The call for ideas - what is it? Part of the process of HPC-ification is to convene a Professional Liaison Group, who will discuss the issues and come up with a proposal. However, in order to avoid accusations of partisanship, there is a big effort to show how open to other ideas they are. The Call for Ideas is one way of presenting the image of openness. Another way is to hold the meeting in public. A third way is to hold a Stakeholders meeting to feed back to a wider group and even to take more comments (scheduled for March in Manchester). It reminds me of 'iteration' carried out by information system designers that I studied in the early 90s. High level policy makers made the decision to centralise knowledge and computerise processes, and engaged Anderson Consulting to help them to do it. A set of people called systems designers went out to discover how the work was being done, came back to the office to encode it into programmes, then sent the change management guys out to take the flak and find out what kinds of problems would need to be overcome when rolling out the new system.
Calling for ideas is a wonderful way of discovering the opposition. It is also a wonderful way of saying that you've consulted widely and listened carefully. But it is not a good way to conduct research, to make an analysis of the situation, and to think through unintended consequences.
The government has already decided that psychotherapists and counsellors constitute a threat to the public, but has not troubled to say how. It has already announced that they shall come under the regulation of the hpc. The government has also stipulated the structure and nature of the hpc in so far as it is able. It is a top down political decision that is enmeshed in a process of law. It is not an enquiry in the scientific spirit of enlightenment - it has no real interest in discovering how best to set things up so that the practice, the patient, the punter, the practitioner are operating in the best of conditions.
Right at the beginning of the meeting the Strathclyde Professor asked the sensible question: what is our role, what are we trying to do? The chair responded: to look at the arguments, to debate, to think, to say what we believe for reasons of public protection, to sketch things out, not hard and fast, but to give three main proposals for the structure. The HPC panel member representing physiotherapists added: it is not necessary to come up with a definitive decision, and the chair reiterated, 'yes, keep it vague, come up with a sketch'. Another HPC panel member, this one a lay member, added 'we aim to favour a model, but we know that it may change'. In the first meeting of the group it had been made plain that the role of the PLG was to recommend something to the HPC council who would propose it to the DH who have a team of writers to turn the proposition into law, should the government agree.
Thursday, 29 January 2009
PLG: Day 1 structure of the register, protection of title
Wednesday 28 January 2009, Thought for the Day on Radio 4 was with the Right Reverend Tom Butler, Bishop of Southwark. As part of his job he is obliged to take up a seat in the House of Lords. His thought for the day was provoked by a 'cash for questions' allegation but led him to speak about the mundane details of the tedious work of a Lord: many hours of rather tedious examination of a bill, line by line. This, he went on, is 'the main contribution of the Lords to our democracy, not dramatic speeches to the gallery but meticulous revising of proposed legislation'.
Put this alongside the fact, now more and more openly acknowledged, that since 1997 the government has passed more laws than at any other time ever, and that many of those laws have been in the form of statutory instruments (which limit the possibility of debate severely), and it is perhaps not suprising that some Lords might be trying to regulate their work flow in the time honoured way of invoking an economic sanction.
No, it's not right and the individuals concerned should certainly be put into question. But there is also another way of looking at it, to wonder how the overall scenery could be contributing to a rash of unusual symptoms.
Tom Butler's thought ended with the words 'I see a House with mostly pretty dedicated and impressive characters working long and hard for the common good'. This was almost exactly the way a fellow member of the public gallery described what she saw at the HPC PLG for C&P later in the same day.
The first meeting of this group had been an unpleasant experience to observe. This was not all due to the inconvenient layout of the seats for sure (which had miraculously been rearranged in spite of letters to the contrary the day before). It was mostly about the implicit force with which the machinery was being applied with the result that debate, discussion, dispute were stifled. Today that was not so much the case.
Nevertheless, the thorny issue of centralised power imposing a state of affairs without a rational debate still has a part to play. But this is a part that has to remain concealed in order for the state to save face. And it is in everyone's interest, apparently, to maintain the mask in place.
There is the substance and there is the structure, and somehow the structure has been bent out of shape, which poisons the stuff of the substance. So, both of these things need to be addressed.
The business of the day took its lead from Michael Guthrie's summary of responses to a section of the call for ideas. But here again, it is impossible to go forward without first attending to the detail of the process. It will be the subject of the next blog.
Put this alongside the fact, now more and more openly acknowledged, that since 1997 the government has passed more laws than at any other time ever, and that many of those laws have been in the form of statutory instruments (which limit the possibility of debate severely), and it is perhaps not suprising that some Lords might be trying to regulate their work flow in the time honoured way of invoking an economic sanction.
No, it's not right and the individuals concerned should certainly be put into question. But there is also another way of looking at it, to wonder how the overall scenery could be contributing to a rash of unusual symptoms.
Tom Butler's thought ended with the words 'I see a House with mostly pretty dedicated and impressive characters working long and hard for the common good'. This was almost exactly the way a fellow member of the public gallery described what she saw at the HPC PLG for C&P later in the same day.
The first meeting of this group had been an unpleasant experience to observe. This was not all due to the inconvenient layout of the seats for sure (which had miraculously been rearranged in spite of letters to the contrary the day before). It was mostly about the implicit force with which the machinery was being applied with the result that debate, discussion, dispute were stifled. Today that was not so much the case.
Nevertheless, the thorny issue of centralised power imposing a state of affairs without a rational debate still has a part to play. But this is a part that has to remain concealed in order for the state to save face. And it is in everyone's interest, apparently, to maintain the mask in place.
There is the substance and there is the structure, and somehow the structure has been bent out of shape, which poisons the stuff of the substance. So, both of these things need to be addressed.
The business of the day took its lead from Michael Guthrie's summary of responses to a section of the call for ideas. But here again, it is impossible to go forward without first attending to the detail of the process. It will be the subject of the next blog.
Innocence or objectivity
There is an impossibility at the heart of the hpc. The impossibility is the assumption of innocence and the relation this has to the supposed position of objectivity. It is not a natural impossibility, like death, in the face of which one can labour heroically, but an unnatural impossibility which can render us at best foolish, at worse pernicious.
Ian Kennedy's Reith Lectures, delivered in 1980, led to a book which he gave the title: The Unmasking of Medicine (London George Allen & Unwin). In it he mounts a polemic against the profession of medicine, accusing medical practitioners of wielding the power over life and death. Kennedy ultimately wanted to know why it should be doctors who have that power, and why it couldn't be 'us' instead. He never elaborated what he meant be 'us', but Ian Kennedy was at that time an academic lawyer - a lecturer at the LSE. It never occurred to him that the profession of medicine ipso facto forced the practitioner into a position which ultimately must tangle itself up with death. In short, Kennedy's fallacy is that medics are inherently unsuitable to practise medicine, and 'we' would do it better, if only, like Austen's Lady Catherine, we had devoted ourselves to the practice. "If I had ever learnt I should have been a great proficient".
The assumption here, to spell it out, is that people fall into different categories. Them, and us: we are good, they are morally stained. It is the myth of the 'beautiful soul'. For surely, had Ian Kennedy chosen medicine, he would be confronted by the impossibilities of the practise himself.
When the Bristol Royal Infirmary row blew up in the national arena, the controversial labour peer Lord Levy phoned Ian Kennedy to invite him to chair the Inquiry. It is in the report of this inquiry that the explicit recommendations are made that the CHRE (see side panel for link) and the HPC be set up on the general principle that objectivity means knowing nothing about the practise. There is an assumption that objectivity can be achieved by obeying a set of rules, and limiting the subjective elements of life to the point of non-existence. It is a naive idea of objectivity, and open to abuse. It also flies in the face of recommendations by Dame Janet Smith, and written by the Right Hon Patricia Hewitt that the preservation of trust (that we have in people in general, including professionals in the medical field) has to be the starting point - that rules should not be written on the evidence of exceptions.
The recommendations of Kennedy's inquiry were taken up in the Health Professions Order 2001, and gave the basis upon which to create the CRHP (which now goes under the name CHRE) and the HPC. The HPO2001 was passed into law through Privy Council, thus making it one of very many pieces of legislation brought into existence without the usual full debate in the houses of parliament.
Laws, even well made laws, have to have careful attention when applying them in practice. And for this a whole other profession has grown up through the custom and practice of centuries: law. There is a common theme: how is the written rule brought to life in particular situations and applied to the life of a real human being. There are examples of bad application of law, with tragic consequences. There are examples of heroic bravery, sometimes also ending in tragedy. There is the letter of the law, and the spirit of the law. But the fact remains that some things, even tho written in books, still have to be carefully interpreted and weighed against the reality of the situation. Following the rules is not an adequate defense. No matter which way you look at it someone has to step in and bear the burden of reality. The rest of us can endeavour to create a society that won't scape-goat them, much less build an edifice upon that scape-goating, if hindsight gives a better solution.
We are back in the province of religion.
Ian Kennedy's Reith Lectures, delivered in 1980, led to a book which he gave the title: The Unmasking of Medicine (London George Allen & Unwin). In it he mounts a polemic against the profession of medicine, accusing medical practitioners of wielding the power over life and death. Kennedy ultimately wanted to know why it should be doctors who have that power, and why it couldn't be 'us' instead. He never elaborated what he meant be 'us', but Ian Kennedy was at that time an academic lawyer - a lecturer at the LSE. It never occurred to him that the profession of medicine ipso facto forced the practitioner into a position which ultimately must tangle itself up with death. In short, Kennedy's fallacy is that medics are inherently unsuitable to practise medicine, and 'we' would do it better, if only, like Austen's Lady Catherine, we had devoted ourselves to the practice. "If I had ever learnt I should have been a great proficient".
The assumption here, to spell it out, is that people fall into different categories. Them, and us: we are good, they are morally stained. It is the myth of the 'beautiful soul'. For surely, had Ian Kennedy chosen medicine, he would be confronted by the impossibilities of the practise himself.
When the Bristol Royal Infirmary row blew up in the national arena, the controversial labour peer Lord Levy phoned Ian Kennedy to invite him to chair the Inquiry. It is in the report of this inquiry that the explicit recommendations are made that the CHRE (see side panel for link) and the HPC be set up on the general principle that objectivity means knowing nothing about the practise. There is an assumption that objectivity can be achieved by obeying a set of rules, and limiting the subjective elements of life to the point of non-existence. It is a naive idea of objectivity, and open to abuse. It also flies in the face of recommendations by Dame Janet Smith, and written by the Right Hon Patricia Hewitt that the preservation of trust (that we have in people in general, including professionals in the medical field) has to be the starting point - that rules should not be written on the evidence of exceptions.
The recommendations of Kennedy's inquiry were taken up in the Health Professions Order 2001, and gave the basis upon which to create the CRHP (which now goes under the name CHRE) and the HPC. The HPO2001 was passed into law through Privy Council, thus making it one of very many pieces of legislation brought into existence without the usual full debate in the houses of parliament.
Laws, even well made laws, have to have careful attention when applying them in practice. And for this a whole other profession has grown up through the custom and practice of centuries: law. There is a common theme: how is the written rule brought to life in particular situations and applied to the life of a real human being. There are examples of bad application of law, with tragic consequences. There are examples of heroic bravery, sometimes also ending in tragedy. There is the letter of the law, and the spirit of the law. But the fact remains that some things, even tho written in books, still have to be carefully interpreted and weighed against the reality of the situation. Following the rules is not an adequate defense. No matter which way you look at it someone has to step in and bear the burden of reality. The rest of us can endeavour to create a society that won't scape-goat them, much less build an edifice upon that scape-goating, if hindsight gives a better solution.
We are back in the province of religion.
Conscientious Objection
Please bear in mind that these notes are written without recourse to a tape recorder and seated in place from which not everyone is visible. This was a particularly turbulent part of the meeting with some comments delivered in arch, barbed manner provoking several members to say 'we should not ridicule these people'. They are not strictly verbatim and the list is incomplete.
There was a part of the meeting today that focussed on Conscientious Objection, or Principled Non Compliance, p 37 of circulated document prepared by Michael Guthrie, Head of Policy and Standards.
The Strathclyde Prof asked HPC Head of Policy and Standards if the PNC suggestion was a practical option in his opinion. Guthrie replied that he could not foresee the government being able to accommodate it. [he spoke v quietly and quickly but this was the gist]
One lay member from the HPC said she had looked carefully at the arguments and chose one to dispute with here. The argument that the practise is entered into by consenting adults could not be supported because, as with dentists or estate agents, great harm could be done. She said 'it flies against the move'.
The HPC member representing Occ Therapy said You can't have your cake and eat it (you can't be on a register to be unregistered).
The User representative said 'What is the purpose of regulation - without statutory regulation people who are known to be harmful will continue to practise. People need to be prevented from practising. Either its the regulator or the law - and you can't have one law for one person and another for another.
Skills for Health quipped: they could always be taken [struck] off the non-register
another voice added "or sent off to Vermont"
The User representative continued: The evidence base [unsubstantiated] is clear that there is harm, the best outcome of these processes is that the vast majority will continue to practise in the way they've done before. Good practitioners will already be doing this. We have to come back again, and again, and again, to Public Protection. We are in the New World now, professional led self regulation is dead. The Health and Social Care Bill last year saw to that. There must now be equal numbers of lay people to professionals in the [regulation of the profession]
SfH said: Totally agree, these people constitute a harm. We must take a very firm view. Compared to other professions Psychotherapy is definitely harmful, potentially, 5% of practitioners cause harm [unsubstantiated]. The public is ill served by ineffective treatments with adverse effects. We hope it [the practise] will become more evidence based, with a little bit more notice of what is known, a general improvement in client care can happen. ...
BABCP said: We must not mock or ridicule these people, but the public needs protecting. The professionals need protection too. I think it [HPC] is a good move for the profession.
BPC: said We are the victim of our own rhetoric. Public Protection - we are part of the public too. We need protection, the clinical community needs protecting. Care providers are vulnerable. The public is at risk from us, but we are vulnerable to them.
HPC Physiotherapist said. Other aspirant groups have had this problem
The Chair: we have all been lobbied, the letter is philosophical. But they point to the confusion of State and Statutory Regulation, the question of totalitarianism. I've lived [or known someone who has lived] in [eastern bloc] for many years, I know what totalitarianism is, this is not that. It might look like it from the outside, but it doesn't feel like it inside the HPC. Also they talk of the medical model ...
CPCAB said The Petition had 1600 names at the beginning of the week, many of those are names of people I know and respect. I am not willingly a part of this but when I saw it couldn't be stopped I decided I had to join in to try to influence it.
HPC speaker said Public Protection also protects the registrant, it helps credibility, they have nothing to do but pay their fee, and gain status and credibility.
HPC Lay member said: HPC upholds public confidence in the profession, its a matter of pride to have been recognised by the HPC - its an external validation.
Amidst all this the COSCA member said: we might consider that there could be a number of registers springing up alongside the HPC one.
The chair suggested a ten minute break, and this discussion spilled into the adjacent room for coffee. On return they talked about the title Psychological Therapist. Then it was over as the HPC Lay member said 'if we think its right we'll do it, and ignore what goes on elsewhere.'
There was a part of the meeting today that focussed on Conscientious Objection, or Principled Non Compliance, p 37 of circulated document prepared by Michael Guthrie, Head of Policy and Standards.
The Strathclyde Prof asked HPC Head of Policy and Standards if the PNC suggestion was a practical option in his opinion. Guthrie replied that he could not foresee the government being able to accommodate it. [he spoke v quietly and quickly but this was the gist]
One lay member from the HPC said she had looked carefully at the arguments and chose one to dispute with here. The argument that the practise is entered into by consenting adults could not be supported because, as with dentists or estate agents, great harm could be done. She said 'it flies against the move'.
The HPC member representing Occ Therapy said You can't have your cake and eat it (you can't be on a register to be unregistered).
The User representative said 'What is the purpose of regulation - without statutory regulation people who are known to be harmful will continue to practise. People need to be prevented from practising. Either its the regulator or the law - and you can't have one law for one person and another for another.
Skills for Health quipped: they could always be taken [struck] off the non-register
another voice added "or sent off to Vermont"
The User representative continued: The evidence base [unsubstantiated] is clear that there is harm, the best outcome of these processes is that the vast majority will continue to practise in the way they've done before. Good practitioners will already be doing this. We have to come back again, and again, and again, to Public Protection. We are in the New World now, professional led self regulation is dead. The Health and Social Care Bill last year saw to that. There must now be equal numbers of lay people to professionals in the [regulation of the profession]
SfH said: Totally agree, these people constitute a harm. We must take a very firm view. Compared to other professions Psychotherapy is definitely harmful, potentially, 5% of practitioners cause harm [unsubstantiated]. The public is ill served by ineffective treatments with adverse effects. We hope it [the practise] will become more evidence based, with a little bit more notice of what is known, a general improvement in client care can happen. ...
BABCP said: We must not mock or ridicule these people, but the public needs protecting. The professionals need protection too. I think it [HPC] is a good move for the profession.
BPC: said We are the victim of our own rhetoric. Public Protection - we are part of the public too. We need protection, the clinical community needs protecting. Care providers are vulnerable. The public is at risk from us, but we are vulnerable to them.
HPC Physiotherapist said. Other aspirant groups have had this problem
The Chair: we have all been lobbied, the letter is philosophical. But they point to the confusion of State and Statutory Regulation, the question of totalitarianism. I've lived [or known someone who has lived] in [eastern bloc] for many years, I know what totalitarianism is, this is not that. It might look like it from the outside, but it doesn't feel like it inside the HPC. Also they talk of the medical model ...
CPCAB said The Petition had 1600 names at the beginning of the week, many of those are names of people I know and respect. I am not willingly a part of this but when I saw it couldn't be stopped I decided I had to join in to try to influence it.
HPC speaker said Public Protection also protects the registrant, it helps credibility, they have nothing to do but pay their fee, and gain status and credibility.
HPC Lay member said: HPC upholds public confidence in the profession, its a matter of pride to have been recognised by the HPC - its an external validation.
Amidst all this the COSCA member said: we might consider that there could be a number of registers springing up alongside the HPC one.
The chair suggested a ten minute break, and this discussion spilled into the adjacent room for coffee. On return they talked about the title Psychological Therapist. Then it was over as the HPC Lay member said 'if we think its right we'll do it, and ignore what goes on elsewhere.'
Being dragged willingly: experience of regulation by the state
During today's meeting of the PLG for C&P one of the group said that she had not wanted to be part of this process, but could see it was happening anyway and thought it was better to join in and to try to influence it, rather than be dragged unwillingly along.
Another member said there was no argument to avoid this process: times had changed, 'that' was history, 'this' is now, it is time for something new. This is new. That's all.
The HPC line is to reduce things to a shorthand: Professionals on the HPC register are safe, it is the others who are not. Then someone will say that professionals were a danger to the public before, and are only being brought under control by the introduction of lay people into their dominion. There is a lot to say here, a lot. But not much is being said in today's climate. There is a caste iron supposition that professionals are dangerous to society, and that lay people on boards and panels are the antidote to that. The force of this argument is quite frightening - it is used as a full stop to any further discussion. It has become a kind of magic bullet. This is the point on which I am focussed. How to uncover the process and mechanism that produces this kind of non-sensical thought. There is no magic bullet. I am more interested in the question: what needs to be done to allow ideas to be discussed and tested so that people can better understand the risks they are asking themselves or other people to take as a consequence.
The difficulty we are now faced with is how to minimise the damage that this twisted logic will cause. Only if we engage in thinking - and think not constrained by fear, nor compelled by brute force - can we hope to get out of this mess.
Another member said there was no argument to avoid this process: times had changed, 'that' was history, 'this' is now, it is time for something new. This is new. That's all.
The HPC line is to reduce things to a shorthand: Professionals on the HPC register are safe, it is the others who are not. Then someone will say that professionals were a danger to the public before, and are only being brought under control by the introduction of lay people into their dominion. There is a lot to say here, a lot. But not much is being said in today's climate. There is a caste iron supposition that professionals are dangerous to society, and that lay people on boards and panels are the antidote to that. The force of this argument is quite frightening - it is used as a full stop to any further discussion. It has become a kind of magic bullet. This is the point on which I am focussed. How to uncover the process and mechanism that produces this kind of non-sensical thought. There is no magic bullet. I am more interested in the question: what needs to be done to allow ideas to be discussed and tested so that people can better understand the risks they are asking themselves or other people to take as a consequence.
The difficulty we are now faced with is how to minimise the damage that this twisted logic will cause. Only if we engage in thinking - and think not constrained by fear, nor compelled by brute force - can we hope to get out of this mess.
Names and naming
The PLG for C&P has been thinking about names that describe or label a practise, and I've been wondering about names that designate a person. I have been quite alarmed by the HPC habit of naming people as potentially unfit for practise before their case is heard. In effect this means that someone has their name exposed in some way for more than a year, and this is obviously a harm. I have wondered whether the HPC should apologise when the FTP panel decides there is no case to answer. When writing about these cases I have deliberately not used the registrant's name. The more cases I went to, tho, the more I began to wonder about the anonymity of the other people engaged in the process. To begin with it never occurred to me to include these people's names. But the more I observed, the more I thought about the meaning of a person's name and how that related to the professional nature of their work.
Being a professional, if you take it etymologically, can mean standing by what you say in public. There are other things to say here, but for now this is what I want to think about. The Fitness to Practise hearings are public spectacles. Board meetings are held in public. The PLG is held in public. The Fitness to Practise hearings are written down by a court stenographer who types up the notes and they become a testament to the process. People's names are used in these documents, and the HPC will send them to you if you request them. They are in the public domain. The people are named, and take responsibility for what they say. They are professionals. The lay members are professional in this respect too. Everyone is willing to act in their own name. No-one is 'just following orders'.
The professional liaison group is populated by people who are willing to speak, but some of these are speaking in their own name, others are speaking on behalf of organisations or associations of others. Should they be named in the notes? How should they be named in the notes? How should their contributions be attributed, and what is the responsibility of a blogger in this respect?
Well, I take responsibility for what I write, and I remind you that you can comment on it - this is the nature of a blog. You can also email me easily enough, and I can change what is written if necessary. The new technologies that have sprung up over the last few years give us new pause for thought. Join me in figuring out how to make this work in the spirit of long term public good. You are welcome.
Being a professional, if you take it etymologically, can mean standing by what you say in public. There are other things to say here, but for now this is what I want to think about. The Fitness to Practise hearings are public spectacles. Board meetings are held in public. The PLG is held in public. The Fitness to Practise hearings are written down by a court stenographer who types up the notes and they become a testament to the process. People's names are used in these documents, and the HPC will send them to you if you request them. They are in the public domain. The people are named, and take responsibility for what they say. They are professionals. The lay members are professional in this respect too. Everyone is willing to act in their own name. No-one is 'just following orders'.
The professional liaison group is populated by people who are willing to speak, but some of these are speaking in their own name, others are speaking on behalf of organisations or associations of others. Should they be named in the notes? How should they be named in the notes? How should their contributions be attributed, and what is the responsibility of a blogger in this respect?
Well, I take responsibility for what I write, and I remind you that you can comment on it - this is the nature of a blog. You can also email me easily enough, and I can change what is written if necessary. The new technologies that have sprung up over the last few years give us new pause for thought. Join me in figuring out how to make this work in the spirit of long term public good. You are welcome.
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