Foreword. Delivering for Health and Applied Psychology: Current workforce, future potential FOREWORD

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1 FOREWORD 1 Foreword The policy direction set by Delivering for Health explicitly reflects the importance of psychosocial factors and lifestyle choices in health and illness. Psychology has much to offer in achieving improvement of both physical and mental health and wellbeing in Scotland. It is clear that the principles and practice derived from psychology are relevant to the training of all healthcare staff and that the delivery of psychological interventions is not the sole preserve of psychologists. Although this report focuses solely on the psychology workforce it should help those engaged in integrated workforce planning to take account of the contribution that professionally trained psychologists can make to achieving their service objectives. Planners at local and regional level may not yet be aware of the full range of the capabilities of professional psychologists and the roles they can fulfil to support the shift in the balance of care. Through partnership working with NHS Boards and Scottish Universities NES has over the last 3 years brokered a significant expansion and modernisation in the training of psychologists for NHS Scotland which is already increasing workforce supply. This report highlights the success of those developments, bringing together data about the current workforce, trainees in the pipeline and future potential workforce supply in a single reference document. There is an inevitable time lag between entry to pre-registration training and the output of trained staff to the workforce. At this time of major service redesign NES is reviewing its priorities, including training numbers, for this professional group, to ensure an adequate supply of appropriately trained workforce for the future. This report is an important part of the work being undertaken by NES to engage service and workforce planners in that review. I commend it to you. Malcolm Wright Chief Executive

2 2 Delivering for Health and Applied Psychology: Current workforce, future potential

3 CONTENTS 3 contents Foreword Executive Summary 1 I. Introduction 11 II. Applied Psychologists in Scottish Healthcare 17 III. Anticipating future service requirements 32 IV. Workforce Supply in V. Characteristics of the Current Psychology Workforce 61 VI. Modernising Clinical Psychology Training 74 VII. Modelling the Future Clinical Psychology Workforce 88 VIII. Future Workforce Supply 97 IX. New Roles for Psychologists in NHSScotland 103 X. Planning for the future 110 References 116 Appendices 1. Glossary of abbreviations and acronyms 2. Developing workforce intelligence to inform planning sources of data 3. Workforce survey form and response codes 4. Student survey form

4 4 EXECUTIVE SUMMARY I. Introduction The purpose of this report is to provide information to assist the coordination of service, workforce and education planning for future psychology services by: raising awareness of the role of applied psychology in delivering improved healthcare outcomes in line with the objectives of Delivering for Health; presenting data about the current and potential future supply of applied psychologists for NHSScotland; providing intelligence about training initiatives for this professional group which will impact on future workforce supply. II. Applied Psychologists in Scottish Healthcare Psychology offers a sound basis for understanding and influencing what people think, feel and do about their health and healthcare. Psychosocial factors are key to success in engaging people in: preventing ill-health; improving physical and mental health and well-being; participating in effective early interventions and in optimal management of long term conditions. Delivery of good quality psychological care is everyone s business in NHSScotland. The input of appropriately trained clinical and applied psychologists to multidisciplinary and multi-agency teams can help achieve the objectives of Delivering for Health. There is a strong evidence base, recognised in SIGN guidelines, for the effectiveness of psychological interventions in achieving positive health outcomes. Clinical psychologists are by far the largest group of applied psychologists currently employed in the NHS and the only applied psychologists for whom the NHS (across the UK) commissions pre-registration training. Uniquely pre-registration training for applied psychologists is at a postgraduate level. The NHS employs applied psychologists with other specialist skills in counselling; health; forensic and neuropsychology. Clinical and other applied psychologists have high level competencies in assessment, formulation and intervention which can be directed at individual, group or systems level, in services delivered to a wide range of client groups of all ages, in the community or in hospital settings. They have expertise in teaching and training

5 EXECUTIVE SUMMARY 5 others and skills in research. Psychological knowledge and skills are relevant to managing change. Clinical and applied psychologists are embracing the modernisation agenda in service and role design. Clinical psychologists in Scotland have led the way in initiatives to achieve greater responsiveness of pre-registration training to changing service needs. A new grade of applied psychologist clinical associate in applied psychology has been introduced in Scotland (Chapter IX for details) equipped with competencies to deliver evidence-based psychological interventions in circumscribed areas of practice to meet service need. Across the UK clinical and applied psychologists are engaged in a programme of work to explore New Ways of Working for applied psychologists in the NHS. This programme is linked to the multidisciplinary endeavour to improve access to psychological therapies in England. It offers opportunities to enhance the contribution applied psychologists make to delivering NHSScotland policy objectives. Service and workforce planners need greater awareness of the role of psychology in delivering service objectives and greater understanding of the skill-mix of applied psychologists available to support the delivery of redesigned services. Planners at local and regional level would be helped by improved access to advice from professionally trained psychologists. III. Anticipating future service requirements Contemporary legislation and new arrangements for the detention, care and treatment of those with a mental disorder will increase demand for psychologists to conduct assessments of capacity and of risk, and to design and ensure effective delivery of appropriate therapeutic interventions. Service objectives and targets derived from Delivering for Health point to an increased need for psychological expertise to support the shift in the balance of care e.g. in the management of long term conditions in the community. Psychologists can also be expected to have a key role in supporting the implementation of the Delivery Plan for Mental Health.

6 6 EXECUTIVE SUMMARY Psychological knowledge and skills are relevant to the agenda for services across the life span i.e. for children and young people s physical and mental health and in services for older adults e.g. support for active ageing, management of dementia. Psychology offers a sound basis for engaging people in behaviour change to achieve physical and mental health improvement across the lifespan. The expectations of patients and of multi-disciplinary and multi-agency teams about access to psychological expertise are increasing. There is a paucity of reliable data to quantify workforce demand for psychologists in NHSScotland. The exception is the CAMHS workforce report which identifies a need for an additional 100wte clinical psychologists to implement the CAMHS service framework. Cogent economic arguments have been made by Lord Layard for the costeffectiveness of improving access to evidence-based psychological therapies, particularly for adults of working age i.e. that the cost of providing mental health services for people with anxiety and depression in particular, is offset by the gain to the economy from returning people to work. The NHS in England has prioritised improving access to evidence-based psychological therapies. There have been several estimates of workforce demand for clinical psychologists and others in mental health services for adults. English estimates, scaled for services to the Scottish population, would imply an indicative target of >1020wte psychologists for adult mental health services alone. These data confirm that the first indicative estimate of workforce requirement (NES, 2002) for the psychology workforce in NHSScotland was conservative i.e wte. Adjusting this figure for the recently identified needs of child and adolescent mental health services (CAMHS) suggests a minimum workforce requirement of 1125wte clinical psychologists in NHSScotland, for mental health services alone (children and adults under 65 years). This does not take detailed account of the contribution that clinical and applied psychologists can make to the improvement of public health, in the management of long term conditions or in services for older adults. Scotland has already invested in expanding and modernising training for psychologists to address this workforce need; service planners need to be aware of the increased numbers of trained psychologists who will be available for employment in NHSScotland from 2007.

7 EXECUTIVE SUMMARY 7 IV. Workforce supply in 2005 In 2005 there were 409.1wte clinical psychologists in NHSScotland, i.e approximately one third of the indicative workforce requirement for mental health services alone. There were in addition 32.5wte applied psychologists. Taken together this represents 1wte clinical/applied psychologist per 11,500 of population in Scotland in In England the notional population served by 1wte clinical psychologist is approximately The model proposed by the Sainsbury Centre for good mental health services represents a staffing ratio of 1wte clinical psychologist per 4883 of population (aged 16-65). There is a wide variation in the staffing levels in psychology services across NHSScotland in all areas of work. The population served by 1wte clinical/applied psychologist in NHSScotland varies between services with the highest and lowest staffing levels: between Boards by a factor of 2 and between Regions by a factor of 1.5. In 2005 there was approximately 1wte clinical/applied psychologist: per 12k of the population aged under 19years; per 11k of the population aged 19-65years and per 39k of population aged over 65years. More than half of all clinical and applied psychologists (231.5wte) are employed in mental health services. This workforce has not grown significantly since The remainder of this workforce are distributed across services for learning disabilities(56.8wte), physical health (55.6wte), neuropsychology (20.7wte), forensic (22.9wte) and other smaller specialist services (a further 54.1wte). Input to physical health services has doubled since There is marked variation between Health Boards in how the psychology workforce is distributed across areas of service e.g. the percentage employed in mental health ranges from 41-85%, in physical health from 0-22% and in services for people with learning disabilities from 0-31%. Strategic planning is required at local level to make best use of this limited workforce in redesigned services if their potential to support the delivery of the objectives of Delivering for Health is to be realised.

8 8 EXECUTIVE SUMMARY A national consensus view of the priorities for workforce development of this small professional group is urgently required so that educational planning can ensure an adequate supply of appropriately trained practitioners to meet future service needs. V. Characteristics of the current psychology workforce This is a relatively young workforce, 49% are aged <40years; an increasing proportion are women (80% of those aged <40 vs. 54% of those >50); 42% work less than full time, on average 0.66wte. In the age range years 44% of men vs 32% of women work less than full-time for NHSScotland; in the age range 40-49years 57% of this workforce works parttime. Further data are needed to understand working patterns, career paths and future aspirations for different age cohorts of this workforce and to inform planning processes. An Amicus survey (in 2004) of workplace difficulties among female clinical psychologists reported problems of access to peer supervision; to continuing professional development (CPD) and promotion, and workload excess relative to contracted hours, particularly among part-time staff. Implementation of Agenda for Change(A4C) should address these issues but this requires to be monitored. Overall clinical/applied psychologists spend 63% of their time in direct delivery of services to patients; the remaining time is principally spent in supporting the training of others (clinical psychology trainees and other staff); management, research and audit, and in CPD. How time is apportioned varies with staff group and seniority. Potential for adjusting roles to encourage staff to continue working beyond the age of 60 has yet to be addressed for this profession. A clear understanding of professional activities and their outcomes for patients is important to service and role redesign and the evaluation of the impact of redesign on the quality and efficiency of care delivered. Assessment of the productivity of psychologists needs to take account of the value of their role in support of the clinical activity of others. It is essential both to clinical and educational governance that clinical supervisors are competent; they need formal educational support to achieve and maintain this competence. NES has developed induction training for new supervisors and is assessing the educational needs of experienced supervisors. Supervisory activities need to be managerially recognised and supported as integral to the service role of

9 EXECUTIVE SUMMARY 9 applied psychologists. There is a need to develop a recognised career path for those seeking to develop competencies in education in support of the work-based learning of others. Currently there is no clear structure for post-qualification specialist training for clinical/applied psychologists. Clinical/applied psychologists need to be able to access leadership/management training if they are to be able to fulfil expectations of their future role development. Training in research skills is integral to the education and training of all applied psychologists. These competencies are important in evaluating the impact of service redesign on patient outcomes. The research capabilities of this professional group need to be more effectively harnessed to generating evidence from practice for NHSScotland. The available workforce data do not adequately capture the contribution of clinical academic staff to NHSScotland. There are concerns about recruitment and retention in this sector reflecting uncertainties about pay and career paths. The turnover rate for clinical psychologists in NHSScotland is low: 6% of the workforce left between 2004 and 2005 and there was a net increase in supply of 4.4%. 18% of the clinical psychology workforce are eligible to retire before They are unevenly distributed across services. Small specialist services and forensic services are particularly vulnerable to losses through retirement in this period. VI. Modernising clinical psychology training NES commissions pre-registration training for clinical psychologists on behalf of NHSScotland. In 2002 NES was charged by SEHD with responsibility for achieving a step change in training capacity and a modernisation of training pathways. Since 2003 NES has been working in partnership with NHS Boards to support an expansion of training capacity tailored to support local service requirements. NES has brokered a more equal partnership between NHSScotland and Universities in the delivery of professional training in applied psychology to ensure fitness for purpose for changing NHSScotland needs. Particular importance is attached to clinical practice education in the workplace and evidence of clinical and professional competence in practice.

10 10 EXECUTIVE SUMMARY In October 2006 there will be 190 clinical psychologists in training in NHSScotland, an increase of 90% on Trainees are NHS employees who are locally employed and managed in services across NHSScotland. Employers are active partners in developing training plans to meet service need as well as professional training requirements. NES is supporting work to develop a standard approach to assessing clinical and professional competence in the workplace across NHSScotland. Flexible training arrangements, unique to Scotland, have been introduced to offer a prompt response to local needs for psychology services in particular areas of work. Work is underway to evaluate the contribution they make to service delivery from their part-time employment during the period of their training. By October 2006, 9 Health Boards, the State Hospital and 2 managed clinical networks (in services for treating cancer and addictions) will be employing 80 trainees with flexible training arrangements designed to meet their local service need. At UK level the profession is addressing the issue of widening access to undergraduate psychology degrees to increase diversity in the pool from which applicants to professional training in applied psychology come. Applications for clinical psychology training still come predominantly from white women. There is significant competition for training places for clinical psychology. Applicants are of high calibre and attrition rates from training are negligible (<5%). Over the last 5 years >90% of those completing training in Scotland took up employment in NHSScotland. Although total training numbers have almost doubled since 2002 and intake numbers have increased, the flexible duration of training contracts means that the output from training will increase more gradually: In clinical psychology trainees completed their training in 2005; the output is expected to be around 45 qualifying each year in 2006 and 2007, rising to 61 in 2008 but falling to 54 in Cost pressures have resulted in a drop in the intake of clinical psychology trainees from 60 in 2005 to 49 in Instability in training numbers makes planning more difficult. Maintaining an intake of about 60 trainees over the next few years would secure a steady supply of trained workforce whose generic competences can be flexibly deployed to meet changing service needs.

11 EXECUTIVE SUMMARY 11 The question of parity of central support for the pre-registration training of other applied psychologists needs to be reviewed, informed by NHSScotland service priorities. VII. Modelling the future clinical psychology workforce While the service is moving towards more integrated workforce planning there remains a need for uniprofessional models to inform decisions about training numbers. A simple supply model has been developed to provide a first estimate of the impact of increased training capacity on workforce supply of trained clinical psychologists for NHSScotland and to inform estimates of the future training numbers required. A number of scenarios were modelled using hypothetical output numbers from training with available data about attrition from training, numbers joining NHSScotland on qualifying and other joiners. In the past NHSScotland has consistently retained 90% of clinical psychologists who completed their training in Scotland. The current models are based on the assumption this will continue to be the case. Headcount data were adjusted for the prevalence of part-time working. The available data suggest that NHSScotland would need to secure a steady output of 60 trained clinical psychologists from its training courses each year to achieve the current indicative workforce requirements by Additional data are needed to show the impact on service delivery of recent training initiatives (i.e. clinical psychology trainees with flexible training arrangements which include part-time employment in areas of service need) and the introduction of clinical associates in applied psychology (in services for primary care and CAMHS). When their input is taken into account workforce supply targets become achievable in a shorter time. Future modelling will be more complex and should take into account professional activity and outcomes in estimating the skill-mix in the psychology workforce required for efficient and effective service delivery. In developing service models for the future planners should take into account the full skill-mix from this profession available to NHSScotland, i.e. taking account of the competencies of other applied psychologists.

12 12 EXECUTIVE SUMMARY VIII. Future workforce supply There is a virtually untapped pool of potential workforce for NHSScotland in the large number of psychology graduates produced each year by Scottish universities. More than half (N=405) of the cohort due to graduate in 2005 with an Honours degree in psychology responded to a survey about attitudes to employment in NHSScotland. The majority perceived difficulty of access to clinical psychology training (92%), competition for assistant posts (91%), lack of training (68%) and of job opportunities for psychologists other than in clinical psychology (62%) and uncertainty about career paths (58%) as barriers to their pursuing a career in NHSScotland. Even so 51% said they thought it likely or very likely they would consider taking up employment in NHSScotland if the opportunity were available. The top 10 factors rated important to students decision making about their future career were: a job which enjoyable and worthwhile, and work life-balance (endorsed by >95% of respondents); good long term salary prospects, challenging work and applying their psychology degree (>80%); a job that offers training and personally being perceived as successful (>70%); good starting salary, paying off student debt and continuing to study psychology (>60%). The majority of respondents are willing to work with all the client groups served by psychology services. Students were more likely to express willingness to work with people with mental health problems or social problems(>80%) than with physical illness or disability (67%); or with offenders (67%); or older adults(65%). Higher levels of interest were expressed in roles involving direct delivery of psychology services to patients than in indirect activities. The majority would have been interested in gaining work experience in NHSScotland as an undergraduate (paid or unpaid) and in opportunities to do their undergraduate research project in that context.

13 EXECUTIVE SUMMARY 13 IX. New Roles for Psychologists in NHSScotland New roles clinical associate in applied psychology have been developed to allow psychology graduates to deliver evidence-based psychological interventions in circumscribed areas of practice to meet NHS service need. NES has brokered partnerships between Universities and NHS stakeholders to develop and deliver new 1 year Masters level practitioner training to underpin these new roles. The MSc in Psychological Therapy in Primary Care (Universities of Dundee and Stirling) equips graduate psychologists with the competencies to deliver psychological interventions for common mental health problems presenting in adults in primary care. Of the first cohort of 26, 25 have successfully completed training and are employed in NHSScotland services. The second cohort of 27 trainees is due to complete training in December A further 18 trainees will enter training in January The contribution of clinical associates to service delivery is currently being audited. A second programme is being developed by the University of Edinburgh working in partnership with NHS Greater Glasgow and Clyde. The learning outcomes are defined in terms of the competencies required to deliver early interventions to improve the mental health and well-being of targeted groups of children and young people and their families. Under the guidance of the Quality Assurance Agency for Higher Education in Scotland the standards for Masters level training in this field have been benchmarked against clinical psychology doctoral training in order that the public, employers and others can understand the capabilities of those with this level of training. Training is subject to academic quality assurance processes but there are currently no systems in place for professional accreditation of training. There are as yet no mechanisms for regulation of these new roles. The new roles, both in training and on entry to the workforce, are being evaluated for A4C at national level. Prior to implementation of A4C, arrangements for their pay were agreed using Whitley scales, giving these trainees parity with first year clinical psychology trainees. Qualified associates are remunerated on the lower spine points of the scale for Grade A clinical psychologists.

14 14 EXECUTIVE SUMMARY It is envisaged that, with educational support, these new roles could be enhanced, contributing to a wider range of service delivery. Associates knowledge and skills should in future be accreditable towards full professional training e.g. in clinical or counselling psychology. It is important for clinical and educational governance that appropriate arrangements are in place for supervision of these trainees and for the appropriate deployment and development of the competencies of trained associates. For these new roles to deliver sustained benefit to patients, employers and planners will need to attend to the continuing support and development of these individuals within the workforce. Planners need to be aware of the contribution these new roles can make particularly to stepped care models of service delivery. Greater engagement of stakeholders, particularly in Community Health Partnerships (CHPs) is required to inform the future commissioning of training at this level. X. Planning for the future The current reorganisation of service delivery offers new opportunities and challenges in planning for psychology services in NHSScotland. A programme of work led by NIMHE is exploring New Ways of Working for Applied Psychologists.This programme is reviewing: access to psychological therapies; psychologists in multi-disciplinary teams; models of organising, leading and managing psychology services; career pathways; new roles; mental health legislation; training. This programme of work is raising issues which are relevant to the Scottish context. Stakeholders in Scotland will have the opportunity to contribute in October The report is planned for May The output from the New Ways of Working programme should give new impetus to linking service workforce and educational planning for the future of psychology services in NHSScotland.

15 INTRODUCTION 15 I. INTRODUCTION This document brings together information about the current and potential future psychology workforce against a background of rapid and complex change in the NHS and in the professional landscape for applied psychologists in healthcare. The aim of this report is to bring together in one place key information to assist the co-ordination of service, workforce and educational planning for the future organisation and delivery of psychology services for NHSScotland by: raising awareness of the role of applied psychology in delivering improved healthcare outcomes in line with the objectives of Delivering for Health, presenting data about the current and potential future supply of applied psychologists for NHSScotland, providing intelligence about training initiatives for this professional group which will impact on future workforce supply. The full report is a reference document containing detailed information in support of each of the three planning elements. A briefer summary document is available separately for those requiring an overview of the contemporary issues for this sector of the NHSScotland workforce. Demand for access to psychology services has consistently outstripped supply. Historically the development of these services has been opportunistic and dependent on local champions. This has resulted in gross inequities of access to services across NHSScotland and unacceptably long waiting times. Locally, psychologists have for several years been active in redesign to improve patients access to psychological services. At national level the Scottish Executive Health Department (SEHD) began to address the problem in 2003 through increased investment via NHS Education for Scotland (NES) to support expansion of training for clinical psychologists in NHSScotland. Significant progress has been achieved through partnership working with local psychology services across NHSScotland. Over the last three years Scotland has been at the forefront in the UK of modernising the culture for pre-registration training for clinical psychologists to achieve greater responsiveness to NHS service needs. This investment is now beginning to produce an increased supply of clinical psychologists and a new source of workforce (clinical associates in applied psychology) available for employment in NHSScotland. At a time of major system change planners and senior managers at regional and Board level and in community health partnerships (CHPs) need to be aware of the size and capabilities of this increased workforce supply and to be engaged in shaping the future capacity and design of training which will be required to meet changing service needs.

16 16 INTRODUCTION Delivering for Health has signalled a shift in the balance of future healthcare delivery in Scotland from hospital to community based care. This shift takes more account than the traditional medical model of the crucial importance of psychosocial factors and human behaviour in health and healthcare. With that shift comes a need to engage people (i.e. the public, patients, their carers and healthcare professionals) in improving health outcomes. Understanding what people across their lifespan think, feel and do about their health and healthcare, both individually and collectively, and having the knowledge and skills to effect change, is core business for applied psychologists. The contemporary policy direction means that psychology has much to offer to service delivery in NHSScotland in support of its health improvement objectives. However this requires new ways of working and new roles for psychologists within multi-disciplinary and multi-agency service delivery. At a time of major change in the whole healthcare system it is easy to overlook this small professional group. While there is ample evidence of measurable benefit to patients from psychological interventions, planners perceptions of psychologists are often informed by traditional practices and historic workforce shortages. Senior managers attention is primarily focused on the larger healthcare professions, all of whom are implementing nationally agreed action plans to align their future training and workforce development with contemporary service needs. Psychological knowledge and skills are relevant across the whole healthcare agenda. There is an unprecedented opportunity in system redesign to take an integrated view of physical and mental health and wellbeing. Professional psychologists are rarely involved in strategic planning at this level. The number of professionally trained psychologists within NHSScotland is likely to remain relatively small. A national view is all the more necessary to make best use of their input, particularly if persistent inequities of access to services across Scotland are to be addressed and an adequate supply of appropriately trained psychologists is to be available to support the delivery of good quality psychological care by more numerous others. There is a challenge to establish the appropriate forum in which the national priority actions for psychology services in NHSScotland can be agreed. There is a large and virtually untapped pool of potential workforce in the large number of psychology graduates leaving Scottish universities each year. The barrier preventing their entering the NHS workforce is lack of access to appropriate training and career paths. Driven by the policy direction in England the profession is actively engaged in a radical review of new ways of working (and training) for applied psychologists to meet the needs of a changing NHS. This programme of work offers new opportunities for developing a flexible workforce of applied psychologists to address NHSScotland s needs in the twenty first century.

17 INTRODUCTION 17 NHS Education for Scotland (NES) has demonstrated it can, through its partnership working, deliver educational developments to support NHS service needs. Clarity about the future plans for service and role development for psychologists in NHSScotland is now required to inform future educational requirements. Historically the number of professionally trained psychologists employed in the NHS was small, principally clinical psychologists, and they were most commonly employed in direct delivery of psychological interventions to patients within the context of mental health services. Now psychologists are employed more flexibly in a variety of roles across a wider range of services in NHSScotland. Increasingly clinical psychologists have a key role in the clinical governance of services delivered by others and psychology services employ a wider skill-mix of clinical and applied psychologists and other clinical staff in a broader range of service settings. The implications of this shift in roles for the relative priorities in the national educational agenda for psychologists need to be examined. Data about the existing psychology workforce are not easily extracted from the national statistics where they are embedded in aggregated data for scientific and professional staff. Annually since 2001 more detailed data about the psychology workforce have been produced by the Information Services Division (ISD) working in partnership with NES. These data are now disseminated electronically annually to coincide with the release of other national workforce statistics. A small subset of these data was included in the National Workforce Planning Framework (Scottish Executive, 2005). The modernisation of pre-registration training in Scotland has resulted in increased training numbers, more flexible training pathways and the introduction of a new grade of applied psychologist (Clinical Associate in Applied Psychology). These initiatives are not captured in the currently available workforce data reports. Information is included in this report to alert planners to the numbers and characteristics of trainees in the pipeline. This report is part of a programme of work being undertaken by NES to raise awareness of the full potential that the discipline of psychology could contribute to Delivering for Health and to inform a strategic review of the educational priorities from Service planning: NES commissioned work to engage stakeholders, including the public and service users, in reviewing key issues for the future design of psychology services in NHSScotland (Psychology into Practice, NES Conference report, 2005). That work highlights specific opportunities for the future contribution of psychology services in support of performance targets for NHSScotland, with recommendations for action to optimise the use of the available supply of psychology workforce. 2. Workforce planning: Workforce planning for services which are being redesigned is a complex iterative process. Current estimates of workforce requirements for psychologists are crude but err on the side of conservatism.

18 18 INTRODUCTION This report highlights the importance of sustaining training numbers at an appropriate level to maintain both the supply of clinical psychologists with generic training and clinical associates with circumscribed training, until better models of future demand are developed i.e. taking into account role and service redesign and the breadth of the applicability of psychology. 3. Priorities in education and training: It is timely to review priorities in the NES educational agenda for psychologists in the light of not only changing service needs but also important professional developments at UK level. The policy direction for mental health services in England is driving a major programme of work to explore New Ways of Working for Applied Psychologists. This wide ranging programme has implications beyond mental health services in England. It is essential that planners in Scotland engage in this work in progress (due to report in May 2007) to ensure that its outcomes will translate effectively for the Scottish context. The recently published report on The regulation of the non-medical healthcare professions (DoH, 2006) gives a commitment to legislate for the regulation of applied psychologists. This will have implications for the education and training required in future to underpin statutory requirements for evidence of fitness to practise and continuing fitness to practise. Key Messages The purpose of this report is to provide information to assist the coordination of service, workforce and education planning for future psychology services by Raising awareness of the role of applied psychology in delivering improved healthcare outcomes in line with the objectives of Delivering for Health. Presenting data about the current and potential future supply of applied psychologists for NHSScotland. Providing information about training initiatives for this professional group which will impact on future workforce supply..

19 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE 19 II. APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE Success in engaging people in preventing ill-health, improving health and well-being, in participating in effective early interventions and in the optimal management of long term conditions requires a co-ordinated bio-psychosocial approach which takes account of the key psychological variables influencing healthcare behaviour. Evidence of patient need for psychology services is manifest in NHSScotland in the prevalence of psychological problems presenting in people across the lifespan in a wide range of service settings, and in the long waiting times for access to many psychology services. The delivery of good quality psychological care is everyone s business in the NHS. The input of appropriately trained psychologists can contribute to the effectiveness of services delivered by multi-disciplinary teams across the healthcare system. Psychology offers a sound basis for understanding and influencing what people think, feel and do about their health and health related issues. Applied psychologists use the principles and methods of psychology to promote the development, well-being and effectiveness of individuals and groups in society. There is a strong research tradition in psychology and a strong evidence base for the effectiveness of psychological interventions in achieving health improvement. Evidence that the knowledge and skills derived from psychology have a significant contribution to make to improving physical and mental health is increasingly recognised in SIGN and other practice guidelines. The current workforce in NHSScotland is largely made up of clinical psychologists. The range of applied psychologists who could usefully contribute to healthcare service delivery in future is wider. The profession is organised in divisions characterised by their specialist training in different applications of psychology. In spite of those differences, applied psychologists share a common base of knowledge and principles derived from basic psychology. These specialist divisions in applied psychology are not well understood by non-psychologists.

20 20 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE This chapter outlines the roles and competencies of this wider family of applied psychologists to assist planners in understanding the range of knowledge and skills that the profession as a whole could bring to NHSScotland in future. Chapter IV presents data about their current numbers in the NHSScotland workforce. 1. Clinical Psychologists Clinical psychologists are the largest and longest established group of applied psychologists employed in NHSScotland and the only group for whom the NHS across the UK commissions pre-registration training. Clinical psychologists: bring psychological theory, evidence and practice to bear on solving clinical problems; assess, formulate and treat clients with a wide range of problems presenting across the life-span in primary, secondary and tertiary services; work within both physical and mental health settings; work directly to solve complex clinical problems involving individuals, carers, couples, families, groups and service systems; offer consultancy, training, supervision and support in support of the psychological skills of others in multi-disciplinary teams; offer research and evaluation skills relevant to service redesign and evaluation of treatment outcomes. Clinical psychologists are currently engaged in processes of service and role redesign, affecting the way the whole of the existing workforce is deployed. Stepped care models (Chapter III, 6) for example, target the time clinical psychologists spend in direct 1:1 patient care to those with complex problems, and increase the proportion of the time available to spend in indirect service activities, such as clinical governance of psychological interventions delivered by more numerous others. A new grade of worker (Clinical Associate in Applied Psychology) is being introduced to increase capacity for direct delivery of psychology services to patients (Chapter IX). The introduction of staff with more circumscribed competencies has implications for the supervisory input required from more highly qualified staff in the team. Changes in the roles and numbers of other key professions with whom psychologists work e.g. psychiatrists, have implications for the role and workload expected of clinical psychologists. (New Ways of Working for Psychiatrists, Department of Health, 2005). It is not yet clear how these new ways of working will impact on future workforce demand for clinical and other applied psychologists. NHSScotland currently employs other applied psychologists in the following main specialisms: counselling; health; forensic and neuro-psychology.

21 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE Counselling Psychologists While counselling psychologists have a number of features in common with clinical psychologists their distinctive features are described below: Counselling Psychologists: specialise in the delivery of psychological therapy, emphasising humanistic values and the importance of the therapeutic relationship and process; require to have a high level of self-awareness and competence in relating personal and interpersonal dynamics to the therapeutic context; undergo personal therapy as a requirement of training. Among applied psychologists currently employed in health, forensic and neuropsychology in NHSScotland the majority are also qualified clinical psychologists. The descriptors for each of these three specialisms are given with a brief statement about the difference in the activities of those who are, and who are not, clinically qualified. It is important for service/ workforce planners, employers and the public to be clear about the competencies which different groups of staff can be expected to bring to service delivery. 3. Health Psychologists The majority of Health Psychologists work primarily in higher education institutions. The number currently employed in the NHS are small. This is a cause for concern given the major contribution they have to offer the contemporary public health agenda. The potential benefit of employing those qualified in health psychology is not yet well understood. Health Psychologists: provide an integrated biological, psychological and social approach to the understanding of physical health and illness; offer the practice and application of psychological research to: - promotion and maintenance of health; - prevention, treatment and management of illness; - identification of key factors in the causation of illness and related dysfunction; - improvement of the health care system; - health policy formulation. In focusing more on systems than individual patients, Health Psychologists tend to occupy a complementary role to that of Clinical Psychologists.

22 22 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE Clinical Health Psychologists work as described above for Clinical Psychologists in the context of multi-disciplinary teams providing services for a wide range of physical health problems including coronary heart disease, cancer, diabetes and obesity. 4. Forensic Psychologists The implementation of the Mental Health (Care & Treatment) (Scotland) Act in particular is expected to increase demand for staff with competencies in forensic psychology. In particular, the principle of reciprocity is expected to drive demand for psychological interventions appropriate to the care plans of those compulsorily detained. Service planning for forensic services, including the new medium secure units, is driving workforce planning for these services and the need to estimate future workforce requirements for psychologists. Forensic Psychologists Psychologists contribute to criminological and legal services in many ways. They may be concerned with the behaviour of people within legal systems: offenders and offending behaviour; crime detection; the administration of justice (including giving of evidence as an expert witness); or in the management of individuals after sentencing. Those employed in the NHS are likely also to be Clinical Psychologists. A variety of offending behaviours are amenable to psychological interventions which may be important to patient rehabilitation e.g. anger management. Failure to provide appropriate psychological interventions may result in longer periods of detention and/or an increased risk of relapse or re-offending. Patients detained under mental health legislation have a high number of mental health needs requiring psychological intervention. Expert assessment of risk is important and fundamental to the compulsory restriction and/or treatment of mentally disordered offenders. Modern methodologies for risk assessment involve a high level of psychological expertise. Clinical forensic psychologists are increasingly asked to advise community and primary care services about patients who have clinical needs but also present forensic issues because of concerns about risk to the public, other patients and staff.

23 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE Neuropsychologists There are increasing calls across the UK for the establishment of better co-ordinated services for people with acquired brain injuries. The needs of those with congenital or birth injuries and those of an ageing population with degenerative conditions e.g. Alzheimer s disease, point to a growing need for neuropsychology services. Neuropsychologists: are concerned with the relationship between brain and behaviour; work with children and adults who have had an illness or injury affecting their brain. This includes degenerative disease of the brain; offer a basis for understanding how brain dysfunction affects thinking, memory, emotions and behaviour Clinical Neuropsychologists carry out specialist assessments of these functions to understand exactly what difficulties the person is having/likely to have and to monitor change. They are often able to advise on the likely outcome of such a condition and how best to cope with any resulting long-term difficulties for the individual and their family. They work with others in rehabilitation and education helping people to minimise their difficulties and where possible return to independent living and work or education. Graduate psychologists without a clinical training have been able to undertake training for circumscribed activities carried out under the supervision of fully trained clinical colleagues. 6. Other Applied Psychologists There are a number of other applied psychologists whose specialist knowledge and skills are relevant to the healthcare agenda. For example, the strategic direction of services for health improvement for children and young people is bringing the work of clinical psychologists in those services closer to that of educational psychologists who are typically employed by local authorities in delivering services to schools. Occupational psychologists apply psychological knowledge, theory and practice to work in its widest sense: how conditions of work and work-related tasks affect people and how people and their characteristics determine how work is done. Some occupational psychologists specialise in areas such as vocational rehabilitation. Others work in-house for organisations, or by consultancy, applying their expertise to identify and resolve organisational issues e.g. managing change. The contribution they could make to the modernisation agenda is NHSScotland is underdeveloped.

24 24 APPLIED PSYCHOLOGISTS IN SCOTTISH HEALTHCARE 7. Traditional training and career path for clinical psychologists Clinical psychology is the only branch of applied psychology for which the NHS (across the UK) funds pre-registration training. Accordingly the training and career path described here refers solely to that group. Training for other applied psychologists will be dealt with in the review of training which is planned for autumn 2006 (Chapter X). Clinical psychology is unusual among healthcare professions in that pre-registration training is undertaken at a postgraduate doctoral level. The figure below depicts a typical career path for clinical psychologists prior to the implementation of Agenda for Change: Undergraduate degree in psychology* (4yrs in Scotland) work experience + typically 2 years Doctoral level training in clinical psychology (3yrs) Grade A clinical psychologist (6-7 years) Grade B clinical psychologist * must confer the Graduate Basis for Registration with the British Psychological Society + may be in employment as an assistant psychologist in NHS but other paid/voluntary work also admissible as relevant Undergraduate Psychology: Psychology is a multi-disciplinary science which brings a wide range of techniques and methodologies to bear on the investigation of human behaviour. Across the UK psychology is one of the most popular undergraduate degree courses. In 2004, the total psychology undergraduate population in the UK was 64,480, with an intake of 12,132 in that year. More than 800 programmes in more than 100 departments of psychology are approved by the British Psychological Society (BPS) as conferring the Graduate Basis for Registration (GBR). In Scotland in 2005 there were 13 Universities offering Honours degree programmes in psychology, not including the Open University. Most psychology graduates do not undertake specialist postgraduate training to become practitioners. The curriculum requirements for GBR are set without reference to applied psychologists or the needs of employers of applied psychologists. Coverage of applied topics in undergraduate programmes will vary from institution to institution. The place of applied psychology in undergraduate programmes is being reviewed within the New Ways of Working programme (Chapter X). Among psychology undergraduates, 80% are women and the majority are white and aged under 20 years. Even so, the popularity of the discipline is such that the absolute numbers of acceptances to psychology courses for people from ethnic minorities is higher than for medicine (BPS/DCP, 2005). The BPS is actively addressing issues of diversity in the