One of the striking things about the public debates on talking therapies is the absence of informed discussion about the working conditions and pay of the people delivering services. During 2016-17 the Surviving Work Survey was carried out to try to get a picture of what is happening in the therapeutic professions and ask some blunt questions about pay, promotion prospects and the decline in decent jobs. 1500 mental health workers completed the 50 questions about working conditions and 68 were interviewed. The national survey results are freely accessible on www.thefutureoftherapy.org with infographics, video, eBook and guidance on setting up Survival Surgeries in your area.
Because of the fear and reluctance in the sector to talk about our working lives, the survey took a long run up involving a campaign of discussion events, blogs and public engagement through www.survivingwork.org to create a safe and critical space where people could talk about their experiences. The survey went out through the main trade unions and professional bodies, including mental health nursing networks. Because of the fear of blacklisting and losing referrals, the survey and the results are anonymous.
We had originally planned to design an online map of working conditions, to highlight regional variations. Although it is true to say that working life in mental health is diverse – with teams and individuals trying to build sustainable services everywhere and with many experienced clinicians being able to influence how work is done – the trends that our survey highlights are uniform across the UK presenting a bleak prognosis for earning a living as a therapist.
The Industrial Relations of Therapy
The industrial relations of mental health services is still in its infancy. Despite the restructuring of the NHS data service – into NHS Digital – and the explosion of Freedom of Information requests being made about health services, we do not know how many people are working in mental health, for whom and how much they are getting paid.
This leaves us with a national mental health policy that is not underpinned by actual facts. We have had a series of workforce strategy documents – from the Taylor report on the future of work, the Stevenson/Farmer review of mental health and employers, to the mental health workforce plan for England slipped in just before the summer break – that have failed to inquire. Seduced by the proposal to increase the mental health workforce by 21,000 these reports have failed to report that they are implementing a strategic downgrading of services. Launched from the shiny safety of London think tanks, and created by individuals and organisations with a profound financial interest in the downgrading and outsourcing of services. Nobody actually working in mental health services is convinced by this rhetoric over the reality that the increasing majority of services are provided by insecure workers in non-clinical roles, often working remotely, with no clinical supervision and, ultimately, without a future prospect of providing good care.
The absence of industrial thinking means that still, despite the growing concerns within services, there is no analysis of what is happening across the sector. It is still largely not known that this is part of a larger degradation of work taking place in the UK labour market implemented through the dramatic rise in self-employment and deprofessionalisation that is established through the ‘gig economy’.
This lack of an industrial perspective is linked to the professional silos that our sector suffers from. Despite a growing number of people working in a range of clinical jobs, in different settings, on different contracts, we still do not quite understand that the working conditions of a psychological wellbeing practitioner in IAPT services is directly related to those of a psychotherapist in private practice.
This is not just an industrial relations problem, it is a political one. As mental health services are co-opted into implementing the government’s attack on welfare provision through introducing mental health ‘services’ into job centres and employment support services into primary care, the lack of informed debate means that so far mental health workers have not been able to respond to the strategic corruption of therapeutic services that is taking place. With the notable exception of the critical networks and new unions such as the Psychotherapy and Counselling Union (PCU), the debates so far about the future of therapy have been institutionally defended and professionally territorial. During the process of carrying out this research, I had been blacklisted by two of the main psychotherapeutic bodies. Despite the recognised lack of mental health workforce data, it appears that independent research is not welcome in the ever-decreasing-circles of our professional institutions.
Combined with this lack of informed policy, is a cultural aspect within the mental health professions of what the psychoanalyst Sally Weintrobe calls, Noas-Arkism. This belief, held at an individual and collective level that enough people have a place on the boat for them to keep things as they are.
Despite the shocking picture presented on www.thefutureoftherapy.org. the research comes from a position of hope. One of the privileges of coming from a trade union background is that you get to see what happens to working people when they have reached a point where they cannot accept their working conditions. What we know is that people can and do organise successfully in the most precarious environments – often self-organising as their institutions fail to represent their interests. This is not principally an ideological response, rather one of necessity.
It is this important and ordinary organising work that often gets missed in the mental health debates. As a result, the principle objective of my research is to help open up a debate about the dual purpose of organising in mental health services – how to make real changes in our working conditions and pay while at the same time sustaining ourselves in the current climate.
What the data shows
Because of the distribution of the survey through unions and professional bodies and networks, there is an over representation of senior clinicians and an under representation of the new generation of non-clinical functions. However, all categories of mental health workers are included in the survey and what the results show is three significant trends.
Trend 1. Growth of precarious work
It is no wonder nobody seems to know anything about therapeutic jobs because it is a complex picture. Although 74% of respondents said they worked for the NHS, 54% are working in multiple settings, many are on short term contracts or hourly paid, running from one job to the next.
There is a very clear picture of ‘flexible’ work in the sector. This is not just about the growth of fixed term or hourly paid contracts – it is also about the emergence a growing majority of people who are working in multiple settings, with several employers and using different modalities.
The first problem that this leads to is that people are confused about who they work for and what their employers’ responsibilities are. When you ask people who their employer is 20% say they are self-employed but when you ask people what kind of contract of employment they have it is 30%. From our survey 8% do not know what kind of contract they have and 8% have no written contract at all.
The nature of flexible work means that people are stretched across a range of services. From our survey, 22% of NHS workers have multiple employers, 54% of respondents work in multiple settings with 91% of self-employed work in multiple roles and settings.
As part of this flexibilisation we have seen the growth of part time work – 29% of survey respondents work part time with 59% of part-time workers work in the NHS and 38% are self-employed. Many people said in the survey and interviews that they cope with work intensification by going part time. These tended to be NHS workers and more senior clinicians. On the other hand newly qualified and trainees were setting up in private practice although with low patient numbers. Nobody I spoke to from this second group was optimistic that they could earn a living from working in private practice.
It is unavoidable to point out that many therapists are not earning enough. A staggering 18% of respondents earn less than £300 per week, with an average income of £401-500 after tax. This is partly explained by one third of people working part time but also relates to two key trends; the growth of unwaged work and self-employment.
Our survey shows that 21% of therapists work unwaged as honoraries but interestingly only 15% were trainees, with 6% representing an emerging group of mainly senior clinicians working for free – most working in the Third Sector and the NHS. The NHS and the Third Sector are quietly sustaining many services on unwaged work with 15% of honoraries estimating a loss of income of over £401 per week. It is worth pointing out that as our professional bodies require clinical hours for training and professional registration we have the curious situation that the bodies charged with protecting the profession are undermining it. It leads to the prospect that the future therapeutic workforce will need to be people only from affluent backgrounds – hence the title of our discussion events last year being “Do you have to marry a rich man to be a therapist in the UK?”. Although there are movements in the BACP and UKCP to challenge the culture of unwaged work, we are a long way from halting the expectation that a large percentage of therapists work for free.
Connected to the low wages in the sector is the growth of self-employment in the public sector, a much misunderstood category of work in the UK. Just under 30% of therapists are self-employed – but living far from the powerful fantasy of a full-time psychoanalyst in an Afghan rugged consulting room. What the survey implies is that self-employed therapists are increasingly being used by employers to avoid social costs of direct employment. They work less hours and earn less pay. No more pensions, no more sick pay, no more CPD. This raises important questions not just about professional liability but also the duties of care of employers. Many mental health workers when asked who they work for will say the NHS but the reality is that as self-employed clinicians there is a growing confusion over clinical and employers’ responsibilities, not least in terms of who is insured for what.
Trend 2. Downgrading & deprofessionalisation
Although 24% of survey respondents work in England’s Increased Access to Psychological Therapies (IAPT) services, many move in and out of working for it. More profoundly, the research shows that the regime of performance data and management introduced through the ‘evidence base’ of IAPT, is now mainstream in mental health services. The use of targets around patient numbers, waiting times and recovery rates goes right across the NHS and primary care meaning that the issue of performance management has become the primary cause for professional concern in the sector.
This is one of the greatest shames for public sector workers of how we have allowed the spread of performance data and performance management to dominate public service. This has led to a growing challenge to the claims of IAPT that it can achieve 50% recovery rates – an obvious gaming of data for anyone working in the service. There has been a deep reluctance on the part of IAPT providers, training and professional bodies to challenge this because of the financial interest in the sector to keep this system in place. IAPT is one of the largest and growing sources of employment in mental health explaining the fear of clinicians to raise their concerns that the wrong things are being measured and the that the failures in patient care is being evaded. The 2017 National Audit Office inquiry into performance data in IAPT services has failed to produce a public report. I am currently waiting for an FOI request to reveal the decision making process in government not to make this report public, as presumably the findings raise public safety concerns about government policy.
In the survey, we asked people “what would improve your working life?” as an open ended question, and the majority of people raised concerns about poor management. This came out vividly in the questions about raising concerns where only 25% of patient concerns were resolved adequately and only 6% of concerns about working conditions. Unsurprisingly patient concerns are taken much more seriously but the 75% of cases left unresolved breaks with the received wisdom that if you present a workplace concern as an issue of patient care then management will respond. The resounding picture is of a management who take a ‘hands-tied-headless-chicken’ school of management.
An average of 5% of people who raised concerns were victimised, many losing their jobs or facing constructive dismissal. This may not sound like much but nothing puts a downward pressure on people raising concerns again than seeing a colleague lose their income. This was the saddest part of the survey for me, how little impact we are having in bringing about real changes at work.
Two things come through in the open questions about working conditions. Firstly that the vast majority of respondents raised concerns about the ethics of working in a system that is based on manipulation of what is really going on in services. This was particularly clear in CAMHS services where the rollout of IAPT directly challenges model ethical services. Secondly, the devastation that people experience through working under this system of performance management, and the everyday grinding down and demoralisation that this results in.
This internal pressure is matched by an external one where, although not yet significant, the crisis in mental health services is a major strategic opportunity for private and third sector contractors and private employment agencies who are literally buying up the growing NHS waiting lists. From our interviews, there appears to be a particular growth in private employment agencies providing IAPT services in Child and Adolescent Mental Health Services (CAMHS) as the Child and Young Persons (CYP-IAPT) services are being rolled out in England. There is also a strategic growth of ‘non-clinical’ jobs – from PWPs to digital CBT programmes, such that many of these jobs will not require clinicians to deliver them. With the advent of Sustainability and Transformation Plans and the oblique Integrated Care Organisations, this process of contracting out mental health services is due to accelerate.
Trend 3. The Jobs Gap
What emerges from the research is that it is through the use of performance data and performance management techniques there is a systematic downgrading across mental health services. On the website we call this the ‘IAPT Juggernaut’ representing the dominance of a particularly rigid modality of what many practitioners are calling ‘sub-therapy’ that extends beyond IAPT services. This is not the contentious debate about cognitive behavioural therapy versus psychotherapy, it is about degradation of clinical into non-clinical work.
Just on the basis of the demography of people working as therapists, the existing workforce crisis will threaten services over the next five years. This relates to two key issues; the gap between qualifications and jobs levels and the ageing workforce.
In the survey we estimated the gap between qualification and clinical seniority – the gap between what we are trained to do and what we are paid to do. We used an analysis of qualification seniority that probably underestimates the qualifications of the respondents partly because respondents did not put down all their numerous qualifications and where qualification level was unspecified. Our categorisation of clinical seniority depended on factors such as clinical lead, team leader/ service management plus clinical role, supervision, clinical training role, specialist psychotherapeutic role, complex case load. Given the downgrading of jobs this is not to say that many of our respondents are not working at a high clinical level – most are – only that their job titles and descriptions do not require it.
Our survey revealed that 37% of respondents have senior psychotherapeutic qualifications but only 26% have clinically senior jobs. This goes up to 48% working below their qualification level in IAPT services.
We are moving away from a professional structure towards a much more generic system of ‘mental health’ professional. Many of the people in the survey raised concerns about the growth of mechanised and short term therapy being offered through IAPT and more generally across mental health. We know that increasingly senior positions are not being filled above Band 8a, and as more and more people become unable to fund their own training, the NHS will face a skills deficit as people cannot afford long term psychodynamic clinical training.
This gap is compounded by the ageing workforce. 60% of respondents are older than 47 years, 21% born before 1959 – going up to 29% in London. Only 19% of respondents are younger than 37. The UK working population average is 35%. Although many experienced therapists are successfully working in a combination of private practice and NHS work, the demography of the sector indicates that they are only able to earn a living having spent most of their working lives in the NHS leaving their pensions and mortgages intact. Unsurprisingly a third of respondents said that the best thing they could do to improve their working lives was to retire.
As the private employment agencies and digital health companies mop up the NHS contracts fully aware of the workforce trajectories, the myth of the self-employed therapist as a sustainable job will become exposed. This has implications for our professional and training bodies, particularly those that are currently recruiting on the basis of a professional fiction.
What lies ahead for mental health services
It is a growing possibility that we are within a decade of the genuinely therapeutic professions dying out. The current economic argument for mental health services is based on the unacceptable working conditions of mental health workers. From the thousands of counsellors working in IAPT to the honorary psychotherapists propping up the Third Sector, working in mental health is posing significant health risks to both clients and clinicians. As we become de-professionalised, downgraded and demoralised and our experienced leadership retired, this leaves the gates open to private providers to fill the gap ‘going forward’ towards a mental health service made up of tick boxes and compulsory wellness with psychoanalysis relegated to a heritage industry.
What is happening now is not an accident. There is a strategic objective behind this promotion of manualized/non-clinical/virtual therapies combined with the growth of self-employment in that it opens up the mental health sector to non-clinical providers. Based on the experience in the public and other sectors we will see the rise of private employment agencies (PrEAs) and large scale contractors and with it the risk of failed contracts and lack of corporate accountability when the lights start to go off.
Despite the resistance to look at the facts, we will inevitably see over the next year more information about the workforce crisis about to hit health and social care. Some of the reasons for this are general – that the UK is a low wage economy, the impact of Brexit, and the unsustainable costs of clinical training and professional registration. All of these factors are bad news for keeping genuine health services alive but mental health services are facing a much deeper crisis over the emergence of sub-therapy and psycho-compulsion and with it the corruption of the therapeutic field.
Firstly, genuine psychotherapy increasingly is not being offered in the NHS because it cannot be done as cheaply as IAPT interventions. This is not to say that the return on investment (ROI) of psychotherapy cannot be argued – it can if you are actually interested in treating actual people with actual mental health problems. But the ‘evidence base’ for IAPT is based on a model of telephone assessments using scripted questionnaires where nobody can actually say how they feel, allowing assessors to refer patients to short term interventions that are not, for example, designed to treat depression. Although increasingly real therapy is not being delivered through IAPT, what matters to the government is that in the short term it is cheaper, particularly if it is delivered by unwaged trainees provided by clinical training and professional bodies.
What may be more problematic in arguing for mental health funding is that because psychotherapy helps people to take control of their own lives it means that the ‘evidence base’ for psychotherapy can not be manufactured around the demands of politically set targets. Although research shows that psychotherapy is highly effective in the long term, it does not compel people to become well in a 6 week period.
Ironically for therapists in the business of talking and thinking, the psychoanalytic professional structures are not doing that when it comes to the future of public mental health services. Although there are some extraordinary people in these systems, the prevalence of Noas-Arkism and the strains of managing decline has provoked both a freezing and a folding inwards. This is not principally a problem of innovation – in my experience clinicians are always having good ideas – rather a problem of professional ethics. That the bodies charged with defending psychotherapy are failing to defend the principles on which they depend.
This might explain the reluctance of the professional bodies to engage in the much needed debate about the future of mental health services with a wider audience including those critical insiders and outsiders who are researching workforce issues. Add to this the temptation to blacklist critics and you end up with a system that cannot hear different views and becomes entrenched in defending their own existence. Although this freezing and folding is understandable as a response to threat, it is about to create a split between the interests of the people providing the services and the people accessing them.
The Organising Challenge
In the long term we know that mental health services deserve a public inquiry into the current regime of performance management – one that is run by a group of people who are not financially invested in the outcome. Co-production and practicing what we preach might be a good idea too. We also know that we need to set up a platform for negotiating over the issue of wages in the sector. Again this should not be populated by the professional bodies alone, stuck between rocks and hard places in defending clinicians and keeping the registration and training gig on the road. Inevitably a public and publicly accountable structure needs to be fought for, but we are a million miles away from achieving this because of the absence of workplace organising that protects therapists’ ability to participate in shaping their working lives.
Something else stood out in our survey – the low number of people who went to a trade union or directly to colleagues with their problems. Outside of the NHS, only 4% of therapists spoke to a colleague about problems at work. For people trained to increase relationality there is a real question why we do not seem to be doing that with the people we work with.
In a context of downgraded mental health services, the fact that mental health workers are unorganised and silenced is a matter for both professional and personal ethical concern. Sometimes working in healthcare forces you to walk a very thin line between the personal and the political – an awkward place somewhere between the consulting room, Whitehall and the board room. If the entire history of improving working conditions through collective action is anything to go by this involves setting the battle lines – the principles that form the basis of care – and the conditions under which those principles can survive. It also requires us making strategic choices about where we target our energies choosing those battles that we have not already lost. It would be a good place to start to block and regulate the growing field of digital providers and private employment agencies before it is too late.
Bearing in mind that the institutions of mental health are themselves facing crisis I am not going to suggest that there is an easy way to collectivise within our professional networks. Having worked in trade unions for much of my working life there is not one romantic bone left in my body about unions as organisations but they are the only show in town when it comes to the hard core employment relations job of defending workers and bargaining over wages.
This is where we need to head, towards creating a platform where wages and working conditions can be negotiated with employers. It is inevitable that this will require working across organisations and networks and stepping out of our professional silos. But most importantly if you as a clinician want to change where the sector is going, you just have to join a union.
There are a growing number of political groups and networks for mental health workers – all of them worth joining with the added bonus that they have yet to be institutionalised and are, well, more fun than your average professional committee meeting. Even though it may mean leaving the house on a rainy Tuesday evening, just do it when you can.
For those of you within the professional bodies please try to stay there but be a pedant and run the risk of people sighing when you raise the issue of employment contracts yet again. If you are part of a structure that can make any difference to the downgrading of services please try to stay within them. We need you more than we ever say.
Although we all struggle with the desire to manage work from under a duvet, to organise a response to the downgrading of services will require us freely associating with as many people as we can at work. Everyday politics is a long-game requiring enormous stamina and a good sense of humour. Rather than launch ourselves all-fists-and-teeth into the next fight or go off-grid living with wolves, one thing that we could do is to attempt to organise support in our own workplaces or local ares.
On www.thefutureoftherapy.org is some guidance on setting up Survival Surgeries based on adult education and organising principles. It is not a magic solution but it does offer a way to start the everyday work of building support for each other in the sector.
Saving mental health services inevitably requires us to resist and challenge the order within which we work and to support each other in making those difficult decisions. We have a choice what we do with this research. We can use it to rip strips off each other, or we can use it to organise.
This article was published in the British Psycho;ogical Society’s Psychotherapy Review Spring 2018 issue here.
The Future of Therapy Website: The national survey results are freely accessible on www.thefutureoftherapy.org with infographics, eBook and guidance on setting up a Survival Surgery in your area. To watch a video presentation of the research findings, recorded at the Tavistock & Portman Clinic go here https://thefutureoftherapy.org/storysofar. Over the next two years we will be publishing a series of academic articles picking up on four key themes: the strategic use of mental health services in welfare reform; honoraries and the link to the therapeutic training and professional bodies; the growth of self-employment and the myth of the therapeutic entrepreneur; performance data and management and the tyranny of targets.
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