over a longer period of time, ensuring that the service is properly structured and funded, is a more realistic option. Trainee and Student Placements It is useful for trainees with sufficient training to undertake a placement within primary care, but such a placement should always be managed. The demands of primary care work mean that it would not be appropriate for a second year counselling student to embark on their first placement in primary care. It would be more suitable for the placement to be part of a primary care counselling training course/module. This is particularly important in that the student requires training to work to a time-limit and the overwhelming majority of counselling/psychotherapy trainings are in open-ended therapy. There needs to be a structure in place, and a relationship between counselling training courses and counselling services, which can provide placements. 15

19 how should counselling services be organised? For effective training placements, conditions need to be established which allow trainees to learn about the complexities of general practice under the mentorship of an experienced counsellor within a managed service. The vast majority of student counsellors are expected to find their own placements, which has resulted in them working in GP surgeries on their own. This is unacceptable, and could be seriously damaging to both patient and student counsellor. The situation for a trainee counsellor in primary care is similar to that of a GP registrar - such a registrar would never be expected to manage a caseload alone in a surgery, and neither should a trainee counsellor. Conditions of service Counsellors (as other mental health professionals) see patients for a percentage of their time with the remainder used for administration, meetings, training and supervision. The recommended time division is 70% clinical, 30% administration. Counselling Hours per 1000 population There is no specific recommendation about the number of hours counselling required per 1000 population. Appendix 4 details the costs associated with a level of provision of 1.5 hours per 1000 population, to guide decisions about service provision. However, it is important to note that this level of provision is only an example. Individual PCG/Ts may decide on higher or lower levels of provision depending on local circumstances and needs. 16

20 Counselling services via an independent/private provider This may be an existing counselling agency tendering for the contract to provide a PCG/T-wide counselling service. The agency may or may not have contact with the existing, independent primary care counsellors. Key issue: Does the provider have experience of primary care counselling? There is concern that the quality of counselling services in general practice will decline through the appointment of unqualified, inexperienced counsellors. Previous research has drawn attention to this problem. 37,38 Much has been done to improve the quality of services, and it would be regrettable if these improvements were undone through inappropriate contracting. Counselling in primary care requires skilled, trained practitioners. They have to be able to offer brief focused counselling, be trained in assessment, mental health issues, psychotropic drugs and risk management. Most counsellors are trained in open-ended, long-term counselling. A provider would need to demonstrate that their counsellors have the additional training, necessary skills and expertise to meet the rigours of primary care work. They would need to ensure that their counsellors either already have the relevant training or are able to attend an appropriate training course. CPC provides these training modules. how should counselling services be organised? It is important to be aware that counselling offered by an inadequately trained counsellor can do damage. Counselling patients who are very vulnerable and giving them inappropriate interventions can do great harm. Short-term counselling requires that the practitioner knows what areas should be addressed and what areas should be left, as opening them up could leave the patient in a worse position than before. It is not appropriate for volunteers to work as counsellors in primary care. With delegated referral responsibility, the referrer has to be satisfied that the health care worker is accountable to a regulatory body. Individual membership of CPC would meet that requirement. Equally it is not safe for student counsellors to work in unmentored placements. A mentored/managed placement is one where the trainee counsellor has a placement with a mentor who is an experienced practice counsellor in a training practice and has separate supervision all within a managed scheme. Employment Issues The majority of counsellors have been on self-employed, individual contracts paid from a variety of sources. Appointing a counsellor for a fixed number of hours per week, in a defined location, at a fixed salary, does not meet the Inland Revenue s definition of self-employed status. The Inland Revenue has a number of badges of criteria, which have to be met to establish self-employed status. 36 Whilst a perception has been that part-time staff can be selfemployed, it is not the legal reality. This is a grey area. In some practices, counsellors have been self-employed and have paid room rental, which would contribute to self-employed status. However, advice taken by CPC indicates that self-employment of counsellors would not meet the Inland Revenue s criteria. If the Inland Revenue decide an individual should have been employed instead of self-employed, the employer is fined and liable for the relevant back tax. Counsellors will eventually have to be on employed contracts, but the question is, employed by whom? This has financial implications for PCG/Ts and for independent providers of counselling services. For example, if a provider of counselling uses counsellors on self-employed contracts, that provider would then be responsible. This is an important issue when contracts are being put in place. 17

21 how should counselling services be organised? Counsellors in primary care have been working in very uncertain circumstances. They have not known whether they will still have a job, or how they will be paid. This is, of course, not a unique phenomenon in the NHS. However, as changes in commissioning are undertaken, sensitivity to the implications for primary care counsellors is desirable. If the agency/provider uses counsellors on self-employed contracts, the issues of employment and the Inland Revenue s definition of self-employed status are not the problem of the commissioner. However, it would be worth reflecting on accountability. There would need to be clarity as to who has responsibility in terms of practice, insurance etc. The commissioner would also have to demonstrate to the public that the provider meets all the requirements of any other NHS health professional. This would include knowledge of the supervision arrangements and their appropriateness. There would need to be sensitive discussion as to whether the agency planned to employ any existing primary care counsellors. What would be the implications if their conditions of service and pay scales were changed and how would they view being employed by a private agency? Grading Criteria and Pay Scales There is no statutory guidance as to pay scales for counsellors. CPC in conjunction with the British Association for Counselling and Psychotherapy (BACP) and UNISON have produced guidelines on pay and grading structure (Appendix 2). Whilst there is a wide variance in pay around the UK, the average range is 20,000-25,000 per annum (full-time equivalent). Indications are that the Department of Health will establish pay scales for counsellors in due course. It is important to recognise that the fact that counsellors are supervised does not mean that they are trainees or incompetent: supervision is a clinical and ethical requirement for the safety of both patient and counsellor. In this model, this is the provider s responsibility. It has become clear in some PCG/Ts that counsellors on a contract with a provider were being paid substantially less than those on independent contracts with the Health Authority. Management For effective accountability, use of resources, audit and evaluation, a counselling service requires managing. This is distinct from clinical supervision. Manager and clinical supervisor have different roles and require different professional skills, training and experience. Management is a non-clinical role. Supervision is entirely clinical. Key issues are both the lack of structure for this post and the lack of management experience of counsellors. Normal practice is that managers are of the same professional group as those they manage. At present, clinical psychologists may manage counsellors, and in the future, a manager who is a counsellor by background may manage a range of professionals, including psychologists and psychotherapists. There are benefits to appointing a manager who is a counsellor, in terms of their clinical understanding of the nature of the work and the issues that affect counsellors, such as supervision, audit and evaluation, training etc. 18