Jucial Review, appealing against the HPC decisions

Someone had been advised by the HPC that the only means of redress open to them after a decision had been made by the HPC was via a judicial review. They duly set one in process, and hired a solicitor. Only then did they discover that they were not in a position to put such a process into play.

This case involved an NHS manager who had been sacked. The HPC tend to trawl these cases and bring them into their own net to re-play the scene and ring out the surplus value. The upshot of this is that the HPC then becomes the complainant in the HPC Process. People who had been involved in the original case might be forgiven for thinking that they still had a part in this second playing of the scene, but in fact they don't. The HPC take over the show - in this way they act on behalf of an imaginary public and take a local sacking into a national misdemeanour.

There are two threads - one is the way a local event is passed to a central court (local difficulties acquire national status), the other is the question of self interest. The original professions were attacked on the grounds that they couldn't be trusted to keep their house in order as they were likely to be biased in their own favour. This inconvenient truth, however, also applies to any new body set up to keep order, it is part of life and must be dealt with by each of us as we act. The idea was that the HPC would always be objective because it has no interest in the professions it manages. However, this completely ignores the interest it has in maintaining itself - it is a naive, puerile view. The HPC is left with no other purpose than to maintain a register and police it - it is administrator, law enforcer, law interpreter, law maker. In the case of the original professions they were also interested in the work itself, and the knowledge pertaining to the work. In fact they were more interested in the work itself for without it they would cease to exist. In the case of the HPC their work - their trade, their profession so to speak - is administrative and legal. They are not interested in the actual work of the people over whom they have such far reaching legal powers. Their business is collecting names onto registers (and money associated), arranging the lists, creating sets of abstract standards of character and practise at a distance, and of enforcing these standards. That's it. It is a false profession, based on nothing. They are under the jurisdiction of another such body (the CHRE) and each of these is under the jurisdiction of the Privy Council, as far as I can see.

My contention is that the HPC is an artificial creation based on a false assumption. This is very shaky ground which sets up a need for a strong policing in order to make it work - an artificial force takes the place of any possible natural order. This sets up an absolute system and places far too much power in the hands of a small set of people. It is a very tricky situation, and one which is out of balance with the requirements of the situation.

It has been very common to explain the creation of the HPC and the CHRE through reference to Harold Shipman. The fear that is created by this move is two fold. There is the fear invoked through reference to a serial killer, and there is fear invoked by the irrationality of the reference to the subject in question. That is, there is no rational link between this murderer, and the creation of a large list, a centralised knowledge base, and an aggressive police force. The link has more in common with a paranoid idea than it does with reason, experience, and rationality.

The Information Commissioner & HPC's FTP

You can go to www.informationtribunal.gov.uk and get copies of cases, I have one whose decision was promulgated on 14 March 2008. According to my dictionary of word origins, promulgate is linked to the idea 'to milk', that is to cause to emerge. This promulgation was set in motion by a series of events which culminated in a Freedom of Information (FOI) request by Ms Z who had referred a case to the HPC. The HPC refused to give the information which led to the Information Commissioner being called onto the scene. He then issued an Information notice requesting sight of the disputed information and the HPC appealed this notice under section 57(2) of the FOI Act.

Are you following all this?

I'm new to all this too, but little by little I intend to try to discover something about the particularity of the time we live in, the institutions we invent, the context in which bits of our lives get lived.

From the promulgated decision I learn things that I already knew: "The HPC is established under the Health Professions Order 2001 (the 2001 Order)" and subtle differences from things that I thought I knew: ... "It's main functions are set out at article 3(2) of the 2001 Order as "...to establish from time to time [my emphasis] standards of education, training, conduct, and performance for members of the relevant professions and to ensure the maintenance of those standards." The main objective in exercising its functions is "to safeguard the health and well being of persons using the services of registrants." This is written in The Order. But there is room for interpretation in practise and it is this that is in question at the Tribunal Service.

"The HPC's functions include the maintenance of a register of health professionals and a mechanism, called the Fitness to Practise process (the Process) whereby the conduct and performance of registrants may be investigated and called to account. An adverse adjudication on a registrant's fitness to practise may lead to, amongst other things, a registrant being removed from the register (such that they could not work in their chosen profession) or conditions being attached to the performance of their profession. Members of the public, employers etc, may make allegations to the HPC with regard to the fitness to practise of particular registrants. Such cases are investigated by the HPC and as a preliminary step in the Process a decision will be taken by a Panel of the Investigating Committee whether there is a case to answer. [If not, the Process ends. If so, a new Committee is called for a full hearing." (Quoted from the Tribunal's introduction.)

In the case in question the initial Committee decided there was no case, so Ms Z made her FOIA request to see on what basis this decision had been made. This was refused by the HPC on the grounds that certain exemptions applied, namely sections 30, 40, and 41... So Ms Z made an application under section 50 of the FOIA for a decision by the Information commissioner as to whether her request had been dealt with in accordance with law. After a lot of argy bargy the HPC filed a Notification of Appeal against the Information Commissioner's Information Notice and so triggered this appeal to tribunal.

It's quite Dickensian - we are in the field of law, very particular human relations, and, by the by, a professional practise.

The Tribunal heard evidence from Mr Jonathan Bracken from Bircham Dysen Bell, who were solicitors for the HPC. Mr Bracken had been involved in the setting up of the HPC and had advised on many of its processes, he had drafted most of its rules. He explained to the Tribunal that the HPC had 'moved away' from a punitive disciplinary scheme, and had put in its place the Fitness to Practise regime. It is a process in two stages. These stages were put into question at the Tribunal and Mr Bracken was revealed as lacking (he had to admit that some of his documents 'perhaps were not as well worded as might be') .

The next in the dock was Ms Kelly Johnson, the HPC's Director of Fitness to Practise. She was obliged to say that 'the practise and procedure guidance were living documents and in certain respects in need of revision'. In the course of her evidence she revealed that the information gained in the Process at the early stage could be shared with the competent authorities of the other European Union states, and in addition, circumstances could arise in which the HPC gave the police a registrant's information prior to a 'no case to answer' determination. Registrants are not warned of these possible disclosures.

To cut a long story short, the Tribunal concluded that 'registrants were unaware of the fact that HPC on occasion made disclosures in the public interest... The reality was that the 'aura' of confidence (as Counsel for the HPC had put it) attached to the information provided by registrants, was not as clear or as bright as contended." [my emphasis] Furthermore, the Tribunal added "this case came nowhere near the mark". Their decision in favour of the Information Commissioner had indeed been unanimous.

A public point of view: Paola

Paola commented recently that: From where I am standing, the HPC has been protecting the professional against ACCOUNTABILITY. This has not helped her either: learning of the dire consequences of her many misguided actions and inappropriate interferences would have given her valuable feedback and helped her in her professional development and in her personal growth: the HPC has failed her too...

She continues:

"I always felt that there would be much more value for us in an apology and in a constructive use of the damage done to my son and myself as an opportunity for education and training, awareness and growth. The HPC does not do these things. In fact, and with reference to my previous post, the HPC does not do apologies either. The HPC does not do feelings and emotions and real people full stop..."

Paola's experience reveals more of the nature of this particular bureaucracy. It has been set up not as a pre-packaged or natural object without history, values, or character. It is a kind of living thing that can be assessed as a creature in its own right. In a previous blog I reported that Mr Williamson (one of the FTP panel chairmen) had pointed out that the HPC was similar to the GMC and that had inherited something from its predecessor (housed in the same building, and perhaps employing some of the same administrators and support staff) the Council for Professions Supplementary to Medicine. There is every reason to procede with an enquiry into the nature of this new thing, and not to assume that an organisation has no character nor that such is irrelevant. It is a necessary discipline to consider the character of the HPC and its conduct and to ask if it is fit for purpose.

There are also the unintended consequences. Paola raises this other point. "It seems to me that there may well be another worrying outcome of HPC regulation, a danger inherent in their structure and procedures: that the academic and professional standing of registrants under investigation will have a bearing on the outcome. In other words, that there will be a hierarchy of vulnerability to sanctions ..."

From my random attendance of FTP hearings I could not help but be struck by the absence of genuine cases raised by bona fide patients. So far there has been an angry and aggressive man shouting at an ambulance driver, a frightened colleague wishing to avoid another hearing about his own conduct, a training manager who thought he would be held responsible for an amblance drivers decisions, and a new recruit anxious not to be contaminated by any kind of accusation that she rules had not been obeyed.

The HPC has a particular nature, which has an effect on those it brings within its domain.

HPC PLG C&P day 2, pm

Towards the end of the HPC PLG for C&P last week the group started thinking about their next meetings. According to the work plan written down by Mr Guthrie, most of these meetings will be taken up with the question of Education and Training/standards of proficiency.

As the group approached this they revived something that Diane Waller had mentioned and parked a bit earlier. It was the question of 'life coaches' and people using other titles but doing similar work. Mr Guthrie had reminded the group that the process was about Protecting Titles, not function. This left the difficult question of figuring out how the HPC could guarantee anyone on its register without recourse to training and validation of practise. There is also the question of what they would do if people simply invented a new title for their work.

This is the way the nightmare works. Having invented a name, they now have to invent a new practise that fits the name and that they can police, otherwise they have no power whatsoever. It is a where the twist in the law is most obvious. The mistake Ian Kennedy and his followers made was to imagine a group of people who were the exception to the rule. The rule was that professionals were not to be trusted, the exception to this rule could alone solve this problem. The exception to this rule is the HPC. When Ian Kennedy said so casually 'why should they [the medics] have the power over life and death' he implicitly also said 'it should be us, who are better'. Which is, of course, nonsense.

What follows is a compact and incomplete account of some of the discussion. I've given it like this as an antidote to the anodyne minutes which reduce all the differences in the group to a single unanimous voice. I have also included their names so that anyone reading this blog might decide to engage in a conversation with any of these people (simple to figure out how through google) on some of the points that they make.

Jonathan Coe (Witness CE) said "The need for standards in professional training is what will protect the public."

Graham Smith (HPC Panel, Physio) linked this to the 'intention to deceive'.

Karen Ablack (UKCP standing in for Kathi Murphy) remarked that 'if people are not doing it [therapy] well enough and they are using my professional title then ...' she left it to her body language to indicate what she would do (flush them down the loo, I guess, she seemed to
indicate poo).

Mary Clark Glass (HPC Panel lay member) said 'we'll get them on it - if you go beyond your skills and competence, you will be called to account'.

Someone said "Prevention is the better protection of the public"

Finally Julian Lousada (BCP) remarked 'we've parked a difficult issue' to which

Diane Waller (chair) replied 'we can be seen to have done justice to the question'.

Sally Aldridge (BACP) then offered to exhume a dead and buried report done by the big 5 some years ago [UKCP, BACP, BPS, BCP, BABCP I think] which had tried and failed to synthesise competencies across the board. Someone else offered another similar dead and buried document, and Peter Fonagy (SfH) offered his NOS. All were eagerly accepted as fodder for the next few meetings.

In this way the work done in these other places by these other people for those other purposes are going to emerge into this tight schedule and could easily be taken up for want of the time to make something more suitable. This is how bad laws get made, and its other people who are going to suffer the consequences without any idea how it happened to them. That's why I'm writing this blog.

Max Weber on Structures of Power

"All political structures use force, but they differ in the manner in which and the extent to which they use or threaten to use it against other political organisations." This is the opening sentence of an essay first published in 1921 but written between 1910 and 1914. He is careful to distinguish the differences in the ways different states make use of their structures of power, as he goes on "Not all political structures are equally 'expansive'. They do not all strive for an outward expansion of their power". He speaks of the jealousy of neighbouring states, of the vulnerability of those in possession of colonies to that jealousy, and of the way that proximity and shape might expose some states to invasion from their neighbours. In the opening paragraph he sketches the usual way a structure might acquire domination over another: "by incorporating [others] or making them dependent."

All this can be read in the collection by HH Gerth and C Wright Mills that I have borrowed from my local Lambeth Library, and which I note (not without interest) was first published in 1948.

He goes on to sketch two broad attitudes that political structures tend to have towards those outside their immediate control. They can be more 'isolationist' or they can be more 'expansive', and of course they can change their mind about this along the way. 'On the basis of this power the members may pretend to a special 'prestige' and their pretensions may influence the external conduct of the structure.. Experience teaches us that claims to prestige have always played into the origins of war... Feudal lords, like modern officers or bureaucrats, are the natural and primary exponents of this desire for power-oriented prestige... power for the political community means power for themselves as well as prestige based upon this power."

"For the bureaucrat and the officer, an expansion of power, however, means more office positions, more sinecures, and better opportunities for promotion (even in a lost war)."

After a short excursion into some moments in history describing states favouring isolationist policies (including Roman, Britian, and Spartan) he returns to the question of fear. "The Spartan aristocrats, so far as they were able, quite deliberately limited their political expansion for the sake of isolation. They restricted themselves to the smashing of all other political strucures than endangered their power and prestige. They favoured the particularism of city states. Usually, in such cases, and in many similar ones, the ruling groups of notables (the Roman nobility of office, the English and other liberal notables, the Spartan overlords) harbor more or less distinct fears lest an Imperator, that is, a charismatic war lord, emerge. A tendency towards centralisation of power goes very readily with a chronically conquering 'imperialism' and the war lord might gain the ascendancy at the expense of the power of the ruling notables."

Weber concludes this opening section by returning to the question of money: "Like the Romans, the British, after a short time, were forced out of their policy of self-restraint and pressed into political expansion. This occured, in part, through capitalist interests in expansion."

In order to try to understand the nature of the hpc it is necessary to understand the context which brought it into existence. I've gone back to Weber as a kind of touch stone. I particularly like the way that he sets off without forgetting that human beings are subject to fear, jealousy, aggressivity, and greed. He doesn't emphasise this unduly, he doesn't do it like Ian Kennedy, and he doesn't pretend it isn't part of the scene. It is the sensibility of a novelist in the service of a sort of science, not the raging of a beautiful soul against the sins of the others.

Local practise, central rhetoric.

The issue that continues to get lost in all this public protection and regulation type talk is the real local problem of the difficulty that people get into when they try to work together. What can be done when someone disagrees strongly with the way their practitioner is operating, or if they think they have been harmed by it in some way? On a comment to a previous blog Paola has talked of the change in relation between her and her son when he began working with a music therapist. The music therapist is registered with the HPC so Paola took her complaint there. Judging from her comments she found the process very unsatisfactory, and instead of reducing her disquiet it has given her more to complain about. From her point of view the HPC is protecting the practitioner against her right to complain.

Jonathan Coe is the chief executive of Witness, a charity set up to help people give voice to their complaints against practitioners. He is on the PLG for C&P at the HPC. At the last meeting (Jan 09) he said that the evidence base was clear that there is harm done by practitioners in the field of counselling and psychotherapy and that something must be done about it. He was particularly concerned to know how to stop someone practising after it had been decided they should be struck off the register. But what, Jonathan, what shall be done? I can see  no good reason to believe that the HPC will make things any better, with it's huge computerised list of names, its random spot checks on Continuing  Professional Development, and the centralised policing of educational standards across the hundreds and hundreds of colleges up and down the country. I can see plenty of reason to believe that it will make things worse.

When it comes down to it, the problem is  how to create conditions for safe practise, for informed and thoughtful practitioners and publics, and for safe and productive forums of debate and disputation. 

At the recent Rally of Impossible Professions, in London (September 2008) a university counsellor gave a little example in the morning of the way that safe spaces were being eroded by the encroaching audit culture. Where once there was a group of practitioners who created a space in which it was possible to discuss the issues and deal with the anxiety arising from some of the work, now the manager closes down difficult topics and imposes brute control.

In an afternoon session at the Rally, Mark Neocleous outlined  the steady rise in the discourse of security and shows how, paradoxically, it creates the conditions conducive to hostility. The repetition of empty phrases like 'we must protect the public', or 'regulation is the only way', or '5% of practitioners are a danger to society' contribute to a rising unease because there is no way to understand what they mean.

It is this that is the crux of the problem. The PLG at the HPC are happy to keep repeating the phrase 'we must protect the public', but are less interested to hear that they are perpetrating a problem that is producing a very real danger for a much bigger public by obliterating the conditions for safe practise and genuine enquiry.  The HPC is part of a very large and long process of centralisation in this country that is steadily tearing knowledge away from practise. Michael Power's ongoing work into the rise of the audit culture leaves the reader in little doubt as to the way that this is happening. Read the beginning of the argument  here and follow it up in his other books, they are very well written, cogently argued, and give an unbiased account of the nitty gritty  way that these things are happening. And they are happening here in the UK.

Centralisation

On this morning's Today programme a piece of news announced that Government Minister's were interested by Denmark's Social Workers' approach to looking after children. Government Ministers, mind.

Five years ago I was at a conference in Birmingham at which a few hundred people (medics, managers, policy makers) were discussing European Health Management issues. I think it may have been a man from Denmark who said with emphasis (that seemed to stun even him) that the British System was so very much more centralised than in all the rest of Europe.

Twenty five years ago, as a freshly minted business studies graduate, I was engaged on a project on the question of Centralisation at British Telecom. This was in the year of its privatisation. It was the first of the nationalised industries to come onto this new scene, and was Mrs Thatcher's innovative entry into creative accounting. At that time the rhetoric was all about decentralisation as the most effective business strategy, and it was used very much as a rationale for flogging the national asset and for dismantling the organisation. Everything was put into question as 'centralisation' was linked to the 'old ways of doing things' (and thus put into the moral bad box) and decentralisation was linked with the cut and thrust of commerce (hence morally good).

I am not interested here in the rights and wrongs of nationalisation and privatisation, but I am (and was) very interested that a centralist decision was being rolled out under the rhetoric of decentralisation and that there was a twist in the idea that seemed impossible to resist. A few years later I fetched up at Thames Water to do an ethnographic study of computer systems design. Here I was amazed to discover that privatisation was in preparation under the signifier centralisation! Thames Water, in virtue of the nature of its business, was very much tied to the ground. It's operations (water works, sewage treatment works) were very much linked to particular localities and had a strong association with people and their bodies. In spite of the obvious reasons for this, 'decentralisation' soon became associated with nationalisation, and hence part of the moral bad ground, and Centralisation became the name of the new strategy, associated with all that was good.

This new strategy at Thames Water was brought in at huge expense from Anderson Consulting. This was one of the Big Five consultancies who enjoyed great success around the world, and who employed the elite of the graduate crop each year. This organisation now goes under the name of Accenture - the name change came shortly after the Enron debacle, I'm sure you will recall. The bulk of the work that I witnessed at Thames Water was to do with the creation of a call centre in Swindon (one of the first of this new idea) which was to be supported by the creation of an immense set of computerised information systems. A significant, yet implicit, part of this new ideology was the belief that it was better to remove knowledge from local human beings, and place it in machines.

I think it would be easy to read this as an attempt to lay blame and seek retribution. I'm sure I am susceptible to that, at least as much as anyone else. But actually I think that this is precisely the problem. It is only just dawning on me, after all these years of study, analysis and consideration, that we as a country (at least) are well on the way to Popper's Nightmare in so far as a certain process of centralisation has been steadily ongoing in so many different areas of our life for at least 25 years - and is accompanied by the rise of a rather ridiculous morality .

The creation of the HPC is very much part of this process, and even with the best will in the world and the greatest minds in the Kingdom, it would be difficult for anyone to overcome the pressure that has been building up over decades which aims to produce intelligent centralised systems based on a pernicious idea, and at the expense of decentralised, real, local, loyal (at least they used to be) human subjects.

Small wonder it is Government Minister's who are so interested in Denmark's Social Workers, or that this counts at mainstream morning national news.

Snow

The last time there was snow like this was 1991. A huge cloud of snow on its way to Moscow dumped itself prematurely on south east England. I remember it well. The roof to our block of flats was removed in readiness for a new set of slates. Perfect timing. But more memorable was the fact that I was off to Moscow for the 33rd Annual Conference for the Young Historians and Philosophers of Science. Much excitement as everyone was saying it was colder in London than in Moscow. I had been offered the chance to go to this conference by Steve Woolgar, who was then the head of a research centre at Brunel University that hosted a number of projects looking at innovation, culture, and technology. I was engaged on an ethnographic study of computer systems designers at in a water company just before privatisation. It was this research that formed the basis of the paper I was to give to the young historians and philosophers in Moscow.

I count myself very lucky to have had the chance to go. There was one MacDonalds in the main square, a single bright blob of colour in a grey landscape with a huge long queue snaking out the door and down the road. Queues were not unusual, of course, and not particular to MacDonalds, they were a part of city life. Other bits of life were also open to me. I was given a room in an appartment of a lovely young woman and her husband for the duration of my stay. Their fridge and cupboards were stocked to the gills with merchandise of one form or another. Their phone rang almost constantly when we were at home, and this was the mechanism that triggered the exchange of money and goods for this family and their friends.

I also remember my amazement when standing at a bus stop with Natasha waiting to get home. We were there for just a few minutes when a car pulled up and we jumped inside. She explained that this was normal - she didn't know the driver, but in return for taciturn grunts she handed him a few coins when we got out. It was not a pleasant social experience, but it was extremely helpful on a cold winter's night.

I had intended to go to the HPC today to observe the Education and Training Committee Panel meeting, but apparently all the buses in London have been suspended, and I'm certainly not chancing my bike. Can you imagine our society developing a private taxi service along the lines that sprung up in Moscow? I wonder what we would do should it ever become necessary to innovate.

Little Dorrit - nobody's fault, everyone's in it

The recent serialisation of Dicken's Little Dorrit was remarkably well timed on the question of unexpected wealth followed by unexpected crash. In an earlier film version of the book, however, the subtitle is added to remind us of the subtle point that Dickens was making throughout the story: Nobody's Fault. This refrain runs through each of the intricate threads of the book and is especially interesting in relation to Arthur Clennam recently returned from 20 years in China. He imagined that his family must be responsible for Mr Dorrit's extended stay in the Marshalsea debtors' prison, and tried to assuage what he felt sure was his guilt in this other family's story, and in doing so unwittingly set up the conditions in which a greater tragedy was to play out.

In the meantime, Mr Merdle, man of the age, was held captive in his position of money maker. Few wanted the trouble of working out how to make their own money increase in value, rather they clamoured to press their cash into his bank in the irrational belief that Merdle could make it increase in value.

A third theme includes the Circumlocution Office where legal documentation and process are entirely submerged in arcane process and bureaucratic nightmare coupled with men who, robbed of any access to worthwhile work of their own, barely rise above the pettiness of obstruction and snobbery.

In the telling of the tale Dickens draws out the characters, and allows this to be the motor of the story. The overall 'fault' is the accumulation of faults of the players.

The Lobbed letter: a few home truths

In yesterday's PLG C&P meeting there was a section devoted to the question 'conscientious objection'. This matter had been reduced to 3 lines in Michael Guthrie's report for the group, but it turns out that some members of the PLG had also received a letter from the College of Psychoanalysts UK. Perhaps not everyone had received it, and it wasn't actually mentioned by anyone on the day. But the letter has now been published on the website of the College of Psychoanalysts-UK (click heading for link).

Dear PLG Member,

We are writing to you as a member of the HPC Professional Liaison Group because we believe it is valuable for all those on this important committee to have equal access to information concerning the question of the proposed HPC regulation of talking therapies and the consultation process so far. This process, unfortunately, has failed to remain faithful to the original Department of Health remit to include representation from the breadth of the professional field and to respect the difference and diversity of the stakeholders concerned. Documents recently released under the Freedom of Information Act, which will be detailed below, make this clear and give us serious concern about the parity and transparency of the consultation to date.

There are three main issues here:
. Misunderstandings about the commitment of all psychotherapy groups to appropriate regulation of the profession in the interests of public protection and the vitality of psychotherapy.
. The importance of explicitly reflecting the particular and differing nature of the psychotherapies in the mechanisms of regulation.
. The hijacking of the process by a minority section of the profession to the exclusion of others.

From the first PLG meeting held on 4/12/08 it seemed apparent that the scope for discussion of these difficult issues is likely to be very limited, with the danger that they will be treated as inconveniences to be given an airing and then ignored. We believe it is important that you are aware that they are not minor details and that thousands of clinicians, as well as academics, intellectuals and public figures, across the country are gravely concerned about the high risks involved in a hasty and ill-informed consultation process. A major media campaign will begin later this year which will draw public attention to these problems.

We understand that it is not the HPC's task to assess whether it is fit for the undertaking the Government has given it, yet that it is within the scope of the PLG to comment on the appropriateness of HPC regulation of the talking therapies and to understand and reflect on the relevant arguments. These arguments relate specifically to the issue of the effectiveness of any future register, the protection of the public and the concern that the action of the HPC in carrying out the task of regulation be proportionate to the requirement that the public be protected. 

Commitment to Regulation

We, and all psychotherapy organisations of which we are aware, have been actively committed to regulation for many years. The self-regulatory systems which have been developed over the last 20 years have grown in sophistication and effectiveness and are continuing to do so. When critiques of the proposed HPC regulatory framework are formulated, the response is often that this is because the clinicians in question just don't want regulation. This is a major misunderstanding. The concern is not with regulation, which already exists, but that the proposed process of HPC regulation will narrow the broad practice of psychotherapy, making much of what currently takes place in reputable psychotherapy consulting rooms illegal in the near future. We are also concerned that the Government's insistence that all psychotherapies be subsumed under the Health Professionals' umbrella will inevitably impose on psychotherapies the same framework as fits the health professions but does not translate to a non health-care profession such as ours.

To date, neither HPC nor Skills for Health have published a risk analysis of the field of psychotherapy, nor research into appropriate forms for its regulation. In Australia, the government aimed initially to regulate psychotherapists and counsellors under a healthcare model, yet after a three year consultation period, they accepted that counsellors were best left to self-regulate, and the same result looks set to happen for psychotherapy. The government there has recognised that statutory self-regulation works better for the protection of the public and for the life of the profession itself. The Australian consultation demonstrated that:

. Counselling and psychotherapy are fundamentally different from the majority of health professions.
. The focus of 'talking therapy' is the relationship and the process of therapy, rather than the performance of certain definable procedures.
. It is difficult and even unhelpful to define competences and scopes of practice in a narrow legalistic sense.
. A diversity of training bodies, professional associations, and theoretical approaches is both a strength and a weakness and requires a model that respects diversity while being clear about standards.
. The profession would be best managed within a self-regulatory model based on professional colleges, which will have the necessary expertise to link training standards and practice.

It seems important to us that the question of the regulation of talking therapies which explicitly claim not to be health-related be given proper consideration. Many clinicians see their work as an exploration of the human condition, a journey in the same sense that becoming a Buddhist monk involves a long process of questioning one's life, ideals and expectations. Like a Buddhist training, this long process of psychotherapy cannot be identified with a set of techniques or procedures to be applied to a human being, but forms rather a strange kind of relationship which operates in unpredictable and unexpected ways. One cannot know what will happen in advance, and change often takes place through surprise, bafflement, shock and disappointment. 


The Particularity of the Talking Therapies

The results of the Skills for Health consultation on psychoanalytic/psychodynamic therapy were published recently in draft form. These are the so-called National Occupational Standards (NOS). They list 451 criteria and guidelines for psychodynamic and psychoanalytic therapy. They dictate every aspect of how therapists should organise their sessions, how they should 'monitor' themselves and how they should carry out their work. They go into minute detail about the timing of interventions, the setting of the therapy, its aims - and even the expression of appropriate 'feelings'. Such an application of externally-imposed rules - most of which were expressly contraindicated by Freud, Jung and the analysts who followed, such as Klein, Lacan and Winnicott - removes the very foundation on which such therapies are based, namely the freedom of both parties to work together authentically and creatively.

If these rules were to be accepted, then it would no longer be possible for many clinicians to work in this country. Although the HPC has been keen to point out their independence from Skills For Health (SfH), it has also been made very clear that the work done by SfH on National Occupational Standards will 'inform' the work carried out by HPC. The NOS draft is an extremely controversial document and the process by which it was arrived at has been shown to be highly partisan, an issue we will come to presently. If the HPC has to gain a full understanding of the profession it hopes to regulate, this understanding risks being biased by the influence of the SfH project.

The SfH project has attempted to shoehorn analytic work into the current culture of outcomes, where all variables must be predicted in advance and evaluated in relation to expected results. Analysis, however, and many forms of psychotherapy, involve an open-ended relationship, where results may emerge that were never predicted or even thought of by the person in analysis. The very distinction between conscious and unconscious motivation that lies at the heart of analytic work is ignored by the proposed regulations which encourage a 'false self', a box-ticking clinician, fearful of being watched by the authorities and anxious to please them. If analysis has an aim, it is to help patients free themselves from irrational forms of authority, exactly those that now threaten to constrain their work within the therapy.

According to the government roadmap, HPC will establish a list of reputable practitioners, which will mean effectively those who adopt their particular formulations as to what talking therapy is about. All the documentation published to date by HPC shows a serious misunderstanding of the nature of analytic work, together with a new insistence on 'good character' defined in highly rigid ways. If this goes ahead, then members of the public will no longer have the freedom to choose their analyst, a fact already brought up by user groups. They will have to select a practitioner from a list which only includes those who practise a particular form of therapy. Practitioners who are totally opposed to the idea of their work as 'healthcare' will have to adopt a healthcare model and become 'model citizens', when the whole of the analytic tradition emphasises that the practitioner's human failings are essential for the analysand to recognise and work with.

Nearly all of the professional groups in the field have agreed that HPC is not suitable as a regulator for a variety of reasons, yet one in particular stands out regarding analytic work. In this work, the analyst puts themself in the place of the object of all the projections of the analysand. Powerful feelings of hatred, disappointment and rage that had once been directed to one's caregivers and then repressed or negated may emerge and now be directed to the analyst. These are features of the phenomenon known as 'transference'. The analysand will not be aware that this is happening, and hence a long, difficult and painful period may follow when these feelings are clarified and worked through. At the same time, the analysand may realise that the analyst is no expert but just a fallible and weak human being. The sanitised image of the practitioner aimed at by HPC cannot fit this model, just as the complaints procedures they adopt are not sensitive to the crucial question of transference. Analytic work requires, in a sense, that the analyst should become a scapegoat, and at the same time, act unpredictably or even shockingly. How else, after all, to overcome the defensive system that someone may have spent their whole life constructing? Change in analytic work rarely comes about by the polite communication of some hypothesis ('When you were a child, X must have happened..'), but through interventions that may seem, or indeed may be, totally unacceptable to the analysand. This is how analysis works, and it is unlikely that HPC complaints panels would be well-suited to assess the complexity and often hidden nature of such issues within a culture where complaints against practitioners by their patients are openly encouraged by the regulator. An extensive literature exists on this question, which has been totally absent from all bibliographies published to date during the consultation process.

Hijacking of the Consultation Process

The consultation process initiated by the Department of Health was intended to assess the feasibility and suitability of state regulation through dialogue with all of the professional field. However, Skills for Health allowed their consultation to be monopolised by a very small number of people with both a narrow and restrictive view of psychoanalytic practice and, arguably, a clear agenda to further their own particular brand of therapy which they endeavour to promote within the NHS. The task of drafting psychodynamic/psychoanalytic competences was given by Skills for Health to Tony Roth and Steve Pilling, employees in the UCL Sub-Department of Clinical Health Psychology run by Peter Fonagy. Fonagy, in fact, chaired the Executive Group and the Strategy Group of the SfH project and also sits on the Reference Group. These researchers, aside from having the link to Fonagy, are known for their work on CBT, a set of therapies which are totally at odds with psychoanalysis and most psychodynamic therapies. It is extraordinary that the work was given to them rather than to one of the many university departments of psychoanalysis in the UK. It raises the question of how the UCL department managed to secure this contract.

This bias was continued in the composition of the project Expert Reference Group and the Modality Working Group, both of which were chaired by Anthony Bateman. Bateman is a close colleague of Fonagy and the two have co-authored a treatment manual for a form of therapy (MBT) which they endeavour to promote within the NHS. Fonagy is Director of the Anna Freud Centre, which holds courses on MBT in conjunction with the UCL Sub-Department of Clinical Health Psychology. These courses are held for those working in the NHS and generate revenue for the institution concerned. There is thus a clear line of economic benefit here. It is perhaps no accident that the competences produced for psychodynamic/psychoanalytic therapy fit MBT remarkably well, but not psychoanalytic work.

It is important for the PLG to be aware here of some history. The BPC is a network of organisations centred around the British Psychoanalytical Society, also known as the Institute of Psychoanalysis - of which Fonagy, Bateman and Julian Lousada are members - an organisation which for many years claimed to be the only psychoanalytic training body in this country. They repeatedly published statements that only their own members were psychoanalysts, and even wrote to newspapers claiming that those who pursued other psychoanalytic trainings were deceiving the public. Over the years many other psychoanalytic organisations were established, attracting trainees who were not drawn to the Institute's practices, their theoretical orientations or the ethics of their selection procedures: gay trainees were not accepted until quite recently. As the absurdity of this position became clear, they moderated their claim to a monopoly, yet there is still a real tension between the Institute - and hence the BPC groups - and the other non-BPC psychoanalytic training organisations in the UK. This is a major political factor in the current regulatory landscape.

The composition of the Expert Reference Group and the Modality Working Group is biased quite radically in favour of BPC - Fonagy and Bateman's organisation - with nearly all members coming from there. The list for the Psychodynamic Modality Group established on 16/10/07 consisted off 11 people, all of whom come from the BPC. Another list sent by SfH to Fonagy in January 2008 received the reply that it "goes slightly too far in the direction of UKCP", yet this list of 16 people included 2 from UKCP compared with 11 from BPC. UKCP, moreover, had pointed out to SfH in Jan 08 that it represented the majority of psychoanalytic practitioners in the UK. Documents released under the Freedom of Information Act show how the lists for the work groups were made up almost exclusively of those from BPC and that, when other names of organisations or user groups that had actually been invited to participate were proposed or added to the lists by SfH, they mysteriously vanish. When further information on these disappearances was requested by The College of Psychoanalysts-UK under the Freedom of Information Act, SfH replied by sending hundreds of pages of totally irrelevant documents relating to the CBT groups and then claimed that they could not help further as they were only obliged by the Act to perform a certain number of hours work collating documents.

We also believe that some BPC groups may have failed to inform their members of developments in the consultation process, with a handful of those on the relevant committees making claims for their membership without proper consultation. It is remarkable how nearly everyone involved in the SfH working groups either comes from BPC or the Fonagy UCL Department. In the list of PLG members that HPC have published, Fonagy's institution is listed as Skills for Health, an extraordinary claim given that, as far as we know, he is not an employee of SfH and is in fact associated with the British Psychoanalytic Council, the same organisation as the person preceding him on the PLG list. If Fonagy's affiliation had been stated correctly, it would obviously have shown a bias in the PLG composition. HPC has thus not acted with transparency in this matter.

Fonagy, likewise, has been relied on in a wholly unprecedented way by SfH: in an email of 19.10.07, Linda Hardy of SfH writes re Fonagy "I sort of feel I don't want to ask him everything". The PLG should be aware that Fonagy is a highly controversial figure in the world of psychoanalysis. He has advocated genetic testing as a guide to focus psychotherapy intervention and brain scanning to 'test' the results of psychodynamic work. He has termed the traditional neuroses 'disease processes' or 'weaknesses in brain function', and even encouraged brain scanning of two year old infants to determine whether psychotherapy intervention is necessary (as reported in The Times 12/5/07). For many, probably most psychotherapists, these are extreme views. There are also other questions here: in an email to SfH he states (incorrectly) that The College is a "largely Lacanian organisation" and then follows this with : "French psychoanalyst - Lacan - intellectual superhero but clinical and ethical problem, ultimately dismissed from the rank of the international psychoanalytic movement". Yet the very same Fonagy can refer on the dustjacket of a recent analytic book to "the intellectual sparkle of Lacanian psychoanalytic scholarship" and "the highest quality Lacanian thinking, creating a firm bridge between two forms of psychoanalytic theorisation that have for too long been separated by inadequate understanding". 

In September 2007 the UCL department apparently sent out a letter inviting participation in the expert reference group for psychodynamic therapy, yet this letter was not received by any psychotherapy organisation that we aware of. It stated that the general framework would be that used for CBT, a fact which would have caused a great deal of protest in the profession had it been known. The methodology of the work is stated as "identifying manuals published in the UK, the US and elsewhere and building the framework from these sources". This would also have caused a great deal of protest in the field for the simple reason that there are no manuals of psychoanalysis, a fact which Fonagy himself points out in a minuted SfH meeting of 11/4/08. On 5/2/08, Roth and Pilling claim to have sourced "the psychoanalytic treatment manuals" for the criteria they have formulated, yet in the list supplied by them in May 2008 to accompany the NOS there are no psychoanalytic texts at all!

The result of the dominance of Fonagy and his colleagues in the consultation process has been the exclusion of other voices : professional groups and user groups have been excluded, despite initial inclusion in draft documents, and the Skills for Health team have even conspired to lie directly to an accredited therapist seeking representation in one of the work groups who had been invited to participate. Steven Richards, Chair of the British Society for Clinical Psychophysiology, contacted SfH on 18.10.07 requesting involvement in the cognitive and psychodynamic work groups. Linda Hardy of SfH writes to Rod Holland, who Fonagy had recommended to SfH to chair this group, on 25.10.07, that "We need not have him on the group if you are not happy - I'll rely on your superior knowledge of the therapies here!". This illustrates SfH's failure to do their work properly, leaving the process open to political manoeuvering. Holland writes that Richard's school of therapy "is at variance with most concepts of CBT", yet SfH do not assess this claim or even object to the exclusion of a diverse practice. Hardy then writes to Richards on 29.10.07, "I contacted the chair of the group with your information and he feels that at this stage, with numbers on the group nearing capacity we really need to give the remaining few places to NHS employed practitioners as they are really underrepresented on the groups". In fact, it is because, as she writes to Marc Lyall two hours earlier on the same day, "Rod does not want this guy on the group.However I'm not sure what to say back to him - it's difficult when we invite people to show an interest and then tell them they can't join a group.I could say we are now seeking more NHS employed practitioners as they are under represented on the groups? [sic]".

When a Freedom of Information Act disclosure made these emails available to Richards, and he took them up with SfH, new correspondence was brought forward - strangely not included in the initial disclosure - which it is quite possible and even likely that SfH actually fabricated (further details available on request). The College has also written to SfH regarding an item of correspondence which we believe was falsified in order to cover themselves about another issue.

SfH appear to have failed to conduct the appropriate research for themselves, relying almost exclusively on 'outsourcing' opinion about what is legitimate and what isn't: this means emailing one of a handful of 'experts' to ask if an academic or clinician that SfH had themselves invited to be part of the consultation process should in fact be 'invited'. These distortions to the consultation process have effectively ruled out a rational assessment of the feasibility and suitability of state regulation.

We very much hope that this has been of use to you in laying out some of the detail behind this difficult issue, and to assure you of our good faith in our effort to ensure that you all have full access to the information that is available. The College would be pleased to meet with you to discuss any of these issues further.

Yours sincerely,
Prof. Darian Leader
President, College of Psychoanalysts-UK

PLG: structure of the register - the call for ideas

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.

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.

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.

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.'

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.

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.

What changes your mind?

The British Psychoanalytical Council is represented on the C&P PLG for the HPC by Julian Lousada. He made two memorable interventions in the first meeting of the PLG - they were made with gusto. First he expressed his discomfort at the amount of pseudo politeness going on in the group which created a pretense thateveryone was friends and all shared the same ideas. He made the very sensible point that this was not true, and the factual point that it was known that the issue that brought them together was itself rather contentious. He called for some straight talking, and to get the issues out on the table. Gusto or not it didn't work.

Later he made a direct reference to the poor excluded group of people who talk of Principled Non Compliance. He thought that this group were isolating themselves and in effect signing their own death warrant. He made a plea that something be done to leave the door open for these poor deluded fools so they would still be able to work after the PLG had done its business.

Judging from this google entry (below), I begin to understand the force of his point, and perhaps the reasons that he made it.

At a Freud Museum Conference in 1999, he delivered a polemic against the comodification of the psy field. Below is a quote from a review of the papers of that day.

THE FUTURE OF PSYCHOTHERAPY
Saturday 20 November 1999

Getting things done' was a theme of Julian Lousada's paper 'The State We're In' in which he pointed out that the government regulation of psychotherapy services may have a negative effect on the essential value of psychotherapy. Julian Lousada is the chair of the adult department at the Tavistock Clinic, London. In a sustained polemic he argued that the trend to turn patients into 'customers' and the service into a 'commodity' is the greatest present threat to psychotherapy. By fostering this 'business state of mind' psychotherapy becomes entirely concerned with instrumental objectives, without real emotional investment. These effects have come about through a change in the form of government intervention. Whereas government used to organise the 'means of production' or supply of services, it is now more concerned with specifying outcomes - "Where government was, now audit and regulation is". This affects not only service provision, but the training of therapists. Lousada pessimistically anticipated that the 'caring professions' may be veering towards a state of mind which itself is scared of forming relationships - the deathknell, surely, of psychotherapy as we know it"

PLG: structure of the register, protection of title

Tomorrow is the second time the PLG for counselling and psychotherapy meet. They have two days scheduled to discuss the 'structure of the register' and to figure out which titles shall be protected.

I shall be there in the 'public gallery' to observe this meeting. As part of my preparation I have been trying to get to know the members of the group, that is, to understand their position and aim in more detail.

To this end I have been looking at a powerpoint presentation given by the Director of Regulatory Policy for the BACP (dated 15 January 2009). This presentation repeats the mistake of the HPC minutes in calling this process statutory regulation. This process is in fact state regulation - as the chair of the PLG said at the last meeting (4 December), and I quote, "if we don't do it to ourselves, the government will do it to us".

The presentation appears to be a wonderful example of how the holistic planner thinks (see Popper's Nightmare - video clip in the sidebar). Of course, I don't know what was said on the day, and the speaker may well have been ironising the process and she went. But the slides are a sustained witness to the attempt of the holistic planner to create a cohesive picture with no cracks in it and make it easier for centralised power holders to make and impose their decisions. But as Karl Popper has forewarned us, it is only easy in theory, and will lead to a nightmare in practice.

The slides show four interlocking pieces of a jigsaw puzzle: State Regulation, HPC, Skills for Health, and IAPT. NICE appears as a bullet point under the heading of IAPT and reminds me how difficult it is to conceptualise reality in this way. The whole country is reduced to four government initiatives, no wonder we're all anxious and depressed.


"The holistic planner overlooks the fact that it is easy to centralise all power, but impossible to centralise all knowledge which is distributed over many individual minds, and whose centralisation would be necessary for the wise wielding of centralised power ... Unable to ascertain what is in the minds of many individuals, he must try to control and stereotype interests and beliefs by education and propaganda, but this attempt to control minds must destroy the last possibility of finding out what people really think. For it is clearly incompatible with the free expression of thought, especially of critical thought, and ultimately it must destroy knowledge. The greater the gain in power, the greater the loss of knowledge." quoted in the Editorial, Times Higher Ed Supp, 8 June 1984(!)

Trust Assurance Safety - the White Paper (Feb 2007)

The Rt Hon Patricia Hewitt, MP, and then Secretary of State for Health, wrote in her Foreword to this White Paper "patients in the UK rightly have great confidence in their health professionals... the preservation of that trust has to be the starting point [of any regulation]... it is all too easy to focus on the incompetent or malicious practice of individuals and seek to build a system from that, [but]... professionalism is an unquantifiable asset to our society which rules, regulations, and systems must support, not inhibit." p1

This document is important in this process as it is where the words are written that produce the justification for the HPC-fication of counselling and psychotherapy - the field that is currently under consideration for state regulation.

Preparing for the next PLG for C&P, 28/29 Jan 09: structure of register

The complexity of this is mind boggling. What is in a name? How can we pin it down? What relation does it have to the practise, to reality, to the real?

Part of this document attempts to summarise points from documents received by HPC in its 'Call for Ideas'. Leaving aside questions of method, science, and truth, it is sufficient to note that 31 named institutions are quoted in this text, including Skills for Health, 'The NHS', IAPT, and New Ways of Working for Psychological Therapists.

Some other institutions include The Tavistock Centre for Couple Relationships, The Association for Rational and Emotive Behaviour Therapy, The Cambridge Body Psychotherapy Centre, The Association of Counsellors and Psychotherapists in Primary Care, and the Stirling District Mental Health Association.

In the spirit of scientific endeavour it would be valid to note the huge variety of responders, including several people speaking in their own name. In fact, this might be the most important point to note. The practise that is currently in question (conjured up by the phrase 'counselling and psychotherapy) is enormously diverse. There are those who think this is the most valid characteristic of a dynamic, responsive field of work - it is close to the ground, answerable to the roots of its practise, known through its context and locality. There are others who think this is a horrible mess that does not convince The Public of its solid knowledge base. This latter group are the ones who work tirelessly to reduce the diversity to a singularity which will be more easily managed by faceless bureaucrats in a centralised institution. These would be the foot soldiers that knowingly or not form the army that populate Popper's Nightmare (see video link in the side panel).

Preparing for the next PLG for C&P, 28/29 Jan 09: minutes of 4th Dec 08

The pack of papers are ready for reading, downloadable from the website (linked to the heading of this entry). The minutes of the last meeting, 4th December 08 are amongst that pack.

Some features of these minutes (as yet uncomfirmed) are noteworthy. First, the meeting is not formally constituted as a committee, tho it has a chair, and a set of minutes. It is a Group. Perhaps for this reason the minute taker has not taken the trouble to associate comments with individual group members, except to note those who are late or not attending. The only person that is named in the whole of these minutes is Professor Peter Fonagy, the spokesman for Skills for Health.
. Naming him in this way suggests that he is a particular kind of member of the group.

Otherwise it is The Group as a whole that acts, and it acts in a limited number of ways. I count them:

The Group was welcomed (2) by President and Chair
The Group introduced itself (1)
The Group noted (28)
The Group approved (1) (the agenda)
The Group received (4) reports from DoH, HPC, a summary of responses from CfI (Call for Ideas), the future workplan.
The Group would report (1) to the HPC in July 2009
The Group was asked (1) to identify areas requiring further work.
The Group felt (1) that some responses to CfI were uninformed
The Group agreed (5)
The Group asked (2) to be kept informed on SfH NOS, how to publicise its work

Most of these actions are posed in the passive, but some of them suggest an active agency, 5 of them consisted of agreeing. Lets look at those 5:

1. The group agreed that it would be be useful for a future meeting of the Group to hear about the experience of a profession which had previously become subject to statutory regulation. (Minute 6.5)
2. the Group agreed that it would be useful to ensure that its work addressed the areas indicated in the [HPC administrative] new profession process. (6.10)
3. The Group agreed that its work should focus on making recommendations on statutory regulation, whilst listening to dissenting and sceptical views. (6.11)
4. The Group agreed that its work should aim to ensure that statutory regulation would protect the public. (6.11)
5. The Group agreed that its discussions should focus on issues which related to protection of the public. (6.11)

Agreeing to comply with all the rules already written down.

Points to note.
1. how is agreement reached by the group? It is not clear.
2. what are the reasons given to support agreement number 1?
3. How will the other profession be chosen, and how will its experience be surveyed and reported? How is this more valuable than attending to the reality of the current practise?
4. How do the administrative procedures of the HPC shape, or impact on, the substantive work of the Group?
5. What is at stake in naming this process 'statutory' regulation, when state regulation is a more truthful description of this work.
6. In what way will dissenting or sceptical views be heard (note 3)? The image conjured up here could easily be understood as a kind of handicap, or distraction to the real work; it pre-supposes an unspecified agreement and prejudges a disposition - a splitting mechanism.
7. How is the public being conceived, and what is the harm, how will it protect?

The phrase 'statutory regulation' is used erroneously throughout this document. The correct term is state regulation - it proceeds directly from the act of the government which itself proceeds from the report of the Bristol Royal Infirmary Inquiry.

The limits placed on this group raise serious questions about the trustworthiness of the process. The group itself is constructed entirely within the domain of the HPC. The chair is already an HPC member, attached via another label. The PLG was selected by this chair in order to minimise the chance of actual debate. The substance of the meeting that did begin to touch the real concerns about the negative effects of this process on the practise has been entirely screened out. Brian Magee, for example (who is attached to COSCA - a group in Scotland), asked the very serious question: would the group be able to conclude that the process of HPC-ification was itself against the best interests of the client/user. Kathi Murphy (attached to Metanoia, an organisational member of the UKCP) had to forcefully remind Peter Fonagy (spokesman for Skills for Health) and Mr Bell (substitute for Rose Mary Owen, from the Relate Institute) that she was not fillibustering when she spoke of the real concerns that she was bound to represent that exist within the UKCP.

The minutes make no reference to the reasons the Chair had for closing the meeting 2 hours ahead of schedule. This remains a fact for conjecture.

More on the meaning of a 'Public Gallery'

Dear Mr Seale

Thank you for your letter dated 21 January, which I received yesterday.

I am surprised and pleased to hear that I am the first to take the trouble to draw to your attention the strange seating arrangements of your rooms, and the first to spend time reflecting on the unintended or unexpected consequences of this. It is good to be of use and to bring something new to light. I wonder, though, why you decline to engage with me on the point. When I described the layout to a colleague, he was most surprised. He had thought that 'public gallery' meant what it said.

I had no idea you were also seated here during the course of that meeting, but am happy to hear you were not uncomfortable. However, I am surprised you are not aware that you and I are in different positions and that this has a bearing on my experience, also it seems necessary to say that though you weren't made uncomfortable this is not evidence that I was not uncomfortable. I do wonder why you are so quick to dismiss my point.

My suggestion that the coffee tables could easily give way to the comfort of the public remains true. It was a simple suggestion made in good will, which you have completely overlooked.

I have been unable to fathom the meaning of your third paragraph (that the public is not expected to participate in the actual meeting itself). In a court of law, a lecture room, or indeed an opera house the audience might not be expected to participate in the actual thing itself, but nevertheless has a role to play. Moreover, it must be rare for the audience to be confined to a corner, and obliged continually to look askance at the backs of many players’ heads.

My other question related to designating the speakers with names and positions - both seating and substantial. Your reply addresses only 2 of my 4 points. You supplied a list of names and organisational associations, but I also asked for their position statements and where they were seated. Even the minimum would have been a welcome addition to the day - my neighbours also spent many minutes looking for such a list on and about the chairs. I understand that you are not obliged, and that we might have brought our own copy, etc but be assured a few of us at least had expected it as a courtesy.

There is little courtesy here, in fact, and I am indeed surprised. Your reply is rather mechanical and lacks a human touch. This gives me cause for concern.

One final point – I should like you to know that I have been writing a blog called ‘hpcwatchdog’ for a few months now, and that I would like to record this correspondence there. May I suppose that you will let me know if you don't agree to this act?

Yours sincerely

creative strategies of resistance to nutty demands and ideas

This is edited from an email comment received from a dedicated shrink:

"I was reminded upon reading your recent posting of the current crop of HPC adverts, in which their key strapline, before everything else, asserts their primary role as "the protection of the public" (presumably, the public is being protected from us). This does seem to imply the existence of some embedded beliefs, prejudices, at work in the HPC that might inhibit full and open debate with such a body.

... In my work I am being audited four times between now and September by various agencies, or parts of agencies (I suppose this is an extension of the same logic, the auditors are there to protect the people I work with from me).

.... I thought of applying for one of the HPC jobs currently advertised in order to sabotage it (but then I thought about ..... life!)"

The responsibility and respect of the public

Dear Dr Anna van der Gaag (President of the HPC)

You were kind enough to welcome us as members of the public, to the first meeting of the PLG for Counselling and Psychotherapy (4 December). In now occurs to me that you might be the person to ask for something quite mundane yet vital in preparation for the next two day ordeal (28 and 29 January).

I found it very uncomfortable at the last meeting partly on account of the strange arrangement of the seating. I had expected to be seated in a 'public gallery' which would afford me the opportunity to view the proceedings and aid my listening and understanding. As it turned out, we were crammed into a corner, and forced to look at the backs of several heads. It was often difficult to know who was speaking as the name tags were not at all visible, this made it difficult for me to follow the discussion at times.

I am rather dreading the repeat of this experience, especially as it will be spread over two days. I have raised this with Messrs Bendall and Seale, but have yet to receive a reply.

But the discomfort of the public gallery was also caused by the substance of the meeting. For example, there were two members of the HPC panel present in this meeting who took up a lot of valuable time apparently reassuring the new professional representatives that in spite of widespread objections from the profession, resistance was going to be futile. This might have been amusing had it been said succinctly, but it was said more than once and at length, which suggests that humour was not the intention. This was odd - what can have been their meaning? Resistance is futile. Wasn't this what the Borg were famous for saying? I should very much have liked to have asked.

A second occasion arose when the spokesman for Skills for Health said there was evidence that 5% of therapists were a serious threat to the public. Can this really be true? Shocking! The HPC say that only 0.23% of other professions represent such a menace. No-one on the committee challenged him. Someone should have. I did wonder whether we had a duty in the public gallery to shout out at that point. What would happen if a voice of conscience were to emit from the back of the room?

It is difficult to know where to post one's questions in all this, and this is why I have finally come up with the idea to write to you. There was more than one moment in the proceedings when our quiet cramped corner was shuffling and muttering under its breath as some committee member or other talked rot. Perhaps there could be a way for the meeting to tolerate or even benefit from some of this frustration. After all, any theatre, even a court of law, can benefit from the feedback of the audience if the performance is outstanding in any way. I hope that the Chairman of the Group is capable of tolerating a groan, a guffaw, or a gasp at least issuing from the back of the room, tho I am sure this would be altogether better managed if we were first accorded the dignity of a properly constructed space.

I do hope you are able to respond.

Yours sincerely

habeas corpus - the case of missing Mr TH

Another missing man at the centre of this pernicious process. When I arrived this morning the waiting room was full of giggling women. It was as if they were out for a day's pleasure. The line manager, the line manager's line manager, and finally, the line manager's line manger's line manager (yes, another case from the NHS). Three women lining up to nail the coffin down of occupational therapist Mr TH.

The third in this happy parade was the one who submitted the complaint to the hpc. She did this about one or two years after Mr TH had left the employ of her team. Why? "he was a threat to public safety."

She spoke so quietly that I had to strain forward to hear her, so I stood up and moved forward to hear the rest of her statement. In the nano second it took for me to settle in the seat in front she was standing up and leaving. That was it! She had been called in order to recite this empty phrase! Bang, the final nail in the coffin.

At no point in this morning's proceedings did anyone mention what it was that he was doing with his patients that was such a threat. The entire discussion revolved around his note taking. The context of this is the computerisation of notes in the NHS - something which other occupational therapists are fed up about.

Why is it a threat to patient safety for Mr TH to not write notes according to the computer developers protocol? 'in case he doesn't come in and someone else has to take over his work'. (We're talking about occupational therapy remember.) Is there an example of the danger that ensued when he did not turn up for work (he went off sick, then resigned a few months after this witch hunt began). No, no examples. No examples at all in fact, all we had were vague generalisations and examples of his administrative skills: did he make a phone call, did he write a note. His work as an occupational therapist was absolutely absent from the case.

The line of questions that were presented to the witnesses got nowhere near uncovering any kind of truth. The three women were vague, one was verbose, and all were well versed in newspeak: 'got to get up to speed', 'golden rule is to keep accurate and up to date records', 'I did an audit of notes', 'a random selection of his files', 'there was insufficient detail', 'notes were vague'. No substantive content whatsoever in any of the three womens allegations. No sign of any patient in trouble, no whisper of any complaint from any of the people he worked with. None. Repeat: NONE.

Yet another case of people occupying positions of power in the New NHS who are blatantly unworthy of the responsibility on their shoulders. No gravitas, no experience, no compassion, no speech of their own, nothing to say except to mouth empty phrases that knock around like bricks doing random damage, no idea except to cover their backs. Not professional.

I wonder what the Panel will decide. Decision so far not posted.

Preparing for the next PLG for C&P, 28/29 Jan 09

[email sent 19th January]
Dear Mr Seale

Looking forward to the HPC PLG for C&P meeting next week, 28 and 29 January, I have written to Mr Bendall to ask if it is possible to organise the room differently so that the public gallery is accorded more respect. I understand that Mr Bendall is not in today, and I suspect he may not be the correct person to whom to address this request, so I have taken the liberty of writing to you.

The problem I refer to is the way the furniture is organised. We are rather pushed into the corner and forced to look at the back of people's heads. This makes it uncomfortable but also very difficult to ascertain who is speaking, and thereby to understand the position from which to make sense of their words.

I think it is common practice for rooms to be organised along the lines of a theatre when the public is allowed to observe. This would be a very welcome innovation not only in the PLG, but also for the fitness to practice hearings and, of course, all other events at which the public is included.

At the very least, if you are unable to innovate in time for next week, may I suggest that you remove the coffee table to another room and allow the seats to occupy the whole of the back wall. Also, it would be enormously helpful to provide a list of the names of the people on the PLG, their affiliation, their position statement, and the seating plan. This would go a long way to relieving the situation.

Yours sincerely




Name and address supplied

Disguising the truth

Mr Marc Seale is the Chief Executive of the HPC. The HPC is a QUANGO - a quasi autonomous non governmental agency. The Longman dictionary definition of this is as follows: set up by a government and having statutory powers in a specific field (eg the race relations board). In this case set up by the Health Professions Order 2001 - HPO2001 - and passed into law by Parliament in early 2002, responsible to, and administered by the Privy Council. Wikipedia adds 'the acronym can carry with it an implication of poor management and lack of accountability.'

At the BSHAA's congress, 18 April 08, Kenilworth, Mr Seale introduced the HPC as 'not a charity'. I wasn't there, but the powerpoint presentation is available on the web to download. One of the slides in his powerpoint show states: Not a charity. The HPC is not a charity. I wonder who might have thought that it was? Perhaps it was a joke, but I wonder why Mr Seale did not take the time given to him by the BSHAA to explain exactly what the HPC was? Perhaps he did in his talk, while his powerpoint projection continued to emit the empty information in large print on the screen that might have dominated the room.

Freud is famous for pointing out that when an analysand says 'it was not my mother' that we are indeed in the domain of the mother. So, is Marc Seale cunningly deploying a trick to subliminally implant the idea into the minds of this potential new source of income that the HPC is indeed a charity? I think we should be told.

The next bullet point on the show said 'the HPC is self financing'. Not a charity, but self financing. This rather suggests that it is competing in the free market and people are freely choosing to purchase its services because they think they are worthwhile. Not at all. Not only is it not a charity, but it is not a regular business, competing alongside a variety of others, either.

The HPC has the power to prosecute people for practising without paying their fee to the HPC. It is underwritten by law to compel money into its coffers through the use of statutory power. Without HPC registration, practitioners cannot use government 'protected' titles. The NHS and its contractors, are obliged to employ HPC-registrants thus creating a Government or Statutorily regulated market.

Why mask the truth in this way?