Reply to CON-sultation: Equity and excellence: Liberating the NHS White Paper July 2010

by Julia Evans on October 9, 2010

9th October, 2010 [Edited & web-links added January 2012]

 

Please note:  Having contributed to many Government CON-sultations, my first in January 2007, I am aware that my comments do not register and I am not alone.  Quote from e-mail received 10th October 2010: ‘ It does make you feel discouraged, my MP now doesn’t even bother to acknowledge mail from me. I have complained to Nick Clegg and Andrew Landsley, guess what, they didn’t reply either. I sometimes feel as though I’m invisible, or too vociferous.’

My experience of CON-sultations teaches me that they have two objectives:

to CON-sult within a tight framework so any comments outside this framework do not register and

to, narcissus like, reflect back to the Government how wonderful their wish-list is and by extension, how wise you all are.

In order to provoke the Government: the Lords, the Commons and their civil servants, into critically engaging with these issues, this will be circulated widely as well as to the DoH.

 

The White Paper: Equity and excellence: Liberating the NHS White Paper July 2010 and the official results of the CON-sultations are available here.

 

Content:

 

1.  The Government’s use of imaginary standards goes unchallenged.

 

2.  Is it possible for a Government to promise safeguarding, the elimination of risk or liberation from Government-initiated-and-supported regulations?

 

3.  What is driving this approach to care?

 

4.  The evidence base

a) House of Lords Select Committee on the Merits of Statutory Instruments

b)  EU Law

c) The King’s College, London study “Statutory Regulation and the Future of Professional Practice in Psychotherapy and Counselling: Evidence from the field”

 

5. Create a broad library of standards for all the main pathways of care  DoH dh_118053 Arms Length Bodies Review July 2010

Counter-indications that this approach is appropriate or works:

a)  The Government driven enforcement of centralised standards into child protection

b)  Statistics which purport to measure care, for example Staffordshire Hospital’s SMRs (Standard Mortality Ratio)

c)  NICE clinical guidelines

 

6.  Outcomes

a)  The King’s College study: the start of an impact analysis: i. The effects of performance management on therapy

 

7.  Fitness-to-practice adjudication for health professionals: assessing different mechanisms for delivery. Note

a)  Fitness to practice standards, entry criterion and much else are derived in committee rooms

b)  These Government-authorised standards are used to persecute practitioners who do not comply with the letter of the Privy Council-driven law.

c)  Most of the ‘complaints’ come from fellow practitioners or non-clients.

d)  Fitness to practice cases are not based in patient abuse

e)  King’s College report:1. Doctors perceptions of regulation in practice i. Doctors: “Guilty until proven innocent” ii. The Blame Society

 

8.  Regulating outcome

 

9.  Prevention

a)  Mental Illness

b)  High quality services

c) Promote prevention

d)  Recovery

e)  Social inclusion as a Government aim

f)  The Prevention Paradox

 

10.  The control of Risk by Government to produce ‘safeguarding’ (HPO2001 and elsewhere)

a)  Industrial definitions of risk (first written and circulated in January 2006)

b)  The system controls practice and thus risk (Written and circulated in 2009)

 

11.  The production of fear & the transfer of risks from the organisation to individual therapists. The dismissal of Anxiety and Fear from the Government’s Systematic Approach

a)  From the King’s College report: the Blame culture

b) The removal of safe places

 

12.  The Government produces and supports stigma by its discriminatory regulatory processes

a)  The mechanism which categorises conditions of mental illhealth is inserted by the Government-invented NICE

b)  The Government-sponsored myth that using centrally-defined systems mental illhealth can be eliminated

c)  ADHD as case study – remember NICE classifications have no biological markers. Where is the stigma coming from if not the Government’s classification systems known as NICE?

 

13.  The Government’s rule book and developing a practice.

a)  From the legislation Wellbeing and Safeguarding in the legislation or the legal definition of units of wellbeing

b)  How do you train an act which relies on individual judgment in conditions of stress?

c) The DoH and its July 2009 Interim Report.

d)  Common sense (savoir-faire) versus slavish adherence to written documents and protocols

e)  Books of rules versus practice in the armed force

_________________________________________________________________________

 

My response to this CON-sultation

1.  The Government’s use of imaginary standards goes unchallenged.

 

Why are equity and excellence imaginary standards?

 

Does the One Absolute Standard ‘Equity’ and One Absolute Standard ‘Excellence’ exist?

 

Equity: I have been given a remarkably healthy body.  I last consulted the medical profession when my son was born in 1992.  So how do you compare equity of provision to me with someone suffering from cancer? Equity is a fine rhetorical word. It cannot be made into a standard measurement. No comparison can be made. Thus, it cannot be said that in the north they have 75% equity and in the south 125%. Such a comparison can be made in financial terms. Is equity a financial term in disguise?

 

Excellence: So the Government proposes that Excellence can be defined and measured just as a production line which produces no rejects is excellent. So services, delivered by practitioners usually one to one, can be compared with Industrial quality standard measurements. And you, the Government, all nod in agreement with Lord Donaldson’s use of high risk industry (CMO report: Good doctors; safer patients, 14th July 2006[i]) to define practitioners who care.

Please ask yourselves what is your evidence that you are in charge of an industry let alone a high risk one. Excellence cannot be measured by your facile tick-box questionnaires.

2.  Is it possible for a Government to promise safeguarding, the elimination of risk or liberation from Government-initiated-and-supported regulations?

 

Clearly, the excuse for top-down interference into care is driven by the fantasy that Governments can protect, eliminate risk or liberate. Government-authorised bodies: Skills for health , NICE , Health Professions Council  (HPC) , Increased Access to Psychological Therapy (IAPT)  all have this at their core. Legislation is put in place, Health Professions Order 2001 (HPO2001) , which carry this fantasy over into Privy-Council   power & backed regulations. If a Government acts to safeguard, protect, eliminate risk and liberate, the fantasy leads it into delusions of absolute power and control. They do not need to research into whether there is a problem to be solved or whether their solution diminishes or increases the problem, they appoint committees to put their solution in.  Indeed Anne Milton, Parliamentary Under Secretary of State (Public Health), Health, has made this fantasy into fact: : 2nd June 2010: 10.14pm to House of Commons(available here) “There is no doubt that vulnerable people are often preyed upon by unskilled and unscrupulous practitioners.”

There is no evidence that this is the case.

The Government will not listen and devises more and more punitive systems of regulation run by supposed non-Governmental organisations who owe their existence to Parliamentary statutes and orders. The main production of this form of totalitarian control is fear.

So this Government proposes to continue to govern services dedicated to care and service by fear. Fear of being caught out not rigidly applying the Government’s clinical judgment of what is good for you.

3.  What is driving this approach to care?

 

Professor Ewan Ferlie, Head of the Department of Management at King’s, comments, ‘Politicians need to balance reacting to rare but high-profile cases of malpractice by introducing new layers of regulation, with its often-detrimental impact on the majority of health professionals, and its enormous financial costs’. From ‘Statutory Regulation and the Future of Professional Practice in Psychotherapy and Counselling Evidence from the Field’ by Dr Gerry McGivern, Dr Michael Fischer and Prof Ewan Ferlie, Department of Management, King’s College, London, and Dr Mark Exworthy, School of Management, Royal Holloway, University of London.  October 2009  referred to as ‘King’s College Report’ and available here.

 

Comments or Drivers:

The Government’s reaction to press comment on infamous criminal cases:  Dr Shipman and Baby P and other criminal doctors who raped (See endnote 1), and so on.

The Government’s belief that centralised health care market means greater centralised control over costs and outcomes. Also contracting out means that direct costs go off the Government’s books. This masquerades as the Lord Protector rules OK. (Remember the Lord Protector’s Government even cancelled Christmas because they were working for the population’s Good.)

 

King’s College: Dr Michael Fischer, Research Fellow in Healthcare Management in the Department of Management, at King’s College added: ‘Our research in an IAPT service also highlights the risks of expanding bureaucracy more focused on outcome measures than actual patient care. It suggests that rather than remote, quasi-legal regulation, interpersonal processes such as clinical supervision and local professional engagement appear key to protecting the public and ensuring safe and effective practice.’

 

Professor Ewan Ferlie, Head of the Department of Management at King’s, comments, ‘This is a relatively small scoping study based upon a limited number of interviews and observation. We do not claim that our findings are representative of the whole field of psychotherapy and counselling, however our research does reflect how regulation is perceived in different contexts.  So it may indicate how future statutory regulation would be interpreted and implemented in practice. Politicians need to balance reacting to rare but high- profile cases of malpractice by introducing new layers of regulation, with its often-detrimental impact on the majority of health professionals, and its enormous financial costs.’

 

King’s College Recommendations include: Professional regulation needs to balance reacting to high profile but rare ‘media spectacles’ with its actual impact on the majority of practitioners’ clinical practice.

 

And single cases make bad law.  And actually gathering and evaluating evidence is far from being driven by headlines but involves thinking. And providing safeguarding and risk-free care from a central control position is what happened in Stalinist Russia.  So by its actions the Government judges all practitioners to be unsafe unless controlled by centrally driven Privy Council power.  Because over the last 10 years, about 10 criminal cases have been spread, salaciously (they sell well) over the press.

 

4.  The evidence base

 

There is none. No-one is asking the Government to drive standard measurements from the centre. No-one, even Dr Shipman’s patients, are demanding central control of risk.  There is no evidence that central control of risk to produce safeguarding works. There is no evidence that NICE can replace an individual’s clinical judgment. There is no evidence that Skill for Health’s competencies can mandate a practice. But no matter – the Government has declared it shall be so and so it is.

 

The following are counter-indications:

 

a) House of Lords Select Committee on the Merits of Statutory Instruments  produced as report: What happened next? A study of Post-Implementation Reviews of secondary legislation

Quotes below are from a download of 9th October 2010 from here. Highlights in italic have been added:

The  Government Response was published by the Committee on 28 January, 2010 and available here.

In this Inquiry report (available here) published on 12th November, 2009, the Committee found that most departments are failing properly to examine whether each significant piece of secondary legislation is achieving the outcome intended for it. Departments do not know whether their legislation is effective, and are missing opportunities to improve the quality of both their policy formulation and delivery methods. In particular departments need to do more to evaluate how the original instrument performed before bringing forward amending regulations.

The National Audit Office conducted a benchmarking study for us (available here): it found that 46% of the sampled SIs with Impact Assessments from 2005 had not been subject to any evaluation of their effectiveness after 4 years, and only 29% had received a full post-implementation review. Although this figure is rather distorted because a few Departments seem much better geared up for the process than the rest.

The report’s main recommendations are:

Government should take a more active role in supervising both Impact Assessment (IA) and

Post-implementation Review(PIR) systems to ensure that the approach is appropriate and the reviews are done. The formats for both should be more closely aligned in terms of content and method.

Departments should ensure that all IAs include a clear statement of the baseline position

against which the change introduced by the legislation can later be measured to assess whether the success criteria have been met.

Departments should propose arrangements for PIR in the consultation exercise on the draft regulations that are appropriate and proportionate to the content of the regulations.

This applies just as much to public sector legislation as to that which affects business.

All PIRs/evaluations on Statutory Instruments should be published online, alongside the original IA.

Each Department should establish and maintain an online register of its legislative portfolio to track PIR commitments, aid consolidation, and also to smooth transition when machinery of government changes are made. End quote.

 

Questions: Where is the baseline position in terms of equity and excellence?

Where is the impact assessment of asserting that liberating the NHS is connected to equity and excellence?

 

b) EU Law

 

“The overall goal [of a regulation] must be to improve welfare for all users of professional services” EU Commissioner Monti as reported in “Competition in Professional Services: New Light and New Challenges”. By Mario Monti, European Commission, for Bundesanwaltskammer, Berlin, 21 March 2003, page 6 available here.

So where is the evidence that driving quality, clinical judgment, excellence, training, job competencies, outcomes measurements from a central control point defined within the Government, is needed and improves the welfare of all users?  Note the EU uses the term welfare not Noddy measurements of customer satisfaction.

 

Further, I strongly recommend you download and read

‘The Regulation of Psychotherapists and Counsellors in the United Kingdom through the HPC: Between State Powers and International Obligations.’ Report by Alessandro Amicarelli JD LLM MBA DHP Phd, Doctor of Research in “International Order and Human Rights”, Department of “Theory of State”, “SAPIENZA” University of Rome, Italy: 20th October 2009

from The National Council of Psychotherapists (est. 1971) web-site here.

 

I understand the arguments to comprehensively dismiss the notion that the HPC, NICE, Skills for Health, Increased Access to Psychological Therapy are not part of the State apparatus of control.

I think it is very scary indeed that the UK Government thinks it can control individual transactions between practitioners and users in the field known as health and social care.

 

There follows an extract from Dr Amicarelli’s report with italic highlights added:

Therefore, I feel that complicating issues include those outlined above and recalled here below:

– HPC Creation: it was created with the Health Professions Order 2001 allowing it full decision-making and self-governing powers against the EU policies clarified by the European Court of Justice in 2002.

– PLG (Professional Liaison Group) establishment: the PLG for psychotherapists and counsellors regulation included only people and groups in favour of regulation (11 external members and 6 HPC members) and the fact that they were selected without any officially announced clear criteria by two members of the HPC, namely the PLG Chair and the HPC President makes it likely that everything had already been planned by HPC to smoothly reach the regulation approval as declared by some opponents.

Absence of any assessment plan : the HPC did not produce any assessment, neither a necessity assessment nor an impact assessment.  How could a regulator, the HPC, decide on a regulation of such an impact having completely no idea of the consequences once approved? The burden of proof is up to the government. The government has delegated its power to HPC. HPC then should have proven such a necessity of regulation. This has not happened.

Page 56

As EU Commissioner Monti declared in the above-mentioned speech (page 6). Then, Cui prodest? Who would really benefit from HPC regulation?

The Public? It has not been proven.

The Practitioners? It has not been proven.

The State? It has not been proven. Page 67

The HPC? It is highly probable being all the powers concerning the lives of hundreds of thousands of people in the hands of only twenty people who are appointed by government and who will be allowed to decide to change rules and to issue verdicts about practitioners at their own discretion without any equal and transparent and fair rule. That could also produce a violation of other ethical norms and so represent a case of conflict of interests: for instance State authorities could perhaps nominate as members people in ways that are unclear, such as appointing relatives or “friends” who may belong to lobbies closer to their political parties. It is also possible that regulators members themselves enact in ways that may be unclear because of all the powers they are allowed.

Any alternative solution?

The only possible ways for counsellors and psychotherapists regulation:

– TO leave anything as it is now on the basis of the demonstrated satisfaction of psychological services users within the present system (HPC survey on psychological services July 2009 – available here)

– TO regulate the field in a different way   End Quote.

 

So Cui prodest? Who would really benefit from the change to state centrally driven control of the practice of care?

The Public? It has not been proven

The Practitioners or care-givers? It has not been proven

The State? Oh yes. They get complete control of treatments, who gives them, and over those who work outside the state Health System and how much they cost. And there is no evidence….

 

c) The study “Statutory Regulation and the Future of Professional Practice in Psychotherapy and Counselling: Evidence from the field”, funded by the General Medical Council and the Economic and Social Research Council (ESRC) Public Services Programme, and available here, examined the way that NHS doctors and therapists, including those in an Improving Access to Psychological Therapies (IAPT) service, said that current forms of regulation affected their clinical work.  Thus until the Government do an assessment this is an impact analysis: Dr Gerry McGivern, Lecturer in Work and Organisations in the Department of Management and lead author at King’s College, London, explains,

The experience of doctors and therapists highlights a number of unintended effects of regulation which adversely affect patient care. Responding to high-profile media spectacles and expanding bureaucracy has created a regulatory climate obsessed with blame, which doctors describe this as “hell” and “reminiscent of the Inquisition”, undermining professional practice, patient safety and care.’

 

5. Create a broad library of standards for all the main pathways of care

Put the National Institute for Health and Clinical Excellence (NICE – www.nice.org.uk) on a firmer statutory footing securing its independence and core functions and extending its remit to social care.

DoH dh_118053 Arms Length Bodies Review July 2010 available here

 

Where is the necessity analysis of the need for a broad library of standards?

Where is the evidence that a library of standards works for a practice of care?

Where is the impact assessment?

There is none because this is driven by the media’s reaction to the Baby P’s case and to the Government’s delusion of omniscience in the practice of giving care.

 

Counter-indications that the Government’s delusional system works:

a) The Government driven enforcement of centralised standards into child protection.

Quote: Sharon Shoesmith, ex-director of Haringey’s social services added: “To construct a narrative so simple – which told the public that Peter Connelly died because Haringey was uniquely weak, sack everyone from the director to the social workers and all would be well – was quite frankly absurd.”

She said the case had had a profound impact on children’s services. “The whole sector is now motivated by a fear of failure, and not the conditions for success.”

The number of children coming into care had increased by 30% and the number subject to a  child protection plan had doubled, she said.

But such measures appeared to have had scant impact on the number of children dying at the hands of parents and close relatives.

Society: ‘Sharon Shoesmith: social services sector gripped by ‘fear of failure”, Wednesday September 15 2010 by Rachel Williams, published in www.guardian.co.uk and available here.

 

Rht Hon Andrew Lansley, Secretary of State for Health moved swiftly to relinquish direct responsibility for implementation of standards for social care and give it to the HPC. These standards were originally put in place in an emotional response to Baby P’s murder. Or more cynically, to grab headlines and show how this powerful Government can protect children from their parents. There is no necessity assessment, no impact assessment and no answers to the question ‘Who benefits?’

Sharon Shoesmith’s statement show that neither children at risk of being murdered nor those who nobly engage with ‘at-risk’ families – the practitioners – benefit. So it must be the Government’s image of Chief Protector which wins.

 

b) Statistics which purport to measure care, for example Staffordshire Hospital’s SMRs (Standard Mortality Ratio)

 

Friday 28 May 2010, More or Less Programme,  Radio 4, ‘Mortality statistics’ and available here.

 

More or Less examines the “standardised mortality ratio” which measures unexpected deaths at hospitals. Defenders say it’s an efficient way of identifying trouble. But some statisticians says it’s time to do away with it. Last year newspapers reported that between 400 and 1200 patients died at Mid Staffordshire Hospital because of poor care. The estimate comes from a statistic called a ‘standardised mortality ratio’.

 

From my notes,

Richard Hamblin of the Health Care Commission stated that (Transcripts of evidence to Enquiry available here): The number of deaths does not show poor quality of care. There is no causal link between SMRs and poor quality care even in Staffordshire Hospital. Staffordshire’s problems were picked up from what patients told the authorities.

 

Professor David Spiegelhalter – Cambridge University (here) or here

1)  Cannot use excess deaths to predict quality of care

2)  Have to find out whether the deaths are extreme or caused by chance

3)  The risk adjustment always eliminates variability between hospitals.

4)  Factors are assumed to the same effect in all situations.

 

Richard Lilford of Birmingham University proposes process – based measurements have two advantages i)  It is easier to identify what process is being used rather than comparison with a standard result. ii) In stead of targetting the extremes this supports a quality improvement in the middle. A hospital is not bad at everything and this enables the process to be improved.  (See here for further comment)

 

So measurements do not guarantee quality of care. Relying on human beings caring enough to notice and report instances is much safer.

Also, please note, there is no way even this omniscient Government can prevent their subjects dying. Dying is not a risk, it is inevitable.

And this Government cannot prevent mental ill-health, either.

 

c) NICE clinical guidelines  (www.nice.org.uk)

 

From: DoH dh_118053 Arms Length Bodies Review July 2010 available here

Section 3.6 The National Institute for Health and Clinical Excellence provides national guidance on public health, health technologies, clinical practice and interventional procedures. Its authoritative advice will be essential in future to support the work of the NHS Commissioning Board in developing quality standards along each part of the patient pathway, and outcome indicators for each step. The National Institute for Health and Clinical Excellence will rapidly expand its existing work programme to create a broad library of standards for all the main pathways of care. The standards will extend beyond NHS care, informing the work of local authorities and the Public Health Service. We intend that the forthcoming Health Bill will contain provisions to put the National Institute for Health and Clinical Excellence on a firmer statutory footing securing its independence and core functions and extending its remit to social care.

 

Remember, there is no necessity analysis, no impact analysis and no proof that this move contributes to everyone’s welfare.

 

Please listen to Professor Tim Kendall, Royal College of Psychiatrists, 7:09 Today Programme, Radio 4, Thursday 30th September available here.

‘Everyone agrees that if there are alternatives, we should be exploring them and looking at what psychological treatments can work and what helps the parents and the teachers.’

From my notes: The diagnosis is elastic so there is no ONE form of ADHD (Attention Deficit Hyperactivity Disorder).

The NICE guidelines are a list of symptoms whose interpretation varies with each practitioner.

In the UK 1.6% of the population are diagnosed whereas in the USA 16% have ADHD.

The diagnosis does not produce certainty of what is being defined.

So the Government, by this move, are taking clinical judgment away from fallible human practitioners and giving it to an infallible broad library of standards. Further, this Government is going to make clinical judgment into a statutory matter. Maybe, as in Stalinist Russia, anyone who disagrees with the State will be ruled as having mental ill-health. Remember, there has been no necessity analysis, no impact analysis and no-one has asked the question ‘Who benefits?’ except the drug companies, of course.

 

Prof Kendall:  There are no physical markers on which to base the diagnosis.

The drug companies support this position: Frank Yocca, AstraZeneca’s head of discovery for central nervous system drugs. Clinical trials are particularly hard to organise for antidepressants because, for a start, medical definitions of depression and its severity are not as clear-cut as for most other diseases. In addition, reliable “bio markers”, objective measurements of disease progress such as brain scans or blood tests, are unavailable. From ‘Health: no room for gloom’ by Clive Cookson and Andrew Jack  Financial Times 14 June 2010 and available here.

 

But the Government knows what is the Good for You.  They will protect you from nasty Anxiety or Depression or ADHD or …. By devising a statutory register of diagnoses and treatments. The Chief Protectors ride to the rescue.

 

So where is the Government’s evidence that NICE clinical guidelines can be used in conditions with no physical markers: depression, anxiety, ADHD, or are you working from Omniscience that is being the All- Knowing-One?

Where is the impact analysis on taking clinical judgment away from skilled clinicians and giving it statutory status?

What happens when an experienced clinician disagrees with the statutorily driven One-Government- Approved Standard? They become criminals?

So as well as tilting at windmills with Ministers dressed as Don Quixote to get them in the mood, Parliament then takes clinical judgment away from clinicians and give a statutorily driven set of judgments the responsibility for diagnosing.

For why? So that High-profile Parliamentarians can appear as Saviours and Protectors (from harm & abuse) on prime time tv – their favourite role.

 

6.  Outcomes

Quotes from: Liberating the NHS: Transparency in outcomes: a framework for the NHS: July 2010: DoH availabel here.

‘This means ensuring that the accountabilities running throughout the system are squarely focussed on the outcomes achieved for patients not the processes by which they are achieved.

 

This accountability starts with the Secretary of State and the Government. Liberating the NHS from central control and political interference does not mean abdicating responsibility for whether the NHS succeeds or fails.

 

We are therefore looking for your help in constructing an NHS Outcomes Framework. A framework that will act as a catalyst for driving up quality and promoting equity and excellence across all services and that will provide an indication of the overall performance of the system in an international context. A transparent framework that will be used to hold the new NHS Commissioning Board to account for progress but equally one that patients, carers and the public can use to hold the Government to account.’

 

Note: 1)   The framework drives up quality.

2) There is no doubt that an absolute standard of quality can be achieved.

3) There is no doubt that overall performance can be measured on a country-wide basis and then compared internationally.

 

What evidence is there for the Government assertion that a framework will drive up quality?

What evidence is there that Lord Darzi’s framework is applicable to conditions where there are no physical markers?

What evidence is there that equity and excellence in terms of outcomes is possible across all the services?

And how do you compare the process of a cure for conditions of depression with mending a broken leg?

 

When individuals differ in how they work, because their experience is unique to them, how do you add up this difference to an indication of overall performance and then compare it to the Government’s ideal standards of equity and excellence?

 

Except in legends of the all powerful gods, what does it mean for the Secretary of State to be responsible for individual practitioners’ interventions? Does this mean, as with Sharon Shoesmith, that every time someone who is being treated for depression commits suicide, the Secretary of State will go on tv saying ‘mea culpa’?

 

a) The King’s College study (available here): the start of an impact analysis: Highlights in italic have been added.  Quote:

2. Psychotherapists and counsellors perceptions of regulation in practice

i. The effects of performance management on therapy

In the mental health service we examined, the organizational requirements for IAPT led to a clinical performance system being introduced across the wider psychological therapies service. Some junior mental health workers and CBT practitioners appreciated the clear structure and model of accountability that the IAPT model provided. The IAPT model may also enable more people with mental health problems to be seen.

More senior therapists, however, described this producing a marked change to the nature of their therapeutic practice: “It moved from being an individual/client relationship to (organisational) productivity. The measure was starting to overshadow… clients saying, oh no, not these measures again…”

Quantifying clinical outcomes, whilst useful for managers and commissioners, was described as decontextualising the complexities of therapy.

Therapists described how representing therapy in simplified and numerical terms affected clinical practice and decision-making. Some aspects of clinical practice can be quantified but measures were experienced as having “a life of their own” which “bullied” therapists into changing their practice to comply with these measures.

A senior therapists described how colleagues had been “in tears” and had to “wrestle with themselves” in complying with this new mode of therapy which they felt was undermining good therapeutic practice.

Simplified, second-order representations (for example numerical data) were perceived to be transforming first order practice. For example, one therapist described how he could not longer make decisions based upon clinical intuition because he may have been accused of disregarding data, even if he felt the data was inaccurate.

So therapists spoke of “losing a clinical mindset” and “something precious” about the nature of their practice.

ii. Reactivity

Therapists spoke in private about how they reacted to the new way of managing the service, “covering themselves” in case things went wrong. This was less about practising safely than of being seen to adhere to protocols – which could sometimes be detrimental to good clinical care. Some therapists described having to select (page 6) clients who would be “easy wins”, or superficially “patching them up” before they could consider any deeper therapeutic work with harder cases, because they needed to achieve reasonable clinical outcome measures. One therapist commented: “Its mistaking the figures… for the thing itself.

The distinction [doesnt] matter anymore… Putting your work into boxes and numbering it conceptualizes it in a particular way, despite your best intentions, and will change it.”

 

But remember outcomes rule OK because the Government’s White Paper states so!

 

7.  Fitness to practice adjudication for health professionals: assessing different mechanisms for delivery.

 

From Fitness to Practice Adjudication for Health Professionals: Assessing different mechanisms for delivery, A paper for consultation Professional Standards Division, Workforce Directorate, Department of Health , 9th August 2010 available here.

‘Professional health regulation is designed to protect the public by ensuring good standards of practice among those who are registered with one of the statutory health regulators. Currently each regulator has powers, and follows set procedures, to investigate any concerns about the fitness to practice of any of the professionals it regulates.’

 

Note:

a) Fitness to practice standards, entry criterion and much else are derived in committee rooms. There is no investigation of whether Lord Donaldson’s import of procedures from Chernobyl, Alpha-Piper Disaster and Aircraft pilot error into his report ‘Better Doctors: Safer Patients’ (See endnote i) is applicable to a practice. There is no consideration of cures which are motored by relationships of care and trust have anything in common with industrial man-machine interfaces.

 

b) These Government-authorised standards are used to persecute practitioners who do not comply with the letter of the law.

Currently there are about 550 competences for psychotherapy. I am liable to be accused of abuse by not complying with any one of them.

 

c) Most of the ‘complaints’ come from fellow practitioners or non-clients.

There is a recent case in the HPC where a senior psychologist (a Professor) was up in front of the HPC, Privy Council- backed-power, kangaroo court because an ex-student did not like his behaviour at a private dinner party.

 

d) Fitness to practice cases are not based in patient abuse.

A psychologist was struck off the HPC register for misconduct on 2oth September 2010 – 16:15 From the HPC web-site (available here): ‘Practitioner psychologist Joyce Davies has been struck off the HPC Register for failing to maintain adequate patient records as well as failing to maintain effective and co-operative communications with colleagues and other health professionals whilst working for NHS Shetland.’ There is of course no evidence how failing to maintain records is the equivalent of abuse. At best, this should be an internal discipline matter within the NHS.

 

e) From the King’s College report (available here):

1. Doctors perceptions of regulation in practice i. Doctors: “Guilty until proven innocent”

Although we interviewed only a small number of doctors, the proportion that had been through (and exonerated in) independent reviews or disciplinary hearings was surprisingly high. Those who had not gone through a review were very aware of colleagues who had, so complaints affected the practice of all doctors. Doctors described reviews as “hell”, “very distressing” and “deeply upsetting”, as fundamentally challenging their core identities, and causing anxiety and depression. Reviews led to doctors feeling isolated, unsupported and “ostracised” by colleagues. GP practices and PCTs did not seem to have adequate support process in places.

This reflects the National Audit Office report (2008) ‘Feeding Back? Learning from Complaints Handling in Health and Social Care’ (available here), which described support for those being complained about as “variable.

Our findings also reflected in research on medical complaints in Canada. [Canadian Medical Protection Agency (1999) Stress and the College Complaints – available here]

So independent reviews and complaints processes, which doctors suggested sometimes took years to resolve, were seen as punishments in themselves in which doctors felt “guilty until proven innocent”.

 

Doctors suggested that complaints were commonly “not [about] criminal activity, theyre things that have gone wrong” or “vexatious”.

This problem was exacerbated in mental health where “false allegations… malicious or based in psychosis… are institutional hazards”.

Given the nature of their practice many doctors felt that complaints were inevitable. Clearly some complaints do relate to issues of serious malpractice but unsubstantiated complaints could also have serious knock-on implications. They could end professional careers, particularly for junior professionals who were seen to be at greatest risk: “they just disappear, even if the allegation is investigated and found to be empty… [Regulation] often falls most heavily… on those who are least securely held within their… institution, so agency nursing, locum doctors, trainees.” Doctors under investigation could also be so preoccupied by the process that they put other patients at risk: “It’s like when you have a pile up on the motorway, you’re so busy looking at the pile up, you’re going to crash your car yourself. It puts me more at risk and it puts other patients more at risk.”

 

ii. The Blame Society

Doctors felt that professional and NHS regulation was driven far more by high profile “media spectacles‟, and what we describe as a “blame society‟, rather than the actual practices of most doctors: “People who are a serious danger to themselves and others… I just want to stress that they‟re a tiny part of my job. Of course that different place is the only thing the papers… the courts… [and] regulators are interested in.” Regulation also appeared to be associated with increasing defensive legal bureaucracy, which did little to improve care. And doctors were conscious of a proliferation of agencies regulating healthcare (which a psychiatrist suggested totalled 37) and a regulatory climate “reminiscent of … the Inquisition.”

This wider climate of the “blame society‟ is not conducive to creating the “blame free culture‟, recommended by the Department of Health in “An Organisation with a Memory‟ [Department of Health Expert Group (2000). An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer and available here] to improve patient safety.

The NAO‟s “Feeding Back‟: 10th October 2008 (available here) also suggests that a substantial number of complainants simply wanted an acknowledgement of a mistake, an apology and to know that measures had been taken to prevent similar mistakes happening again but many were driven to litigation through frustration with the complaints process.

So there appears to be a vicious circle associated with current healthcare regulation, with NHS professionals and organisations trying to defend themselves against complaints but in doing so frustrating complainants to the point of driving them to litigation. Intervening in this vicious circle could save time, money, improve the experience of complainants and professionals, patient safety and learning.

 

iii. Reactivity

Reactivity is a term used in research to describe the way subjects can react and change their behaviour if they know they are being studied; so researchers can play an active role in creating the behaviour that they wish to observe undisturbed. Similarly, some doctors appeared to have reacted to the prevalence and consequences of regulatory complaints by developing a new model of consultation:

“there are two people in the consultation. There’s you and the patient – safeguard yourself first. It’s a different consultation model…

Everything that you do and say in a consultation can be used against you”. This model undermined the relationship between doctors and patients and meant that doctors were practising to minimize the risk of a complaint rather than doing what was best for the patient. The defensive model affected, for example, end of life care where doctors were less prepared to allow a patient to die at home for fear of a complaint. A GP described how colleagues had not addressed the poor practice of a colleague for fear of a harassment charge.’ End quote

 

So with no impact analysis, the Government has radically altered the relationship between the practitioner and the user.

They have, in effect introduced a spy camera in each consulting room.

Remember, I work with those who are emotionally disturbed. I am found guilty of abuse if my clinical judgment leads me to acts which are not described in the fitness to practice manual, like not writing up notes.

The Stasi is here in the UK and flourishing under the rule as described in this White Paper.

You, the Government, have taken away responsibility for their practice from practitioners and given it to a bunch of systems.

 

8.  Regulating outcomes

 

Quotes from the White Paper:

The White Paper,  Equity & Excellence:Liberating the NHS, 12th July 2010 & available here, sets out a vision for an NHS centred around the needs of patients.

One of the key features of the plans is to free regulatory environment. This document sets out proposals to liberate providers from central Government controls and to develop Monitor as an independent economic regulator for health and adult social care. With greater autonomy comes clearer accountability. Providers will be freed from control by hierarchical management. Instead they will be subject to effective quality and economic regulation, so that patients know the services are safe, and the taxpayer gets better value. Clinically-led commissioning, payment by results and choice will drive improvements in quality beyond essential regulatory standards.

 

The Government’s approach is that where specific control mechanisms are needed for providers, these should in general take effect through regulatory licensing and clinically-led contracting, rather than hierarchical management by regions or the centre. All providers of NHS care should be able to compete on a level playing field, so that they succeed or fail according to the quality of care they give patients and the value they offer to the taxpayer.

 

Comment: I have already circulated a paper on IAPT and how this is a political intervention to produce Lord Layard’s promised economically happy population.

So the government promises the services are safe – the Government can control those who delight in criminal acts.

The Government, being ominiscient and playing at being god, can also control the quality of individual one on one transactions through regulatory licensing and clinically-led contracting. In my youth, the use of this form of power was called idolatrous. Never mind, I am wrong and the Government is always right.

Further, the Government is so powerful it can stop individuals performing criminal acts of abuse.  I think they should immediately tell the police how to do it.  They must not keep this secret to themselves.

 

Quotes from the King’s College report op. cit.:

4. Recommendations

i. Our findings, echoing our earlier research[ [McGivern, G. and E. Ferlie (2007) ‘Playing Tick Box Games: Interrelating Defences in Professional Appraisal’. Human Relations, 60 (9)  p1361-85, and available here, &  Exworthy, M. (1998) Clinical Audit in the NHS internal market: from peer review to external monitoring. Public Policy and Administration, 13 (2) p40-52.and available here], highlight the continuing important role of professionals in professional regulation and the risks of expanding managerialised regulation, based upon what we have termed “second- order processes”.

We suggest that interpersonal processes within clinical supervision, rather than distant quasi-legal regulation, are the key to protecting the public and ensuring the safety and efficacy of practice.

As Prof Christopher Hood notes, face-to-face scrutiny is far less vulnerable to gaming strategies than the “arcane and impersonal process of reporting from one bureaucracy to another in a closed professional world” [ Christopher Hood, ‘The Numbers Game’, Spring 2007, and available here. ]

 

ii. There is a policy risk of expanding and cosmetic regulatory systems. There needs to be an effective professional regulation framework in place, agreed by the professions, to ensure that poor practice and “difficult colleagues are effectively dealt with. This route poses major challenges for supervisors, employing organisations and professional regulators.

But our data leads us to ask whether mandatory professional regulation, owned by the profession(s) of psychotherapy and counselling, in practice, may be a more effective way to protect the public than statutory regulation by a quasi-governmental body.

Our concern with statutory regulation is

first, whether its processes are sufficiently subtle to regulate the practices of psychotherapists and counsellors, involving complex relationships and emotion, which are difficult to represent in documentation.

Our second apprehension is that statutory regulation is more oriented towards a public settlement between politicians, the media and law at macro-level than its effects upon professionals and clients/patients in practice.

For regulation to be effectively implemented and interpreted in practice, counsellors and psychotherapists need to believe in it, while maintaining the “formative spaces bridging regulation and professional development. We wonder whether the profession(s) of psychotherapy and counselling may be better able to span the macro and micro-level demands of effective regulation.  End quote

 

So the choice is between a remote legalistic form of regulation or something which works……..

 

9.  Prevention

 

From Customer Services Department – Health (possibly the DoH) response to my July 2010 e-mail to Mr Burns, Minister for State – Health:

Our ref: DE00000524198 – Mental health policy 10th August 2010

I can assure you that the Government recognises that mental health services are a vital part of the NHS and understands that high quality services must promote prevention, recovery and social inclusion for people who experience mental illness.

 

a) Mental Illness

The Government seem to be able to classify those subjects who are substandard – depressed, anxious, etc –

from ‘the normal’ using a classification systems of symptoms. The Government’s Customer Services Department has no doubt, which I always find a very interesting symptom.

So the Government divides its subjects into those who experience mental illness and those who do not.

So the Government and its Customer Service Department are superior to the rest of us in that they know who is mentally ill and who is not.

Of course, by definition, no member of this superior Government or its Customer Services Department is mentally ill. But, having divided the mentally ill and therefore substandard, from those who do not suffer and are therefore normal, then the Government and its Customer Service department is able to issue decrees on how the mentally ill are to be brought up to Government standard – see NICE (www.nice.org.uk) clinical guidelines and IAPT (www.iapt.nhs.uk).

 

b) High quality services

 

The Government’s Customer Services Department – Health issues a guarantee that it is possible to drive high quality services . They are quite certain that high quality services for those defined by Government- devised NICE clinical guidelines as having mental illhealth are a certainty. It appears that the Government’s Customer Services Department – Health is in control of The Truth about the aetiology, occurrence and treatment of mental illhealth. Thus, they are driving from a central control point which has an inhuman total grasp of everything which is located in the area of mental health. Not for this Government, any doubt and it does not recognise individual difference in aetiology or subjective occurrence of what they categorise as mental illhealth or difference in approach between the DoH’s scoping project’s (July 2006) [available here ] 550 organisations involved in supporting practices or difference between individual practitioners.

Treating them (practitioners & sufferers) as cogs in Lord Donaldson’s high risk health industry turns them from human beings into objects.

 

c) Promote prevention.

 

Quoted from Wikipedia and available here

Geoffrey Rose  DM,  DSC, FRCP, FFPHM, was an eminent  epidemiologist whose ideas have been credited with transforming the approach to strategies for improving health. He was formerly the Emeritus Professor of Epidemiology at the Department of Epidemiology, London School of Hygiene and Tropical Medicine.

‘High-risk strategy’

According to Rose, the ‘high-risk strategy’ to prevention is a clinically-oriented approach to preventive medicine which focuses its efforts on needy individuals with the highest levels of the risk factor (‘the deviant minority with high-risk status’), and utilizes the established framework of medical services. In other words, the ‘high-risk strategy’ is ‘a targeted rescue operation for vulnerable individuals’. The aim is to help each person reduce the high level of exposure to a cause or to some intermediate variable. Main strengths of this strategy include: the intervention may be matched to the needs of the individual; it may avoid interference with those who are not at a special risk; it may be accommodated within the ethical and cultural values, organization, and economics, of the health care system; selectivity may increase the likelihood of a cost-effective use of resources.

Main weaknesses of the high-risk strategy are:

prevention may become medicalized;

success may be palliative and temporary;

the contribution to overall (population) control of a disease may be small;

the preventive intervention may be behaviorally or culturally inadequate or unsustainable;

it has a poor ability to predict which individuals will benefit from the intervention

 

So this strategy relies on defining the deviant minority with high-risk status. So this Government via NICE (www.nice.org.uk) and IAPT (www.iapt.nhs.uk) defines the deviant minority as those without Lord Layard’s economic happiness (so they are without a job) and puts into place a political strategy to turn them into normal.

This is not a practice of care.

This is a political population control strategy driving through the medical model through NICE determinations of treatments to Government defined outcomes: ‘normalised’ members of the electorate.

 

I find this politically offensive. It is approaching the Third Reich and its delusions of how it was in control of human nature.

 

d) Recovery

 

This is based on an assumption about human nature, I do not like.

So the Government’s Customer Service Department – Health aims to redesign human nature so it is normal in its eyes and wishes to eliminate mental illness.  So we all become identikit UK-standard human beings with any differences wiped out.

I submit that this is not a proper aim for a Government unless you take the Third Reich as exemplar.

 

e) Social inclusion as a Government aim

 

What does the Government’s Customer Services Department – Health mean by social inclusion?

That the Government-backed manipulative processes as detailed in NICE (www.nice.org.uk), Skills for Health (www.skillsforhealth.org.uk) and IAPT (www.iapt.nhs.uk) have worked and produced a UK-standard-normal-economically-active human being. The Government’s Customer Services Department – Health has eliminated difference. How powerful is that!

This Government is able to not only put in place regulations which produce normality but they can then promise social inclusion.

Just as the Third Reich did for those with blond hair and blue eyes.

 

f)  The Prevention Paradox

Quoted from: ‘Choose the yum and risk the yuk?’  Viewpoint By David Spiegelhalter, Professor of risk understanding, University of Cambridge,  Wednesday 6th May 2009 and available here.

Nudging’

‘These issues are tricky, and reflect a basic tension between individuals and society’s points of view.

If everyone improved their lifestyle just a bit, then the benefits to the overall health of the nation would be large but each individual would not notice the difference.

An inspired epidemiologist, Geoffrey Rose, called this the Prevention Paradox and we see it being played out again and again.

That is why it is understandable that attempts to create these shifts in behaviour by exhorting people to change tend to fail – and make them anxious and guilty.

It explains the current call for society-wide actions such as minimum alcohol pricing, and enthusiasm for ‘nudging’ people towards better behaviour.’ End quote

What to say?  The Government’s unhealthy obsession with ‘Wellbeing’ (HPO2001) & ‘Happiness’ (Lord Layard & David Cameron) will not lead to a redesign of what it is to be a human-BEING.

 

10.  The control of Risk by Government to produce ‘safeguarding’ (HPO2001 and elsewhere)

a)  Industrial definitions of risk (first written and circulated within Parliament & the DoH in January 2006)

Risk is used 105 times – usually in conjunction with ‘high’ and ‘industry’ in the Lord Donaldson’s White Paper ‘Good Doctors, safer patients’ (See endnote i).

For example (quotes from the repot): Page viii ‘The bottom line is that lighter-touch regulation of doctors – whether on grounds of cost, regulatory ideology or professional acceptability – would mean that some ongoing risks to patients would have to be tolerated by society.

Page ix Unsafe care can arise in two main ways: from human error in a weak system (addressed in my earlier report, An organisation with a memory 13th June 2000 & available here ) and from poorly performing doctors; both are important, but the risks posed by the former are many times greater than those posed by the latter.

Page ix Regulation of doctors is much less thorough than that of professionals in other high-risk industries, such as civil aviation.’  End quote.

 

Some questions for the Government to answer:

What are the risks to patients which would have to be tolerated?

Define them. I remind you that criminal acts are not tolerated.

What are the instances of human error in psychopractice which cause unsafe care? How many and how are they defined?

What is the evidence that the practice of care is an industry?

What is the evidence that the practice of care is high risk – how is this definition reached?

How is civil aviation (or Chernobyl or Alpha Piper disaster – See Lord Donaldson’s report & endnote i) defined as a comparator for health care?

What is the evidence that it is an appropriate comparator?

On sloppy assumptions such as these, expensive safeguarding systems are built………

 

Reference: White Paper: ‘Good doctors, safer patients’ Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients A report by the Chief Medical Officer: Lord Donaldson (Sir Liam Donaldson) Department of Health 2006 (see Footnote i)

 

b) The system controls practice and thus risk (Written and circulated in 2009)

 

The use of empty knowledge by the Government’s enforcing systems has been commented on in my submission to the Health Profession’s Council’s (HPC) CON-sultation, ‘Call for Ideas’ (available here) from which I quote (My submission).

The type of knowledge implied by the HPC’s regulation is inappropriate to the regulation of the practice of Talking Therapy.

Behind each enforcing system (examples given below) is empty knowledge. Three different forms of knowledge are defined in the submission.  Empty Knowledge or the One Knowledge or the One Standard or the Good or Science has all subjective meaning removed. It is absolute, unchanging and without meaning. The One Standard Meaning (usually centrally defined) is enforced in the Government’s raft of regulations [ii] .

From White Paper: Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century 2007.  (Please notice the transformation between the two white papers. The first refers to Doctors and the second to Health Professionals. Thus, Psychopractitioners become Health Professionals.  This transformation has never been justified by a Government addicted to the words ‘evidence-based.)

Examples of the reliance on inhuman knowledge (or Empty Knowledge or the One Knowledge) from the Foreward of ‘Trust, Assurance and Safety’ written by The Rt Hon. Patricia Hewitt, MP Secretary of State for Health

Professional regulation must create a framework that maintains the justified confidence of patients in those who care for them as the bedrock of safe and effective clinical practice and the foundation for effective relationships between patients and health professionals.

 

It is all too easy to focus on the incompetent or malicious practice of individuals and seek to build a system from that starting point, …….

 

We need a system that understands the pressures and strains under which all professionals operate and shows understanding, compassion and support where these are appropriate.

 

It also means a system that is better able to identify people early on who are struggling – perhaps with personal problems of mental health or addiction – and supporting them,

 

It means a system that is better able to detect and act against those very rare malicious individuals who risk undermining public and professional confidence.

 

This reminds me of the tale, The Emperor’s New Clothes:  I am the child saying: But have you noticed the system is bare?

Has no-one else noticed the UK Government is making a complete fool of themselves whilst systematically showing off their new clothes?

 

Comments on the Foreward:

Two unconnected statements are joined together to produce: The system becomes Big Brother.

The system is the foundation of the relationship of care between two human beings.  The system becomes humanised.

The system provides the framework which produces trust.

The system understands pressure and strains.

The system is more able than the police to detect those about to commit criminal acts.

What is the evidence that weak systems cause unsafe care within the practice of talking therapy involving two human beings?

What is the evidence that systems can better treat distressed humans than another human being?

 

Has anyone in the government read ‘Animal Farm’ or ‘Brave New World’?  No really – I am very concerned about the level of education required to become a member of either House within Parliament.

The system is inhuman in that it guards the One Empty knowledge and has no doubts about its truth and efficacy. I define the authoritarian use of this absolute form of knowledge as abusive.

 

It denies our common humanity.

 

I suggest that Government-prescribed systems of ‘care’ for those of us with government-defined mental ill- health are much more abusive than practices supported by the diversity of training organisations (the DoH’s 2005 scoping project (op. cit.) counted in excess of 570).

Where is your evidence that I am wrong?

 

Reference: White Paper: Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century  Presented to Parliament by the Secretary of State for Health, The Rt Hon. Patricia Hewitt, MP, by Command of Her Majesty February 2007

 

11.  The production of fear & the transfer of risks from the organization to individual therapists. The dismissal of Anxiety and Fear from the Government’s Systematic Approach. (Italic highlights added.)

 

a) From the King’s College report: the Blame culture:

This legalistic approach to practices of care produces fear because practitioners know that if anything goes wrong the blame will be stuffed into them, for example, Baby P and Anne Milton’s June statement (op. sit.) to Parliament that practitioners abuse vulnerable subjects.

Remember, the system rules OK and is never wrong, so it is automatic that the practitioner must be substandard.

b) The removal of safe places

Quote from King’s College report:  iii. Formative spaces

Therapists, like doctors, commented on the importance of formative spaces, such as clinical supervision or reflective practice groups. However, some therapists described how organisations were reacting to the risks associated with mental healthcare in ways that could undermine practice and transfer risks from the organization to individual therapists.

For example, an IAPT team leader described how in supervision they discussed each case, rather than devoting time to more complex or difficult cases, so that “at least its written down and its all formalized. If theres an incident, theres a claim in the future… that would have been an opportunity for it to be discussed but if it wasnt discussed, thats a practitioners [responsibility]”.

So here the representation of second order (organisational) risk management practices was also beginning to overshadow actual first order clinical risk management. Although there are differences between the IAPT and psychotherapy and counselling in their models of delivering care, there is a risk that supervision may develop in the same way in both.

 Interviewees also described how the pressures put upon the IAPT service to produce outcomes were causing therapists considerable anxiety, but managing the emotional aspects of mental health work did not appear to have been considered within the IAPT model.

A lead CBT therapist commented that they were “not CBT robots. Supervisors are on the receiving end of all the anxiety and insecurity [which has] been dismissed within IAPT.”

A senior therapist in the wider mental health service described “clinical supervision… where you can in a fairly relaxed way, actually talk about… I made a real hash” as “very precious oases in a sort of desert of figures and processes and procedures.”

Yet the pressures of achieving IAPT outcomes were resulting in clinical supervision being missed altogether, or being seen as “operational management”. Our findings highlight the crucial role that supervisors play in mediating between the demands of performance management and effective clinical practice.

 

So the Government rules, at a discrete distance, by increasing anxiety and the use of fear.

 

12.  The Government produces and supports stigma by its discriminatory regulatory processes

a) The mechanism which categorises conditions of mental illhealth is inserted by the Government-invented NICE (www.nice.co.uk)

NICE, which this Government proposes to put in a regulatory framework, supports the myth that symptoms bundled into classifications without biological markers have the same accuracy as classifying a broken leg. There is, of course, absolutely no evidence which supports the Government’s belief.

But no matter, the Government is omniscient in all matters, so proposes system of delivery of so-called health care which resembles Stalinist Russia.

And individual difference between sufferers and those prepared to engage with their distress, the practitioners, is wiped out.

From henceforth, you will behave to the centrally defined standard of excellence – whether user or practitioner.

So this categorisation produces absolute certainty of who is mentally ill and who is normal. And nobody challenges this nonsense.

I dislike this separation into mental illhealth and Government-standard normal. I prefer this definition:

Molloy hopes the event (Warning: May Contain Nuts, a cabaret) will close the gap between those who have experienced mental illness and those who haven’t. “Mental illness isn’t abnormal,” she says. “It just exaggerates experiences that everybody goes through. Everybody has felt sad, been slightly hyperactive. Mental illness isn’t this separate world – it’s just a step beyond the normal world.” quoted in ‘The comedy of mental health issues’ by Brian Logan, The Guardian Thursday 7th October – available here.

 

When is the Government going to stop regulating the conditions which produce stigma and discrimination?

 

b) The Government-sponsored myth that using centrally-defined systems mental illhealth can be eliminated

 

Preventive strategies have as a base assumption that the risk of death or mental illness can be removed.

There is no evidence for this astounding assumption but no matter for this know-all, centrally-controlled government. They are all-powerful and going to remove mental illhealth so everyone is normal or matches Lord Layard’s standard of economic happiness.

And supine Parliament nods wisely and says ‘A very good thing this safeguarding the population against mental illhealth’ and the production of internationally recognised happiness in stead.

 

c) ADHD (Attention Deficit Hyperactivity Disorder) as case study – remember NICE (www.nice.org.uk) classifications have no biological markers.

Where is the stigma coming from if not the Government’s classification systems known as NICE?

 

Quotes from: ‘A genetic cause for ADHD won’t necessarily reduce the stigma attached.  Scientists who believe that labelling mental health problems ‘an illness’ will reduce prejudice may find the opposite is true’ by Ben Goldacre in The Guardian, Saturday 9 October 2010 available here:

‘What does it mean to say that a psychological or behavioural condition has a biological cause?

Over the past week more battles have been raging over attention deficit hyperactivity disorder (ADHD), after a paper published by a group of Cardiff researchers (available here) found evidence for a genetic association with the condition. Their study[iii] looked for chromosomal deletions and duplications known as copy number variants (CNV) and found that these were present in 16% of the children with ADHD.

What many reports did not tell you –  including the Guardian (available here) – is that this same pattern of CNV was also found in 8% of the children without ADHD. So that’s not a massive difference.

More interesting were the moral and cultural interpretations heaped on to this finding, not least by the authors themselves. “Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children,” said  Professor Anita Thapar [see endnote iii]. “We hope that these findings will help overcome the stigma associated with ADHD.”

 

Does the belief that such problems have a biological cause really help to reduce stigma?  (Or I am tempted to add, have a Government-supported classification)

 

In 2001, Read and Harre (available here[iv]  explored attitudes among first-year undergraduate  psychology students, with questionnaires designed to probe belief about the causes of  mental health problems, and responses on six- point scales to statements such as: “I would be less likely to become romantically involved with someone if I knew they had spent time in a psychiatric hospital.”

People who believed more in a biological or genetic cause were more likely to believe that people with mental health problems were unpredictable and dangerous, more likely to fear them and more likely to avoid interacting with them. An earlier study in 1999 by  Read and Law [v]  (available here) had similar results.

In 2002  Walker and Read [vi]  (available here) showed young adults a video portraying a man with psychotic symptoms, such as hallucinations and delusions, then gave them either biogenetic or psychosocial explanations.

Yet again, the “medical model” approach significantly increased perceptions of dangerousness and unpredictability.  (JE adds: this is the model as used by the Government in NICE classifications)

In 2004  Dietrich and colleagues [vii]  (available here )conducted a series of structured interviews with three representative population samples in Germany, Russia and Mongolia.

Endorsing biological factors as the root cause for schizophrenia was associated with a greater desire for social distance.

Lastly, more compelling than any individual study, a review of the literature [viii] (available here ) to date in 2006 found that overall, biogenetic causal theories, and labelling something as an “illness”, are both positively related to perceptions of dangerousness and unpredictability, and to fear and desire for social distance.

They identified 19 studies addressing the question. Eighteen found that belief in a genetic or biological cause was associated with more negative attitudes to people with mental health problems. Just one found the opposite, that belief in a genetic or biological cause was associated with more positive attitudes.

These findings are at odds with everything that many people who campaign against stigma have assumed for many years, but they’re not entirely nonsensical.

Jo Phelan, in her paper  “Genetic bases of mental illness – a cure for stigma?” [ix] (available here), said that a story about genetic causes may lead to people being conceived of as “defective” or “physically distinct”.

It can create an associative stigma for the whole family, who in turn receive labels such as “at risk” or “carrier”.

This stigma may persist long after ADHD symptoms have receded in adulthood: perhaps a partner will wonder: “Do I really want to risk having a child with this person, given their genetic predisposition?”

Perhaps it will go further than that: your children, before they even begin to show any signs of inattentiveness or hyperactivity, will experience a kind of anticipatory stigma. Do they have this condition, just like their father? “It’s genetic you know.”

Perhaps the threshold for attaining a diagnosis of ADHD will be lower for your children: it’s a condition, like many others, with a notably flexible diagnostic boundary.

Blaming parents is vile. But before reading this research I think I also assumed, unthinkingly, like many people, that a “biological cause” story about mental health problems was inherently valuable for combating stigma. Now I’m not so sure. People who want to combat prejudice may need to challenge their own prejudices, too.

End quote

 

My conclusion, which seems obvious to me, is that the Government’s Clinical categorisation of their subjects into mental health issues or normal, produces stigma. If the Government is certain I have mental health issues, diagnosed ‘scientifically’ through their very own NICE (www.nice.org.uk) clinical guidelines, and this is backed by legislation, then I must be sub-the-Government’s-standard human being. But this is OK because the Government can make conditions of mental illhealth disappear.

 

Why continue labeling the population in this manner?

 

13.  The Government’s rule book and developing a practice.

 

So the Government, through its application of Privy Council power as directed in HPO2001, understands a practice better than those who have undertaken years of training and supervised practice

 

a) From the legislation: Wellbeing and Safeguarding in the legislation or the legal definition of units of wellbeing

 

The main objective of The Health Professions Order 2001 (HPO2001) is ‘to safeguard the health and wellbeing of persons using or needing the services of registrants or health professionals’ (S3.4). This is enacted through the Privy Council by the creation of the Health Professions Council. The principal functions of the HPC (from the Order): 22. Section 3: (1) There shall be a body corporate known as the Health Professions Council (referred to in this Order as “the Council”). (2) The principal functions of the Council shall be to establish from time to time standards of education, training, conduct and performance for members of the relevant professions and to ensure the maintenance of those standards. (3) The Council shall have such other functions as are conferred on it by this Order or as may be provided by the Privy Council by order. (4) The main objective of the Council in exercising its functions shall be to safeguard the health and wellbeing of persons using or needing the services of registrants

‘Safeguarding’ and ‘wellbeing’ in HPO 2001:

Wellbeing and safeguarding are two words, constructions, or concepts in use by Government in changing the practice of all health professionals.

Comments: the Government by using these terms promises to safeguard wellbeing and health.

Is any Government able to safeguard wellbeing and health? Indeed, is it desirable for Government to safeguard? Is it possible to agree the One standard, Government-approved and legally enforceable, centralised description of wellbeing? Is your definition of wellbeing the same as mine? So how can these individual definitions be integrated into the One standard definition?

 

It is intriguing that a government, from whose collective lips the words ‘evidence-based practice’ fall so easily, produces no evidence of a link between legislation and the public’s wellbeing. The public’s wellbeing is also assumed rather than defined. It is not even defined in the courts as the enactment of HPO2001 is shunted through the Privy Council which is centrally driven.

The process of “causa sui” in use in our primary legal system is foreclosed. The Privy Council deals in absolutes. The Privy Council, on behalf of the Government, is in control of all standards including those for education, training, conduct and performance. (See objective number 2 of HPO2001 given above) This eliminates all practitioner experience and the gathering of that experience within the training organisations.

So the governance and training of a practice is given to remote legally-defined Councils who usually depute this to academia.

So the Government, through its agency the HPC, understands a practice better than those who have undertaken years of training and supervised practice. Yes it is so – it is on the statute book.  The Government knows what is good for you and your wellbeing.

 

Reference: These arguments are taken from Julia Evans: Well-Being and Happiness… as used by the UK Government in Psychoanalytical notebooks:  No 16 Regulation and Evaluation May 2007 page 143.  This is now published at www.lacanianworks.net and available here.

 

b) How do you train an act which relies on individual judgment in conditions of stress?

 

In the Lacanian orientation there are four components:

the individual’s analysis,

supervision,

development of practice through case presentations and

developing new frameworks in response to developments in the clinic.

Although the individual analysis may finish, the other three components always remain in place. Thus, the training develops each practitioner’s savoir-y-faire – the knowing-how-to-do.

When confronted with a challenge in the clinic, one does not reach for the rule book.  The practice and the discussion of practice informs the individual’s actions. Ethics is not a rule-book: Thou shalt not forget an appointment but is based on principles of practice. These can be accessed at the London Society of the New Lacanian School’s web-site.

So although meetings with subjects take place with two people present, the practice is not isolated. It is constantly being brought into conversations with supervisors and colleagues.

And it is a practice – it is not static. It is in continual development.

c) The DoH and its Interim Report.

This was set up in 2004.  There follows an edited version of its findings.

When it was presented to Ros Meade, a civil servant, then of the DoH, she blanked it. This was the correct thing for a Government employee to do. Why? As explained in part a), the form of training, etc has been decreed by Parliament in HPO2001. Further, Parliament has instructed the Privy Council to use its powers to ensure the letter of the law is obeyed so that ‘safeguarding of health and wellbeing’ can be produced.

So the following is the DoH rubber- stamping that those affected have been consulted. Hundreds of years of developing how to transmit a practice are jettisoned.

The Government knows what is best for you.

 

Key statistics for you to consider: 37,000 practitioners were sent a questionnaire. So a conservative estimate is that by regulating the talking therapies you are interfering in at least 37,000 practices.

Let’s state they see 10 clients a week, so in any week you are interfering in at least 400,000 subjects’ lives.

There are at least 570 training organisations.  So practice can be classified in at least 570 different ways.

What is your evidence that there are sufficient abuses happening to implement a centralised control system?

 

Are you really prepared to wipe out 560 organisations in order to have the satisfaction of absolute central control?

 

This push to regulation may be coming from 5 of these organisations who sense control over the Government-supported job market. (& payment thereof) What is your evidence that these 5 practices should be given precedence over the other 565?

Quotes from: ‘Interim Report to the Department of Health on Initial Mapping Porject for Psychotherapy & Counselling’ by Sally Aldridge & James Pollard BACP/UKCP Project Co-ordinators, July 2005, Funded by the DoH  (available here )

 

Edited from ‘Summary of Findings’

1.   Training

Training is the major entry route into psychotherapy and counselling. 95% of counsellors and psychotherapists are trained and the majority practise within the scope of their training.

There is no one route of entry to either psychotherapy or counselling in the UK through training. We have identified 570 different practitioner training courses. However, 63% do not have professional body recognition although many of these are validated through the Further or Higher Education system.

There are a large number of titles for both training courses and individual counsellors and psychotherapists.

2.   Standards of Education and Training and Standards of Proficiency

The HPC’s focus on the Health Service and University education does not closely match current patterns of practice or of training provision.

There are a variety of approving bodies for training – academic, vocational and professional. There are a significant number of training providers linked to no external quality assurance systems.

There is a spread of training between the sectors and recognised educational levels, both academic and vocational.

The development of psychotherapy and counselling training in Higher Education is significant but there remains a substantial group of trainings not validated within Higher Education.

30% of counselling training is in the Further Education sector.

3.   Conduct and Ethics

All organisations responding to the research have complaints and conduct processes, however levels of lay representation and public accountability are low.

Codes of conduct and ethics fulfil or exceed HPC requirements.

Complaints heard by the HPC are substantively different to those received by counselling and psychotherapy organisations. Most complaints in this field concern aspects of interpersonal relationships and the therapeutic process.

Many professional bodies carry out both a regulatory and disciplinary function

4.   The size of the occupational field

For this research 20% of a potential 37,500 members were sent a questionnaire and 44% replied.

The level of training activity suggests that the number of counsellors and psychotherapists in the UK is growing rapidly.

There is a large number of small psychotherapy and counselling organisations.

90% of counsellors and psychotherapists are in paid work.

Over 25% of all psychotherapists and counsellors work with children.

5.   Future development

The joint BACP/UKCP research project has looked at existing training and qualifications, and the standards on which they are based; and codes of ethics and conduct, comparing these with HPC processes. The project has been undertaken within a limited time scale and has focussed on the areas already outlined. Further substantive work will need to be undertaken to ensure that an accurate representation is carried forward into proposals for statutory regulation. The review recommends:

A deeper enquiry into the provision of training, its characteristics and the standards that are applied. Research into student satisfaction levels in relation to training.

Further research into the distinctions within the field.

Research into the possibilities and difficulties entailed in linking training standards with external assessment frameworks.

Research into training and practice of those working with children and adolescents.

Consideration of the implications of including counselling and psychotherapy within the Framework for Higher Education Qualifications.

Research into the issues raised by the development of a core curriculum for psychotherapy and counselling. Bringing registers and fitness to practice procedures to acceptable levels.

Establishment of a separate body to handle conduct processes for all, achieving best practice separation. Further research into the scope of the professions beyond the framework of the professional associations.

End quote

 

None of this was done.

There is no evidence that training within the talking therapies is appropriate within an academic, higher educational establishment.

There is no evidence that this is a high-risk industry.

There is no evidence that external assessment frameworks are needed.

 

But it gives Politicians so much media time when they boast about protecting the population from harm and abuses which only exist in their imaginations.

 

d) Common sense (savoir-faire) versus slavish adherence to written documents and protocols

Officers bearing firearms have to use their savoir-faire when the decision to shoot is taken. Killing someone is very different to the King’s College description of having made a mess but the principles are the same.

It is more important that someone’s judgement is trained so they are able to make a good enough decision under stress than any number of written protocols. You can listen to the report at the web-link below.

Please listen.

You, the Government, cannot train judgements used by practitioners in social care, the talking therapies, and police marksmen by enforcing written protocols.

It does not work and does not produce the Government’s, via the Privy Council and HPO2001, ‘safeguarding health and wellbeing.’

0751  Today programme  Saturday 9th October 2010 available here.

The coroner who presided at the inquest into the death of Mark Saunders has written to the Home Secretary warning that armed police need to use their common sense” more than what he calls “slavish adherence” to written documents and protocols. Andy Hayman, former Assistant Commissioner of the Metropolitan Police and Jenny Jones of the Met Police Authority debate if this advice is correct. Listen here.

 

e) Books of rules versus practice in the armed forces.

From my notes of a talk by Canon Chancellor of St Paul’s Cathedral, Giles Fraser who also lectures in ethics at the MOD’s Defence Academy on ‘Battlefield Ethics’ 5th September 2010  (See endnote [x] )

 

With rule-based ethics, you need lots of rules to cover all eventualities: Several encyclopaedias to rule on warfare. This leads to the question ‘How do you administrate from the rules?’ When prosecuting, do you read vast swathes of the books out loud to the soldier? Well, if you are the Army probably not.

 

Other ways of approaching ethics include Aristotle’s virtue ethics, Elizabeth Anscombe (20th century): it’s about your character and a former soldier: knowing what you stand for.  (In the Army, stories play a big part in creating this) and moral identity – how we are shaped.  Aquinas stated that what you do, follows who you are.

 

The Army trains and practices until clear positions from which to act appear. (end of notes)

 

With a practice, if it is not based within a rule-book, the position from which to act has to be developed. This involves formation: your own submission to the practice, your ability to put this savoir-faire to work, constant change and development as the journey continues.

This is very far from the training and supervision procedures as defined by the HPC’s entry criterion & fitness-to-practise standards, Skills for Health’s competencies & NICE.

Also HPC trials rely rigidly on the rulebook & Privy Council direct power.

If you are the HPC, then Ethics are defined from the rule-book because the Government/HPC have failed to tackle the question ‘what form of ethics are appropriate for a practice?’ or even ‘what is a human-BEING?’

Not how can the Government destroy the 570 training organisations, but how can they help each organisation to provide a sound, experience-based, training so that when practising, talking therapists may make good-enough decisions under stress.

 

g) Blame, – emphasis away from rules to relationships and supervision in the King’s College report .

 

From quotes to the King’s College report, previously given, the conclusion can be drawn that

rule-based regulation smothers relationships.

In practices, which rely on individual acts, this introduces risk rather than eliminates.

 

I remind you that there is no evidence that current processes have failed.

Further, there is no evidence that more than 570 training organisations are failing.

And HPO2001 is based on the Government’s delusional grasp of centralised, Privy Council power.

 

This attempt to centrally provide ‘health and wellbeing’ and legislation putting NICE, Skills for Health and IAPT in place needs removing from the statute book.

 

Providing ‘Equality and Excellence’ and ‘Health and Wellbeing’ from a central control point somewhere within Government is a misuse of the emergency powers granted to the Privy Council.

Further, to provide protection from those the Government defines as abusive, leads to more abuse, taint, and so on.

The use of the high-risk health industry as the driving force should be stopped.

The Government must desist from reducing human-BEINGS to objects in a production process held in their protected market in the provision of health care.



[i] Note added 27th January 2012: ‘Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients’: report by the Chief Medical Officer, Lord Donaldson: July 14th 2006 and available here. This report led to the Department of Health’s White Paper: Trust, assurance and safety: The regulation of health professionals: 21st February 2007 and available here.

Quote from its web-site: This White Paper sets out a programme of reform to the United Kingdom’s system for the regulation of health professionals, based on consultation on the two reviews of professional regulation published in July 2006: Good doctors, safer patients by the Chief Medical Officer (CMO) for England and the Department of Health’s ‘The regulation of the non-medical healthcare professions’. It is complemented by the Government’s response to the recommendations of the Fifth Report of the Shipman Inquiry and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries, Safeguarding Patients, which sets out a range of measures to improve and enhance clinical governance in the NHS.

[ii] These distinctions are further developed in my post published at www.lacanianworks.net as Psychotherapy is imposed: Psycho-analysis© works: Psychoanalysis operates by Julia Evans on December 15, 2010

[iii] ‘Rare chromosomal deletions and duplications in attention-deficit hyperactivity disorder: a genome-wide analysis’ by Dr Nigel M Williams, Irina Zaharieva, Andrew Martin, Kate Langley PhD, Kiran Mantripragada PhD, Ragnheidur Fossdal PhD, Hreinn Stefansson PhD, Kari Stefansson MD, Pall Magnusson MD, Olafur O Gudmundsson MD, Omar Gustafsson PhD, Prof Peter Holmans PhD, Prof Michael J Owen MD, Prof Michael O’Donovan MD, Prof Anita Thapar MD , The Lancet, Volume 376, Issue 9750, Pages 1401 – 1408, 23 October 2010, Published Online: 30 September 2010.

[iv] John Read, Niki Harré  Psychology Department, The University of Auckland, Auckland, New Zealand,  ‘The role of biological and genetic causal beliefs in the stigmatisation of ‘mental patients’’ Journal of Mental Health, 2001, Vol. 10, No. 2 , Pages 223-235

[v] Read and Law ‘The Relationship of Causal Beliefs and Contact With Users of Mental Health Services To Attitudes To the ‘Mentally Ill’’, Int J Soc Psychiatry, September 1999 45: 216-229,

[vi] I.Walker & J. Read, Psychology Department, University of Auckland, New Zealand.  ‘The differential effectiveness of psychosocial and biogenetic causal explanations in reducing negative attitudes toward “mental illness”.’ Psychiatry. 2002 Winter;65(4):313-25.

[vii] Sandra Dietrich, Michael Beck, Bujana Bujantugs, Denis Kenzine, Herbert Matschinger, Matthias C. Angermeyer. ‘The relationship between public causal beliefs and social distance toward mentally ill people’ Australian and New Zealand Journal of Psychiatry Volume 38, Issue 5, pages 348–354, May 2004

[viii] Read, J., Haslam, N., Sayce, L. and Davies, E. (2006), Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica, 114: 303–318.

[ix]   Jo C Phelan, Dept of Sociomedical Sciences, Columbia University, ‘Forum: Genetic bases of mental illness – a cure for stigma?’ Trends in Neurosciences, Volume 25, Issue 8, 1 August 2002, Pages 430–431

[x] Giles Fraser has recently revisited this topic in: A regiment forms a moral soldier.  Church Times (www.churchtimes.co.uk). 20th January 2012  Available here.  It is on my New Year’s list of resolutions to post this to ‘regx2: Quotable quotes’ …