Workforce Planning for Psychology Services in NHS Scotland psychology 2003repor… · Contemporary...
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NHS Education for Scotland (NES) Information and Statistics Division (ISD) Workforce Planning for Psychology Services in NHS Scotland Psychology Services Characteristics of the Workforce Supply in 2002
Transcript of Workforce Planning for Psychology Services in NHS Scotland psychology 2003repor… · Contemporary...
NHS Education for Scotland (NES)
Information and Statistics Division (ISD)
Workforce Planning for PsychologyServices in NHS Scotland
Psychology Services
Characteristics of the Workforce Supply in 2002
Foreword
Contemporary health policy in NHS Scotland recognises the importance ofpsychological factors in improving the physical and mental health andwellbeing of the people of Scotland. It is important for the delivery of goodquality psychological care that the correct numbers of well trained staff areavailable for career posts in psychology services across NHS Scotland.
Workforce planning is a difficult task, particularly at a time of major redesign ofservices and redefinition of professional roles. Nonetheless it is an essentialelement, linking service planning to educational development and provision.The availability of good quality data is essential to informing these planningprocesses.
This report presents the output of a two year collaboration between NHSEducation for Scotland (NES) and the Information and Statistics Division (ISD)designed to develop a data collection system to capture information aboutpsychology services across NHS Scotland. The Steering Group is to becommended for the breadth and depth of information which has beencollected and analysed with care to provide a valuable summary of the currentworkforce supply of psychologists and other clinical staff currently employed inthese services.
This report is timely. The organisation of psychology services in Scotland isunder review, with support from the Centre for Change and Innovation. Newmodels for optimal utilisation of psychologists are being explored, in thecontext of multi-disciplinary and multi-agency collaboration in the delivery ofpsychological interventions. This year NES has commissioned a majorexpansion of the training capacity for Clinical Psychologists and is developinggreater flexibility in training pathways forpsychologists to meet service needs.
The data presented in this Report and itsSupplement are therefore a valuable baselineagainst which the impact of thesedevelopments can be monitored at local,regional and national level.
Ann MarkhamChair,NHS Education for Scotland
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Contents
Executive Summary 3
1. Introduction 8
2. Policy and Professional Background 12
3. Developing Intelligence for Workforce Planning 24
4. The Workforce of Clinical and Applied Psychologists in NHS Scotland 32
5. Skill-mix in the Organisation of Psychology Services 54
6. The Characteristics of the Workforce 65
7. The Dynamics of Workforce Supply 81
8. Summary and Concluding Discussion 91
References 105
Appendix A: Membership of the Steering group 109
Appendix B: Acknowledgements 110
Appendix C: Glossary of abbreviations and acronyms 111
Appendix D: Current training and professional roles of clinical staff in psychology services 112
Appendix E: Survey form and definition of codes 118
Appendix F: Developments in the modernisation of postgraduate training for psychologists in Scotland 121
Appendix G: The dynamics of supply – the impact of expanding training capacity 123
Executive Summary
Introduction
• This is the second in a series of reports designed to inform workforceplanning for psychology services in NHS Scotland.
• The first report (NES, 2002a) reviewed the key factors relevant to workforceplanning and used the best available published data to make the case foran increase in training capacity for Clinical Psychologists to meet workforcerequirements.
• Since then SEHD have committed to support a step increase in capacity forClinical Psychology training, contingent on modernising training pathwaysto increase responsiveness to service need.
• Reliable data about the current workforce is essential to informing planningprocesses for service and workforce development and for educationalprovision.
• This report presents the results of a two year project to develop andevaluate a data collection system to describe the workforce employed inpsychology services across NHS Scotland.
Policy and Professional Background
• Contemporary SEHD policy offers unprecedented potential for Clinical andApplied Psychologists to make a significant contribution to improving thephysical and mental health and well-being of the people of Scotland.
• A key issue is how psychology services should best be organised to allowthis relatively small professional group to work effectively with others in amultidisciplinary and multi-agency context, while retaining the functionalintegration essential to their own professional efficiency and effectivenessand to clinical governance objectives.
• Psychologists are engaged in service redesign and there is a growingrecognition that the roles of Clinical and Applied Psychologists arechanging. A variety of approaches have been adopted to the developmentof a skill-mix within psychology services to meet the demand forpsychological interventions.
• The training and career pathways for psychologists are beginning to changein response to the modernisation agenda, offering greater responsiveness toservice need and greater flexibility for individuals.
• There is a need for greater consensus about the strategic direction of serviceredesign of psychology services within NHS Scotland. The development andevaluation of a shared model or models of service organisation wouldgreatly assist the workforce planning process and educational development.
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• Strategic planning requires a clear understanding of the status quo fromwhich developments are to be initiated and reliable intelligence as amonitor of progress.
Development of Intelligence for Workforce Planning
• A project was initiated by SCPMDE and taken forward by NES, incollaboration with ISD, to develop and evaluate a system for collecting dataabout the workforce employed in psychology services in NHS Scotland. Theworkforce was surveyed in 2001 and 2002.
• The parameters of the survey sample were carefully defined to include allclinical staff (psychologists and non-psychologists) delivering psychologyservices. Data were collected separately about Clinical Psychology traineeswho were excluded from the workforce survey.
• The imminent modernisation and expansion of training for psychologistsrequires a response from NHS Scotland in terms of planned developmentsin psychology services to employ the growing numbers of trained staff whowill become available. There is a need for a data collection system capableof monitoring holistically the impact of developments in training on theworkforce in psychology services across NHS Scotland.
• The 2001 data, which should be regarded as the baseline against which toassess future change, are given in the Supplement to this report.
• There was evidence that in spite of teething problems, this projectgenerated data about this sector of the workforce which was more reliableand more informative than pre-existing data sources.
• There is a clear need for on-going data collection to ensure the availabilityof reliable and up-to-date information about the workforce in psychologyservices and to build up the longitudinal database that is needed to informprojections of future workforce supply.
• The aims of continuing data collection and the parameters of the surveysample need always to be clearly defined, taking account of the policydirection for psychology services and the availability of complementarydatasets. The survey must develop in a way which is compatible withnational developments in workforce planning in Scotland.
• There is a clear need to move beyond a simple count of individuals orwhole-time equivalents to take more account of professional activities andpatterns of working.
The Workforce in Psychology Services
• In 2002 there were 338.6wte Clinical, 14.2wte Counselling and 6.5wteHealth Psychologists in NHS Scotland. This represents an overall increase intheir numbers of 10.5% since 2001.
• In spite of this, there was still only 1wte Clinical Psychologist perapproximately 15,000 of the general population in Scotland in 2002 i.e.about a third of the indicative workforce requirement of NHS Scotland citedin the previous report (NES, 2002a).
• In addition, psychology services employed: 73.3wte Assistant Psychologists;11.0wte CBT therapists: 15.9wte Counsellors; 5.0wte other therapists and7.6wte other clinical staff, bringing the total workforce to 472wte.
• The ratio of Clinical and Applied Psychologists to the aggregate of theseother clinical staff was 76%:24%.
• The majority (n=308.8wte, 65%) of the workforce in psychology serviceswere employed in Mental Health services for patients across the life-span.The remaining 35% were distributed across a wide range of services. Themain areas of work can be summarised as Learning Disabilities (66.2wte,14%), Physical Health (41.8wte, 9%), Neuropsychology (22.0wte, 5%),Forensic (13.6wte, 3%) and Other (19.8wte, 4%).
• Analysed by the age of patients/clients served, the majority (354.9wte,75%) of the workforce in psychology services were working with adults inthe age range 20-64 years, across the range of areas of work.Approximately one in five (93.2wte) worked in psychology services forChildren, Young People and their families. Services for Older Adultsemployed a mere 4% (19.0wte) of the workforce and the remainder of theworkforce (4.9wte) provided psychology services across these agecategories.
• The survey confirmed that psychology services are inequitably distributedacross NHS Scotland.
• In 2002, none of the Island Boards had local psychology services. On themainland, the Health Boards with the highest staffing relative to the size ofthe population they served had more than twice the workforce inpsychology services of those with the lowest staffing. None was close to thefirst indicative requirement of 1wte per 5,000 of general population whichwas the indicative estimate for fully trained Clinical Psychologists (NES,2002a).
• There was no evidence of a linear relationship between staffing provision inpsychology services and remoteness/rurality or social deprivation across themainland Health Boards.
• The distribution of Clinical and Applied Psychologists varies across theHealth Boards of Scotland. There is also variation in the use of skill-mixwithin psychology services from one Health Board to another. It is beyondthe scope of this survey to say whether these differences reflect localrecruitment issues, opportunistic development or strategic planning to meetlocal service needs.
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• Variations in the workforce supply in psychology services were reported byareas of work and the target age of the patients/clients served.
Characteristics of the Workforce
• The workforce of Clinical and Applied Psychologists are predominantlywomen (71%). The men tend to be older than the women (median agesrespectively 47years and 38years). The distribution of ethnic origin in theworkforce is comparable to that in the Scottish population. 97.8% of theClinical and Applied Psychologists are white.
• There was a sex difference in the proportion of Clinical Psychologists whohad grade B posts. The difference between men (57% Grade B) andwomen (34% Grade B) did not seem to be satisfactorily explained by theage difference nor by the distribution of part-time working between thesexes. Further information about the career patterns and aspirations of theworkforce would be helpful to inform future workforce planning.
• 32% of this sector of the workforce works part-time.
• In all, there were 124 other clinical staff employed in psychology servicesacross NHS Scotland.The largest single group of them were AssistantPsychologists (n=73). They were predominantly women (88%), young(median age 25years) and in posts with fixed term contracts (63%).Typically they are seeking work experience to enhance their application forclinical training places.
• Other clinical staff bring a range of skills and experience to psychologyservices. Although median age varies across staff categories these staff are,in general, more likely to be older. Although 45% of CBT therapists weremen, the majority of clinical staff overall (85%) are female.
• The report presents data about the distribution of workforce characteristics(gender, part-time working, age and MHO status) across the service toshow variations by area of work, target age of patients/clients served andHealth Board area.
• The net gain to the workforce was a total of 47 Clinical and AppliedPsychologists in 2001/2. The greatest turnover was in the age range 25-34years and resulted in a gain of more women than men in a ratio 3.7:1.Most of the turnover was in Grade A Clinical Psychology posts.
• 79% of the ‘joiners’ had qualified in Scotland.
• Among the other staff groups the dominant feature was the high turnoverof Assistant Psychologists.
• The proportion of the workforce eligible to retire in the next 5years (2002-7) was defined from age at the time of the survey assuming a retirementage of 60years. For staff with MHO status, retirement figures werecalculated from age 55years.
• On this basis there were 108 staff in psychology services (20% of the total)who could retire by 2007. Services vulnerable to staff loss in this timeperiod were identified. They should be engaging now in successionplanning.
• This loss of expertise is a serious issue at a time when there is an increasedneed for supervision of clinical work in the workplace. There is an urgentneed to develop arrangements to maintain some contribution to the servicefrom these experienced workers without compromise to their pensionarrangements.
• The vast majority (91%) of Clinical Psychology trainees completed theirtraining satisfactorily in 3years. Retention of those trained in Scotland isgood. 91% had secured employment in NHS Scotland.
• The impact on the service of doubling training capacity was modelled usingdata from the workforce survey and the training course leavers of 2002.This suggested that even with 64 trainees in each year of the 3-year trainingprogramme, it would take 38 years to double the current stock of trainedClinical Psychologists in the workforce.
• It is likely to be possible to increase training capacity beyond the figuremodelled. The intake for 2003/4 will be of 65 trainees. Nonetheless it isclear that both service redesign and new developments in training andcareers will be required to deliver psychology services to meet SEHD policyobjectives and patients’ needs.
• The introduction of flexible training arrangements offers the opportunity toorganise the delivery of training to achieve greater responsiveness to localservice needs. A new training programme is proposed, to equip graduatepsychologists with competencies to contribute to services for commonmental health problems among adults. It is anticipated this will be openfrom 2004/5.
• The next report in this series will examine data collected about plannedservice developments and information about service redesign to inform theforecast of demand. Future supply will be modelled based on a number ofscenarios, informed by developments in training. The gap between supplyand demand will be examined to inform future workforce and trainingrequirements.
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This is the second in a series of reports concerned with workforce planning forpsychology services in NHS Scotland. This report presents data to describe thecharacteristics of the workforce currently engaged in the delivery of psychologyservices and the current status of factors likely to affect change in thatworkforce, to inform projections of future workforce supply. The effect ofplanned service developments on the future demand for psychology serviceswill be the subject of the next report.
Psychological knowledge and skills have an important contribution to make toachieving the objectives of contemporary healthcare policies to improve thephysical and mental health and well-being of the Scottish population. There isconcern about the availability of sufficient numbers of appropriately trainedstaff to deliver psychological services across NHS Scotland.
It is recognised that psychological interventions for healthcare problems can bedelivered by a variety of healthcare professionals and others, in a wide range ofsettings across and outwith the NHS. The reports in this series focus on theskill-mix of staff employed within NHS psychology services, with particularreference to Clinical Psychologists who are currently the largest singleprofessional group in this context.
Development of a strategic view of service organisation for psychology servicesis essential to workforce planning and to the development of training forpsychologists to meet future service requirements. There is an urgent need fora shared view among the relevant stakeholders of the model or models ofservice organisation which will optimise the contribution that professionalpsychologists can make to health care in Scotland, both directly and throughtheir work with others in a multidisciplinary and multi-agency context. As carepathways emerge and working patterns change the workforce will increasinglybe defined in terms of the roles and competencies required to deliver theservice. In a complex and dynamic healthcare system workforce planning isnecessarily an iterative process. However strategic planning for the futureneeds to start from a sound basis of understanding the status quo from whichprogress is to be made. This report therefore aims to build on the account ofpsychology services given in the previous report, by adding substantive newScottish data to describe the current workforce supply. This is the first steptowards developing the intelligence systems of the calibre required to informfuture planning processes.
The Clinical Psychology Workforce Planning Report 2002
The ‘Clinical Psychology Workforce Planning Report’ was published by NHSEducation for Scotland (NES1, 2002a). This reviewed the key factors relevant toworkforce planning for Clinical Psychologists, in the context of their role inmultidisciplinary teamwork in services across NHS Scotland. It highlighted the
Introduction
1 Acronyms areintroduced, with the fulltext to which they refer,on their first appearancein the text. Thereafteracronyms are usedthroughout the textunexplained. For ease ofreference a glossary ofthe acronyms is providedin Appendix C.
strong evidence-base for health gain resulting from psychological interventionsand noted that the importance of psychological factors in health andhealthcare is increasingly recognised by the Scottish Executive HealthDepartment (SEHD) in contemporary policy documents.
That report presented evidence that, in spite of the broad applicability ofpsychological knowledge and skills to healthcare, the provision of qualifiedClinical Psychologists was insufficient to meet service requirements. Dataderived from the National Manpower Statistics (ISD Scotland, 2001) showedthat with an average of 1 whole time equivalent qualified Clinical Psychologistper 14,220 of the population, Clinical Psychologists represented less than 0.4%of the workforce in NHS Scotland.
The Clinical Psychology Workforce Planning Group, responsible for that firstreport, also commissioned three sub-reports on services for primary care,learning disabilities and cancer (NES 2002b;2002c;2002d). These highlightedthe consequences of chronic understaffing: long waiting times (particularly inprimary care); gross inequities of access to services (e.g. in learning disabilities)and absence of services, in spite of evidence of patient need and potentialbenefit (e.g. cancer). An overarching concern was the lack of input bypsychologists to strategic planning processes concerning psychological aspectsof health care, through which these issues might be addressed.
Strategic Planning for Psychology Services
Historically, the fragmentation of psychology services, as well as their small size,has militated against their visibility to planners. This is changing, althoughsome psychology services in NHS Scotland still lack coherent organisation atHealth Board level.
There is good evidence of local involvement of psychologists across NHSScotland in service redesign e.g. ‘The Directory of Abstracts’ from the NationalClinical Psychology Conference on Innovation in Training and Practice(SCPMDE, 2002). Such projects generate data which could usefully informwider service developments. It is not yet clear how psychology services will linkinto planning processes at regional level, but at national level, the ChiefMedical Officer’s Psychology Advisory Group is an important avenue forcommunication about service planning. Furthermore, a growing number ofpsychologists are involved in SEHD initiatives although there is no seniorpsychologist within SEHD to act as lead officer for psychology services acrossNHS Scotland.
The absence of an integrated approach to strategic planning for psychologyservices remains a handicap to workforce planning at every level. There isconcern in this small profession about how to relate to new workforcestructures at local, regional and national level to ensure the correct numbers of
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well trained staff are available to deliver good quality psychological care acrossthe healthcare agenda.
Expansion and Modernisation of Training
In contrast to most other healthcare professional groups, the workforceshortage in Clinical Psychology is readily remediable i.e. by removing the blockat entry to training. In England annual increments in training capacity over thepast decade have allowed expansion of services south of the Border, althoughdemand continues to outstrip supply, and training numbers are continuing toincrease year on year. In Scotland, there has been no commensurate increasein training capacity in this period.
The first report in this series presented the best available data to make the casefor the urgent need to double training capacity for Clinical Psychologists inScotland. SEHD has given a commitment to support a step increase in trainingcapacity from 2003. This support is contingent on modernisation to aligntraining and career pathways with contemporary policies for service andworkforce development. This second report will begin to consider the impactof increased capacity and flexibility in training on future workforce supply.
The ‘Clinical Psychology Workforce Planning Report’ (NES, 2002a) did considerthe contribution to NHS psychology services made by other psychologists withdifferent levels and types of training, and by therapists with other professionalbackgrounds, employed in those services. It clearly recognised the need to linkthe expansion and modernisation of training to changing models of servicedelivery and role redesign for Clinical Psychologists.
The Need for Data about the Workforce
Reliable and up-to-date intelligence, both about service requirements and thechanging skill-mix in psychology services, was highlighted in the first report inthis series as essential to future workforce planning. Under the auspices of theScottish Council for Postgraduate Medical and Dental Education (SCPMDE),the Clinical Psychology Workforce Planning Group commissioned a two yearproject to pilot and evaluate data collection systems to address this. The workwas taken forward by NES, in partnership with the Information and StatisticsDivision (ISD) of the Common Services Agency (CSA). This report presents thefirst output from that project.
The output is in the form of data to describe the workforce andrecommendations to inform future data collection. The latter should not beoverlooked as the continuing effort to collect reliable intelligence about theworkforce remains essential to monitoring progress and informing futureplanning.
This report focuses on the most up to date data derived from surveying the
workforce in 2002. Data derived from the 2001 survey are presented as aSupplement to this report. Data were locally collected and are reported atHealth Board and national level. Clearly the figures can be aggregated toprovide information at regional level as required.
The modernisation agenda is gathering momentum within the NHS. Redesignof psychology services is coinciding with a time of change within theprofession generally. These changes have important implications for theprofessional roles, and hence the education, training and career development,of psychologists. This two-year project therefore marks the baseline againstwhich the impact of these changes can be monitored and represents a firststep towards providing the level of intelligence required to inform futureservice, workforce and educational planning processes.
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i) Policy Context
Scotland’s Health White Paper: ‘Partnership for Care’ (2003) recently outlinedthe direction of a major programme of reform of NHS Scotland which hascrucial implications for future planning for psychology services. Investment inhealthcare is being increased with the aim of improving the health of thepopulation of Scotland through improved and redesigned services.Responsibility for assessing local health needs and commissioning appropriatehealthcare to meet those needs, will rest with the Unified Health Boards, withinwhich community-based services will be strongly represented.
The modernisation agenda laid out in the White Paper and othercontemporary policy documents offers exciting potential for AppliedPsychologists to make a much greater contribution than before to healthcare inScotland. Delivery of that potential will critically depend on effectivedeployment of the workforce engaged in the delivery of psychological servicesacross the whole healthcare system, including the input of psychologists asexperts to the strategic planning processes for implementation of these policydirectives.
The emphasis on improving health, both physical and mental, is grounded inthe community and gives new prominence to well-being, health promotionand early intervention. The aim is explicitly to seek to influence lifestyle andother factors which adversely affect health particularly of ‘at-risk’ groups, andto do so through inter-agency partnerships. Particular attention is being givento the Early Years, Teenage Transition, Health in the Workplace and tocommunity-based plans for socially disadvantaged groups. Clearly theknowledge and skills of a range of applied psychologists have much tocontribute to this agenda.
Contemporary policy documents have consistently stressed the importance ofpatient-centred services. The White Paper goes further in recognising theimportance of the interpersonal skills of staff in making that aspiration a realityand in identifying the provision of communication skills training as a highpriority. Much of the evidence about communication skills derives from thepsychology literature. While it is clear that these skills can be improved withtraining, there are questions about how that training can be most cost-effectively delivered. For training to influence practice requires that skills bepractised and reinforced in the workplace. While psychologists do have thecompetencies required to support this culture change, the existing psychologyworkforce is not yet sufficient to contribute effectively to the implementationof this policy across NHS Scotland.
‘Partnership for Care’ places great emphasis on improving the quality of servicethroughout the healthcare system, strengthening systems for setting and
Policy and Professional Background
monitoring standards through NHS Quality Improvement Scotland. There is astrong evidence- base for psychological interventions and psychologists areincreasingly involved in the development of treatment protocols and practiceguidelines and in the setting and monitoring of clinical standards. A BriefingPaper has recently been prepared by the CMO Psychology Advisory Committee(NES, 2003b) to highlight a range of recent psychological research relevant tocontemporary clinical practice.
The implementation of evidence-based practice remains a challenge forpsychology services with current staffing levels. To address this psychologistsneed to be more proactive in bringing the evidence of health gain frompsychological interventions, both at systems level and for the individualpatient, to the attention of service planners. It cannot be assumed thatinterventions of proven effectiveness when delivered by Clinical Psychologistswill be equally effective when delivered by less skilled practitioners. Investmentin service development/evaluation and appropriate clinical governance systemsis required to ensure quality standards of care are achieved and maintained.
The identification of waiting times as a key priority for improvement isparticularly pertinent for psychology services where long waiting times havebeen a chronic problem, particularly in primary care.
The White Paper recognises the importance of clinical leadership in theredesign of services. This is particularly timely and crucial with respect to thepsychological elements of healthcare delivery. There is an urgent need forstrategic planning to ensure that effective organisational structures aredeveloped to enable the significant contributions that trained AppliedPsychologists could make as experts to fulfilling SEHD policy objectives acrossthe healthcare agenda.
Psychologists recognise that delivery of psychology services involves amultidisciplinary skill-mix. A variety of models have emerged for psychologiststo work with other clinical professions, or with workers from other agencies, todeliver psychological services effectively. It is unlikely, given the variation ofneeds and resources across Health Board areas, that ‘one size’ will fit allservices. There is however a need for service models to be developed on thebasis of strategic planning, and evaluated for their effectiveness in deliveringservices to meet population needs.
There is growing recognition of the roles that fully trained AppliedPsychologists can play in service development and evaluation as well as in thetraining and supervision of others to ensure recognised standards in thedelivery of psychological interventions. Training, supervision and continuingprofessional development and attention to clinical governance issues arerecognised as crucial to establishing and maintaining the competence of all
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staff delivering psychological interventions. All of these activities, which requireprotected time, are integral to the workforce development agenda. There isthe further issue for this small profession of how to input to systems forworkforce planning, at local, regional and national level, to achieve the futurestaffing levels required to make the delivery of the potential benefits ofpsychological interventions a reality across NHS Scotland. This is particularlyimportant given that Mental Health Services have been identified as a‘pathfinder’ for the new Workforce Planning Unit in SEHD.
There is a challenge across all healthcare professions to recruit and retainsufficient numbers of staff to meet service needs. The need to make best use ofresources is stimulating review of roles within professions as well as acrossclinical teams. While recognising and reinforcing the need for ensuring qualitystandards of professional training and practice, SEHD policy challenges thepsychology profession to adopt a more flexible approach to its ownprofessional training and development to meet the needs of a modernisinghealth service in Scotland as a major employer.
ii) Redesign of Psychology Services
To respond optimally to meet the increased demand for a full range ofpsychology services, the structure and function of psychology services must bere-examined to ensure the best use of limited resources. Two conceptualmodels, separately developed, can usefully be brought together for thispurpose:
A Basic Framework of Competence for Psychological Care
A systematic model, widely recognised among psychologists (ManagementAdvisory Service,1989), conceptualised three levels of skill in the delivery ofpsychological care. More recent articulations (Ayrshire & Arran Health Board,1999) used the same framework to map the basic competencies required ofhealthcare staff to deliver ‘core tasks’ at each Level, in a variety of servicesettings (see Figure 1). It is recognised that there is a continuing proliferationof more detailed competency frameworks in healthcare. The Ayrshireexperience with this basic framework suggests it could usefully be more widelyapplied in NHS Scotland in support of designing services to meet the SEHDpolicy objectives for improved psychological care.
The framework, outlined in Figure 1, recognises that all healthcareprofessionals require to have a level of psychological skill and knowledge(designated Level A in Figure 1) which enhances their work with all patientsacross the spectrum of healthcare.
Figure 1: A Basic Competency Framework for Psychological Care
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CORE TASKS LEVEL A LEVEL B LEVEL CBasic psychological Circumscribed The application of the
care psychological care discipline of Psychology
to health care
Heightening
awareness of
psychological
factors in health
Direct psychological
intervention with
individuals,
families &
organisations
Psychological
research &
evaluation
Communication skills
Basic counselling skills
Ability to promote
psychological health
Communication skills
Empathic skills
Ability to recognise
signs of psychological
dysfunction & to seek
advice
Audit of defined
psychological
characteristics
Circumscribed
teaching/ training
packages
Recognition of need
for referral on
Psychological
assessment/ treatment
programmes to
protocol
Specialist psychological
therapies
Competence in
circumscribed
psychological skills
Competence in
psychological research
methods
Evaluation of impact of
psychological factors in
a range of settings
Preparation of relevant
teaching/ advisory
material based on
psychological knowledge
& theory
Teaching & supervision
in relation to complex
psychological issues
Formulation of multiple
factors influencing
psychological well being
Development of tailored
psychological treatment
plans in complex cases
Psychological advice/
supervision to colleagues
in a range of settings
Psychological theory-
based formulation &
enquiry in a range of
health problems
Source: Ayrshire & Arran Health Board (1999) The Basic Framework: Levels of Skill andCompetency in Psychology, Ayrshire & Arran NHS Board.
Chartered Clinical/
Counselling
Psychologists (Levels A,B
&C) working in a range
of settings
Appropriately
delivered by:
All health care
professionals
Assistant (graduate)
Psychologists
specialist accredited
therapists
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In this framework, Applied Psychologists with accredited professional trainingare recognised as having the highest level of psychological knowledge andexpertise (i.e. Level C in Figure 1). In NHS Scotland, the largest contribution topsychological care at Level C (in terms of numbers of staff and their range ofactivity) is made by Clinical Psychologists. They apply psychology tohealthcare through their roles in teaching, supervision and research, as well asin direct care of patients. Hence they also have an important role in supportingthe work of other at Levels A and B.
There are a number of other Applied Psychologists whose postgraduatetraining is accredited by the British Psychological Society who can bring thediscipline of psychology to bear on the health needs of the population at LevelC. Of these, NHS Scotland currently employs Counselling Psychologists andHealth Psychologists. Whereas Counselling Psychologists, like ClinicalPsychologists, engage in direct work with individual patients, the training ofHealth Psychologists equips them more explicitly to intervene at the systemslevel. Where Health Psychologists are involved in the design, delivery andevaluation of direct interventions for patients these will generally be directed atchanging health-related behaviour. Particulars of the current training and rolesin healthcare of the different types of Applied Psychologists are given inAppendix D.
In addition, there is a growing resource of healthcare professionals who haveacquired specific psychological skills to a level which qualifies them to practisein defined areas of work. At this level, i.e. Level B in Figure 1, staff have thecompetencies required to deliver circumscribed psychological care, informedby psychological theory and the best available evidence-base, with support andsupervision from appropriately qualified Applied Psychologists.
There has until now been a lack of accredited training designed to allowgraduate psychologists to acquire clinical skills to enable them to function atLevel B. Large numbers of psychology graduates are produced each year in theU.K. They represent an important pool of potential workforce for NHS Scotlandif training and other professional issues can be addressed. A number of recentproposals from north and south of the Border offer options for training andemploying psychology graduates which deserve to be implemented, evaluatedand compared.
A proposal to provide a one-year training programme at this level is beingdeveloped in a partnership between the Universities of Stirling and Dundeewith NHS Education for Scotland. The aim is to equip graduate psychologistswith the competencies required to enable them to deliver psychologicalinterventions for common mental health problems. Further information isgiven in Appendix F. South of the Border graduate psychologists are stronglyrepresented among those embarking on training programmes for ‘graduate
workers’ in primary care. These are multidisciplinary programmes and thelearning objectives are more limited with respect to psychological interventioncompared with the Scottish programme.
A proposal for the development of an Associate Clinical Psychologist grade inthe NHS is under consideration in the north of England (Mowbray, 2003). Therole is one which undertakes psychological assessment and treatment usingapproaches and techniques that can be described by procedure and protocoland are applicable to individuals, couples, groups or families in their context.An 18-month training is proposed for these career positions. It is envisagedthese Associate Clinical Psychologists would work under the supervision andmanagement of Clinical Psychologists and would be able to progress to thisstatus themselves, through further accredited training. Proposals for a pilotimplementation scheme are currently out for consultation (Mowbray, personalcommunication).
Investment in training and supervision can extend the application of thisframework to the practice of professions not conventionally associated with thedelivery of psychological interventions e.g. management of dental anxiety. Thisframework points to the need of all healthcare professionals for training andsupport in communication skills, including the ability to recognisepsychological distress and when it is necessary to seek more specialist advice toalleviate it. This is as relevant in the clinical priority areas of cancer or coronaryheart disease (for example, in assisting patients’ adjustment to, and ability tocope with, their physical illness and treatment), as it is in the field of mentalhealth.
There is therefore a need for a critical mass of ‘expert’ Applied Psychologistswho can support such a model of psychological care through theirinvolvement with staff at all three levels of skill across healthcare settings.
A ‘Tiered’ Model of Service Provision
‘A Framework for Mental Health in Scotland’ (SEHD HDL(2001) 75) referred insome detail to distinct ‘tiers’ of service provision i.e. in the community, and atprimary, secondary and tertiary care level. This tiered approach to theorganisation of Mental Health services is intended to facilitate patients’ accessto the appropriate level of help, within the most convenient context. The basiccompetency framework outlined above can readily be applied to this tieredmodel. Thus staff in voluntary organisations in the community, and primarycare staff, for example, need to be equipped to respond to adults’psychological needs with the competencies categorised at Levels A and B ofthe framework shown in Figure 1. Access to informed literature, self-helpmaterials and appropriate advice and support are essential if the help providedat these tiers is to be effective.
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At all ‘tiers’ of service delivery there is a need for some input of specialistpsychological expertise to support and inform the care provided. The AppliedPsychologist’s role may vary across the different tiers. For example, in thecommunity the role may more appropriately become one of servicedevelopment and evaluation e.g. exploring the psychological factors impingingon ‘high risk’ groups of the population, rather than on direct care.
This tiered model also recognises the need for a network of specialists at thesecondary care level if patients are to receive evidence-based interventions,tailored to their needs and delivered by accredited practitioners. Thedevelopment of services for patients with particular problems may need to beat an area-wide, cross-boundary or national level to make best use of resources.
Services for children and older adults are also increasingly conceptualised on atiered model aiming to ensure that the right level of skills and resources areaccessible in the context which is as near to the patient as possible.
The development of the model of psychological care described here, requiresconsideration of the varying levels of skilled contribution made by other healthand social care staff to psychological care, and the particular expert role whichpsychologists require to offer in support of staff and patients, across all tiers,age groups and priority services. There is now a need to review experience ofgood practice in the application of these models, to encourage greaterconsensus among stakeholders about the strategic direction of futuredevelopment and redesign of psychology services.
Skill Mix in Psychology Services
At primary, secondary and tertiary care levels, the demand for psychologicalskills consistently outstrips supply. The effect of this varies: from services beingoverwhelmed, resulting in long waiting times, to there being almost no serviceinput, stifled demand and a search for alternative sources of provision, asexemplified in a proliferation of counselling and complementary therapyservices for cancer patients.
Across NHS Scotland psychology services have adopted a variety of approachesto service organisation in an attempt to meet this supply gap. Some servicesare staffed exclusively by Clinical Psychologists with or without support fromAssistant Psychologists i.e. graduate psychologists without a clinical or otherprofessional qualification. Other services have employed staff with a mix ofdifferent skills and training. These may, for example, include other trainedApplied Psychologists, cognitive behaviour therapy nurses, other therapists andcounsellors.
The managerial integration of non-psychologists delivering psychologicalinterventions into psychology services may be relatively unimportant. However
the functional integration of the range of practitioners engaged in the deliveryof psychological services is crucial for efficient and effective activity in sharedpriorities, such as supervision and CPD. A functional organisational structure isparticularly important for professionals and agencies sharing a psychologicalmodel of care and clinical governance objectives. Psychologists with anaccredited postgraduate training in Applied Psychology relevant to healthcaree.g. Clinical Psychology do have the breadth and depth of knowledge and skillto play a leading role in the organisation of systems for the delivery ofpsychological interventions.
This report presents data about the current skill mix employed withinPsychology Departments, as a baseline against which to gauge the impact ofpolicy affecting service developments and training capacity.
This report examines in particular the deployment within areas of specialistwork of psychologists and of their non-psychologist colleagues within the sameservice.
iii) Changing Career Pathways for Psychologists in ScottishHealthcare
The redesign of psychology services and subsequent modelling of futureworkforce requirements means that due consideration will need to be given toissues affecting the training, recruitment, retention and career paths ofpsychologists. There are currently a number of active issues which areimportant in this context.
Graduate Psychologists
There is a large pool of potential recruits to NHS psychology services in theannual output of psychology graduates, not all of whom may want to becomeClinical or Counselling Psychologists or to undertake a doctoral level trainingprogramme. In the face of such overwhelming service demand forpsychological knowledge it is an irony that there are currently so few avenuesto enable those graduates to acquire clinically useful skills to an accreditedlevel, short of full professional training as an Applied Psychologist. Many of thehistoric concerns in the profession about the introduction of partially trainedpsychologists (registration, accountability, occupational standards, careerdevelopment etc) could now be addressed through the modernisation agendain the NHS and more flexible training pathways. A number of new proposalsfor training and employing graduate psychologists were flagged earlier in thisChapter (see section 2 ii) A Basic Framework of Competence for PsychologicalCare). Further information about training developments in Scotland is given inAppendix F.
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Assistant Psychologists
The conditions of employment of psychology graduates working as unqualifiedAssistant Psychologists are a matter of current concern. Although Assistantsfulfil a valuable support function within many Psychology Services, there is nocareer path for these individuals and no system for accrediting their learningexperience, which is at present highly variable. The Clinical PsychologyWorkforce Planning Group believed that this grade should gradually be eroded,the posts declining as greater opportunities to access Clinical Psychology andother training e.g. the above mentioned course, became available. Althoughthis would be experienced as a loss to the service in the short term, it wouldbe redressed in time by the gains of more trained practitioners available forrecruitment to the service.
Clinical Psychology Training
With the support of SEHD through NES, the training capacity for ClinicalPsychology in Scotland will undergo a step increase from 2003. The combinedintake to Scotland’s two doctoral training programmes in 2003 will number65 trainees, an 80% increase on the intake of 2002. The Clinical PsychologyWorkforce Planning Report (NES, 2002a) cited an indicative workforcerequirement of 1wte psychology post for every 5000 people in the population.The target set was therefore to achieve and sustain at least a doubling oftraining capacity. SEHD support for this expansion is contingent onmodernisation.
Training accreditation criteria have recently been defined in terms ofcompetencies, conferring greater flexibility in how trainees are deployed in theservice to acquire their generic knowledge and skills. Systems for local‘ownership’ of training places and more flexible routes through training arebeing introduced with the aim of increasing the responsiveness of training toservice needs. Training issues will be reviewed in greater detail in Chapter 7 ofthis report. A brief summary of progress in the modernisation of training isgiven in Appendix F. The impact of these developments on recruitment to theScottish NHS workforce will need to be closely monitored in future.
Other Applied Psychologists
Psychology as a discipline offers a body of scientific knowledge and a range ofpractical professional skills of potential benefit to the NHS. There has been alack of clarity about how the varied training, experience and competencies ofthe range of Applied Psychologists should optimally be deployed in Scottishhealthcare. The employment of Applied Psychologists in the past may havereflected difficulties in recruiting Clinical Psychologists rather than as a positiverecognition of their distinctive contribution. It is not clear how improved accessto clinical training will impact on recruitment of other Applied Psychologists.
There is a need to increase awareness of what the wider range of AppliedPsychologists could contribute to the modernisation agenda. Inter-agencycollaboration to improve integration of care pathways should increase jointworking between psychologists in different sectors e.g. Child and EducationalPsychologists, and is likely to impinge on the future organisation of NHSpsychology services.
European Framework for Psychologists’ Training
Efforts have been underway since 1990 to promote greater transparency ofqualifications across Europe to facilitate professional mobility. A commonEuropean Framework for education/training for independent practice inprofessional psychology was proposed in 2001 by Project EuroPsyT. Furtherinformation is given on their website listed in the Bibliography. The project wascarried out with the support of the European Community under the Leonardodo Vinci programme. The framework proposed for developing professionalcompetence was conceptualised in 3 phases over 6years : a 3-year Bachelordegree or equivalent; a 2-year Master’s degree and a third phase of a year’ssupervised practice. The key issue was that the pattern of inputs was envisagedas shifting over time from theoretical knowledge and academic skills in theearly years to a growing emphasis on practitioner skills, training and supervisedpractice in the later years. With considerable support for the Framework inEurope the project team have attracted further funding to develop a EuropeanDiploma in Psychology to be piloted in the different countries involved. Theprinciples behind the Leonardo project are concerned with professionalmobility and the maintenance of quality standards. What remains unclear is theextent to which this framework provides for generic e.g. Clinical Psychology ascompared with specialist training Clinical Child Psychology. Were theseproposals to be implemented, particularly with the impetus of a Directive fromthe European Parliament there could be significant implications for workforceplanning for psychology services in Scotland.
Statutory Registration
Currently the BPS operates a non-statutory register of Chartered Psychologistswhose qualifications and training have been scrutinised and accredited.Chartered Psychologists agree to abide by the BPS Code of Conduct. It isanticipated that psychologists in professional practice will shortly be statutorilyrequired to register with the Health Professions Council (HPC). This will beimportant in protecting the public and ensuring professional standards ofpractice across psychology services. In future this will have implications forrecruitment. While implementation is expected to begin in autumn 2004 it islikely there will be a 3-5 year grand-parenting period for admission ofpsychologists not currently registered with the BPS.
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The BPS already has a policy to make CPD mandatory for CharteredPsychologists holding Practising Certificates and is currently developingmechanisms for implementation of this policy. Statutory Registration willimpose requirements for evidence of Continuing Professional Development(CPD) to meet revalidation criteria.
Policy Guidelines in the Practice of Clinical Psychology (BPS, Division of ClinicalPsychology, 2003) already recommend that all aspects of a ClinicalPsychologist’s work should be supervised throughout their career, with asuggested minimum time commitment of an hour for every 20 sessionsworked. These developments, which are essential to ensuring thatpsychologists maintain and develop their competence to practice haveimplications for working patterns and hence for workforce planning.
Mental Health (Care and Treatment) (Scotland) Act
This new legislation received Royal Assent in April 2003. It is designed to givebetter protection and rights to people with mental disorders. It explicitlyrecognises the role of psychological interventions and for the first time in UKlegislation gives a specific statutory role to psychologists in deliveringcompulsory treatment under court order. There is now a period of preparationfor implementation of the Act which is likely to impinge significantly on theworking patterns of psychologists in the forensic field. The Code of Practicebeing developed will be concerned with the assessment, treatment and riskassessment of mentally disordered offenders in relation to their mental healthneeds, their offending behaviour and the risk they pose to themselves andothers. Ministerial assurances have been given that the Code of Practice willexplicitly refer to the input of Clinical Psychologists.
Agenda for Change (Department of Health, 2000)
Retention of qualified Clinical Psychologists within NHS Scotland is currentlygood, and excellent in comparison to the retention of doctors or nurses. This isclearly affected by opportunities for career progression. Remuneration relativeto other professionals in the NHS who have postgraduate qualifications and toother non-NHS Applied Psychologists is also relevant.
Agenda for Change will be highly influential to future workforce planningthrough its impact on job evaluation and pay. Psychologists in the consultantgrade (Grade B), or aspiring to that grade, are vigilant to the relative pay andconditions of consultant medical staff, since they hold similar clinical roles andaccountability, particularly in the arena of mental health. There are alreadyexamples of Clinical Psychologists who act as Lead Clinicians in the areas ofMental Health and Learning Disabilities Services. Other than in Acute Services,the clinical leadership role within multidisciplinary teams across a range ofsettings also frequently falls to psychologists.
This report will examine the current balance of grades within the profession,whilst acknowledging that pay and conditions are a pivotal factor inmaintaining the workforce.
iv) Resource Management
The optimal deployment of scarce resources to meet the healthcare needs ofthe local population poses one of the greatest dilemmas for Psychology andTrust managers, particularly when long waiting times pertain for adults,children and older adults across many specialist services, and especially inprimary care. Furthermore, there are gaps in the ‘ideal’ tiered model described,where there is little scope for focus on health promotion, well-being, riskreduction or early intervention and there is restricted access to specialistassessment and treatment, for example, in learning disabilities, physical illnessservices and neuro-rehabilitation. Whilst there are many examples of good andinnovative practice across Scotland (SCPMDE, 2002), this is often dependenton particularly high level of multi-disciplinary and management support, whereagreement has been reached on the benefits of evaluated practicedevelopment. Too often there has been a lack of resource to enable theexperience of such initiatives to be sustained or generalised across NHSScotland.
There is now a need for a clear strategic direction in the future development ofpsychology services. What is required is the co-ordinated development andevaluation of a model or set of models for delivery of psychological servicesacross NHS Scotland, taking into account the influence of geographic location,the particular area of work and the need for flexibility to local service needsand conditions. The question of how services should be organised to make useof the generic and specialist expertise of the full range of Clinical and AppliedPsychologists is important, not only for optimising the current contribution ofthis profession to the multidisciplinary and multi-agency programme for healthimprovement in Scotland but for improving future workforce planning. Withthe prospect of a step increase in Clinical Psychology training capacity andgreater flexibility in training pathways there is the prospect of an imminent andsustained increase in workforce supply. This needs to be matched by plannedservice development.
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A new dataset has been created at ISD by bringing together data from severalsources as listed below and summarised in Figure 2. This dataset has beenused to describe the characteristics of the current workforce in PsychologyServices in NHS Scotland and to begin to explore the dynamics of supply.
Figure 2: ISD Psychology Workforce Information
i) Psychology Services - Workforce Survey 2001
The aim of the project initiated by SCPMDE, was to develop and evaluate asystem for collecting data to describe the workforce employed in psychologyservices across NHS Scotland. It was anticipated that the methods andprocedure would be informed by this two-year project and revised forsubsequent iterations of the data collection process. At a time of serviceredesign and modernisation of training it was envisaged that the data wouldserve as a baseline against which change in the workforce could be assessed.
The Survey Sample
A survey was undertaken to describe the workforce as at September 30th2001. All qualified Applied Psychologists and non-psychologists providingclinical services within NHS psychology departments were included. Noattempt was made to capture data about NHS staff outwith psychologyservices who provide psychological interventions e.g. cognitive behaviouraltherapists, nor about psychologists providing clinical services in non-NHS
Developing Intelligence for WorkforcePlanning
Psychology ServicesSurvey 2001
Psychology ServicesSurvey 2002
Clinical Psychology TrainingCourse Leavers Survey
ISD PsychologyWorkforce Information
Extracts fromNational Manpower Statistics
(NAMS)
Extracts fromScottish Health Statistics/
Population Statistics
settings e.g. employed by the Prison Service or Local Authorities. The intentionwas to capture clinical sessions provided by psychologists with honorary NHScontracts e.g. clinical academics employed by Universities. AssistantPsychologists were included but staff who provided administrative and clericalsupport to the Psychology service were not.
Clinical Psychology trainees were also excluded. Data about their clinicalattachments are available through the training courses. As their training iscompleted in September, data about course leavers to supplement the survey,were obtained by a separate exercise. These data are reported in Chapter 7 ofthis report and in the corresponding Tables and Figures of the 2001Supplement to this report.
Survey Methodology
The fields of the survey form [ISD (M) 40] and database were modelled on theISD survey of medical staff (MEDMAN) and adapted by the Clinical PsychologyWorkforce Planning Group to capture the appropriate information about thisstaff group. A copy of the survey form and response codes in given inAppendix E.
Each Trust in NHS Scotland was invited to participate in the survey and toidentify a named individual to be responsible for returns. The survey wastargeted directly to NHS psychology services across Scotland with the rationalethat compliance and data quality were likely to be improved if those providingthe data had an interest in its reliability. In most cases the named individualswere psychologists themselves. These individuals were invited to an inductionmeeting to explain the nature and purpose of the survey and to answerqueries.
The staff for whom ISD (M) 40 forms (see Appendix E) were completed arecategorised as follows: Clinical Psychologists, Counselling Psychologists, HealthPsychologists, Other Psychologists (e.g. Assistant Psychologists) and Other NonPsychologists (e.g. CBT Therapists, Counsellors).
Data were collected about individual contract details: national insurance andpayroll numbers; employing Board/Trust; number of sessions; area of work;target age group of patients; class, type & term of contract; start date inpresent post and date at which an individual was appointed to their currentgrade; reason for leaving the service and the date of contract termination.Data to describe professional status were collected in a variety of ways:Chartered status; professional group within applied psychology; grade. Therewere also fields to record those who were Heads of Psychology Services andthose holding Mental Health Officer status. Personal details recorded weredate of birth, country of birth, sex, ethnic origin and year/country ofqualification.
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Data Management, Analysis and Reporting
The completed forms were returned to ISD and the data entered into thePsychology Services Database. This database has in-built validation rules whichclass data which may be incorrect into queries, errors and rejections. Recordscontaining data that were incorrect were returned to the Trusts for clarification,and the database records then amended accordingly. Problems wereexperienced in 2001 with the reporting of the number of sessions when thesewere not integers. This was due to the format of the form which was revisedfor 2002 to reduce the frequency of errors.
The analysis and interpretation of the data were undertaken with a SteeringGroup (see Appendix A) which included representatives from the Heads ofPsychology Services in Scotland (HOPS). The HOPS group acted as thereference group for the project throughout. Data were analysed and whereappropriate reported to one decimal place.
The previously unpublished data for 2001 represent the baseline against whichfuture change in the workforce should be measured. However for clarity themain body of this Report presents the most recent data i.e.incorporating the2002 survey. The corresponding data for 2001 are presented as a Supplementto this report.
ii) Psychology Services- Workforce Survey 2002
The Survey Sample
The 2001 survey was repeated, applying the same sampling criteria, to capturechange in the workforce as at 30th September 2002. Again, a named contact,often the same person as in 2001, was identified for each Trust as co-ordinatorfor the return of the data.
Methodology
Information about joiners was added to the database and details of the dateof, and reason for termination of the contract were recorded for leavers.Details of other changes, for example, in the number of sessions worked or ingrading, were also recorded for retained staff whose contracts had changedsince the survey of 2001. The 2002 survey form and response categories areshown in Appendix 4.
The survey data for 2002 were analysed, interpreted and reported by theSteering Group as before. This Report reflects the most up to date intelligenceabout the workforce in psychology services in NHS Scotland derived from thebaseline data (2001), updated for 2002.
iii) Commentary on the survey sample and methodology
Survey sampling
The survey does not cover the full range of staff providing psychology serviceswithin NHS Scotland. The data need to be interpreted with due regard tothese sampling limitations.
Initially there was difficulty in identifying where psychologists were employed,especially in regions where services are fragmented. That may have resulted inomissions to the dataset, particularly in 2001. Every effort was made to alertthe entire workforce to the survey. There remains a risk, particularly in HealthBoards without an area organisation for psychology services, that single-handed practitioners and/or small specialist services could be overlooked insuch a survey. However with increased publicity for the survey in successiveyears of the numbers of staff missed are expected to be small and diminishing.Services purchased by the NHS Boards from outwith their own area e.g.services for Island Boards provided by mainland Boards have not beenadequately captured. Similarly psychology services purchased for the NHS fromthe independent sector e.g. neuro-rehabilitation services, were not included inthe Survey.
Secondly, the survey was confined to NHS Scotland. The contribution ofpsychologists who deliver clinical services from their employment in othersectors such as the University may not have been adequately captured.Certainly the contribution of academic psychologists to the NHS throughother activities e.g. service-related research or consultancy is not representedhere. The voluntary and charitable (for example Maggie’s Centres) sectors,local authority and prison services were not captured at all. Hence the serviceavailable to patients in a number of specialty areas of work e.g. cancer services,may not be adequately represented. Additional work will be required if futuresurveys are to reflect the development of joint working for example with SocialServices or Educational Psychologists. The State Hospital did not participatealthough invited to do so. Thus the survey does not fully represent the statusof the NHS workforce in Forensic or Forensic Clinical Psychology.
Timing of the survey
The survey date of September 30th was chosen to coincide with other NHSworkforce surveys and hence to facilitate data sharing and comparison. It wasrecognised that data about the intended employment destination of courseleavers would need to be obtained via the Clinical Psychology training courses,since they would not be in employment at that date. The survey does appearto underestimate the number of Assistant Psychologists relative to other datasources. This may be because Assistant Psychologists who have been successfulin obtaining a training place leave their employment in advance of the start of
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the new academic year. Many Assistant Psychologist posts arise as a result ofvacancies occurring over the course of the year. Thus the numbers of AssistantPsychologists in post is likely to be at its lowest when the availability of newstaff is at its highest i.e. as Clinical Psychology trainees complete their trainingat the end of September.
Response rate
There is no gold standard source of information about the absolute number ofpeople employed in NHS psychology services in Scotland to serve as adenominator against which to judge response rate to this survey. There aresignificant discrepancies between the survey data and the National ManpowerStatistics as described below. However within the sampling constraintsdescribed, the returns rate for completed survey forms was 92% in 2002, andmissing data from these completed returns amounted to 0.8% of the totalrequested.
Methodology
There is always a compromise to be reached in survey methodology betweenthe desire to collect as much information as possible and the need to keepdata collection forms short and simple to complete, to encourage compliance.The selection of data to be captured in this survey was influenced by the needfor information about fully trained Clinical Psychologists. This resulted in someshortcomings in capturing relevant details of the skill-mix employed inpsychology services. This should be addressed in future surveys.
The data captured allow the headcount or number of whole time equivalents(wte) to be computed. They do not give information about how those staffare deployed, beyond the number of sessions they provide to a specified targetage group of patients, in a specified area of work. Given the importance ofplanning for redesigned services which make best use of the available skill-mix,it will be necessary in future to record information about individuals’ activities,for example in direct provision of service to patients versus time spentsupervising the clinical work of others.
In spite of the induction procedure a few fields proved problematic forrespondents. For example some respondents interpreted ‘date appointed topresent grade’ with reference to their pay spine point. Where data could notbe reliably interpreted, that field was omitted from this report.
Comparison with Psychology Services across the UK
The value of collecting compatible data about psychology services across theUK was recognised at the outset. At the time the Scottish survey was initiatedthere was no reliable system for collecting data about the psychologyworkforce in place elsewhere in the U.K. Subsequently the British
Psychological Society worked with the Department of Health to develop anEnglish Survey of ‘Applied Psychologists in Health and Social Care and in theProbation and Prison Service’. This was based on the Scottish survey anddesigned to allow comparison of the data collected, but as the title implies, thedata were derived from a wider sample than the Scottish NHS-based survey. Areport is in preparation (Lavender, Personal Communication). The EnglishSurvey also introduced some refinements e.g. in attempting to categoriseactivity. The English experience will in turn inform future data collection inScotland. The English survey was a single cross-sectional study and to datethere are no plans for continuous workforce monitoring south of the Border.
The British Psychological Society Welsh Branch sponsored a comparable surveyof psychology workforce in healthcare, prison and probation services in Walesin 2002 (BPS:Welsh Branch,2003).
iv) Other data sources
Clinical Psychology Training Course Leavers
Details of Clinical Psychology training in Scotland at the time of the survey aregiven in Appendix D. Clinical Psychology trainees complete their training atthe end of September. Their entry to the workforce is therefore not captureduntil the workforce survey of the following year. The two Scottish ClinicalPsychology training courses agreed to collect and share data from theirtrainees on completion of training, in a format compatible with the workforcesurvey. These data, which include information about the trainee’s futureemployer, area of work and contract details, are summarised in Chapter 7.
National Manpower Statistics (NAMS)
These NHS workforce statistics are derived from data held in the ScottishStandard Payroll System, and are published by ISD on an annual basis.Although inadequate to reflect the detail required for managed workforceplanning for psychology services, data from NAMS do allow for comparativeassessment of the numbers of workers per staff group in NHS Scotland.
Clinical Psychologists, Counsellors, Psychotherapists and Health Psychologistsare all classified as Clinical Psychologists in NAMS. Thus, NAMS records amarked excess of Clinical Psychologists relative to the ‘true’ figure. Cognitivebehavioural therapy nurses are recorded as nurses and hence would not belinked to psychology services in this system.
Other Data
Reference has been made in this document to other published data sourcese.g. Scottish Health Statistics and Population Statistics of 2001 and ISDScotland on-line. Descriptions of these datasets and full references are cited inthe text.
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v) Recommendations for future data collection
It is important that the aim of any data collection system is clearly defined. Theaims of the original project were clearly stated and the outcome suggests thatdata collection needs to be maintained: a) to ensure that to ensure theavailability of a reliable and up-to-date source of information about theworkforce in psychology services and b) to provide the longitudinal databasethat is required to inform projections about the future workforce. Theexperience of this 2-year project suggests some improvements for the future.
Sampling
It is important to be clear about the inclusion and exclusion criteria for thesample to be surveyed. The parameters for this programme of work need to bekept under review as the nationally co-ordinated programme of workforcedevelopment gets under way. The original project defined its parameters interms of all clinical staff employed in NHS psychology services across NHSScotland. Whether that remains appropriate in the longer term will depend onthe strategy for organisation of psychology services and the availability of datafrom other sources.
Even within the parameters clearly defined for the survey the projecthighlighted the difficulties of obtaining a complete dataset. The difficulty ofidentifying psychologists in small or fragmented services is being reduced asawareness of the survey increases among the workforce. There are still specificsampling problems to be overcome in mapping the workforce in somepsychology services: in forensic services; in services to Island Boards from themainland; in the input to the NHS of psychologists employed in the academic,independent or other sectors; and, to reflect joint working with other agencies.
Without a clear understanding of the ‘true’ sample size it is impossible to beconfident about the response rate and accordingly data have to be interpretedwith caution. The move to statutory registration will in time provide a meansof independently validating such survey samples of psychologists.
Timing
There are inevitable advantages and disadvantages to any timing chosen for anannual data collection exercise. The problem could best be overcome byhaving a ‘live’ database in which electronic entries for those joining andleaving the workforce could be entered throughout the year, keeping the coredataset continuously updated.
Methodology
Experience of the initial project highlighted a number of desirableimprovements in the data collection form, the guidance notes for completingthe form and the validation rules for accepting the data. Codes in the relevant
fields will be aligned with the new codes that are to be adopted by NHSScotland across the workforce. Explicit account will be taken of the tier atwhich service is being provided. The recording of sessional commitments willmore accurately capture part-time working in all areas; and the inclusion ofmore codes will ensure that all areas of work are recorded, with particularattention to clinical priority areas. Further information on service role will give afirst estimate of the proportion of time spent in service delivery, for example, ascompared with time spent in the teaching, training and supervising of others.The data being collected from trainees completing training needs to bebrought more closely into line with the workforce survey.
Other Issues
There is a need for longitudinal data. Inevitably this takes time to accrue. Inany case contemporary workforce modelling requires additional data to informassumptions on which workforce models are built. For example there is a needto understand better the impact of contemporary policy directives on ways ofworking. These needs for intelligence may be better met by well-targeted, timelimited projects rather than as part of this process of continuous workforcemonitoring. While there are advantages in this small profession for thefeasibility of collecting more sophisticated data there are issues aboutmaintaining good compliance from the workforce to ensure the quality of thedata collected and about compatibility with the data being collected by otherstakeholders. These data should be valuable not only for service planning atlocal, regional and national level for services in Scotland but also amenable tothe collation of a professional profile of psychologists at UK level.
The survey form has been redesigned for 2003. The methodology has beenreviewed to improve sampling and data validation procedures. The next surveywill be undertaken to describe the workforce in psychology services in NHSScotland as at September 30th 2003. The survey of trainees competing theirClinical Psychology training has been revised to bring it into line with theworkforce survey. The course leavers will also be surveyed in September 2003.
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This is the first publication of data derived from the two-year projectundertaken by NES and ISD in psychology services. The main body of thisreport presents the latest available data about the workforce employed withinpsychology services in NHS Scotland i.e. derived from the 2002 Survey. Detailsof the sample and methodology are given in Chapter 3.The baseline forassessment of change should be taken from 2001, the first year for whichSurvey data are available. The 2001 data, which are previously unpublished,are presented in a separate Supplement to this report. For ease of reference the2001 data are given in a series of Tables and Figures, mirroring the 2002 dataas they appear in this report. Both data-sets i.e. for 2001 and 2002 will beelectronically accessible in autumn 2003, via both the ISD and NES websites.
The interpretation of time trends in the data from only two time points i.e.2001 and 2002, is unlikely to be reliable. Data from the two Surveys aretherefore presented together in this report only judiciously e.g. to give anoverall picture.
This Chapter focuses on psychologists employed in NHS Scotland who havecompleted a professionally accredited postgraduate training in AppliedPsychology (See Appendix D for details).
Fully trained Clinical Psychologists are by far the largest single group. Datareferring only to them are presented under the heading ‘Clinical Psychologists’or ‘CP’. Where appropriate the data are presented separately for Grade A andGrade B (the more experienced) Clinical Psychologists. Data about the othersmaller groups of Applied Psychologists i.e. Counselling or Health Psychologistshave been aggregated under the heading ‘Applied Psychologists’ or ‘AP’. Theseaggregated data are not presented with a breakdown by Grade. Where dataabout Clinical and Applied Psychologists have been aggregated in the Tablesthese appear under the heading ‘All Applied Psychologists’.
Data pertaining to other clinical staff providing psychology services, (i.e.Assistant Psychologists and other therapists who are not psychologists) arepresented in Chapter 5. Data about Clinical Psychology Trainees are presentedseparately in Chapter 7.
The data in Chapters 4 and 5 focus on service provision. These data are quotedin terms of whole time equivalents of staff input. The total number of wholetime equivalents shown in the Tables may not equal the sum of the parts. Thisis due to the effect of numbers being rounded to 1 decimal place and summedto the nearest whole number. It is important to note that whole timeequivalents (wte) are not the same as the number of staff (headcount)employed. Those latter figures are more appropriately given in Chapter 6which deals with the characteristics of the people who make up the workforce.
The Workforce of Clinical and AppliedPsychologists in NHS Scotland
i)The Workforce of Clinical and Applied Psychologists
In 2002 NHS Scotland employed a total of 359.3wte Clinical and AppliedPsychologists (Table 1). Of those 338.6wte (95%) were Clinical Psychologists.This represented an overall increase in the numbers of Clinical and AppliedPsychologists of 10.5% over the year since the 2001 survey.
At the time of a survey conducted in 1998 (SCPMDE/CAPISH,1999), therewere 300.2wte Clinical Psychologists in NHS Scotland (121.8 Grade B and178.4 Grade A). Current staffing represents an 18.6% increase on that figure.Proportionately Applied Psychologists have increased markedly, up 47% since2001, but the absolute numbers are small. While an overall trend to increase inthe psychology workforce is encouraging the rate of growth has been slowrelative to demand. The figures remain a long way short of the indicativetarget of 1wte psychologist per 5,000 people in the population, cited in thefirst report in this series (NES, 2002a) which implied a workforce requirementin excess of 1000wte for NHS Scotland.
For the period for which data are available the overall ratio of Grade B: Grade AClinical Psychologists has remained in the range of 1:1.3 to 1:1.5. Of AppliedPsychologists in 2002, 14.2wte were provided by Counselling Psychologists.The remaining 6.5wte comprised Health Psychologists.
In spite of increasing awareness of the broad applicability of psychology tohealthcare, the provision of all Applied Psychologists in general, and ClinicalPsychologists in particular, per head of population in Scotland remainssignificantly lower than for other professional groups in NHS Scotland. There is1wte Applied Psychologist for every 14,095 people in the general population inScotland and 1wte Clinical Psychologist for every 14,956 of general population(Table 1). Corresponding figures for the per capita of general population to1wte of other clinical staff groups in 2001 are much lower: Nursing and
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Clinical Psychologists Applied Total Population Population per 1 Population per 1Psychologists of Scotland* wte Clinical wte of all Applied
Psychologist Psychologists
Grade B Grade A
2001 135.8 175.2 14.1 325.1 5, 064, 200 16, 284 15, 577
2002 141.1 197.5 20.7 359.3 5, 064, 200 14, 956 14, 095
Table 1: Clinical and Applied Psychologists (wte) employed in psychology services in NHS Scotland in2001 and 2002
* Source: Estimated Population Statistics, mid-year estimates at 30 June 2001, Scottish Health Statistics, ISD Scotlandon-line
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Midwifery – 98; Medical – 427; Allied Health Professionals – 700; Dental -1,981; Scientific and Professional – 2,802; Qualified Pharmacists - 7, 646. Thesefigures are taken from the Medical and Dental Census; National ManpowerStatistics (NAMS); General Medical Practitioner Database and General DentalPractitioner Database for 2001 (ISD Scotland).
In this context it is worth noting that the Survey data point to a smallerworkforce of fully trained Clinical Psychologists than the NAMS database(National Manpower Statistics from Payroll), which reported 393wte qualifiedClinical Psychologists in 2001. Reasons for the discrepancy were discussed inChapter 3. It is unlikely that the absence of data from the State Hospital in ourSurveys accounts for the whole of the difference. It is more likely that theNAMS data represent an overestimate of the input from Qualified ClinicalPsychologists because of the other staff groups included in this category forpayroll purposes.
Area of Work
Staff completing the Survey identified their area of work from a list of morethan 30 fields. This allowed them to endorse a generic area e.g. ‘GeneralPhysical Health’ or a single specialist area within it e.g. Cardiology. Wherepeople were engaged in multiple areas of work not adequately summarised bythe generic field name, this was captured by logging separately the number ofsessions spent in each area.
The distribution of Clinical and Applied Psychologists across the main genericareas of work is shown in Table 2. These headings are inclusive of services topeople across the lifespan, i.e. services to children, young people and theirfamilies; adults and older adults have been aggregated. The distribution ofservices by target age of the clients/patients served will be examined separately.
The ratio of Grade B: Grade A Clinical Psychologists varies across different areasof work from 1:1.6 and 1:1.7 for Mental and Physical Health respectively to the‘Other’ smaller specialty areas where Grade B’s outnumbered Grade A’s in theratio 2.3:1.
As anticipated, the majority (65% and 63% respectively) of the input fromClinical Psychologists (221.5wte) and from Applied Psychologists (13.0wte) isexpended in the area of Mental Health. Mental Health is also the area in whichthere is most evidence of variation in the skill mix employed in psychologyservices, particularly in services for adults. Accordingly discussion of adultmental health services is deferred to Chapter 5 so that the whole workforce inthat area can be reviewed together.
The workforce of Clinical and Applied Psychologists available to NHS Scotland,across areas of work other than Mental Health, is tiny (Table 2). This level ofstaffing is unlikely to offer sufficient specialists to meet the particular needs ofchildren and older adults in each of these areas, as well as providing for theadult services, which tend to dominate psychology service provision. This willbe examined in greater detail in the next section.
Only 4.5% of this workforce are employed in neuropsychology, includingneuro-rehabilitation and spinal injury, in NHS Scotland. This is a traditionalpreserve of Clinical Psychologists where unusually, the ratio of Grade B: GradeA is 1:1. The survey is likely to give an underestimate of the psychological inputto this area. It does not include psychological services e.g. in neuro-rehabilitation, purchased by the NHS from the independent sector. Thecontribution of clinical academics to this small specialty is also important inScotland and may not have been fully captured.
Again the forensic data are an under-representation of input to that areabecause of missing data from the State Hospital. Informed by experience the2003 survey will endeavour to reach all of the workforce employed in NHSpsychology services. The ‘other’ specialty areas of work are illuminated inFigure 4.
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Area of Work Clinical Psychologists Percentage ratios of Applied All Applied Grades B : A for Clinical Psychologists Psychologists
Psychologists
Grade B Grade A
Mental Health 86.8 134.7 39 : 61 13.0 234.4
Learning 19.7 24.4 45 : 55 - 44.1Disabilities
Physical Health* 11.5 19.6 37 : 63 6.7 37.8
Neuropsychology 8.0 8.1 50 : 50 - 16.1
Other• 10.8 4.6 70 : 30 1.0 16.4
Forensic 4.5 6.1 42 : 58 - 10.6
Total 141.1 197.5 42 : 58 20.7 359.3
Table 2: Clinical and Applied Psychologists (wte) employed in psychology services in NHS Scotland in2002, by area of work
* see Figure 3 for distribution• see Figure 4 for distribution
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The workforce in Learning Disabilities, a well-established area of work forClinical Psychologists, and that in Physical Health, a relatively new area for allApplied Psychologists, warrant further comment here:
Learning Disabilities
Currently there are around 120,000 people with some degree of learningdisability in Scotland (SEHD, 2000). Estimates suggest a cumulative increase of1% per annum in prevalence figures as people with learning disabilities areliving longer. The input of Clinical Psychologists, representing an overall ratioof 1wte per 2721 of this population, has remained steady over the two Surveys(See Table 2A in 2001 Supplement). The Survey suggests there are no otherApplied Psychologists in this area of work in NHS Scotland.
The need for assessment and management of complex and challengingbehaviours, including the autistic spectrum disorders is well recognised as anappropriate focus for the specialist expertise of Clinical Psychologists. Thesesevere difficulties present in a small but significant minority of people withlearning disabilities. There is evidence that with increased public andprofessional awareness, the prevalence of autistic spectrum disorders isincreasingly markedly in Scotland.
The contribution that Clinical Psychologists can make more broadly, across thetiers of service provision, may be less well understood. The closure of largehospitals has resulted in a greater onus on community-based services forpeople with learning disabilities. The resulting dispersal of services hasimplications both for the provision of appropriate supervision for thosedelivering services in the community and the optimal size and deployment ofthe specialist workforce required to support those dispersed services. Certainlythere are examples of psychologists playing a key role in innovation in servicedesign and delivery (SCPMDE, 2002). There is also a growing body of evidenceof the effectiveness of cognitive approaches to interventions for anxiety,depression and interpersonal difficulties among people with mild to moderatelearning difficulties (NES, 2003c).
The national review of the contribution of nurses and midwives to the care andsupport of people with learning disabilities – ‘Promoting Health, SupportingInclusion’ - was published in 2002. This recognised that people with learningdisabilities have complex health, social and educational needs which requiresupport and that their problems are compounded when those needs are notrecognised and appropriately met. The review highlighted the educational andtraining needs of nurses to address these issues. Clinical and AppliedPsychologists clearly have a role to play in support of their learning objectivesand indeed at each level of the proposed tiered model of service delivery.
The Public Health Institute for Scotland has undertaken a comprehensivenational assessment of the health needs of children and adults with learningdisabilities and a report is anticipated later this year which should inform futureworkforce planning in this area. A conference on Workforce Planning forpsychology services, hosted by the British Psychological Society in February2003, heard English recommendations of a minimum requirement of 4wteClinical Psychologists per 250,000 of general population. Applied to Scotlandthis would imply a requirement of 81wte Clinical Psychologists for services forpeople with learning disabilities.
Physical Health
The input of Clinical and Applied Psychologists to the area of Physical Healthhas increased by 45% since 2001 (see Table 2A of 2001 Supplement). Howeverthe absolute numbers remain small and the psychologists’ input is thinlyspread across a wide range of specialties (see Figure 3). Some work asgeneralists, providing psychological expertise across a range of medicalspecialties. Others specialise in developing services for a single patientpopulation, through their work with multidisciplinary teams and clinicalnetworks.
There is as yet insufficientpublished data available to informthe workforce requirement acrossthis relatively new and multifacetedarea of development forpsychology services. The project ofwhich these Survey data are partalso included a survey of plannedservice developments in Trustsacross NHS Scotland. This wasundertaken to provide a firstestimate of future workforcedemand and should be helpful inthis regard. These data will bereported in the next report in thisseries. There is nonetheless a
challenge in introducing psychology services into the acute medical sectorfrom a zero base.
The contribution of psychology services to the clinical priority areas of cancer,coronary heart disease and stroke warrants further discussion, along with thevalue of their input services for diabetes as an exemplar of psychologicalservices in the management of chronic conditions across the lifespan.
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■ General■ Cardiology■ Diabetes■ HIV/Aids■ Liaison■ Obstetrics■ Oncology■ Pain■ Physical
Rehabilitation■ Plastic Surgery■ Spinal Injury■ Other
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Figure 3: All AppliedPsychologists (wte)employed in PhysicalHealth in NHSScotland in 2002, byspecialist area(expressed as apercentage ofN=37.8 wte)
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Cancer: Tumour-specific managed clinical networks are the corner-stone ofservice provision for the common cancers (Scottish Executive, 2003). These areco-ordinated through Regional Cancer Networks which themselves shareinformation and experience. At the time of the survey in 2002 there were4.4wte Clinical Psychologists in post in Oncology. Inevitably therefore, theaccess of these networks to psychology services remains patchy. There areencouraging signs of investment in psychology posts from the fundingallocated to implementing the ‘Cancer in Scotland’ policy. Evidence of theimpact of this investment is already apparent in the inclusion of a sectioncovering ‘Clinical Psychology Issues’ in the SCAN Annual Report (2002).
CHD and Stroke: Morbidity and mortality resulting from cardiovascular diseaseremains a matter of grave concern in Scotland. ‘Coronary Heart Disease andStroke: Strategy for Scotland’ (SEHD, 2002b) highlights the need for apreventive approach, more actively promoting lifestyle change to reduce riskand improve future health. Much of the evidence as to how this could beachieved derives from Health Psychology. There are as yet few employmentopportunities for Health Psychologists to engage with services in NHS Scotlandto help achieve this objective. Each NHS Board will be expected to have amanaged clinical network, with a quality assurance programme, in place for itslocal cardiac services by April 2004. A similar priority action has been identifiedfor Stroke, where a National Advisory Committee is being created to advise onall matters relating to Stroke, including workforce issues. The weight of theevidence has led to clear guidelines (SIGN 57, 2002) that both psychologicaland educational interventions should be available in comprehensive cardiacrehabilitation programmes. The guidelines also point out that patients withmoderate or severe psychological difficulties warrant specialist intervention.
It is clear that Clinical and Applied Psychologists have much to contribute tothe development of healthcare services across this area. The survey dataidentified only 1.0wte Clinical Psychologist in cardiology. It is not clear whetherany additional input is obtained from psychologists in more generalist posts in‘Physical Health’ or ‘Physical Rehabilitation’. The 2003 survey will separate outthese specialist areas to allow changes in the workforce in these key clinicalpriorities to be more accurately monitored in future.
Diabetes: The other clinical condition to flag here is diabetes. Currently thisaffects around 3% of the Scottish population but the number is estimated tobe about to double in the next 10-15 years (Scottish Executive, 2003). TheScottish Diabetes Framework (SEHD, 2002d), which provides a strategy for theimprovement of care, recognises the importance of attending to psychologicalissues for people with diabetes across the lifespan. Psychological difficulties canimpede adequate disease control through poor patient compliance withtreatment, with potentially serious consequences. The survey identified 0.6wte
Clinical Psychologist employed in this area. Although there may be someadditional input offered through general Physical Health posts the need for anexpansion in the workforce in this area is clear.
Other Areas of Work
The category ‘Other’ in Table 2 represented an aggregation of 8 fields of thesurvey form. The distribution of 16.4wte of all Applied Psychologists working inthose ‘Other’ areas of work is shown in percentage terms in Figure 4.
While the Survey should havecaptured any academic sessionsin the contracts of NHS Clinicaland Applied Psychologists, it islikely that the clinicalcontribution to the NHSthrough the Honorary contractsof academic ClinicalPsychologists was under-represented. The contribution tothe NHS of any other academicApplied Psychologist is likely tohave been missed. For examplethe input of a HealthPsychologist, in a consultancycapacity to the NHS, would not
have been captured by the survey methodology unless the work wasundertaken under contract to an NHS psychology service.
Alcohol Services: At the time of the 2002 survey there were 4.3wte ClinicalPsychologists (2wte Grade B and 2.3wte Grade A) and 0.3wte CounsellingPsychologists employed in services for Alcohol and Substance Misuse. Therecent Health Technology Assessment Report on ‘Prevention of relapse inalcohol dependence’ (Slattery et al, 2002) highlighted the evidence for theclinical and cost-effectiveness of psychological interventions and recognisedthat much of this evidence derives from interventions delivered by ClinicalPsychologists. Clearly these interventions cannot be equitably accessed acrossNHS Scotland with current staffing levels. The practical solution recommendedby the Report was the involvement of Clinical Psychologists in the developmentand evaluation of protocols for interventions and in the training andsupervising of staff to deliver them. Recommended staffing levels for this clientgroup were reviewed by the British Psychological Society in 2000. Theguidance given, for 1wte Clinical Psychologist per 250,000 of generalpopulation, would imply a workforce requirement for this area of 20.3wte inNHS Scotland, more than a four-fold increase in current provision.
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■ Academic■ Alcohol & substance misuse■ Dentistry■ Occupational health
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Figure 4: All AppliedPsychologists (wte)employed in ‘other’areas of work acrossNHS Scotland in2002 (expressed as apercentage ofN=16.4wte)
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Services for Target Age-Groups
Survey respondents identified the target age of the clients/patients they servedas: adult; children, young people and their families (for brevity this is labelled‘Children’ in Tables throughout this report and the Supplement); older adultsor a fourth category (‘Age Unspecified’) which allowed for services whichspanned across two or more of these categories. The distribution of Clinicaland Applied Psychologists across the target age groups is shown in Table 3.
It was recognised that local services employ different practices with regard toage-bands of eligibility. The Survey avoided applying age ranges to the fieldsused. The age-spans conventionally applied to the available population dataare explained in the Footnote to Table 3. The mapping of population figures tothe categories of Target Age is therefore inexact, particularly in the transitionfrom children’s to adult services. Furthermore it was not appropriate tocalculate ratios per head of population for the small number of Clinical andApplied Psychologists who worked across the age ranges, categorised here as‘Age Non specific’. The per capita ratios in Table 3 should therefore beinterpreted as indicative only. Even with this caveat it is clear that presentstaffing levels are low for all age ranges but particularly so in services for olderadults.
Clinical Applied All Applied *Population *Population *PopulationPsychologists Psychologists Psychologists per 1wte per 1wte
(CPs) (APs) of CPs of all APs
Grade B Grade A
Children 22.0 53.2 2.0 77.2 1, 222, 602 16, 258 15,837
Adults 108.5 135.5 18.7 262.6 3, 034, 417 12, 436 11,555
Older 7.6 6.9 0.0 14.5 807, 181 55, 668 55, 668Adults
Age Non 3.0 1.9 0.0 4.9 - - -specific
Total 141.1 197.5 20.7 359.3 5, 064, 200 14, 956 14, 095
Table 3: Clinical and Applied Psychologists (wte) employed in psychology services in NHS Scotland in2002, by target age of clients/patients served
*N.B. The population data refer to the number in the population in the age range to which the psychologyservices are targeted. Age definitions have been applied to the population data as follows: Children 0-19 years;Adults 20-64 yrs; Older Adults 65yrs+ as provided by ISD Scotland National Statistics; SKIPPER (3) 6.3
The distribution of all Applied Psychologists by both area of work and targetage of the clients/patients served is shown in Table 4.
Services for Adults
The majority of all Applied Psychologists, 72% of wte Clinical and 90% of wteApplied Psychologists, are employed in delivering psychology services toadults. Of these, 63% are in Adult Mental Health services across a range ofsettings. The staffing of psychology services for Adult Mental Health, by bothpsychologists and non-psychologists, is discussed in greater detail in Chapter 5.The remaining 37% of wte are deployed across the areas of work described inthe preceding section.
Older Adults
Table 3 presents stark evidence of the paucity of input from ClinicalPsychologists to, and the complete absence of Applied Psychologists in,services for older adults. Input comes almost equally from Grade A and GradeB Clinical Psychologists.
The ratio of staff to the population in this age group attests to the shortfall inthe workforce. The challenge facing NHS Scotland in providing good qualitypsychological healthcare for older adults may be better appreciated withreference to the population projections in Figure 5 which anticipate that by2031 the number of people over the age of 65 will have risen to 1.2 million.
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Area of Work Children, Young Adults Older Adults Age Non-Specific TotalsPeople and Families
Mental Health 57.0 164.5 12.9 0.0 234.4
Learning 5.7 37.0 0.0 1.4 44.1Disabilities
Physical Health 9.2 27.3 0.3 1.0 37.8
Neuropsychology 1.4 14.1 0.6 0.0 16.1
Other 2.1 11.1 0.7 2.5 16.4
Forensic 2.0 8.6 0.0 0.0 10.6
Total 77.2 262.6 14.5 4.9 359.3
Table 4 : All Applied Psychologists (wte) employed in psychology services in NHS Scotland in 2002, byarea of work and target age
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‘Adding Life to Years’, the Report of the Expert Group on Healthcare of OlderPeople (SEHD, 2002a) made clear recommendations to effect improvement inthe care of older people. While there are common principles linking the care ofthe older adults with good quality healthcare for any age-group, systems forolder adults also need to be sensitive to the particular needs of people in laterlife. Given the high prevalence of co-morbidity in older people, staff needroutinely to be able to deal with both mental health and physical health ordisability issues in tandem.
A number of initiatives are underway to develop and improve community careservices. Professionals in Community and Primary Care need access to ClinicalPsychologists, for example to support the delivery of psychologicalinterventions in those settings. Clinical Psychologists also have an importantcontribution to make to services for people with dementia, both in specialistassessment and in care e.g. working with challenging behaviour and moodproblems. Contemporary developments within mainstream healthcare inclinical priority areas, i.e. cancer, CHD and stroke, diabetes and mental health,are also expected to give particular attention to older service users. Althoughthe vast majority of strokes occur in people over the age of 65 years,psychology posts for older adults have mainly been developed in mental healthservices and hence have not embraced this area of service need.
The challenge for psychologists specialising in this area is to know how best tosupport and advance these wide ranging policy initiatives with the existingworkforce. The lack of clinical supervisors experienced in work with older adultsthreatens to become a limiting factor in the expansion of Clinical Psychology
2001 2006 2011 2016 2021 2026 2031 2036 2041
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* ****
*
1250
1000
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0-15Age bands (years)
16-2425-3435-4445-5455-64
65+
Pop
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Year
Figure 5 : Projectionof population ofScotland from 2001to 2041, by agegroup
Source: GovernmentActuary Department,Scotland 2001
Training which requires trainees to gain experience of working with peopleacross the life-span. Although historically recruitment to this area wasproblematic, the problem now is the particular dearth of funded posts forservices to this target age.
Published estimates of the numbers of Clinical Psychologists required, based onnational estimates of need (BPS, 1995) and local estimates derived fromTayside (Stirling, 1998), suggest a workforce requirement of 1wte per 10,000population of older people. It has been suggested (BPS, 2002a) that 1wte:5,000 population of older adults may be a more realistic estimate of theworkforce needed to meet the increased range of care, including preventiveand treatment interventions, expected in primary care settings in future. Toachieve a significant increase in the workforce in the short to medium term theprofession needs to invest in more training of Clinical Psychologists for servicesfor Older Adults. There is also a need to address alternative models of serviceorganisation through redesigned services employing a wider skill-mix of staff.
Services for Children, Young People and their Families
Relative to services for older adults the services for the other end of the agespectrum look at first glance at Table 3 to be relatively well resourced. Howeverthe recently reported evidence that up to 70% of referrals to Child andAdolescent Clinical Psychology services wait more than 12 weeks (PHIS, 2003)suggests that there is a capacity problem.
‘Partnership for Care’(SEHD, 2003) re-affirmed the commitment to healthpromotion, prevention and early intervention as key to the strategy forimproving the mental and physical health of the population. To be maximallyeffective attention to these elements of healthcare needs to start before birth inpreparation for healthy pregnancy and early identification of those most at risk.
The Child Health Support Group has developed a national template for ChildServices for NHS Boards to assist in the planning and co-ordination of servicesfor the age range 0-19years (Child Health Support Group, 2000). For wellchildren, the aim is to inform and empower parents to take healthy choices inthe care of their children and subsequently to educate and empower youngpeople themselves. Resources and services are then directed to families withidentified needs with the aims of risk reduction, early detection andappropriate effective treatment and care.
The existing psychology workforce is engaged in efforts to integrate their workinto the range of services implicated in this agenda and with the work ofothers across the relevant agencies, to improve co-ordination of provisionacross the developmental years.In planning psychology services to Childrenand Families a comprehensive spectrum of psychological needs have to beconsidered i.e. those of parents and families as well as of the children
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themselves. Services are needed which can span the range from pregnancy,through infancy, childhood and the teenage years, into the transition toadulthood. By promoting and optimising emotional, social and cognitivedevelopment, Clinical and Applied Psychologists can contribute to physical andemotional health and well-being in childhood and to reduction of disorder inadult life. Early intervention and prevention in disorder and disability, achievedby targeting services to vulnerable children and families is increasinglyrecognised as clinically effective and cost-efficient.
Clinical Psychology Services are traditionally subsumed under the heading of‘Mental Health Services’. The PHIS report (2003) presented prevalence data tosuggest that 9.5% of young people (age 5-15 years) have a ‘mental disorder’of sufficient severity and persistence to impact on the child’s functioning orrelationships. The most common problems referred to Clinical Psychologyservices are behavioural problems, Attention Deficit Hyperactivity Disorder andAnxiety. Referrals of children with autistic spectrum disorders are alsoincreasing. Psychology services however typically offer a much wider range ofassessment and intervention resources across the development spectrum thanonly their contribution to mental health teams.
Clinical Psychologists have a psycho-educational focus as well as providingtherapy e.g. in helping children and families to develop skills of adjustment,coping and resilience. Psychologists providing these services do thereforeengage in consultancy and training for others as well as in providing directassessments and intervention for children, young people and their families.
There is ample evidence that Clinical Psychologists have the potential to makea wider contribution across the healthcare agenda for children and youngpeople (BPS 2002b). Psychological problems commonly arise in children whoseprimary problem is one of physical illness, disability or abuse. There is thereforealso a need for Clinical Psychologists to work closely with paediatric services. Inaddition, there are particular challenges in meeting the psychological needs ofadolescents with physical health problems as they negotiate the transition inprovision of their medical care from a children’s setting to adult services.
There are examples of innovative developments in NHS Scotland in healthpromotion e.g. consultancy to health visitors, parenting skills projects; servicesfor ‘at risk’ groups e.g. ‘looked after’ children and early intervention e.g. forpsychosis. However access to such services is patchy across Scotland. Theconcept of ‘health promoting schools’ gives new impetus to closer workingbetween clinical and educational psychologists. These developments alsohighlight the fact that the role of the Clinical Psychologist in a complex servicenetwork is likely to change over time as the skills, capacity and resources inother parts of the network change. Staff do require to be flexible to adjust tothis ever-changing environment.
There is a significant challenge at local level to deploy psychology resources toplay their full part in developing integrated services that span the range frompromoting health and wellbeing to providing specialist services for optimalcare of those with emerging or established mental health difficulties. AWorkforce Planning Group for Children’s services is being set up to monitor theimpact of planned service developments on workforce requirements.
ii) Clinical and Applied Psychologists by Health Board Area
Remote and Rural Issues
The Scottish Executive (SEHD, 1999) noted that ‘providing health services tosparse populations dispersed over many hundreds of miles of land and sea isone of the distinctive features of the NHS in Scotland’. It has been suggestedthat 10 of Scotland’s Health Boards require to make significant provision forremote and rural areas i.e.
• Argyll & Clyde • Ayrshire & Arran• Borders • Dumfries & Galloway • Grampian • Highland• Orkney • Shetland • Tayside • Western Isles
The issue of how to organise and staff psychology services, particularly at thecommunity and primary care level, in remote and rural areas has not yet hadthe attention given to other health care provision (SCPMDE, 2000; NES,2003a).
There are the same challenges for psychology services in recruitment andretention of staff and the same issues about the educational support requiredto assure quality standards in what are more often generalist than specialistservices. It is notable that there are no psychology services based in the IslandBoards which do not figure in the analyses that follow in this report. It isrecognised that future data collection needs to map psychology services whichthey purchase from mainland Boards.
Social deprivation
Poverty and social disadvantage are associated with poorer physical and mentalhealth. Efforts to tackle social inequalities are central to contemporary healthpolicy and it is clearly as relevant to consider social deprivation in apportioningpsychological services as it is for other health care resources. It is beyond thescope of this report to consider a detailed breakdown of service provision bysocial need. DEPCAT ratings (SEHD,1999) provide a useful summary ratingfrom 1 (most affluent) to 7 (most deprived) of all the postcode areas inScotland. The ratings do not refer to individuals but to the areas in which theylive. These ratings can be aggregated to determine the percentage of the
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population in each Health Board living in poor conditions (DEPCAT ratings 6 or7). The distribution of those figures, shown in Figure 6 is relevant tointerpreting the data about provision of psychology services in those areas.
Figure 7 exemplifies the difference in size and composition of the input of allApplied Psychologists to psychology services across NHS Scotland. Thisinformation should be taken in conjunction with the data in Chapter 5 on skill-mix before conclusions are drawn about the total psychology service provisionin any Health Board area. It is beyond the scope of this report to discuss thedifferences between local services in detail. The reasons for differences areprobably multi-factorial and may reflect local recruitment/retention issues oropportunism as much as strategic planning to meet local service need.
The variation in employment of Applied Psychologists (i.e. other than ClinicalPsychologists) across Health Board areas is exemplified in Figure 7 bycomparing for example Lanarkshire or Grampian with Forth Valley or theBorders. The differences observed may be the result of strategic planning, interms of the optimal skill-mix selected to deliver local service requirements.Alternatively the explanation may be more ad hoc i.e. where there arerecruitment difficulties employers are more flexible in recruitment policy.
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Percentage of the population in DEPCATs 6&7■ 0%■ 1-15%■ 16-50%■ >50% (Greater Glasgow)
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HighlandGrampian
Lothian
BordersLanarkshire
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Ayrshire & Arran
Fife
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Figure 6:Distribution ofthe percentageof the Scottishpopulation inDEPCAT ratings6 & 7 (mostdeprived), byHealth Boardarea.
It is also to note that particular Health Boards may provide regional- ornational-level services which are used by clients/patients beyond theirimmediate Health Board area.
Figure 7 also shows differences in the ratio of B Grade to A Grade ClinicalPsychologists across Health Boards. Promotion to B Grade may be one way toretain staff. Thus, departments that have experienced difficulty in recruitingare more likely to have vacancies in Grade A posts. Departments also vary inthe tendency to associate the B Grade primarily with managerial roles. Thismay change given the increasing expectation that Clinical Psychologists willprovide consultancy services from an early stage in their post-qualificationcareers.
The significance of the variation in wte of all Applied Psychologists acrossHealth Boards is better understood with reference to the size of populationserved by each Board area. Table 5 highlights striking evidence of the inequityof service provision across NHS Scotland. The Island Boards do not haveresident psychology services and hence are not included in Table 5.Arrangements for input from visitors from mainland Board services and via tele-medicine links were not captured by this Survey but should be monitored infuture.
The rank ordering from most (1) to least (12) well staffed Health Board areas isnumbered for easy of reference to Table 11, which takes account of the fullcomplement of staff in psychology services.
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Figure 7: ClinicalPsychologists (wte)by Grade andApplied Psychologists(wte) in NHSScotland in 2002, byHealth Board area.
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It is important to stress that no assumptions about the quality of serviceprovision should be made from these data which refer only to the quantity ofstaff in psychology services in these Health Board areas.
No Health Board approached the target of 1wte per 5,000 of population,derived from Paxton and D’Netto (2001) and cited in the first report of thisseries (NES, 2002a). Psychology services in Greater Glasgow, which haveexpanded by 26% since 2001, had the highest staffing of fully qualifiedpsychologists of any in Scotland, with a ratio of 9,766 to 1wte. Even so, it islikely that this establishment is still insufficient to meet the needs of thispopulation particularly given the psychological morbidity associated withurban deprivation(Figure 6). It is therefore of concern that there are more thantwice as many Clinical and Applied Psychologists per head of population inGreater Glasgow as there are in neighbouring Lanarkshire or Argyll and Clydewhich have many similar problems but much lower staffing ratios.
On the whole more rural services e.g. Borders or Highland, tend to have fewerClinical and Applied Psychologists per head of population than the HealthBoards with major conurbations i.e. Greater Glasgow, Lothian, Tayside. Theexceptions to this observation i.e. in Dumfries and Galloway (1wte per 12,524)and in Fife (1wte per 10,439) where there are more psychologists per capitathan in Grampian (1wte per 16,331), suggest that other factors, such asservice organisation, may also be relevant. All these figures should be reviewedin the context of information about other clinical staff in these services, whichis given in the next Chapter.
Population per 1wte
<10,000 10,000 - 14,999 15,000 - 19,999 >20,000
1.Greater Glasgow 2. Fife (10,439) 6. Borders (15,063) 12. Lanarkshire (21,116)(9,766)
3. Dumfries & Galloway 7. Grampian (16,331)(12,524)
4. Lothian (13,226) 8. Forth Valley (16,621)
5. Tayside (13,593) 9. Ayrshire & Arran (16,665)
10. Highland (18,167)
11. Argyll & Clyde (19,298)
Table 5: Ratio of per capita population to 1wte of All Applied Psychologists in NHS Scotland in 2002, byHealth Board area.
Another key factor for service planners is that population projections vary fordifferent parts of the country (Figure 8). These projections are likely to createincreased pressure on services in Forth Valley for example, where thepopulation figures per 1wte of all Applied Psychologists are already high. Thepredicted drop in population in Lanarkshire is not sufficient to suggest anyrelief of pressure on services there.
Psychology services by Area of Work and Target Age, by HealthBoard
Not only is the absolute size of psychology services, in terms of the wte ofClinical and Applied Psychologists, highly variable across NHS Scotland, butwhere the psychologists are deployed also varies across Boards i.e. in terms oftheir area of work and the target age of the people they serve (Tables 6 & 7).
As noted in the previous section, it is beyond the scope of this survey tocomment in detail on local service variations which may be a strategicresponse to local need or more often, the reflection of a cumulative history ofad hoc developments and opportunism. Table 6 shows the distribution ofClinical and Applied Psychologists across areas of work, by Health Board.
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Figure 8:Percentage changein population inScotland from2000 to 2016, byHealth Board area
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The growth in the area of Physical Health is led by the two Boards in theCentral Belt, where investment is focussed on Glasgow and Edinburgh, twomajor medical centres. There is however a real challenge for thesepsychologists in reaching beyond the specialist centres to network withpsychology services closer to the communities where their patients live.Typically those psychology services lack expertise in physical health psychologyand are already struggling to provide adequate input to meet demand intraditional areas of work e.g. adult mental health.
The distribution of Clinical and Applied Psychologists by Target Age of Patientsserved is shown in Table 7. The dearth of services for older adults highlightedin the previous section is underlined in Borders, Forth Valley, Highland andGrampian where no psychologists at all were employed in that specialty area.Elsewhere services for that age group are provided by only ClinicalPsychologists (see Table)
Mental Learning Physical Neuro- Other Forensic wte of AllHealth Disabilities Health Psychology Applied
Psychologists
Argyll & Clyde 15.8 2.9 1.8 1.2 0.1 - 21.8
Ayrshire 15.8 2.6 1.9 0.6 1.1 - 22.0& Arran
Borders 5.2 1.0 0.4 - 0.5 - 7.1
Dumfries & 8.8 1.0 1.0 1.0 - - 11.8Galloway
Fife 23.7 4.8 3.6 - 0.4 1.0 33.5
Forth Valley 12.4 2.5 1.1 0.3 - 0.5 16.8
Grampian 21.6 5.5 1.6 2.0 0.5 1.0 32.2
Greater Glasgow 52.8 7.8 13.6 1.9 8.9 4.1 88.9
Highland 8.2 2.8 - 0.5 - - 11.5
Lanarkshire 19.3 3.0 1.2 - 1.3 1.4 26.2
Lothian 32.9 7.0 9.1 6.6 1.2 2.1 58.9
Tayside 17.9 3.2 2.5 2.0 2.4 0.5 28.5
Scotland 234.4 44.1 37.8 16.1 16.4 10.6 359.3
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Table 6: All Applied Psychologists (wte) in NHS Scotland in 2002 by area of work and by Health Board area
For each Health Board area in NHS Scotland with psychology services, the agedistribution of the population is shown in Table 8.
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Children Adult Older Adult Age Non wte of all Applied specific Psychologists
Argyll & Clyde 2.2 18.8 0.8 - 21.8
Ayrshire & Arran 6.4 14.1 0.8 0.7 22.0
Borders 2.0 4.6 - 0.5 7.1
Dumfries & Galloway 1.7 8.2 0.9 1.0 11.8
Fife 8.8 21.8 2.5 0.4 33.5
Forth Valley 4.4 12.4 - - 16.8
Grampian 7.0 24.8 - 0.4 32.2
Greater Glasgow 26.7 55.8 4.5 1.9 88.9
Highland 3.7 7.8 - - 11.5
Lanarkshire 1.0 23.9 1.3 - 26.2
Lothian 11.2 45.0 2.7 - 58.9
Tayside 2.1 25.4 1.0 - 28.5
Scotland 77.2 262.6 14.5 4.9 359.3
Children(0-19yrs) Adult(20-64 yrs) Older Adult(65 + yrs) Total population
Argyll & Clyde 102 139 250 553 68 008 420 700
Ayrshire & Arran 88 999 216 418 62 873 368 290
Borders 24 554 62 171 20 225 106 950
Dumfries & Galloway 34 166 85 169 28 445 147 780
Fife 86 098 206 644 56 948 349 690
Forth Valley 68 825 167 639 42 776 279 240
Grampian 126 003 319 882 79 165 525 850
Greater Glasgow 211 439 519 723 137 008 868 170
Highland 50 288 123 842 34 790 208 920
Lanarkshire 140 667 332 991 79 572 553 230
Lothian 181 795 481 853 115 352 779 000
Tayside 91 091 416 938 70 454 388 750
Scotland 1 222 602 3 034 417 807 181 5 064 200
Table 7: All Applied Psychologists(wte) in NHS Scotland in 2002, by target age and by Health Board area
Table 8: Population estimates for Health Board areas, by target age (2001)
* Source: Estimated Population Statistics, ISD - SKIPPER(3) 6.3
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The inequities of access to psychology services for Older Adults are graphicallydemonstrated by Health board area in Figure 9.
Marked inequities in services for Children, Young People and their Families areapparent across NHS Scotland when the provision of psychologists is expressedwith regard to the size of the population in that age group in each HealthBoard area. (Figure 10). Note that with respect to these services all but 1wte ofinput referred to here comes from Clinical Psychologists (Table 3).
Figure 9: Population(inthousands) aged >65years per 1wte of allApplied Psychologists inpsychology services forOlder Adults in NHSScotland in 2002, byHealth Board area.
■ Argyll and Clyde■ Ayrshire and Arran■ Borders■ Dumfries and Galloway■ Fife■ Forth Valley■ Grampian■ Greater Glasgow■ Highland■ Lanarkshire■ Lothian■ Tayside
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Figure 10: Population(in thousands) aged 0-19 years per 1wte of allApplied Psychologists inpsychology services forChildren, Young Peopleand Families in NHSScotland in 2002, byHealth Board area.
The figures need to be viewed with some caution given that the populationfigures refer to 2001 and the survey data to 2002, and that the populationdata refer to the age range 0-19 years, when the services in question may varyin the age ranges they serve.
Services in Lanarkshire appeared particularly thin at the time of the 2002survey but subsequent enquiry suggests this may reflect missing data. Even soacross the other Health Boards differences between the best and poorestserved areas are marked. Argyll and Clyde and Tayside have >40,000 people inthe 0-19 year age range per 1wte Applied Psychologist while only in Fife andGreater Glasgow is the ratio <10,000 per 1wte.
The provision of qualified Clinical and Applied Psychologists for Adult servicesvaries less widely (Figure 11). The range runs from Greater Glasgow and Fifewith figures of 1wte for around 10,000 of the adult population compared with>16,000 per 1wte for psychology services for adults in Tayside and Highland.
Workforce planning has not hitherto been undertaken at a regional level forpsychology services. The information conveyed in Figures 7-11 would allow therelevant data to be identified and aggregated on a regional basis if required.
Whether for strategic reasons, or borne of necessity to meet service need,many psychology services in NHS Scotland now employ a more diverse skill-mix within their services. Thus in addition to Clinical or other AppliedPsychologists with an accredited postgraduate training they may employgraduate psychologists with no accredited qualification in Applied Psychologyand non-psychologists who bring a variety of therapeutic skills from a differentprofessional background. These wider issues of skill-mix are addressed in thenext chapter.
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Figure 11: Population(in thousands) aged20-64 years per 1wteof all AppliedPsychologists inpsychology services forAdults in NHSScotland in 2002, byHealth Board area
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It is well recognised that psychological interventions can be delivered byappropriately trained staff from a range of backgrounds. There is considerablecontemporary interest in how psychologists can best work with other servicesand agencies in the delivery of good quality psychological healthcare. There isa challenge to develop an integrated network of services from the currentdiversity of provision. The key issue is to ensure that service-users are seen bystaff with a level of training and skill appropriate to the severity/complexity oftheir difficulties. There are also important concerns about ensuring that thosedelivering psychological interventions have access to appropriate clinicalsupervision to ensure that quality standards are maintained. The pressure tomake the best use of available resources to meet service demands forpsychological interventions underpins much of what follows in this Chapterabout service organisation and skill mix.
The vast majority of fully qualified Clinical and Applied Psychologists do workin a multidisciplinary context and the other clinical staff with whom they workare typically managed in other sectors of the NHS. It was beyond the scope ofthis survey to map those relationships. What the survey sought to determine,and what is reported in this Chapter, is the extent to which psychologyservices themselves employ a skill mix of staff, beyond psychologists with anaccredited postgraduate training in a recognised branch of Applied Psychologyrelevant to healthcare.
The survey was designed to identify the numbers of the following clinical staffemployed in psychology services in NHS Scotland: Assistant Psychologists (i.eunqualified graduate psychologists); other psychologists (e.g. psychologistsfrom outwith the UK working towards accreditation) and non-psychologists(e.g. CBT therapists).
The larger categories of staff identified by the survey are referred to individuallyi.e. Assistant Psychologists, CBT Therapists, Counsellors. The term ‘OtherTherapists’ refers to non psychologists whose free text responses to therelevant survey field, were given in terms of some form of ‘therapist’ i.e.psychotherapist; family therapist; group analytic therapist; music therapist.‘Other Clinical Staff’ is the catch-all category applied to include all job titlesgiven by respondents which were not captured by the preceding categoriese.g. clinical scientist; nurse; play and development nurse; research assistant. Itwas beyond the scope of the survey to capture data about their qualificationsor other professional credentials.
i) All Clinical Staff in Psychology Services
In the Tables that follow, data about all Applied Psychologists (i.e. all qualifiedClinical and Applied Psychologists) have been included to give a picture of allthe clinical staff in psychology services across NHS Scotland. This enables the
Skill-Mix in the Organisation of PsychologyServices
proportions of the various categories of clinical staff in the workforce to bedemonstrated.
Overall the survey data suggest the workforce has increased by 15.7% since2001 (Table 9). The difference in the numbers of Assistant Psychologistsbetween 2001 and 2002 accounts for more than a third of the apparentincrease in the total figures. The apparent increase should therefore beinterpreted with caution. Assistant Psychologists are typically seeking theopportunity to become Clinical Psychology trainees. On September 30th thenumbers of Assistant Psychologists in the workforce is unstable, varying withthe number who have successfully obtained training places (which may be oncourses across the UK) and with when they resign their Assistantships to takethem up. The true annual increase in establishment for psychology services istherefore likely to be significantly lower than Table 9 suggests.
The input of CBT therapists shows the largest increase of any single staff groupi.e. 57% between the 2001 and 2002 surveys. This is encouraging but theabsolute numbers of them employed within psychology services remains small.It is beyond the remit of this survey to interpret whether this reflects a strategicplanned development, opportunism or a reflection of recruitment difficulty.
ii) Skill Mix by Health Board area
The variation in the skill mix in psychology services across Health Boards can beseen in Table 10. Services vary markedly in their composition. Ayrshire andArran is an example of an integrated area service which has strategicallydeveloped a workforce with a range of professional skills and backgrounds. Bycontrast the area service in Tayside has historically employed onlypsychologists. The percentage of the total clinical staff in psychology serviceswho are fully qualified Clinical and Applied Psychologists varies across NHSScotland from 92% in Highland where there are few other staff, to less thanhalf of the staffing (49%) of the psychology service in Ayrshire.
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All Applied Assistant *CBT Counsellors Other Other Total All Psychologists Psychologists Therapists Therapists Clinical Staff Psychologists
: Others (%)
2001 325.1 50.2 7.0 14.4 4.7 6.6 408.0 80 : 2080% 12% 2% 4% 1% 2% 100%
2002 359.3 73.3 11.0 15.9 5.0 7.6 472.0 76 : 2476% 16% 2% 3% 1% 2% 100%
Table 9: Categories of clinical staff(wte) employed in psychology services in NHS Scotland in 2001 and2002, as a percentage of total workforce in service
*Most CBT Therapists are qualified nurses N.B. The figures do not always tally due to rounding to one decimal place.
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Table 10 : Categories of clinical staff(wte) employed in psychology services in NHS Scotland in2002, as a percentage of the total workforce in service, by Health Board area
All Applied Assistant CBT Counsellors Other Other TotalPsychologists Psychologists Therapists Therapists Clinical Staff
Staff
Argyll & 21.8 15.8 - 3.0 - 1.6 42.2Clyde 52% 37% 7% 4%
Ayrshire 22.0 7.0 5.0 6.5 1.0 - 41.5& Arran 53% 17% 12% 16% 2%
Borders 7.1 2.0 - 0.3 2.0 - 11.462% 18% 3% 18%
Dumfries & 11.8 0.5 - 5.3 1.5 - 19.1Galloway 62% 3% 28% 8%
Fife 33.5 3.0 6.0 - - 1.0 43.577% 7% 14% 2%
Forth 16.8 1.0 - 0.8 - - 18.6Valley 90% 5% 4%
Grampian 32.2 5.5 - - 0.5 - 38.284% 14% 1%
Greater 88.9 16.0 - - - 2.0 106.9Glasgow 83% 15% 2%
Highland 11.5 - - - - 1.0 12.592% 8%
Lanarkshire 26.2 5.0 - - - 2.0 33.279% 15% 6%
Lothian 58.9 7.0 - - - - 65.989% 11%
Tayside 28.5 10.5 - - - - 39.073% 27%
Scotland 359.3 73.3 11.0 15.9 5.0 7.6 472.076% 16% 2% 3% 1% 2%
N.B. Percentages do not always amount to 100% because of rounding to the nearest whole number
The extent to which the total clinical staff represented in Table 10 can beconceived of as a critical mass cannot be assumed from the figures alone. Theeffectiveness of those staff is likely to be critically affected by the localorganisation of services which may be a coherent area service amenable tostrategic planning as in the examples given. Services in Argyll and Clyde, forexample, have been administratively divided while those in Lothian andGrampian have historically been fragmented, presenting greater difficulty forcoherent planning for psychology services across such Health board areas.
Table 11 reflects the provision of psychology services across Health Boardareas, when all clinical staff in those services are included in the evaluation, andaccount is taken of the local population base. This gives a rather differentimpression from the picture presented in the previous chapter when only thetrained psychologists were considered (Table 5). For ease of reference the rankorder of Health Boards in Table 5, based of staffing levels of Clinical andApplied Psychologists from most (1) to least (12) well staffed per head ofpopulation served, are given in blue in parentheses.
While it remains the case that the areas with the highest staffing ratios havemore than twice the provision of the lowest, the rank ordering of the individualBoards has changed relative to Table 5 underlining the need for extremecaution in the use and interpretation of such league tables. No assumptionsshould be made about the quality of the services offered based on these data.
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Population per 1wte
<8,000 8,000 - 9,999 10,000 - 14,999 15,000 - 19,999
2.(2) Fife (8,039) 8.(4) Lothian (11,821)10.(8) Forth Valley(15,013)
3.(1) GreaterGlasgow (8,121)
11.(12) Lanarkshire(16,664)
4.(9) Ayrshire &Arran (8,874)
12.(10) Highland(16,714)
5.(6) Borders (9,381)
6.(5) Tayside (9,968)
7.(11) Argyll &Clyde (9,969)
9.(7) Grampian(13,766)
1.(3) Dumfries &Galloway (7,737)
Table 11. Population per 1wte of all clinical staff in psychology services in NHS Scotland in 2002,by Health Board area.
Figures in blue in parentheses refer to ranking in Table 5
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Proper interpretation of the differences in staffing of psychology services acrossHealth Board areas requires a much more detailed understanding of how thevarious staff groups are deployed. The key issue is the effectiveness of thedifferent models of service organisation in terms of meeting local service needin the context of local conditions affecting the workforce. This goes wellbeyond the available data.
The 2003 survey will begin to collect information about clinical activities e.g.time spent in clinical services to patients, time spent in teaching or supervisingothers etc. It is recognised that the amount of such information that can bereliably or informatively captured in a survey of this kind is limited. Moredetailed data from a cross-sectional study of exemplars, drawn fromcontrasting organisational models is required.
What is clear is that even when all clinical staff are included in the count,staffing levels in psychology services remain generally low but worryingly so inForth Valley, Lanarkshire and Highland.
Skill Mix by Area of Work
The deployment of a skill-mix in psychology services differs by area of work(Table 12). The categories of clinical staff listed at the start of this chapter wereaggregated as ‘Other’ for the purposes of this analysis because the vastmajority of that aggregated grouping of clinical staff (85%) are deployed inthe area of mental health.
The reasons behind the skill-mix reported are also likely to vary by area ofwork. In Mental Health, where a broadly based skill mix is most in evidence, itis likely that this reflects positive local planning decisions for at least aproportion of psychology services.
The small specialties (itemised in Figure 4) aggregated under ‘Other Areas ofWork’ in Table 12, and Physical Health (itself an aggregate of smallerspecialties) often lack the critical mass to support diversity of a skill-mix withintheir staffing structure. Indeed these are often relatively new developmentareas where qualified Clinical or Applied Psychologists offer a single-handedinput. By contrast the more traditional areas of Learning Disabilities and Neuro-psychology services seem to be heavily dependent specifically on the input ofAssistant Psychologists. It is not clear from the survey data whether this reflectsthe need of those services for that level of input to support the routine work offully trained staff or difficulty in recruiting trained psychologists to substantiveposts.
Skill-mix by Target Age-group
The distribution of clinical staff across psychology services for different targetages are shown in Table 13.
It is reassuring to see that those who work across a broader age range than thethree age-defined categories, are fully qualified Applied Psychologists. Theirgeneric training should equip them with the breadth and depth ofcompetencies to offer services across the lifespan.
Of services for target age-groups, services for Children, Young People and theirFamilies have the highest percentage of trained Applied Psychologists. Table 3demonstrated that almost all (but 2wte) of those Applied Psychologists areClinical Psychologists. Children’s psychology services employed approximately18% of the wte input of Assistant Psychologists in 2002 but relatively few otherstaff. It is interesting that there are no CBT therapists employed in this sectorgiven that the age range covers a span to young adulthood.
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All Applied Assistant Other* TotalPsychologists Psychologists (% of total) Clinical Staff(% of total) (% of total) (% of total)
Mental Health 234.4 39.9 34.5 308.876% 13% 11% 100%
Learning Disabilities 44.1 17.5 4.6 66.267% 26% 7% 100%
Physical Health 37.8 4.0 - 41.890% 10% - 100%
Neuropsychology 16.1 5.9 - 22.073% 27% - 100%
Other 16.4 3.0 0.4 19.883% 15% 2% 100%
Forensic 10.6 3.0 - 13.678% 22% - 100%
Staff Group Total 359.3 73.3 39.5 472.276% 16% 8% 100%
Table 12: Categories of clinical staff (wte) employed in psychology services in NHS Scotland in 2002,as a percentage of total workforce in service, by area of work
*Other includes CBT Therapists, Counsellors, Other Therapists and Other Clinical Staff. N.B. The workforcepercentages do not always amount to 100% due to rounding to the nearest whole number.
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Such limited services as there are for older adults employ only psychologistsand rely heavily on the input of assistants who represent 24% of the workforcein psychology services for that age-group.
Overall 75% of the workforce in psychology services are deployed in servicesfor adults in the age range 20-65 years and it is in these services that the skill-mix is most apparent. All the CBT therapists, 99% of counsellors and 84% ofthe other therapists that are employed in psychology services are workingwith adults. The data from adult mental health services, which represent thelargest single area of work for clinical staff in psychology services in NHSScotland warrant further elucidation.
Adult Mental Health Services
The data show an overall increase of 11% in the staffing of psychology servicesin the general area of adult mental health from 2001 to 2002 (Table 14).Furthermore current staffing levels represent an increase of 28% over the172.74 wte recorded in 1998 (SCPMDE/CAPISH, 1999).
All Applied Assistant CBT Counsellors *Other Other Clinical TotalPsychologists Psychologists Therapists therapists Staff
Children 77.2 13.0 - 0.2 0.8 2.0 93.283% 14% <1% <1% 2%
Adult 262.6 55.8 11.0 15.7 4.2 5.6 354.974% 16% 3% 4% 1% 2%
Older Adult 14.5 4.5 - - - - 19.076% 24%
Age 4.9 - - - - - 4.9Non specific 100%
Total 359.3 73.3 11.0 15.9 5.0 7.6 472.0
Table 13: Categories of clinical staff(wte) employed in psychology services in NHS Scotland in 2002,as a percentage of total workforce in service, by target age
The distribution of staffing in these services relative to the distribution of theadult population across Scotland is shown in Figure 12. Clearly there aresignificant variations in clinical staffing provision for psychology services in thisarea of work across Health Board areas.
Adult mental health services across Scotland are experimenting with redesignof services to meet local service need and this is reflected in the variation in thedistribution of the local workforce across particular service settings (Table 15).
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Figure 12: Population(in thousands) aged20-64 years per 1wteof all clinical staff inpsychology servicesfor Adult MentalHealth in NHSScotland in 2002, byHealth Board area
■ Argyll and Clyde■ Ayrshire and Arran■ Borders■ Dumfries and Galloway■ Fife■ Forth Valley■ Grampian■ Greater Glasgow■ Highland■ Lanarkshire■ Lothian■ Tayside
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All Applied Assistant CBT Counsellors Other Other Clinical TotalPsychologists Psychologists Therapists Therapists Staff
2002 164.5 25.4 11.0 14.3 3.5 3.0 221.774% 11% 5% 6% 2% 2%
2001 156.9 17.7 7.0 12.8 2.6 2.0 199.079% 9% 4% 6% 1% 1%
Table 14: Categories of clinical staff(wte) employed in psychology services for Adult Mental Healthin NHS Scotland in 2001 and 2002 as a percentage of the total workforce in psychology services forAdult Mental Health
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Table 15: Number (wte) of all Applied Psychologists and other clinical staff employed in psychologyservices for Adult Mental Health in NHS Scotland in 2002
*'Total Other Staff' refers to the aggregate numbers of Assistants, CBT Therapists, Counsellors, Other Therapistsand Other Clinical Staff.
‡ In Primary Care/Community the workforce included 1wte Applied Psychologist not graded as either A or B.For the purposes of this Table those wte were included under Total Other Staff
General Acute Continuing Care/ Primary Care/Mental Health Enduring Illness Community
A B A B A B A B
Argyll & Clyde 4.4 5.2 6.4 0.1 - - - 1.0 - 0.9 1.8 2.0
Ayrshire & Arran 2.4 2.8 7.4 - - - 2.5 1.0 - 1.4 - 6.1
Borders - - - - - - 1.2 0.5 - - 1.5 2.3
Dumfries & - - - - - - - - - 3.2 3.0 6.6
Galloway
Fife - - - - - - 0.7 1.0 1.0 7.2 5.0 6.0
Forth Valley 3.3 1.7 - - - - 0.5 0.8 - 2.0 - 0.4
Grampian 10.7 4.6 1.0 0.5 - 1.0 0.6 1.0 - 0.1 - -
Greater Glasgow 2.5 4.1 1.0 - - - 2.6 2.8 - 10.4 10.3 7.0
Highland 0.5 2.0 1.0 - - - 1.0 - - 2.0 - -
Lanarkshire 1.6 1.1 1.0 0.6 - - 0.7 1.8 0.5 9.0 2.5 2.5
Lothian 5.4 4.4 - - - - 2.0 0.7 - 6.2 2.0 2.0‡
Tayside - 0.6 - - - - 1.0 - - 10.0 3.3 3.0
Scotland 30.8 26.5 17.8 1.2 - 1.0 12.8 10.6 1.5 52.4 29.4 37.9
All Applied Total All Applied Total All Applied Total All Applied TotalPsychologists Other Psychologists Other Psychologists Other Psychologists Other
Staff* Staff* Staff* Staff*
The fields of the survey may not have adequately captured local differences inthe terminology used to describe how staff are deployed between communityor primary care settings and referral services for out-patients referred fromprimary care or community mental health teams directly to psychologydepartments where the clinical staff may offer a range of clinical services. Nordo the data capture the emergence of Psychological Therapies services. Thiswill be rectified in future surveys.
The Primary Care Sub-Group of the Clinical Psychology Workforce PlanningGroup reviewed Psychology Services to Primary Care in 2002 and published asubsidiary report (NES, 2002b) to the main Clinical Psychology WorkforcePlanning Report . The subsidiary report is available on the NES website. Itconsidered the workforce implications of two models of delivery ofpsychological services to primary care and adult mental health out-patients(excluding continuing care for those with more severe mental healthproblems). Regardless of the service model the report estimated a need for296wte psychologists in these services, arguing this would allow for areduction in waiting times and a revision of the most appropriate use ofpsychologists’ time in these settings. The Survey data reported here has madeavailable a more accurate picture of the current workforce than was availableto the authors of that report. The current provision of 139.1wte AppliedPsychologists in those settings underscores the shortfall in the workforcerelative to their recommendations. These must now be regarded asconservative in the light of ‘Partnership for Care’ which recognises a muchgreater role for psychological knowledge and skills across the healthcareagenda, including prevention, but with an emphasis on the input atcommunity and primary care level.
Table 15 also demonstrates clearly the lack of psychology input to acutemental health services and, more worryingly, the paucity of clinical staffengaged in psychological services for those with severe and enduring mentalillness. These data suggest there is a continuing challenge for NHS Scotland inmeeting Clinical Standards for Schizophrenia (CSBS, 2002) and an impendingchallenge in achieving the culture change in mental health services implied bythe provisions of the new Mental Health (Care and Treatment) (Scotland) Act(2003).
A detailed paper is being prepared for publication on behalf of the BritishPsychological Society (Lavender, Personal Communication) which develops apossible service model for comprehensive adult mental health services, in thecontext of the NHS policy framework in England. It attempts to specify thecomponents required to deliver psychological services to a population of250,000 assuming 160,000 adults of working age, with average psychologicalmorbidity (i.e. between 26,000 and 37,000 have mental health problems, and
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these are severe for 7,500 of them). The Department of Health’s NationalService Frameworks do not exactly map on to NHS Scotland policy documentsand they have introduced new workers to the mental health workforce e.g.‘Gateway’ workers, ‘1000 Graduate workers’, not matched in Scotland.Nonetheless Lavender offers a serious attempt to describe the range of servicesthat such a community would require and to place Clinical Psychologistswithin multidisciplinary teams in a range of roles to make best use of the skill-mix envisaged. The projected requirement for Clinical Psychologists to input tothe range of adult mental health services required by this model is of the orderof 30wte. These figures do not take into account provision for specialist cross-area or national services. Applied to NHS Scotland this would imply aworkforce requirement of 608 wte Clinical Psychologists in this area of workalone.
There may however be new ways of addressing at least some of this shortfallthrough proposals for Associate Clinical Psychologist grade (Taylor & Mowbray,2003).
This and the preceding Chapter have focussed on the workforce in psychologyservices. The development of these services critically depends on the input ofthe people who make up the workforce. Their characteristics are described inthe next Chapter.
The Characteristics of the Workforce
i) Clinical and Applied Psychologists
In September 2002 there were 403 Clinical and Applied Psychologistsemployed in NHS Scotland, of whom 381(95%) were Clinical Psychologists.The remainder were Counselling Psychologists (n=15) and Health Psychologists(n=7).
In all, women made up 71% (n=285) of this sector of the workforce. Thepercentage of women among Clinical (271 of 381) and Health Psychologists (5of 7) was 71% in both cases. The percentage of women among CounsellingPsychologists was lower, i.e. 60%, but the numbers (9 of 15) were small.
Overall the Clinical and Applied Psychologists ranged in age from 27years to64years with a median age of 39years. Among Clinical Psychologists, the menwere somewhat older (Range: 28-64yrs.; median: 47yrs.) than the women(Range :27-63yrs.; median: 38yrs.). The age distribution for all AppliedPsychologists differed between the sexes (Figure 13). Women in their thirtieswere the predominant age group among female Clinical and AppliedPsychologists. By contrast the age distribution for men was bimodal with apeak of 25% of male Clinical and Applied Psychologists in the age range 50-54years compared with less than 10% of the female workforce in this age group.
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Figure 13: TheAge Distributionfor All AppliedPsychologists inNHS Scotland in2002, by sex.
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The workforce were comparable, in terms of their ethnic origins, to the generalpopulation in Scotland. At the time of the 2002 survey, 97.8% (n=394) of theClinical and Applied Psychologists in the workforce were white. Data from the2001 census showed that 98% of the general population of Scotland are white(General Register Office for Scotland, 2003).
More than half (54%, n=218) of all Applied Psychologists employed in NHSScotland were born in Scotland. In all, 88% (n=353) were born in the U.K. Ofthe remaining 50 Clinical and Applied Psychologists, 44% were born in Europe(including Eire). The place of birth of the remaining 28 people (7% of the totalApplied Psychology workforce) spanned a range of countries world-wide.
Of the Clinical Psychologists, 69% (n=263) had qualified in Scotland, and afurther 24% (n=92) elsewhere in the UK. Only 7% of the Clinical Psychologyworkforce in NHS Scotland had obtained their clinical training outwith the U.K.Of them, approximately half (n=14) had qualified in Europe, the remainder(n=12) elsewhere around the world. The pattern was different among theother Applied Psychologists. One third of Counselling Psychologists (n=5)qualified in Scotland, one third in England and the remainder elsewhere,predominantly (4/5) outwith Europe. By contrast all but one of the HealthPsychologists reported that they had qualified in Scotland.
Thus, the survey data describe a workforce of Clinical and AppliedPsychologists in psychology services in NHS Scotland in 2002 in which white,female Clinical Psychologists predominate and in which two thirds of the stafftrained in Scotland.
It was beyond the scope of the Survey to collect detailed information aboutrespondents’ professional qualifications. These will vary with the professionalgroup and the age of the staff, since professional requirements have changedover the years. They will also vary with the country in which the persontrained. Data were however collected about the year in which staff qualified topractise. The number of years qualified was obtained by subtracting the yearrecorded in the Survey from 2003.The data are shown in Table 16.
As expected the workforce comprised staff with a wide range of experiencefrom the recently qualified to those who qualified 40 years ago. Overall themedian time since qualification was greatest for Clinical Psychologists. Thesedata are difficult to interpret in a cross-sectional study without knowing whatproportion of the time after qualifying is spent in the workforce. Later in thischapter we will examine the proportion of the workforce who work full-time ateach age range across the working life-span.
The date staff were appointed to their present post was given by the monthand year of the appointment. The time in post was calculated to the nearestwhole as at September 2002. Where the number of months was less than sixmonths, this was ignored. Where the number of months was six or more, thetime in the post was rounded up to a full year. The number of years qualifiedand the time in post for all Applied Psychologists is shown in Table 16.
It was interesting that although ‘time in the present post’ varied widely, i.e.from less than 6 months to 34 years, the median was as low as 2 years overall.This does suggest that there is movement in this workforce, some of thedynamics of which will be explored in the next Chapter. Median ‘time inpresent post’ was less for Counselling and Health Psychologists who were morelikely to be more recent appointments to psychology services than for ClinicalPsychologists, a third of whom have been in their present post for 7 years ormore.
The psychology profession is preparing for the introduction of StatutoryRegistration under the Health Professions Council. It is anticipated thatimplementation, which will apply to all psychologists who offer a psychologicalservice as a psychologist, will begin in the latter half of 2004. It is therefore ofinterest that of all Applied Psychologists surveyed in 2002, 23% (n=92) werenot Chartered by the British Psychological Society. Chartered status does implythat the individual has undergone training which has been subject to scrutinyand found to meet the required professional standards and that they haveagreed to adhere to a Code of Conduct. While this remains voluntary theabsence of Chartered status should not be taken to imply that individuals are
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Clinical Counselling Health TotalPsychologists Psychologists Psychologists
N=381 N=15 N=7 N=403
Years qualified:Range 0-40 0-40 1-11 0-40
Median 10.5yrs 7yrs 3yrs 7yrs
Time in present post:
Range 0-34* 1-8 0-3 0-34
Median 4yrs 1yr <6months 2yrs
Table 16: Years qualified and time in present post for all Applied Psychologists in NHS Scotland in2002
* These data refer to N=390 posts. 9 Clinical Psychologists held 2 posts, each for different periods of time. Thesewere counted separately. Where individuals held 2 posts for the same duration, these were not double counted.
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not properly trained. Currently there are a range of reasons why individuals arenot Chartered.
Among Clinical Psychologists arrangements for BPS accreditation of traininghave been in place longest and there is funded access across the U.K. totraining which confers eligibility to Chartered status. Nonetheless, there were84 (22%) Clinical Psychologists who were not Chartered. This may simplyreflect unwillingness on the part of individuals to join (and pay fees to) aprofessional body on a voluntary basis. The Survey identified 7 individuals whowere working towards a BPS Statement of Equivalence i.e. formal professionalrecognition that their training and experience are equivalent to BPS Charteredstatus.
Eleven (73%) Counselling Psychologists had Chartered status. It is much harderfor psychologists to attain this in Scotland, where there is no BPS accreditedtraining course for Counselling Psychologists. Those wishing to attainChartered status have to compile their own training plan leading to the BPSDiploma and typically to fund their own route to meeting BPS requirements.
Among Health Psychologists, 4/7 (57%) were not Chartered. This may reflectthe fact that the Regulations for Qualification as a Chartered HealthPsychologist are relatively new. Most of those who have this status haveachieved it under ‘grand-parenting’ arrangements. Although Scotland has hadpostgraduate opportunities for psychologists to study health-related issues, theavailability of BPS accredited courses in Health Psychology is a recentdevelopment. The second stage of preparation for becoming a CharteredHealth Psychologist requires evidence of supervised practice in HealthPsychology. There are no recognised or financially supported routes throughthese requirements currently available in Scotland.
The introduction of Statutory Registration will have implications for workforceplanning not only in terms of assuring the qualifications of future recruits butin terms of the revalidation of the existing workforce.
Grading of Clinical and Applied Psychology Posts
In September 2002, none of the Counselling Psychologists in NHS Scotlandwere employed at Grade B. For Health Psychologists there is no agreed gradingsystem. However, the grading of the workforce in Clinical Psychology doeswarrant closer examination. Here a marked difference in the proportion of menand women who held Grade B posts was observed (Table 17). The explanationfor this is likely to be multi-factorial.
Four women were in the anomalous position of being simultaneouslyemployed at both Grade A and Grade B, in different posts. Removing themfrom the calculation to avoid double counting, the percentage of women withGrade B posts was 34% compared with 57% among men. In 2002, menrepresented less than 29% of the Clinical Psychology Workforce in total, but41% of Grade B Clinical Psychologists in NHS Scotland were men. Age may bea contributory factor in that, the men in the survey were, on average, olderthan the women. It may also be that gender differences in the extent of part-time working and/or time out of the workforce influenced career progression.The available data allow only a cross-sectional analysis of this point later in thisChapter.
Historically sex differences in the division of family responsibilities would havebeen an important factor influencing the difference in the career pathways andprogression between men and women. It is beyond the scope of this two-yearproject to explore contemporary career pathways in detail. However Figure 14gives an indication of the difference between the sexes in the proportion ofmen and women in each age band who had Grade B posts in 2002. Thenumber of Clinical Psychologists attaining Grade B before the age of 35yearswas tiny for either sex. After that time the proportion of men at Grade Bincreased steadily. After the age of 40 the clear majority of men in each agerange were employed at Grade B. By contrast the number of women at gradeB did not exceed the number at grade A until the 45-49 age group. Even inthe older age groups a significant proportion of women were still employed atgrade A. Patterns of work are changing for both sexes in response to changingattitudes to domestic responsibilities and work-life balance. It is not yet clear towhat extent the observed distribution of Grade B posts is also in a process ofchange. This needs to be better understood and kept under review in
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Women (N=271) Men (N=110) Total (N=381)
No. of Grade B 91* 63 154% of N 34% 57% 40%
No. of Grade A 176* 47 223% of N 65% 43% 59%
Other* (% of N) 4 (1.5%) - 4 (1%)
Table 17 : Grade and Percentage of part-time workers among Clinical Psychologists in NHSScotland in 2002, by sex
*There were 4 women who were employed at both Grade A and at Grade B. They were classified as ‘other’ forthe purposes of this Table and were excluded from the counts for both Grades. They were included in thedenominator for the purposes of calculating the percentage for each Grade.
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successive surveys to inform both future workforce planning and theeducational agenda. Currently there is no specific educational provision toprepare Clinical Psychologists for the transition from Grade A to Grade B.While this specific issue is likely to be overtaken by the changing careerstructure heralded by Agenda for Change, the absence of coherentprogrammes to support post-registration training and development in ClinicalPsychology does need to be addressed. The professional development of thoseworking part-time and the educational needs of those returning to work after acareer break have hitherto been neglected.
Figure 14 : Number(headcount) of GradeA and Grade B ClinicalPsychologists inpsychology services inNHS Scotland in 2002,by age and sex.
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Contracts
The majority of contracts held by Clinical and Applied Psychologists (65%)were categorised by survey respondents as Whitley Council contracts. A further32% were Trust contracts. At the time of the survey in 2002,there were anadditional 10 contracts in place: 4 locum Clinical Psychologists, 5 honoraryNHS contracts and 1 Bank contract.
Further details of the contracts held by Clinical and Applied Psychologists inNHS Scotland are shown in Table 18. Twelve Clinical Psychologists, 3% of theClinical Psychology workforce, each held more than one contract. For four ofthem the second contract was in addition to their full-time contract. Theremaining eight people each held 2 part-time contracts. The net effect of this isthat there were 7 Clinical Psychologists whose contractual commitmentsamounted to more than a full-time job, 3 for whom the part-time contractsadded up to one full-time contract and 2 for whom the combined part-timecontracts amounted to less than a full-time post. For this reason there arediscrepancies in figures given for totals for different variables in this sectiondepending on whether the data refer to the number of individuals or to thenumber of contracts.
Overall 32% of contracts in this sector of the workforce were for less than full-time work. Gender differences in patterns of part-time working across the age-span are shown in Figure 15. There were one or two men in every age bandwho worked part-time. It is beyond the scope of the survey to know whetherthey were also employed as psychologists in some other setting outwith theNHS. It is interesting to note that the number of men working part-timeincreased in the older age groups, markedly over the age of 60 years. Althoughthe absolute numbers were still small it would be illuminating to have more
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Counselling HealthClinical Psychologists Psychologists Psychologists
Grade A Grade B
Fixed-term (n) 12 4 2 1
% Fixed-term 5% 3% 13% 14%
Whole-time 152 108 12 5
Part-time 78 50 3 2
% part-time 34% 32% 20% 29%
Table 18 : Clinical and Applied Psychologists in NHS Scotland in 2002: percentage with part-timeand fixed-term contracts
* Total greater than headcount reflect individuals with >1 contract
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details about the work undertaken by these older Clinical and AppliedPsychologists. The pattern was significantly different among women where themajority of those in the 35-44 year age range worked part-time. Thereafternearly half of the female workforce in this sector worked part-time. This maygo some way to explain the apparent differences between the sexes inprogression to Grade B (Figure14). A better understanding of the attitudes towork, career aspirations and choices of psychologists over their working liveswill be required to inform future workforce planning.
Another key factor affecting workforce planning is the award of Mental HealthOfficer (MHO) status. MHO officers were defined as staff: ‘used wholly or partlyfor treatment of persons suffering from mental disorder who devote the wholeor substantially the whole of their time to the treatment or care of suchpersons’. The outmoded terms, including the definition of ‘mental disorder’were derived from the 1983 Mental Health Act. The key issue for this report is
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Figure 15 : Percentageof Clinical and AppliedPsychologists engagedin full-time and part-time working in NHSScotland in 2002, byage and sex.
the effect of MHO status on service contribution for the purposes of calculatingretirement benefits. Clearly it is beyond the scope of this report to consider thecomplexity of the calculation for individuals. The potential impact of MHOstatus on the workforce in psychology services can be conveyed by allowing forthe scenario of those with MHO status retiring at the age of 55years.
Of 130 of all Applied Psychologists with MHO status 129 were Clinicalpsychologists. The other was a Counselling Psychologist. Thus approximately athird of this sector of the workforce could retire at the age of 55years. Of thosewith MHO status 25% were aged >50 years at the time of the 2002 survey.There was a gender difference. Within the workforce aged 50 or over 65% ofwomen and 48% of men had MHO status.
The age distribution of those with MHO status is shown in Figure 16. Thedistribution of these staff across NHS Scotland will be reviewed later in thisChapter.
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Figure 16 : Percentageof all Clinical andApplied Psychologistswith MHO status in2002 by age and sex.
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ii) Other Clinical Staff
In total, there were 125 Other Clinical Staff i.e. in addition to Clinical andApplied Psychologists, employed in psychology services in NHS Scotland in2002. Their age and sex distribution is shown in Table 19. Again womenpredominated, representing 86% of this sector of the workforce overall. Therewere differences in the composition of the various categories of staff, in termsof both age and sex. At the time of the 2002 survey a relatively highproportion (5 of 11) of the CBT therapists employed in psychology serviceswere male but the numbers were small.
Table 19 also shows the marked difference in median age of the different staffgroups. Assistant Psychologists are typically, but not exclusively youngpsychology graduates who are preparing to apply for a training place inClinical Psychology. There is evidence of mature psychology graduates beingemployed at this Grade. The data show that the other staff groups employedin psychology services are typically older.
There were no marked differences in age between men and women acrossthese staff groups except among Counsellors where the 2 men had a medianage of 62.5 years compared to the median for their female counterparts of51.5 years (N=24, Range 41-59years).
The vast majority (97.6%) of these ‘Other Clinical Staff’ were white.
More than three-quarters (78%) of the Assistant Psychologists were born inScotland and 14 of the remaining 16 were born in the UK. Similarly themajority (90%) of the other categories of clinical staff employed in psychologyservices in NHS Scotland were born in the UK with 66% of their total numberhaving been born in Scotland.
Assistant CBT Counsellors Other Other TotalPsychologists Therapists Therapists Clinical
N=73 N=11 N=26 N=7 Staff N=125N=8
Men 9 (12%) 5 (45%) 2 (8%) 0 (0%) 1(13%) 17(14%)
Men & Women: Age Range 22-59yrs 31-56yrs 41-66yrs 31-57yrs 29-47yrs 22-66yrs
Median 25yrs 41yrs 52.5yrs 44yrs 40yrs 29yrs
Table 19: Age and sex of other categories of clinical staff employed in psychology services in NHSScotland in 2002.
The number of years that staff had been qualified and their years in theirpresent posts are shown in Table 20. Assistant Psychologists are generallyrelatively recent graduates who typically work at this level to gain experienceen route to applying for clinical training. The data confirm this. Among theother categories of clinical staff, who were typically more mature in years(Table 19), the data presented in Table 20 suggest that clinical qualificationswere more often acquired in adulthood. Many of these staff were relativelyrecent appointments.
The shortage of trained Clinical Psychologists coupled with increase demandfor psychological interventions and an increased willingness to examinealternative models of service delivery has resulted in an increasing diversity inthe workforce employed in psychology services in NHS Scotland. The datasuggest that in addition to psychology graduates employed as AssistantPsychologists these services have increasingly employed clinical staff from otherdisciplines to deliver psychological interventions. Typically these are maturewhite women who have obtained their qualification to practice in adulthood.
Contracts
Details of the contracts held by this sector of the workforce are shown in Table21.
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Assistant CBT Counsellors Other Other TotalPsychologists Therapists Therapists Clinical
N=73 N=11 N=26 N=7 Staff N=125N=8
Years qualified:Range 0-11 3-6 0-16 2-7 1-25 0-25Median 2yrs 5yrs 5yrs 4yrs 6yrs 2yrs
Years in present post:Range 0-3 0-3 0-7 1-6 0-5 0-7Median <6months 2yrs 3yrs 2yrs 3yrs 1yr
Table 20: Years since qualifying and years in present post for other categories clinical staff inpsychology services in NHS Scotland in 2002.
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There were 3 people, 2 Assistant Psychologists and 1 Counsellor who had eachmore than 1 contract. Hence the total number of contracts in Table 21 exceedsthe headcount. In each case these individuals had both a Whitley Council anda Trust contract and their combined commitment amounted to more than 1wte.
In all, 63% of contracts in this sector were described as Whitley Councilcontracts while the remaining 37% were Trust contracts. 77% (n=37 of 48)Trust contracts were held by Assistant Psychologists.
More than half of this sector of the workforce had fixed term contracts. This isalmost entirely due to the way in which graduate psychologists are employedas Assistant Psychologists which is often using money from vacancies. Theproportion of part-time contracts in this sector of the workforce is heavilyskewed by the counsellors and other therapists, the majority of whom havepart-time contracts.
In all eight (6.4%) of the clinical staff in this sector of the workforce had MHOstatus.
iii) The Workforce in Psychology Services
Of the characteristics described, those which impinge most immediately onworkforce planning are gender, particularly where that is linked to increasedlikelihood of part-time working, and age, particularly in relation to MHO status,and its potential impact for retirement. It is therefore of interest to considerhow those characteristics were distributed across psychology services in NHSScotland in September 2002.
Assistant CBT Counsellors Other Other TotalPsychologists Therapists Therapists Clinical
N=73 N=11 N=26 N=7 Staff N=125N=8
Whitley contracts 38 5 25 6 6 80(n)
% Whitley 64% 45% 96% 86% 75% 63%
Fixed- term 63 4 - 1 1 69
% Fixed- term 55% 36% - 14% 13% 56%
Part-time 4 - 20 5 1 30
% Part-time 5% - 77% 71% 13% 24%
Table 21 : Characteristics of the contracts of other categories of clinicalstaff in psychology services in NHS Scotland in 2002
Area of Work
The distribution of these characteristics in the workforce across the broad areasof work are shown in Table 22.
At the time of the 2002 survey, Physical Health, a relatively new area of workfor psychologists, had a high proportion of female staff although theproportion of part-time workers in that area is average for psychology services.By contrast, in forensic services, the data captured by the survey showed ahigh percentage of female staff and a higher than average proportion of part-time workers. However this dataset is known to be an incompleterepresentation of that area of work given the lack of data from the StateHospital. In the small specialties aggregated under ‘other’, the relatively higherproportion of men was associated with a lower proportion of part-timeworkers.
There were no significant age differences in the age distribution of clinical staffacross these areas of work. Overall around a quarter of them have MHO statuswhich would allow them to retire at the age of 55years. The proportion withMHO status is as expected much higher in Forensic but surprisingly low inneuropsychology.
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Area of Work % Female % Part-time Age range of % of workforce(Total no. of clinical staff) whole workforce with MHO status
Median
Mental Health 74% 30% 22-64yrs 27%(n=374) 39yrs
Learning Disabilities 73% 22% 22-63yrs 25%(n=79) 38yrs
Physical Health 86% 30% 24-63yrs 21%(n=63) 37yrs
Neuropsychology 76% 28% 22-63yrs 7%(n=29) 37yrs
Forensic 85% 35% 22-56yrs 45%(n=20) 35.5 yrs
Other (n=38) 63% 26% 22-66yrs 42%43yrs
Total (N=528) 74% 29% 22-66yrs 26%39yrs
Table 22: Characteristics of the workforce of all clinical staff in psychology services in NHS Scotlandin 2002, by area of work
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Target Age
The distribution of personal characteristics of the work force by the target ageof the population they serve is shown in Table 23.
Services for Children, Young People and their Families had the highestproportion of female staff and of part-time workers. The median age wasyounger than in services for other age groups and relatively few staff in thisarea of work had MHO status. In the small workforce in services for OlderAdults the female:male ratio was relatively high but there were notably fewerpart-time workers. The age distribution in this small group was representativeof the workforce in psychology services as a whole but more of them, almost athird, had MHO status. Among those providing psychology services for a widerage span of patients/clients there was a notably higher percentage of men andfewer part-time workers. This was on average an older subgroup of theworkforce two thirds of whom had MHO status.
By Health Board Area
In psychology services across Scotland the percentage of women in theworkforce varied from 68% in Fife to 84% in Argyll & Clyde. Differences acrossHealth Board areas in percentage of part-time workers in psychology serviceswere much more marked. In Highland only 8% of clinical staff were part-timewhereas in Dumfries and Galloway 62% were part-time.
Target Age % Female % Part-time Age range of % of workforce(Total no. of clinical staff) whole workforce with MHO status
Median
Children, young 83% 33% 22-63yrs 20%people and families 34yrs(n=107)
Adult 73% 30% 22-66yrs 27%(n=412) 39yrs
Older Adults 80% 20% 22-62yrs 32%(n=25) 36yrs
Age non-specific 56% 22% 31-61yrs 67%(n=9) 44yrs
Total (N=528) 74% 30% 22-66yrs 26%39yrs
Table 23: Characteristics of the workforce of all clinical staff in psychology services in NHS Scotlandin 2002, by target age of patients/clients served
There was no evidence of a clear linear relationship between gender and part-time working when the proportions of the workforce in each category werecompared across Health Board areas. In Argyll and Clyde, for example, theproportion of female workers was high (84%) and of part-time workers,relatively low (20%) while in the Borders where the percentage of women inthe workforce was lower i.e. 69% of the psychology service, the proportion ofpart-timers was higher i.e. 38%. Further data are required to understand thebasis of the part-time arrangements recorded in this workforce.
The are differences in the age distribution across Health board area. Themajority of services have staff in their twenties although the youngest staff inDumfries and Galloway and in Highland are in their early thirties. All serviceshave staff in their late fifties and early sixties. Services in Dumfries and Gallowayare notable for the highest median age, some 11years greater than the overallmedian and 16 years older than the median for the service with the youngestworkforce (Greater Glasgow)
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Health Board Area % Female % Part-time Age range of % of workforce(Total no. of clinical staff) whole workforce with MHO status
(Median)
Argyll & Clyde 84% 20% 23-59 (40) 29%
Ayrshire & Arran 73% 35% 22-61 (43) 24%
Borders 69% 38% 22-57 (39) 8%
Dumfries & Galloway 73% 62% 31-59 (50.5) 23%
Fife 68% 28% 23-59 (39) 26%
Forth Valley 75% 46% 24-66 (45.5) 29%
Grampian 73% 33% 23-56 (36) 16%
Greater Glasgow 72% 23% 22-63 (34) 28%
Highland 69% 8% 31-58 (37) 31%
Lanarkshire 71% 23% 25-64 (36) 26%
Lothian 78% 39% 24-62 (39) 30%
Tayside 79% 21% 22-64 (38) 28%
Table 24: Characteristics of the workforce of all clinical staff in psychology services in NHS Scotlandin 2002, by Health Board area
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For most Health Board areas the proportion of staff in psychology services whohave MHO status was in the range 24%-31%. Outliers were the Borders andGrampian where respectively 8% and 16% of the workforce had MHO status inSeptember 2002. The implications of the combined impact of the distributionof age and MHO status on potential loss of staff due to retirement is exploredin the next Chapter.
The Dynamics of Workforce Supply
The two year data collection project allowed a preliminary exploration ofchange in the workforce in psychology services in the period betweenSeptember 30th 2001 and September 30th 2002. Data were recorded aboutthose who left their posts (‘leavers’) in that period as well as about new recruitsto the workforce (‘joiners’). Changes in the workforce were examined acrossstaff groups and across psychology services to highlight net effects. While itwould be premature to project from these data to predict future workforcesupply particular attention will be given in this Chapter to two factors affectingthe dynamics of workforce supply. The first, age, taken in conjunction withMHO status is relevant to potential loss of workforce due to retirement; thesecond factor is the impending increase in the supply of Clinical Psychologistsfollowing the expansion of training capacity in Scotland.
i) Clinical and Applied Psychologists
Between the 2001 and the 2002 surveys 33 Clinical and Applied Psychologistsleft their jobs. Of these 32 were Clinical Psychologists and 1 was a HealthPsychologist. This represents a turnover of 9% in the stock of Clinical andApplied psychologists in the workforce in 2001. The reasons for their leavingwere shown in Figure 16.
In the same period 80 Clinicaland Applied Psychologistsjoined the workforce inpsychology services in NHSScotland. Eight of thoserecorded as ‘leavers’ also tookup new employment withinNHS Scotland as ‘joiners’ inthis time period. The net gainto the workforce over theyear was a total of 47 Clinicaland Applied Psychologists.
The personal characteristicsof the ‘joiners’ and ‘leavers’are shown in Table 25. Notsurprisingly the greatest
turnover was in the age range 25-34 years. The net effect however was of anincrease in the workforce across the age span, including a net gain of 7 Clinicaland Applied Psychologists over the age of 45 years. Women are in the majorityin this sector of the workforce and more women than men both left and joinedthe service. The net effect of turnover was an increase in the numbers of bothsexes with the gain the number of women being greater than the increase in
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■ Personal■ Promotion■ Work related e.g
end of contract,lateral move
■ Retirement■ Negative e.g dissatisfaction
with job
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Figure 17: Leavers’(all AppliedPsychologists)reasons for leavingtheir jobs in 2001-2(as a percentage ofheadcount, N=32)
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the number of men by 3.7:1. Most of the turnover was in Grade A ClinicalPsychologists but there was also a net gain of 11 Grade B posts, 6 HealthPsychologists and 2 Counselling Psychologists. The net gain was greater in full-time than in part-time posts in the ratio approximately 3:1.
Of the 80 ‘joiners’ the majority i.e. 79% (N=63) had qualified in Scotland. Ofthe remainder only 6 had qualified outwith the U.K.
ii) Other Clinical Staff
The high turnover of Assistant Psychologists is the dominant change in theworkforce among the other categories of clinical staff included in the survey.Of Assistant Psychologists included in the 2001 survey 30(58%) had left theirjob by the time of the 2002 survey. All but 1 of them gave work-relatedreasons for leaving. This was not surprising given that 83% (i.e. 43 of 52) ofthem had fixed term contracts in 2001. Reasons for leaving also reflected thatthese psychology graduates are typically seeking a range of experience tosupport their application for clinical training. Thirteen of them gave as theirreason for leaving ‘further education’. Of them, 10 were going into ClinicalPsychology training in Scotland, 2 in England and 1 was going to other
‘Leavers’ (n) ‘Joiners’ (n) Net Effect in 2002
Age Range:25-34yrs. 14 35 +2135-44yrs. 8 27 +1945-54yrs. 4 13 +9>54yrs. 7 5 -2
Sex:Male 12 23 +10Female 21 57 +37
Grade:A 25 59 +34B 8 19 +11Other - 2 +2
Contract:Full-time 20 55 +35Part-time 13 25 +12
Table 25: Clinical and Applied Psychologists – Characteristics of ‘joiners’ and leavers’ and net impacton the workforce in psychology services in 2002.
unspecified further education. Three leavers among the assistant psychologistsre-entered the workforce as ‘joiners’ in another post in NHS Scotland in 2002.In all there was a net gain to the workforce of 56 Assistant Psychologistsbetween the surveys of 2001 and 2002. The size of this difference is likely tobe an artefact of the instability of this sector of the workforce in Septemberwhen the surveys were conducted. Assistant Psychologists typically leave theirposts in late summer if they have been successful in obtaining a training placein Clinical Psychology to start in the autumn. New graduates may not offerthemselves for employment till some months after graduating and given thatthey are unqualified Departments may prefer not to employ them until theautumn.
The characteristics of the ‘joiners’ and ‘leavers’ among the AssistantPsychologists are shown in Table 26. Counsellors were the other groupshowing staff turnover in this sector of the workforce. The characteristics oftheir ‘joiners’ and ‘leavers’ are also shown in Table 26.
Predictably there was a net gain of graduate psychologists in the under 25 yearold age group but the modal gain among Assistant Psychologists was in theage range 25-34 years. Change in the stock of counsellors also increased thenumber of more mature staff in the workforce. The ratio of women continuesto increase with the net gain in the number of women significantly greater forboth these staff groups than the increase in the number of men. Over the yearthe gain in full-time workers was greater than in part–time workers among
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Assistant Psychologists Counsellors
Joiners Leavers Net effect Joiners Leavers Net effectN=56 N=30 + 26 N=7 N=3 +4
Age range<25 28 8 +20 - - -25-34 24 19 +5 - 1 -135-44 3 3 - 1 1 -45-54 - - - 3 - +3> 55 1 - +1 3 1 +2
SexMen 9 4 +5 - 1 -1Women 47 26 +21 7 2 +5
ContractFull-time 52 27 +25 - 1 -1Part-time 4 3 +1 7 2 +5
Table 26: Assistant Psychologists and Counsellors – Characteristics of ‘joiners’ and ‘leavers’ and theirnet impact on psychology services in 2002.
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Assistant Psychologists. Among counsellors the net gain of 4 part-time staff wasoffset by the net loss of a full-time counsellor. All of the counsellors recruitedhad trained in Scotland.
Psychology services in NHS Scotland gained 6 other clinical staff between 2001and 2002 (4 CBT therapists, 1 group analytic therapist and 1 nurse). Four ofthem were in the age range 25-34 years but the other two were over 55yearsof age. Two were men and all had full-time contracts.
iii) Retirement
As the post-war generation reach retirement age and the birth-rate continuesto fall there are concerns about the dwindling size of the workforce in Britain.It is expected to have contracted by 10% by 2030 (Cole, 2003). Cole citesdata to highlight the proportion of the NHS workforce approaching retirementand expresses particular concerns about the nursing population where UK widedata suggest 26% were aged 50 or over in 2002.
In the absence of longitudinal data about psychology services, we are not ableto project the likely rate of loss of staff due to retirement. However the surveydata do allow the numbers of staff aged > 55years in 2002 to be identified.They could retire by 2007. Estimates in this section are based on theassumption that staff in the age group 50-54 years with MHO status couldretire over the same period. For each area of the service in the Tables whichfollow, figures have been extracted and aggregated to give an estimate of thepercentage of the workforce in that area of the service who could retire in theperiod 2002-7, referred to as ‘the next 5 years’.
In addition, staff who were in the age range 50-54 years without MHO status,and staff in the age range 45-49 years with MHO status, would be eligible toretire by 2012. These figures are shown under ‘2007-2012’ in the Tables andreferred to in the text as the ‘the next 10 years’. The following Tables showthat, other things being equal, some areas of the service may be morevulnerable than others, to the loss of staff due to retirement over the next 5-10years.
Table 27 presents the data for retirement in the next 5-10years by area ofwork. It is a problem in a small profession that service developments maydepend on small numbers of people making the service vulnerable to their loss.This is exemplified by the disproportionately high risk of retirement (29% inthe next 5 years, 45% over the next 10 years) across the diverse smallspecialties aggregated under ‘other areas of work’. Given the diversity ofservice provision aggregated within the area of ‘Physical Health’ the potentialloss of a fifth of the experienced workforce in the next 5 years overall is alsolikely to mask the threat of the complete loss of services in some areas. Thesedata suggest an urgent need for attention to succession planning.
Even in the relatively better staffed Mental Health services planners need totake cognisance of the potential loss of up to a third of the workforce in thisarea by 2012. Adult Mental Health services would appear to be particularlyvulnerable given that services are seeking to negotiate not only service and roleredesign but to absorb a major expansion in training numbers. Therequirements of the clinical governance agenda will place an increasingrequirement on psychology services in this area for the input of experiencedstaff.
The relatively small group of staff providing services across a wider age-spanwere previously noted (Table 22) to be older and more likely to have MHOstatus. With 45% of them eligible to retire in the next 10 years (Table 28),succession planning would again seem to be indicated for their services.
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2002-2007 2007-2012
N % of total workforce N % of total workforce
Mental Health 69 18% 52 14%
Learning Disabilities 9 11% 7 9%
Physical Health 13 21% 3 5%
Neuropsychology 3 10% 5 17%
Forensic 3 15% 1 5%
Other 11 29% 6 16%
2002-2007 2007-2012
N % of total workforce N % of total workforce
Children, Young 16 15% 8 8%People &their Families
Adults 72 17% 57 14%
Older Adults 5 20% 2 8%
Age unspecified 3 33% 1 11%
Table 27: All Clinical staff currently in psychology services in NHS Scotland: percentage eligible forretirement in the next five (i.e. 2002-2007) or ten (i.e. to 2012) years, by area of work.
Table 28: All Clinical staff in psychology services in NHS Scotland: percentage eligible for retirementin the next five (i.e. 2002-2007) or ten (i.e. to 2012) years, by target age of patients/clients served.
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There are significant differences across Health Board areas (Table 29) in thepercentage of staff eligible to retire in the next 10 years ranging from 57% inDumfries & Galloway and in Forth Valley, to 19-21% in Greater Glasgow,Grampian and Fife
iv) Retention of Clinical Psychology Trainees
Trainee Clinical Psychologists are NHS employees who spend more than half oftheir time in supervised practice in the service. It is generally acknowledgedthat they make an increasingly valuable contribution to the service over thetraining period. There is no formal system of accredited training posts for themin NHS Scotland so it is difficult to map their impact on the service reliably.Their progress through clinical placements is well documented by the trainingcourses. Their contribution to the service does need to be offset against thedemand that they represent, on the time of trained staff, for clinical teachingand supervision.
2002-2007 2007-2012
N % of total workforce N % of total workforce
Argyll &Clyde 12 27% 7 16%
Ayrshire & Arran 9 18% 12 24%
Borders 2 15% 2 15%
Dumfries & Galloway 10 38% 5 19%
Fife 8 17% 2 4%
Forth Valley 6 25% 6 32%
Grampian 3 7% 6 13%
Greater Glasgow 15 13% 7 6%
Highland 2 15% 2 15%
Lanark 9 26% 2 6%
Lothian 9 12% 8 11%
Tayside 8 19% 9 21%
Table 29: All Clinical staff in psychology services in NHS Scotland: percentage eligible for retirementin the next five (i.e. 2002-2007) or ten (i.e. to 2012) years, by Health Board area.
Trainees were not included in the survey of the workforce. It is however a keyissue in the dynamics of workforce supply, to understand the extent to whichthose trained in Scotland stay to take up employment in psychology services inNHS Scotland. For the purposes of this report trainees in the last year of their3-year doctoral training programme were surveyed in September 2002. Dataabout the preceding year’s output of newly qualified trainees are given in theSupplement to this report.
There were 32 trainees due to complete their training in 2002, 16 on each ofthe 2 training courses. Three (9%) failed to complete satisfactorily all thecourse requirements on time: 1 had to resubmit their thesis, the remaining 2had to undertake additional clinical work.
The output of 32 trainees ranged in age from 25-49 years with a median of 29years. The majority were female (88%) and white (97%). Approximately two-thirds (68%) of them were born in Scotland and in all, 88% had been born inthe U.K.
All but 3 of them i.e. 91%, had secured employment in NHS Scotland beforequalifying. Data are not available by Health Board area but these individualswill be identified as ‘joiners’ in the survey of September 2003. Although theywere all going to be employed full-time, one of them would have a remit splitover two different areas of work. The areas of work where this cohort wastaking up employment are shown in Figure 18.
Note the categories of ‘Areaof Work’ used in this surveywere slightly different fromthose used in the survey inthat ‘Target Age’ was notcaptured as a separate field. Itwas interesting that amongthe new recruits in AdultMental posts there was 1wtespecifically allocated tocontinuing care for severe andenduring mental illness.
The majority of newly qualifiedClinical Psychologists enter theworkforce on the pay range
spine points 32-34. In the output of 2002, 1 trainee was recruited on spinepoints 30-32, 3 cited a pay band starting at spine point 32 but running beyondspine point 34, 2 cited spine points 33-35 and 2 spine points 34-36. It isbeyond the scope of this survey to interpret whether these differentials
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Figure 18: ClinicalPsychology trainees:first post-qualificationemployment in NHSScotland in 2002, byarea of work
■ Children, YoungPeople & Families
■ Adult Mental Health■ Learning Disabilities■ Forensic & Offenders■ Physical Health■ Neuropsychology■ Older Adults■ Alcohol & Substance
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represent local recruitment issues, individual particulars of the new recruits orother factors.
Comparison with the corresponding data in the 2001 Supplement showsrelative stability in the output of the Clinical Psychology training courses year on year. The figures are encouraging both in the low levels of attrition fromtraining and the high levels of retention of newly qualified trainees in NHSScotland. Those delayed in completing course requirements do eventuallyqualify as Clinical Psychologists. What is less encouraging is the net gain to theworkforce when this supply is set against the loss of older staff throughretirement.
The Scottish Executive gave a commitment through NES to support a stepincrease in training capacity from 2003. That support was contingent onmodernisation to increase the responsiveness of training to service needs. It isimportant to begin to anticipate the likely impact of that training on futureworkforce supply.
v) Impact on the service of increasing training capacity
There was an incremental increase in training numbers of +4 , i.e. to 36 trainees,in the intake to training for 2002/3. The first workforce report in this series (NES,2002a) estimated that training capacity for Clinical Psychologists would need atleast to double to meet the workforce requirements of NHS Scotland. Given thetime that this would take to implement and to impact on the service thisestimate was accepted as the order of increase that would be required. It wasreasoned that there would be time and opportunity for course correction in thisplan were the modernisation agenda radically to alter the target workforce.
An initial analysis has been undertaken to forecast the impact of achieving adoubling of training capacity (relative to the 2001/2 figures cited in this report)on the stock of trained Clinical Psychologists. Data from the workforce surveyand from course leavers were used to inform the following assumptions:
• the leaving rate of qualified Clinical Psychologists 2001-2002: 8%
• the attrition rate of trainees 2001-2002: 3%
• the number of qualified Clinical Psychologists in 2002: 381
• the current number of trainees: 32
These parameters were used to run the model, details of which are given inAppendix G. Figure 19 shows the position at the time of the survey (2001/2) insolid lines, with training capacity of 32 trainees per year and an establishment of 381 Clinical Psychologists. Were those conditions to prevail the modelsuggests a steady state has almost been reached in which the rates of inflow and outflow leave the stock unchanged.
The dotted lines in Figure 19 show the impact of doubling training capacityfrom 2001/2 numbers. The same assumptions have been made about theattrition rate for trainees and the leaving rate for qualified staff. Given thatthese are tentaive assumptions the resulting model must be viewed withcaution. With these assumptions the model suggests that if the training intaketo the existing 3–year courses were 64 trainees it would take 38 years todouble the workforce to 762. In the same period with 2001/2 trainingnumbers the workforce stock would be predicted to rise only to 388. Themodel suggests that with the doubled training numbers steady state in theworkforce would be reached at around 776 qualified Clinical Psychologists.
Good progress has been made in expanding training capacity. The intake toClinical Psychology training in NHS Scotland in 2003/4 will be 65 trainees.While training capacity greater than the figures modelled will bring someimprovement in the model this time frame is a matter of concern, given theurgency of service need. This underscores the need both for service redesignand the training developments outlined in Appendix F.
Introduction of flexible training
Concerns have been expressed about the impact of increased flexibility on theduration of training. This is rather to miss the point that increased flexibilityenables psychology graduates equipped with defined clinical competencies tomake a contribution to the service, albeit under supervision, in an area of localneed for a sufficiently long period to be useful. While clearly these assertionsmust be justified by evidence from independent outcome evaluation, thepreliminary uptake of flexible training, shown in Table 29 is encouraging.
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Time (years)
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Qualified Clinical Psychologists: expanded training capacity.
Figure 19: Impact(shown in dottedlines) of apermanent 100%increase in trainingcapacity relative tocurrent capacity
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The intake to Clinical Psychology training in 2003 will include 20 trainees onflexible training contracts. This means that from 2004 they will be making apart-time contribution to the service in the areas shown in Table 29.
Table 30: Service base for flexible trainees (n=20) from 2004
Unless otherwise indicated there was 1 trainee assigned to each area of work listedfor each Health Board
Eight of these trainees are on a 4-year programme and 12 on a 5-year plan.The service and training components are remunerated separately to ensure nodetriment to trainees following these routes.
Clearly it is too soon to know how flexible training will take its place in theportfolio of training opportunities available to psychologists seekingemployment in NHS Scotland.
Next report
The next report will examine the data collected about planned servicedevelopments and subsequent developments in service organisation andredesign to inform demand forecast. Future supply will be modelled based ona number of scenarios informed by developments in training. The gap betweensupply and demand will then be examined to inform future workforce andtraining requirements.
Health Board Area of Work
Borders Child health
Fife Child and Adolescent Services (n=2)Adult Mental Health (Primary care)Learning Disabilities
Forth Valley Adult Mental Health (Rehabilitation and continuing care)
Grampian Older Adults Learning Disabilities
Highland Older Adults (n=2)
Lothian Primary careAlcohol servicesPhysical healthNeuropsychologyLearning disabilities (n=2)Adult Mental Health (West Lothian)Cancer (SE Scotland Cancer Network)
Tayside Learning DisabilitiesAdult Mental Health
Summary and Concluding Discussion
The project described in this report was designed to provide information tocontribute to planning processes for workforce development and education.The objective was thereby to ensure the availability of sufficient numbers ofappropriately trained staff to deliver psychology services to the standardrequired to meet policy objectives for improving the physical and mental healthand wellbeing of the people of Scotland.
Introduction
• This is the second in a series of reports designed to inform workforceplanning for psychology services in NHS Scotland.
• The first report (NES, 2002a) reviewed the key factors relevant to workforceplanning and used the best available published data to make the case for anincrease in training capacity for Clinical Psychologists to meet workforcerequirements.
• Since then SEHD have committed to support a step increase in capacity forClinical Psychology training, contingent on modernising training pathwaysto increase responsiveness to service need.
• Three subsidiary reports (NES, 2002b, c, d) on psychology services forprimary care, learning disabilities and cancer highlighted problems ofwaiting times, inequity of access and an absence of psychology service inclinical priority areas in spite of evidence of potential for health gain. Acommon theme across these reports was the lack of input by psychologiststo strategic planning for psychological aspects of healthcare.
• The need for reliable data about the current workforce was recognised asessential to informing planning processes for service and workforcedevelopment and for educational provision.
• This report presents the results of a two year project to develop andevaluate a data collection system to describe the workforce employed inpsychology services across NHS Scotland.
• The baseline data from 2001 are presented in the Supplement to this report.This report focuses on the most up to date data, from the 2002 survey ofthis workforce.
Policy and Professional Background
• Contemporary SEHD policy offers unprecedented potential for Clinical andApplied Psychologists to make a significant contribution to improving thephysical and mental health and well-being of the people of Scotland.
• A key issue is how psychology services should best be organised to allowthis relatively small professional group to work effectively with others in amultidisciplinary and multi-agency context while retaining the functionalintegration essential to their own professional efficiency and effectivenessand to clinical governance objectives.
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• The framework of 3 levels of competence in psychological care originallyproposed by Mowbray (MAS, 1989) and developed for use in serviceplanning in Ayrshire and Arran (1999), is useful in conceptualising theredesign of psychology services.
• At Level A all healthcare professionals require to have a basic level ofpsychological knowledge and skill to enhance their work with patientsacross the spectrum of healthcare. At Level B a variety of clinical staff havethe competencies to deliver circumscribed psychological interventionsunder supervision. At Level C the fully qualified Applied Psychologist canbring the breadth and depth of the discipline of psychology to bearcreatively on complex or severe psychological problems. In this modelthose at Level C also have a role in supporting the work of others at LevelsA and B.
• Psychology service delivery is increasingly conceptualised within a tieredmodel, from the community level through primary and secondary care tospecialist services at tertiary level. While the psychologist’s role will varyacross the tiers it is important to recognise that there is a need for the inputof professional psychological expertise to support the information andpsychological care provided at each tier.
• Psychologists are engaged in service redesign and there is a growingrecognition that the roles of Clinical and Applied Psychologists arechanging. A variety of approaches have been adopted to the developmentof a skill-mix within psychology services to meet the demand forpsychological interventions.
• The training and career pathways for psychologists are beginning tochange in response to the modernisation agenda, offering greaterresponsiveness to service need and greater flexibility for individuals.
• There is a challenge in matching the pace of change in healthcare policyand professional affairs. There is a need for accredited training to be moreresponsive to service requirements while maintaining appropriateprofessional standards to protect the public from malpractice. This iscomplicated by powers over healthcare policy being devolved to Scotland,while professional regulation is a U.K. reserved power. This brings the riskthat future professional developments are driven by service policy for theNHS in England without due regard for the distinctive needs of the Scottishhealthcare system. Continuing efforts in communication and collaborationwill be required to ensure that opportunities for developing and evaluatingnew ways of working are viewed synergistically on both sides of the Border.
• There is a need for greater consensus about the strategic direction of serviceredesign of psychology services within NHS Scotland. The development andevaluation of a shared model or models of service organisation wouldgreatly assist the workforce planning process and educational development.
• Strategic planning requires a clear understanding of the status quo fromwhich developments are to be initiated and reliable intelligence as amonitor of progress.
Development of Intelligence for Workforce Planning
• A project was initiated by SCPMDE and taken forward by NES, incollaboration with ISD, to develop and evaluate a system for collecting dataabout the workforce employed in psychology services in NHS Scotland. Theworkforce was surveyed in 2001 and 2002.
• The parameters of the survey sample were carefully defined to include allclinical staff (psychologists and non-psychologists) delivering psychologyservices. Data were collected separately about Clinical Psychology traineeswho were excluded from the workforce survey.
• The survey form (Appendix E) was adapted from the instrument used tocollect data about the medical workforce. Survey forms were administereddirectly to psychology departments for completion to describe theworkforce as at September 30th, 2001.
• The data were managed at ISD. They were analysed, interpreted andreported by a Steering Group with representation from the group of Headsof Psychology Services in Scotland.
• The 2001 data, which should be regarded as the baseline against which toassess future change, are given in the Supplement to this report.
• The survey was repeated in 2002 to assess change in the workforce. Thosedata, which build on the 2001 baseline and represent the most up to datedata available about this sector of the workforce, are presented in thisreport, in the light of other relevant national statistics.
• A separate survey was undertaken, in collaboration with the two ClinicalPsychology Training courses in Scotland, to capture data about thedestinations of course leavers.
Evaluation of Data Collection System
• There was evidence that in spite of teething problems, this projectgenerated data about this sector of the workforce which was more reliableand more informative than pre-existing data sources.
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• There is a clear need for on-going data collection to ensure the availabilityof reliable and up-to-date information about the workforce in psychologyservices and to build up the longitudinal database that is needed to informprojections of future workforce supply.
• There is a challenge to ensure that data are captured about the contributionof Clinical and Applied Psychologists. Their numbers are small and arereadily overlooked in the face of other professional groups that faroutnumber them. They are widely and thinly distributed across NHSScotland and its partner agencies. They therefore represent a smallproportion of the workforce even in services for Mental Health, the area ofwork in which approximately two-thirds of them are employed.
• The imminent modernisation and expansion of the capacity of training forpsychologists requires a response from NHS Scotland in terms of planneddevelopments in psychology services to employ the growing numbers oftrained staff available. There is a need for a data collection system capableof monitoring holistically the impact of developments in training on theworkforce in psychology services across NHS Scotland.
• Given the importance of developing a skill-mix to make best use ofresources in delivering services, it is desirable to have information about therange of staff delivering psychological interventions in NHS Scotland.Through this survey, it is only feasible to contribute to that agenda bycollecting data about the staff employed within NHS psychology services.
• The aims of continuing data collection and the parameters of the surveysample need always to be clearly defined, taking account of the policydirection for psychology services and the availability of complementarydatasets. The survey must develop in a way which is compatible withnational developments in workforce planning in Scotland.
• NES will continue to support data collection in 2003/4 and to work in closecontact with the National Workforce Development Unit. Some modificationsof method and procedure will be introduced in the 2003 survey.
• At a time of service redesign and role review there is a key issue about whatdata are required to be maximally informative to planners. Equally there is aneed for consistency to ensure that trends can be identified over time.Compliance with the survey will be enhanced if the data requirement is keptto a minimum. Subsequent iterations of the workforce survey should allowthe dataset to be updated from the baseline which has now beenestablished.
• Minor adjustments to a few parameters have been introduced for 2003 tobring the fields into line with the new core data required across the NHSworkforce.
• There is a need for a clear shared nomenclature to describe the model ofservice organisation to facilitate the capture of compatible data aboutservice delivery across NNHS Scotland. Some fields have been revised forthe 2003 survey in the light of experience to improve the mapping ofwhere and how psychologists are employed.
• There is a clear need to move beyond a simple count of individuals orwhole-time equivalents to take more account of professional activities andpatterns of working. A new field has been introduced into the 2003 surveyto capture information about ‘service role’. This is a first step towardsdistinguishing the proportion of time spent in clinical service and otherrelated activities e.g. supervision of others, and between those clinicalactivities and management or CPD for example.
• The issues of changing patterns of working may be better explored in thefirst instance at least, in discrete cross-sectional studies.
• With Mental Health as the ‘pathfinder’ for the National WorkforceDevelopment Unit in Scotland and with shared interest in data collectionabout psychologists from the BPS at U.K. level, it is recommended thatfuture development of this data collection system be undertaken inconsultation with all the key stakeholders.
The Workforce in Psychology Services
The data presented in the preceding chapters have been aggregatedthematically here to allow a more coherent summary and discussion of thepoints raised.
• In 2002 there were 338.6wte Clinical, 14.2wte Counselling and 6.5wteHealth Psychologists in NHS Scotland. This represents an overall increase intheir numbers of 10.5% since 2001.
• In spite of this, there was still only 1wte Clinical Psychologist perapproximately 15,000 of the general population in Scotland in 2002 i.e.about a third of the indicative workforce requirement of NHS Scotland citedin the previous report (NES, 2002a).
• The ratio of Grade B :Grade A Clinical Psychologists was 42%:58%.
• In addition, psychology services employed: 73.3wte Assistant Psychologists;11.0wte CBT therapists: 15.9wte Counsellors; 5.0wte other therapists and7.6wte other clinical staff , bringing the total workforce to 472wte.
• The ratio of Clinical and Applied Psychologists to the aggregate of theseother clinical staff was 76%:24%.
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• Assistant Psychologists typically have fixed term contracts and are oftenemployed from vacancies in established posts. Furthermore AssistantPsychologists are typically seeking places on Clinical Psychology trainingcourses which start in September/October each year. This sector of theworkforce is therefore intrinsically unstable, and particularly so at the time ofthe workforce survey.That caveat is important in interpreting the apparentoverall increase of 13.6% in the workforce in psychology services from 2001to 2002.
• The majority (n=308.8wte, 65%) of the workforce in psychology serviceswere employed in Mental Health services for patients across the life-span. The remaining 35% were distributed across a wide range of services. Themain areas of work can be summarised as Learning Disabilities(66.2wte,14%), Physical Health (41.8wte, 9%), Neuropsychology (22.0wte,5%), Forensic (13.6wte, 3%) and Other (19.8wte, 4%). The figures forForensic Services were an underestimate because data were not returnedfrom the State Hospital.
• Analysed by the age of patients/clients served, the majority (354.9wte, 75%)of the workforce in psychology services were working with adults in the agerange 20-64 years, across the range of areas of work. Approximately one infive(93.2wte) worked in psychology services for Children, Young People andtheir families. Services for Older Adults employed a mere 4% (19.0wte) of the workforce and the remainder of the workforce (4.9wte) providedpsychology services across these age categories.
• The survey confirmed that psychology services are inequitably distributedacross NHS Scotland.
• In 2002 none of the Island Boards had local psychology services. On themainland, the Health Boards with the highest staffing relative to the size ofthe population they served, had more than twice the workforce inpsychology services of those with the lowest staffing. None was close to thefirst indicative requirement of 1wte per 5,000 of general population whichwas the indicative estimate for fully trained Clinical Psychologists (NES,2002a).
• There was no evidence of a linear relationship between staffing provision inpsychology services and remoteness/rurality or social deprivation, across themainland Health Boards.
• The distribution of Clinical and Applied Psychologists varies across the HealthBoards of Scotland. There is also variation in the use of skill-mix withinpsychology services from one Health Board to another. It is beyond the scopeof this survey to say whether these differences reflect local recruitment issues,opportunistic development or strategic planning to meet local service needs.
By Area of Work
Mental Health
• 65% of the input of Clinical & Applied Psychologists is to Mental HealthServices across the lifespan. There is also most evidence of skill-mix in thestaffing of those services.
Adult Mental Health
• The area of Adult Mental Health was given particular focus as the largestsingle employer of psychology services: 221.7wte of the total workforcesurveyed were employed in this area.
• The workforce consisted of 152wte Clinical and 12.6wte Counselling. Therewere in addition 25.4wte Assistant Psychologists, 11.0 CBT therapists,14.3wte Counsellors, 3.5wte other therapists and 3.0wte other clinical staff.
• Psychology services are actively engaged in redesign and the organisationof services in this area varies across Scotland. It is beyond the scope of thisreport to comment in detail on this diversity which may be a reflection ofopportunistic developments in response to local conditions or a strategy forservice provision to meet local needs.
• The survey noted local differences in the nomenclature used to describeservices. This, together with the organisational differences, made it difficultreliably to discriminate general mental health services from psychologyservices to primary care. The 2003 survey will introduce new fields to definethis area of work more clearly.
• Adult outpatients referred to psychology services with mental healthproblems require a range of service provision. This employs the largestsingle group of the workforce i.e.193.8wte.
• The data show a lack of psychology input to acute mental health serviceswhere the total workforce in NHS Scotland was 2.2wte.
• There was also a paucity of staff employed in services for people with severeand enduring mental illness. There were 10.6wte Grade B, 12.8 Grade Aclinical psychologists and 1.5wte other clinical staff in this area.
• This highlights the challenge for services in NHS Scotland in meetingclinical standards for schizophrenia and in making appropriate provision forthe implementation of the Mental Health(Care and Treatment) (Scotland)Act.
Services for People with Learning Disabilities
• The dispersal of services for people with learning disabilities, followinghospital closure, has had implications for service organisation and staffing.
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• Clinical Psychologists are involved in service redesign in this area and havea contribution to make across the tiers of service provision i.e. in support ofthose providing dispersed services in the community as well as themselvesproviding specialist services.
• In 2002, there were 44.1wte Clinical and no Applied Psychologists inpsychology services for people with learning disabilities. The ratio of GradeB: Grade A Clinical Psychologists was 45%:55%. There were also 17.5wteAssistant Psychoogists and 4.6wte other clinical staff employed in theseservices.
• Staffing levels have been recommended in England to ensure sufficientnumbers of fully trained staff to contribute across the tiers of serviceprovision. Applied to Scotland these figures imply a requirement of 81wteClinical Psychologists in this service area, almost double the currentestablishment.
Physical Health
• There is growing recognition of the evidence of health benefit to patients ofattending to the psychological aspects of physical healthcare. In spite ofthis the provision of psychology services to the clinical priority areas ofcancer, coronary heart disease and stroke is grossly inadequate to meetservice needs.
• Similarly the optimal management of chronic conditions across the life-spane.g. diabetes requires that attention be given to psychological factors andpatients’ health-related behaviour. Current staffing of psychology services isinsufficient to provide appropriate specialist psychological support to theseservices
• In 2002 there were 31.1wte Clinical and 6.7wte Applied Psychologistsworking in psychology services across the area of Physical Health in NHSScotland. The ratio of Grade B:Grade A Clinical Psychologists was37%:63%. In addition these services employed 4.0wte AssistantPsychologists
• There is a challenge to develop psychology services from a zero baseparticularly given the competing demand for resources in the acute servicessector where the needs to provide medical and surgical interventions andnursing care are pre-eminent. There is a tendency for isolated ad hocdevelopments in psychology services to occur, supported by localchampions. While individually these may be important developments forthe specific local service there is a need to avoid a proliferation of isolatedsingle-handed specialists. Psychology services for specific medical specialtieshave much in common and benefit from functional integration.
Neuropsychology
• There were 16.1wte Clinical Psychologists and no Applied Psychologists inneuropsychology services, including neuro-rehabilitation. Among them theratio of Grade B:Grade A was 1:1.
• The figures are likely to be an underestimate of the input of psychologiststo this area of work because the survey did not include services to the NHSfrom the independent sector and may have missed the contribution ofsome clinical academics.
• In 2002 there 5.9wte Assistant Psychologists employed in this area.
Forensic
• The survey did not fully capture the NHS workforce in forensic servicesbecause the State Hospital did not participate in the survey although invitedto do so. This may have been because of other processes of review whichwere underway in that sector at that time.
• Survey forms were returned for 9.6wte Clinical Psychologists. There were noreturns from Applied Psychologists in this area. The ratio of Grade B:GradeA Clinical Psychologists was 42%:58%. There were in addition 3.0wteAssistant Psychologists in this area included in the survey.
• In view of the sampling limitations the data for this area of work should beinterpreted with caution.
Other Areas of Work
• There were 15.4wte Clinical and 1.0wte Applied Psychologists, 3.0wteAssistant Psychologists and 0.4wte other clinical staff employed inpsychology services across a range of other areas of work. Of these, AlcoholServices require special mention.
• In spite of the prevalence of alcohol problems in Scotland, and the evidenceof benefit of psychological interventions delivered by Clinical Psychologistsreviewed in the recent QIS report (Slattery et al, 2002), there were only4.3wte Clinical and 0.3wte Applied Psychologists employed in services forAlcohol and Substance Abuse throughout NHS Scotland in 2002.
• BPS recommendations for psychology services for this client group implythe need for a fourfold increase in the current provision in Scotland.
By Target Age of the Patients/Clients Served
Adults
• The survey recorded that 72% of all Clinical (244wte) and 94% of allApplied (18.7wte) Psychologists were employed in psychology services foradults in NHS Scotland in 2002.
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• The ratio of Grade B:Grade A Clinical Psychologists was 44%:56%
• Most Clinical and Applied Psychologists working with this age group wereengaged in delivering mental health services (63%). The proportionsengaged in other areas of work were as follows: physical health(10%);learning disabilities(14%); forensic (3%); neuropsychology(5%) and ‘other’(4%).
• Services for adults showed the greatest evidence of the use of a skill mix ofstaff. Overall there were 55.8wte Assistant psychologists; 11wte CBTtherapists, 15.7wte counsellors; 4.2wte other therapists and 5.6wte otherclinical staff employed in psychology services for this age group.
Older Adults
• In spite of evidence of the ageing of the population psychology services forolder adults in Scotland remain rudimentary, employing a total of 14.5wteClinical and no Applied Psychologists in 2002.
• This amounts to 1wte per 55,000 of the older adults in the population (i.e.age >65years) and less than a fifth of estimated requirements (1wte per10,000 older adults in the general population) based on needs assessmentin Tayside.
• The ratio of Grade B:Grade A Clinical Psychologists was 52%:48%
• Most Clinical and Applied Psychologists working with this age group wereengaged in delivering mental health services (12.9wte, 89%).Theproportions engaged in other areas of work were as follows: physical health(0.3wte, 2%); neuropsychology (0.6wte, 4%) and ‘other’ (0.7wte, 5%).
• There were in addition 4.5wte Assistant Psychologists but no other clinicalstaff employed in psychology services for Older Adults.
Children, Young People and their Families
• Contemporary health policy is committed to health promotion, preventionand early intervention, with a focus on childhood and teenage years, as themeans of improving the physical and mental health and well being of theScottish population in the longer term.
• Clinical and Applied Psychologists have a major contribution to make tothis agenda which is unlikely to be achieved with the existing workforce of75.2wte Clinical Psychologists and 2.0wte Applied Psychologist in theseservices.
• This amounts to approximately 1wte trained psychologist per 16,000 of theScottish population in the age range 0-19years.
• The ratio of Grade B: Grade A Clinical psychologists was unusual in this areaof service i.e. 29%:71%. This may reflect the number of younger women inthis workforce.
• Most Clinical and Applied Psychologists working with this age group wereengaged in delivering mental health services (57.0wte, 74%).Theproportions engaged in other areas of work were as follows: physicalhealth(9.2wte,12%); learning disabilities(5.7wte,7%); forensic(2.0wte,3%);neuropsychology (1.4wte,2%) and ‘other’ (2.1wte,3%).
• There were in addition 13.0wte Assistant Psychologists and 3.0wte otherclinical staff employed in psychology service for this age range.
By Health Board Area
• While it is beyond the scope of this report to comment on local serviceorganisation there are some striking differences in the provision ofpsychology services across NHS Scotland.
• In general the variations across Health Boards are not readily accounted forin terms of social deprivation indices or rurality.
• The variations may reflect opportunistic response to local conditions or thestrategic development of services to meet local service needs. They may alsoreflect alternative service provision locally available. Differences in the size ofthe service should not be interpreted as being synonymous with the qualityof service provided. This survey was concerned with describing theworkforce and not with assessing service outcomes.
• When all clinical staff in psychology services were included there werestriking variations in provision in adult mental health services consideredagainst the size of the adult population served in each Health Board area.There was almost a three-fold difference in the ratio of population to 1wteof staff in the service with the highest staffing (Dumfries & Galloway) to thelowest (Highland, Forth Valley, Lothian)
• Inequity of access to psychology services for older adults was apparent inthat 3 health Boards (Highland, Forth Valley and Borders) had nopsychology provision for that age-group. Staffing levels were generally lowand only in Tayside did services for older adults achieve a ratio of 1wte stafffor less than 14,000 older adults.
• There was marked variation in provision of services for Children, YoungPeople and their Families across Scotland.
• Greater Glasgow appears well provided with 1wte staff in psychologyservices for approximately 8000 of the population in the age group 0-19years. However Greater Glasgow also provided supra-regional andnational services for this age-group.
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• These are crude figures since the age range which service cater for do notexactly map on to the population statistics which are available for the agerange 0-19years. There was a five-fold difference between the services withthe highest staff per capita (Fife, Greater Glasgow) compared with thosewith the lowest staffing per capita for this age group (Argyll & Clyde,Tayside). A difference of this magnitude does suggest some underlyinginequities of service provision.
Characteristics of the Workforce
• The workforce of Clinical and Applied Psychologists are predominantlywomen (71%). The men tend to be older than the women (median agesrespectively 47years and 38years). The distribution of ethnic origin in theworkforce is comparable to that in the Scottish population. 97.8% of theClinical and Applied Psychologists are white.
• The majority (88%) were born in the U.K. and 69% qualified in Scotland.
• This sector of the workforce comprised staff with widely varying experience(from less than a year to 40 years since qualifying) but showed evidence ofmovement with the median time in present post of only 2 years.
• It was not feasible for the survey to collect data on individuals'qualifications. The accreditation of Clinical Psychology training is relativelywell established making the data from that group relatively straightforwardto interpret. With more recent definition of requirements for BPSaccreditation of training for other groups of Applied Psychologists theremay be some variation in the qualifications, training and experience ofindividuals who have been aggregated in these categories for the purposesof this survey. This difficulty will be overcome once Statutory Registrationhas been implemented.
• There was a sex difference in the proportion of Clinical Psychologists whohad grade B posts. The difference between men (57% Grade B) andwomen (34% Grade B) did not seem to be satisfactorily explained, by theage difference nor by the distribution of part-time working between thesexes. Further information about the career patterns and aspirations of theworkforce would be helpful to inform future workforce planning.
• 32% of this sector of the workforce worked part-time. It was beyond theremit of this survey to ascertain whether these staff also worked inpsychology services outwith NHS Scotland in the remaining time.
• In all there were 124 other clinical staff employed in psychology servicesacross NHS Scotland.
• The largest single group of them were Assistant Psychologists (n=73). Theywere predominantly women(88%), young (median age 25years) and inposts with fixed term contracts (63%). Typically they were seeking workexperience to enhance their application for clinical training places.
• There are notably some older graduate psychologists employed as AssistantPsychologists. While their maturity often makes a valuable contribution tothe service their opportunities to access clinically relevant training are oftenlimited with current training provision.
• Other clinical staff bring a range of skills and experience to psychologyservices. Although median age varies across staff categories they are ingeneral more likely to be older. Although 45% of CBT therapists were menthe majority of the clinical staff overall (85%) were female.
• The report presents data about the distribution of workforce characteristics(gender, part-time working, age and MHO status) across the service toshow variations by area of work, target age of patients/clients served andHealth board area.
• While these variations are of local and regional interest the relevance at thelevel of national report is the extent to which these parameters will informthe modelling of future workforce scenarios to inform planning.
Dynamics of workforce supply
• 33 Clinical and Applied Psychologists left their jobs in 2001/2. 80 joined theworkforce of whom 8 had been ‘leavers’. The net gain to the workforce wasa total of 47 Clinical and Applied Psychologists in 2001/2.
• The greatest turnover was in the age range 25-34 years and resulted in again of more women than men in a ratio 3.7:1. Most of the turnover was inGrade A Clinical Psychology posts.
• 79% of the ‘joiners’ had qualified in Scotland.
• Among the other staff groups the dominant feature was the high turnoverof Assistant Psychologists.
• The proportion of the workforce eligible to retire in the next 5years (2002-7) was defined from age at the time of the survey, assuming a retirementage of 60years. For staff with MHO status retirement figures were calculatedfrom age 55years.
• On this basis, there were 108 staff in psychology services (20% of the total)who could retire by 2007.
• The distribution of these staff across psychology services of NHS Scotlandsuggests that some services will be more vulnerable than others to staff lossin this time period. They should be engaging now in succession planning.
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• While the absolute numbers of staff may be retrievable given the expansionof training the loss of experience and expertise is a more serious issueparticularly at a time when there is an increased need for training andsupervision of clinical work in the workplace. There is a real and urgentneed to develop creative and attractive arrangements to maintain somecontribution to the service from these experienced workers withoutcompromise to their pension arrangements.
• The vast majority of Clinical Psychology trainees complete trainingsatisfactorily. For 9% in 2002 this was delayed because they had failed tocomplete all the requirements of the training programme in 3years.
• Retention of those trained in Scotland is good. 91% had securedemployment in NHS Scotland before qualifying.
• The impact on the service of doubling training capacity was modelled usingdata from the workforce survey and the training course leavers of 2002.This suggested that even with 64 trainees in each year of the 3-yeartraining programme, it will take 38 years to double the current stock oftrained Clinical Psychologists in the workforce.
• While it is likely to be possible to increase training capacity, the intake for2003/4 will be of 65 trainees, it is clear that both service redesign and newdevelopments in training and careers will be required to deliver psychologyservices to meet SEHD policy objectives and patients’ needs.
• The introduction of flexible training arrangements offers the opportunity toorganise the delivery of training to achieve greater responsiveness to localservice needs. A new training programme is proposed, to equip graduatepsychologists with competencies to contribute to services for commonmental health problems among adults. It is anticipated this will be openfrom 2004/5.
The next report in this series will examine data collected about planned servicedevelopments and information about service redesign to inform the forecast ofdemand. Future supply will be modelled based on a number of scenarios,informed by developments in training. The gap between supply and demandwill be examined to inform future workforce and training requirements.
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Child Health Support Group - National Template for Child Services (2000).Further information can be obtained from the following website:(http://www.show.scot.nhs.uk/isd/child_health/conference)
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Lavender (personal communication) Report of the English Survey of AppliedPsychologists in Health and Social Care and in the Probation and Prison Service Inpreparation for BPS and DoH by Ian Gray, Tony Lavender and Anne Richardson
General Registrar Officer for Scotland(2003) Scottish Population Statistics: http://gro-scotland. gov.uk/grosweb/grosweb.nsf/pges/censushm
ISD, Scottish Health Statistics, Scotland on-line(http://www.isdscotland.org)
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ISD, General Medical Practitioner database from National Manpower Statistics,2001(http://www.isdscotland.org)
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ISD, Scotland National Statistics; SKIPPER (3) 6.3
Management Advisory Service (1989) Review of Clinical Psychology Services;Activities and Possible Models (Mowbray) MAS, Cheltenham
Mental Health (Care and Treatment) (Scotland) Act. Further information can beobtained from the following website:(http://www.hmso.gov.uk/legislation/scotland/acts2003/20030013.htm_)
Mowbray D (2003) The Development of a role of Associate Clinical Psychologist: Afeasibility study, MAS
National Health Service Reform and Health Care Professions Act 2002. Furtherinformation can be obtained from the following website:(http://www.hmso.gov.uk/acts/acts2002/20020017.htm)
NHS Education for Scotland (2002a) Clinical Psychology Workforce PlanningReport; NES, Edinburgh (http://www.nes.scot.nhs.uk/psychology/publications)
NHS Education for Scotland (2002b) Clinical Psychology Workforce PlanningGroup - Report by the Primary Care Sub-Group; NES, Edinburgh (http://www.nes.scot.nhs.uk/psychology/publications)
NHS Education for Scotland (2002c) Clinical Psychology Workforce PlanningGroup - Psychology Services to Learning Disabilities; NES, Edinburgh (http://www.nes.scot.nhs.uk/psychology/publications)
NHS Education for Scotland (2002d) Clinical Psychology Workforce PlanningGroup - Contributions of Psychology to Cancer Care; NES, Edinburgh (http://www.nes.scot.nhs.uk/psychology/publications)
NHS Education for Scotland (2003a) Education and Training for the DentalTeam in Remote and rural regions in Scotland. Report of a Working Group(http://www.nes.scot.nhs.uk/publications/documents/remote_and_%20rural_report.pdf)
NHS Education for Scotland (2003b) Recent psychological research of significanceto the delivery of healthcare in Scotland. CMO Psychology Advisory Committeebriefing paper (www.nes.scot.nhs.uk/psychology)
Paxton, R. & D’Netto, C (2001) Guidance on Clinical Psychology WorkforcePlanning Division of Clinical Psychology Information Leaflet No.6. BritishPsychological Society, Leicester(http://www.bps.org.uk/documents)
PHIS Health needs of children and adults with Learning disabilities (Report inpreparation)
Public Health Institute of Scotland (2003) Child and Adolescent Mental Health -Final Report(http://www.phis.org.uk/about/pub)
Scottish Executive Health Department (1999) Report of the National Review ofResource Allocation for the NHS inScotland, Fair Shares for All (The ArbuthnottReport). (http://www.scotland.gov.uk/library2/doc01/fsag-00.htm)
Scottish Executive Health Department (2000) The Same As You? A Review ofServices for People with Learning Disabilities (http://www.scotland.gov.uk/library3)
Scottish Executive Health Department (HDL 2001 75)(2001) Framework forMental Health in Scotland(http://www.show.scot.nhs.uk/sehd/mels/HDL2001_75annexA.pdf)
Scottish Executive Health Department (2002a) Adding Life to Years: A Report ofthe Expert Group on the Healthcare of Older People(http://www.show.scot.nhs.uk/SEHD/publications)
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Scottish Executive Health Department (2002b) Coronary Heart Disease andStroke: - Strategy for Scotland. Further information can be obtained from thefollowing website:(http://www.scotland.gov.uk/library5/health/chds-04.asp)
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Scottish Executive Health Department (2003) Partnership for Care: Scotland 'sHealth White Paper(http://www.scotland.gov.uk/library5/health)
Scottish Executive (2003) Health in Scotland 2002(http://www.scotland.gov.uk/library5/health)
SCPMDE (2000) Seeking Solutions, Report of conference hosted by SCPMDE inNairn(http://www.show.scot.nhs.uk/scpmde/publications/R&Rreport.pdf)
SCPMDE (2002) Directory of Abstracts from National Clinical PsychologyConference:-Innovation in Training and Practice hosted by SCPMDE, Dunblane,Scotland
SCPMDE/CAPISH (1999) Psychology Services in Scottish Healthcare, SCPMDE,Edinburgh
SIGN guideline number 57 for Cardiac Rehabilitation (2002)(http://www.sign.ac.uk/guidelines)
Slattery J et al. (2003) Prevention of relapse in alcohol dependence - HealthTechnology Assessment Report 3, Glasgow, Health Technology Board forScotland(http://www.htbs.co.uk/docs)
South East Scotland Cancer Network (2002/2003), Annual Report(http://www.scanweb.hw.ac.uk/scanDR/NVC/765/Display/pdf/SCAN_AnnualReport_2002-03.pdf)
Stirling E. (1998) Clinical psychology services for older people. Paper prepared forTayside Health Board
Thomson L.(2003) Report of the Working Group on a Forensic School forScotland. University of Edinburgh, Edinburgh
Workforce Development Confederation. Further information can be obtainedfrom the following website:(http://www.wdc.nhs.uk)
Membership of the Psychology WorkforceSteering Group
Dr Ann Smyth (Chair) National Director of Training for Psychology Services,
NHS Education for Scotland, Edinburgh
Mr John Cameron Clinical Director, Psychology Directorate, GreaterGlasgow Primary Care NHS Trust
Dr George Deans Head of Adult Mental Health Directorate, Royal Cornhill Hospital, Aberdeen
Mr Hugh Toner Area Head, Fife Clinical Psychology Services, Sratheden Hospital, Cupar
Mrs Zena Wight Director of Psychology Services, Strathdoon House, Ayr
Ms Helen Allbutt Research and Information Co-ordinator, NHS Education for Scotland, Edinburgh
Dr Liz Jamieson Project Manager, ISD, Trinity Park House, South Trinity Road, Edinburgh
Ms Barbara Moore Information Analyst, ISD, Trinity Park House, South Trinity Road, Edinburgh
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The Steering Group gratefully acknowledges the contribution of the followingpeople to this Report:
Dr Katharine Sharpe (Head of Workforce Information Unit, ISD) designed theoriginal survey and oversaw the first phase of its implementation and RachelHamlin carried out the initial work on the project.
The ISD IT department, in particular David Greig who developed andsupported the Psychology database
Scott Heald (Acting Head of Workforce Information) managed the teamanalysing and reporting the data.
Dr Colin Tilley (Research Fellow in Health Economics, Dental Health ServicesResearch Unit, Dundee Dental Hospital) did the analyses reported in Chapter 7which project the impact of expansion of training on the future supply ofClinical Psychologists
Prof. Tony Lavender ( Salomons and BPS Workforce Planning Adviser),Prof.Tom McMillan ( University of Glasgow), Mark Ramm (Orchard Clinic,Royal Edinburgh Hospital) and Ms. Judy Thomson (Yorkhill) all read andprovided helpful comment on an earlier draft of this manuscript
Prof Tony Lavender and Prof Derek Mowbray (MAS and NorthumbriaUniversity) gave permission for pre-publication drafts of their manuscripts tobe cited in this report.
Dr Carole Allan (University of Glasgow/West of Scotland Clinical Psychologycourse) and Ms Ann Green (University of Edinburgh/East of Scotland ClinicalPsychology Course) initiated and implemented the survey of traineescompleting clinical training.
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Acknowledgements
Glossary of Abbreviations and Acronyms
AP Applied Psychologist
BPS British Psychological Society
CBT Cognitive Behavioural Therapist
CP Clinical Psychologist
CPD Continuing Professional Development
CSA Common Services Agency
CSBS Clinical Standards Board for Scotland
DoH Department of Health
GBR Graduate Basis for Registration (with the BPS)
HDL Health Department Letter
HOPS Heads of Psychology Services in Scotland
HPC Health Professions Council
ISD Information and Statistics Division
MEDMAN Medical and Dental Manpower
NES NHS Education for Scotland
NHS National Health Service
PHIS Public Health Institute for Scotland
SCPMDE Scottish Council for Postgraduate Medical and Dental Education
SEHD Scottish Executive Health Department
wte Whole Time Equivalent
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Applied psychologists all use the principles and methods of the discipline ofpsychology to promote the development, well-being and effectiveness ofindividuals and groups in society. Qualified psychologists all have an accreditedfirst degree in psychology(Graduate Basis for Registration –GBR- with the BPS),followed by an accredited postgraduate qualification which confers eligibility toapply to the British Psychological Society for Chartered status.
The numbers of undergraduates including a course in psychology in theirdegree programme is large. It is important to note that the numbers for whompsychology was the main subject, studied in sufficient breadth and depth tosatisfy BPS requirements for GBR is much smaller. Nonetheless this is asignificant , and largely untapped pool of potential workforce for NHS Scotland.
There is a substantial research component both to the undergraduate degreecourse and to postgraduate training. Applied psychologists in healthcare arecommitted to assessment of clinical effectiveness and to evidence-basedpractice.
In spite of increasing specialisation in the BPS Divisions of applied psychologythere remains a substantial common core of generic psychologicalcompetencies (National Occupational Standards in Applied Psychology,Generic). The point was well made in the SCPMDE/CAPISH review (1999) thatdifferent titles reflect nuances of difference in specialty rather than offundamental substance. Historically there are differences in the trainingarrangements in Scotland for these groups.
Clinical Psychology
Clinical psychologists are problem-solvers, formulating clinical problems inpsychological terms and drawing creatively on a breadth of psychologicaltheories, evidence and techniques to develop ways of addressing thoseproblems. Clinical Psychologists work directly with complex problems involving,individuals, couples, families, groups and service systems. They offerconsultancy, training, supervision and support to carers and health careprofessionals to maximise the use of their psychological skills. They work acrossa wide range of specialties as exemplified in this report providing services topatients/clients across the lifespan and across a wide range of service settings.
Applicants for training have to have GBR and evidence of relevant workexperience. Current training is by a 3-year, full-time, University-basedpractitioner doctorate. Trainees are NHS employees who spend around 55% oftheir time on clinical placement in the NHS under the supervision of anexperienced Clinical Psychologist. The remaining time is divided betweenformal teaching, private study and the research component, which includescase-studies and service-related projects. All courses are regularly monitored bythe BPS for accreditation purposes.
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Current training and professional roles ofclinical staff in psychology services
Scotland has 2 Clinical Psychology training courses. Currently the University ofEdinburgh/East of Scotland course links with the following Health Board areas:Highland, Grampian, Tayside, Fife, Forth Valley, Lothian and the Borders. TheUniversity of Glasgow /West of Scotland course provides for Dumfries andGalloway, Ayrshire and Arran, Argyll and Clyde, Greater Glasgow andLanarkshire. SEHD has vested responsibility in NES for commissioning ClinicalPsychology training numbers.
Newly qualified Clinical Psychologists are employed at Grade A. There areprofessional guidelines for CPD (BPS, 2003) and a new system for piloting theirimplementation is being piloted. However there is no clear framework for post-qualification specialisation or for accrediting competence in clinical teaching orsupervision. A panel of National Assessors is available to provide qualityassurance for appointments to the higher grade, Grade B. Applicants for theseposts have must have had ‘substantial experience, typically 6 or 7 years, atGrade A but idiosyncratic arrangements may be made to secure candidates to‘hard-to-fill’ posts. The advice of National Assessors is increasingly sought inrecruitment, selection and re-grading issues. They have recently revised systemsfor training and supporting new Assessors to increase consistency of advicegiven. They now operate according to published guidelines (BPS,2002) andhave systems for reviewing difficult decisions and auditing outcomes.
Counselling Psychology
Counselling Psychology is a relatively new branch of Applied Psychologyspecialising in the delivery of psychological therapy. Underlying CounsellingPsychology is a humanistic value system which views clients difficulties indevelopmental terms, as adaptations, rather than as pathology. CounsellingPsychologists work with clients with a variety of problems and difficulties andmay work with individuals, couples families or groups depending on theindividual Counselling Psychologist’s training. Particular emphasis is given tothe therapeutic relationship and process and the psychologist’s competence inmanaging personal and interpersonal dynamics in the therapeutic context isseen as important. Undertaking personal therapy is therefore an integral part ofthe training of counselling psychologists.
Graduates with GBR require to complete an accredited post-graduate trainingcourse (3-year full-time or part-time equivalent) or to gain the BPS diploma inCounselling Psychology via the ‘independent route’. There are no accreditedtraining courses in Scotland. The independent route involves supervisedpractice and personal study. There are procedures for formal assessment ofacademic and research competence. Evidence of practical competence, in atleast 2 models of psychological therapy, acquired through supervisedplacements in at least 2 different settings is examined in a variety of ways.Participation in experiential workshops concerned with psychological
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counselling skills is also required. Evidence of personal development throughpersonal therapy and reflective practice is mandatory.
Postgraduate training is likely to be self-financed. Chartered CounsellingPsychologists then work in a variety of settings. Those who work within theNHS have parity of pay and conditions with Chartered Clinical Psychologists.
Health Psychology
Health psychology provides an integrated biological, psychological and socialapproach to the understanding of physical health and illness. It involves thepractice and application of psychological research to the promotion andmaintenance of health; the prevention, treatment and management of illness;the identification of key factors in the causation of illness and relateddysfunction; the improvement of the health care system and involvement inhealth policy formulation.
Health Psychology is a relatively new field of applied psychology at least interms of its defined professional identity. In focussing more on systems thanindividual patients Health Psychology occupies a complementary role to that ofClinical Psychology.
Training is in two stages: graduates with GBR are required to complete a BPSpostgraduate training course in Health Psychology to acquire the requiredknowledge base. There are 2 accredited training courses in Scotland. Thesecond stage consists of 2 years of supervised practice, which is examinedthrough a portfolio presented to the BPS. The psychologist is required todemonstrate evidence of competence in 4 core areas: professional issues;research; consultancy; teaching/training, and 2 others chosen by the candidatefrom a list of 8 units e.g. implementation of interventions to change health-related behaviour; provide expert opinion and advice including the preparationand presentation of evidence in formal settings.
The regulations for qualification as a Chartered Health Psychologist have onlyrecently been defined so the majority of those with this professional statushave achieved it through the ‘grand-parenting’ arrangements for scrutiny andaccreditation of their curriculum vitae. In Scotland Health Psychologists aretypically employed in the academic sector though they are making anincreasing contribution to the NHS in England.
Neuropsychology
Neuropsychology is concerned with the relationship between the brain andbehaviour. Clinical Neuropsychologists work with children and adults who havehad an illness or injury affecting their brain. These include head injury, strokes,tumours, infections and degenerative diseases of the brain as well as conditionsaffecting other parts of the body which can influence brain function e.g. heart
Appendix
disease. Clinical Neuropsychologists have a scientific understanding of howbrain dysfunction affects thinking, memory, emotions or behaviour. They areable to carry out specialist assessments of these functions in order tounderstand exactly what difficulties the person is having or is likely to have andto monitor change. They are often able to advise on the likely outcome of sucha condition and on how best to cope with any resulting long-term difficulties,both for the individual and their family. Clinical Neuropsychologists workclosely with other colleagues in rehabilitation and education, helping people tominimise their difficulties and where possible to return to independent livingand to work or education.
Generic Clinical Psychology training will include some coverage ofneuropsychology topics and may offer clinical placements in this area.Historically Clinical Psychologists may have developed their expertise throughclinical experience with or without structured CPD. Graduate psychologists,without a generic clinical training, have been able to undertake training forcircumscribed activities, under the supervision of fully trained clinicalcolleagues.
The criteria for accredited training in Clinical Neuropsychology have relativelyrecently been specified (BPS, 2000). These now require evidence of a higherlevel of specialist knowledge and skill. NES has sponsored the introduction of anew postgraduate course in Clinical Neuropsychology at the University ofGlasgow from 2003, the only one in Scotland. The course offers training at 3levels from Masters’ degree and Diploma level, to access to modules for CPDpurposes
Forensic
Psychologists contribute to criminological and legal services in many ways andthis area is generically referred to a forensic psychology. Psychologists may beconcerned with the behaviour of people within legal systems: offenders andoffending behaviour; crime detection; the administration of justice (includinggiving of evidence) or the management of individuals after sentencing.Psychologists interested in forensic matters are often called upon to giveevidence to the courts and in other judicial processes, as an expert witness.They are to be found working in prisons, special hospitals and securepsychiatric units, in university departments and in probation and social workservices. Those employed in the NHS are likely to have additional skills inClinical Psychology.
A variety of offending behaviours are amenable to psychological interventionswhich may then be important to patient rehabilitation e.g. angermanagement. Failure to provide appropriate psychological interventions mayresult in longer periods of detention and/or an increased risk of relapse or re-
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offending. Patients detained under mental health legislation have a highnumber of mental health needs. Psychological interventions are increasinglyrecognised within the range of types of treatment these patients require.Expert assessment of risk is important, and fundamental to the compulsoryrestriction and/or treatment of mentally disordered offenders. Modernmethodologies for risk assessment involve a high level of psychologicalexpertise. In this context Clinical Psychologists in forensic services areincreasingly asked informally to advise community and primary care servicesabout patients/clients who have clinical needs but also present forensic issues,because of concerns about risks to the public, other patients and staff.
The existing Clinical Psychology training courses include some teaching onForensic topics and there are opportunities for clinical placements in Forensicsettings.
There is a 1-year masters level course in Forensic Psychology at GlasgowCaledonian University open to Graduate or Clinical Psychologists working inthe Forensic field.
With the new Mental Health (Care and Treatment) (Scotland) Act, 2003 thereis likely to be an increased requirement for specialist Forensic Psychologists.Planning for additional secure units is at an advanced stage in Scotland andthe needs for community-based forensic services are likely to place increasingdemands on this service sector.
The shortfall in the supply of psychologists to forensic services in Scotland isevident in the recruitment problems reported in this area of work across NHS,local authority and prison services.
A Working Group was recently created to review the provision of forensiceducation and training in Scotland. The report of its findings (Thomson, 2003)identified a gap in training opportunities and proposed a multidisciplinarypostgraduate course in Forensic Studies. A flexible, part-time programme wasproposed offering a 2-year Masters level degree, a 1-year diploma or modularaccess for CPD. Information about this proposal has recently been circulated topotential stakeholders for discussion.
Other Applied Psychologists
While the information given above covers the range of Applied Psychologistscurrently employed in NHS Scotland there are others whose specialistknowledge and skill are relevant to the healthcare agenda.
The ‘Joint Future’ agenda is bringing the work of Clinical Psychologists inservices for Children, Young People and their Families closer to the work ofEducational Psychologists who are typically employed by the Local Authority inservices to schools.
Appendix
A range of academic psychologists have research interests relevant to thedelivery of healthcare. A growing number are specifically interested in how toapply psychology to making teaching and learning more effective. The needfor evidence–based education for healthcare professional is attracting growinginterest and concern and it may be helpful to NHS Scotland, through NES, toengage more professional educational expertise in the future development ofclinical training in the workplace.
Occupational psychology applies psychological knowledge theory and practiceto work in its widest sense: how work tasks and conditions of work affectpeople and how people and their characteristics determine how work is done.Some occupational psychologists specialise in areas such as vocationalrehabilitation. Others work in-house for some organisations or by consultancy,applying their expertise to identify and resolve organisational issues e.g.recruitment/selection. The contribution they could make to the NHS isunderdeveloped.
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Psychology Staff - Notification ofAppointments and Staff ChangesFor all Grades, Excluding Trainees
National Health Service in Scotland Information & Statistics Division
In ConfidenceISD(M)40 (03/10/2001)
INPUT TYPE: (1) The total number of sessions in an average 4 week period should be recorded.I = Insert ( e.g. for new appointment)A = Amend (for change in data other than Part A )T = Termination of Appointment (part A,E,C(a)only)E = Error Correction
Part D : TERMINATION DATAComplete PART A: Key Data and PART C(a)
Reason for Leaving (41)and Date of Termination(42)
COMPLETED BY:
DATE: Tel No:
Part A : KEY DATA Complete All FieldsNational Insurance No. (2) Admin. Trust/Health Board (3) Payroll Number (4)
Part B : APPOINTMENT DATA
Trust/Health Board (i)(5) Trust/Health Board (ii)(9)
Sessions (i) (6) Sessions (ii) (10)
Target Age (i) (7) Target Age(ii) (11)
Area of Work (i) (8) Area of Work(ii) (12)
T / H Board (iii) (13) T / H Board (iv) (17)
Sessions (iii) (14) Sessions (iv)(18)
Target Age (i) (15) Target Age(ii) (19)
Area of Work (iii) (16) Area of Work (iv) (20)
New appointment - complete all fieldsChanged appointment - complete relevant fields only
Class of Contract(21) Type of Contract(22)
Term of Contract(23)
Date Start in Post(24)
Date Appointed to Present Grade(25)
Head of Service Mental HealthContract (Y/N) (26) Officer Status (Y/N) (27)
Part C : PERSONAL DETAILS
(a) Complete the following fields
Status(28) Professional Group(29)
If ‘Other’ specify_________________
Grade (30)
Surname (31)
First Forename (32)
Second Forename
Third Initial (33)
Maiden Name (34)
Date of Birth (35) Sex (36)
Complete the following fields
Country of Birth (37) Ethnic Origin (38)
Country of Qualification (39) Year Qualified (40)
Please return to: ISD Scotland, Room C 120, Trinity Park House, Edinburgh EH5 3SQ
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EAppendix
Part A: Key DataNational Insurance Number (2)9 Character Field: Two Alpha, 6 numeric, 1 alphae.g. AB173412D
Payroll Number (4)8 Character Field: 1st alpha, 2nd – 8th numerice.g. K1234567
Part B: Appointment DataTarget Age (7) (11) (15) (19)Code Target Age ADU AdultCHI Children, Young People and FamiliesOAD Older Adults (Health Care for the
Elderly, Dementia)ALL All
Area of Work (8) (12) (16) (20)Code Area of Work ACA AcademicALC Alcohol and Substance MisuseDEN DentistryFOR Forensic and OffendersGMH Mental HealthCCM Mental Health - Continuing Care /
Enduring Mental IllnessPCC Mental Health - Primary Care /
Community PsychologyAPC Mental Health - Acute Psychiatric CareGPH Physical HealthCAR Physical Health - CardiologyDIA Physical Health - DiabetesHIV Physical Health - HIV/AidsLIA Physical Health - LiaisonOBS Physical Health - ObstetricsONC Physical Health - OncologyPAI Physical Health - PainPHR Physical Health - Physical RehabilitationPLS Physical Health - Plastic SurgerySPI Physical Health - Spinal InjuryOPH Physical Health - OtherLDI Learning DisabilitiesLDO Learning Disabilities - OffendersLDM Learning Disabilities - Mental HealthLDC Learning Disabilities - ChallengingBehaviourNEU Neuropsychology & NeuroRehabilitationOCH Occupational HealthPRE PreventionPRI Prison ServicePSX PsychoSexualSMA Service ManagementMIN Services to Cultural MinoritiesSTU Student HealthOTH Other
Class of Contract (21)Code Class of ContractNHS Whitley CouncilTRU Trust Contract (Non Whitley)HON Honorary ContractLOC Locum Contract BAN Bank Contract
Type of Contract (22)Code Type of Contract WT Whole TimePT Part Time
Term of Contract (23)If Fixed Contract : indicate number of years andpart yearsIf Open Contract : indicate “z”
Part C: Personal Details
Status (28)Code Status0 Graduate1 Not Chartered2 Chartered3 Working Towards Statement of
Equivalence4 Non Graduate - Other Qualification
Professional Group (29)Code Professional Group0 Clinical Psychologist1 Counselling Psychologist2 Health Psychologist3 Other Psychologist4 Other Not Psychologist (specify)
Grade (30)Code GradePQB Post Qualified B (Senior Grade)PQA Post Qualified AASST Assistant Unqualified OTHR Other
Country Codes (37, 39)Either numeric or alpha code can be usedCode Description01 SCO Scotland02 ENG England03 WAL Wales04 NIR N Ireland05 EUK Elsewhere UK06 REP Eire07 EEA Other European Economic
Area Countries08 IND India, Sri Lanka, Pakistan,
Bangladesh09 ANZ Australia, New Zealand10 OCC Other Commonwealth
Countries (excluding Canada)
11 EUR Non-EC Countries in Europe
12 ASI Other Countries in Asia13 AME Other Countries in America14 AFR Other Countries in Africa15 CAN Canada16 OTH Elsewhere
ISD (M)40 LIST OF CODES
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Ethnic Origin (38)The category to be recorded for an employee is the ethnic origin as defined by the individual concerned.
Code Description Code Description WB White British PA Pakistani WI White Irish BG Bangladeshi OW Any other white AO Any other asian background MC White & Black Carribean BC Caribbean MA White & Black African BA African WA White & Asian BO Any Other black background MO Any other mixed background CH Chinese IN Indian OT Any other ethnic group NK Not stated
Part D: Termination Details
Reason for Leaving (41)AGE Age Retiral VDP lack of promotionDED Death in Service VDJ job content unsuitableTHG Dismissal Health Grounds VDE earningsTCO Conduct VDH working hoursTCA Capability VDC working conditionsTFE Failed Examination VDO otherTPU Probation Unsatisfactory VMH Moving HouseTQU Qualification VTR Travel problemsTRD Redundancy VAL Accomadation LackTET End of Training VPY PayTEC End of Contract VRH Health RetiralTOT Other Substantial Reason VPR PromotionRED Redeployment VLM Lateral MoveVRE Vol. Early Retirement: Efficiency of the ServiceVRO Early Retiral: Organisational Change VTH - higher gradeVTL - lower gradeVCC Career ChangeVIH Ill Health/CapabilityVTE Voluntary Further Education / Training Place in Clin Psychology in EnglandVTS Voluntary Further Education / Training Place in Clin Psychology in ScotlandVFT Voluntary Further Education / Training – OtherVFE Further Experience
EAppendix
NES is working with stakeholders on a planned programme of trainingdevelopment for psychologists for NHS Scotland. The strategic objectives are :
• To increase training capacity for Clinical Psychologists while maintaingprofessional accreditation standards;
• To achieve a prompt an sustainable response to service need;
• To align the training and career pathway for psychologists withcontemporary service and workforce development policy, and
• To make best use of resources
Local Contracts
• Training accreditation criteria have recently been described in terms of acompetency framework. This offers greater flexibility in the use of clinicalplacements.
• NES has introduced a new funding system to increase local ‘ownership’ oftrainees.
• Employers are being encouraged to engage with the training courses andwith NES to develop individual learning plans for trainees which meet bothlocal service needs and professional training requirements.
Flexible Training Arrangements
• Currently the University of Edinburgh/East of Scotland course consists of 6modules delivered over 3 years.
• From the intake of 2003/4 flexible training arrangements are being offeredwhereby all trainees complete a first year full-time programme (2 modulesof the course) involving academic teaching and 2 clinical placements. Thisis designed to offer trainees a sufficient level of core competencies to makea useful service contribution under supervision.
• Thereafter trainees on the flexible training route are employed in NHSScotland in an area of psychology service determined by local service need.These trainees are based in that area of service for the remaining period oftheir training making an increasing contribution to the service as theirexperience of work in that area grows.
• From that base in the service trainees access the remaining elements oftraining required for professional accreditation, on a part-time basis.
• It is hypothesised that this flexibility will be of benefit to recruitment insome specialties and in some geographic areas. It may also better equiptrainees for the new roles that Clinical Psychologists are being expected toadopt in tiered services.
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Developments in the modernisation ofpostgraduate psychology training in Scotland
Appendix
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FAppendix
• The outcome of these developments in training must be evaluated,including from the perspective of the NHS.
• The Glasgow/West of Scotland course is organised differently and currentlyoffers only a 3-year full-time programme.
Quality Assuring Clinical Supervision
• Clinical training relies heavily on the clinical teaching and supervisionoffered by NHS staff. Historically this has not been recognised by NHSservice managers, in systems for funding training or in the careerdevelopment of the individuals concerned.
• Investment in training clinical supervisors to accredited standards will be animportant issue in delivering the modernisation agenda.
• This is particularly important given the role that Clinical Psychologistsalready play in the teaching, training and supervision of other staff in thedelivery of healthcare as well as of Clinical Psychology trainees
• An educational needs assessment has been completed and a curriculum forsupervisors is under development.
A new Postgraduate Course for Psychologists
• Proposals for a new 1-year masters level course for psychology graduates(with GBR) are being developed jointly by the Universities of Stirling andDundee.
• The course will combine academic teaching and clinical practice
• The aim is to equip psychology graduates with the competencies requiredto deliver psychological interventions for common mental health problemsin a primary care setting.
• It is envisaged that those completing the course satisfactorily would beemployed in the NHS under the supervision of a fully qualified ClinicalPsychologist.
• It is envisaged that the selection processes and competencies involvedwould be such that these individuals would be eligible to progress to fulltraining in Clinical Psychology and that their training and experience shouldbe accreditable towards that end.
The purpose of this analysis is to forecast the impact of different trainingpolicies on the stock of trained Clinical Psychologists in NHS Scotland. This isan initial run, and a number of assumptions have been made about the processthat determines the stock of Clinical Psychologists. Thus, these forecastsshould be viewed with some caution.
For this initial run of the model, the following data parameters have been used:
• the leaving rate of qualified Clinical Psychologists 2001-2002: 8%
• the attrition rate of trainees 2001-2002: 3%
• the number of qualified Clinical Psychologists in 2002: 381.
• the current number of trainees: 32
The number of qualified and employed Clinical Psychologists in any period t,nt, is determined by the number of qualified Clinical Psychologists who remainemployed from the previous period, ρn
t-1, plus the number of trainees who
undertake a 3-year training course, χt-3
, which they complete with probabilityα
3. Or,
(1)
Equation (1) contains a number of important assumptions. First, the process isentirely deterministic. Second, (1-ρ), 0 < ρ < 1, is the sum of the annual leavingrate of qualified Clinical Psychologists employed in period t - 1 and the annualjoining rate of qualified Clinical Psychologists not employed in period t - 1.Third, the analysis is restricted to the (exogenously determined) number oftrainee Clinical Psychologists on 3-year training courses only.
Equation (1) is a first order difference equation that can be solved to reveal thedynamic properties of the stock of qualified Clinical Psychologists. That solutionprovides some insight into the policy experiments that follow. The solution toEquation (1) is
(2)
where n0denotes the initial condition of the series.
Equation (2) states that the number of qualified workers depends upon theinitial number of trained workers (n
0); the net rate of attrition of qualified
Clinical Psychologists (ρ); the exogenous number of trainees per period (χ)
and their associated attrition rate (α3).
Figure 19 illustrates the time path of trainees and qualified ClinicalPsychologists working in NHS Scotland. If the set of assumptions continue tohold the number of qualified Clinical Psychologists working in the NHS inScotland will increase slightly over the long run. Intuitively, this is because the
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The dynamics of supply – the impact ofexpanding training capacity
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Appendix
attrition rate of trainees and qualified psychologists is lower than the rate atwhich Clinical Psychologists are trained.
If the number of trainees remains constant over the duration of the simulationperiod, χ
t-= χ , then Equation (2) can be written
(3)
Hence, the steady state number of qualified Clinical Psychologists – the numberof Clinical Psychologists that just balances the rates of inflow and outflow toleave the stock unchanged – is therefore
(4)
The shallow slope of the number of qualified Clinical Psychologists in Figure 19reflects the proximity of the current stock of workers (380) to the steady state.
A permanent increase in the number of trainees.
The purpose of this section is to simulate the impact of increasing the numberof trainees on the stock of qualified Clinical Psychologists. This analysis isdeliberately highly stylised because of the nature of the assumptions imposed.Consequently, these simulations should be interpreted with some caution.
Table 31 calculates the impact of a permanent increase in the number oftrainees from period t - 3. For example, a unit increase in the number oftrainees on the three-year course increases the stock of qualified CPs by α
3 in
period t ρα3 +α
3 in period t + 1, and so on.
Table 31: a permanent one unit increase in trainees
Time period
Figure 19 illustrates the impact of a permanent 100% increase in trainingcapacity (dashed lines) relative to the current training policy.
From Table 31 the impact of a permanent increase of 1 trainee per annum onthe 3-year training course increases the steady state stock by about 12 workers.
(5)
Therefore, doubling the number of trainees on the three-year course increasesthe steady state stock of workers by (12.125x32 =) 388 Clinical Psychologiststo 776 (Figure 19).
Future research
Future analysis of the dynamics of supply in Clinical Psychology should bedirected towards relaxing the assumptions imposed upon this analysis. Inparticular, robust estimates of (age-specific) attrition and joining rates wouldallow future analyses to capture important practical elements of workforceplanning. Whilst these data are not currently available it is expected that thecontinued development of data collection tools will provide these data in duecourse. Until these estimates are available, however, any conclusions drawnfrom any analysis will be tentative.
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GAppendix
NHS Education for Scotland (NES)2nd Floor, Hanover Buildings66 Rose StreetEdinburgh EH2 2NNTel: 0131 225 4365Fax: 0131 225 5891www.nes.scot.nhs.uk
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Psychology Workforce ProgrammeWorkforce GroupInformation and Statistics Division (ISD)Trinity Park HouseSouth Trinity RoadEdinburgh EH5 3SQTel: 0131 551 8472Fax: 0131 551 1392www.isdscotland.org
