Report prepared for. Division of Clinical Psychology, British Psychological Society. Date: 14 th September 2007 MHS 937

Transcription

1 Report prepared for Division of Clinical Psychology, British Psychological Society Understanding CUSTOMER NEEDS Of Clinical Psychology Services Date: 14 th September 2007 MHS 937

2 Executive summary In response to the changing climate of the NHS this project was commissioned to gain an understanding of customers needs and devise a marketing strategy for the profession of Clinical Psychology. This document contains the first stage of that process in terms of identifying customer needs and perceptions. For the purposes of this document the term customer refers to those financing services i.e. commissioners and managers of services, not patients who in this context would be perceived as consumers. A two phase approach was taken in order to gather information. Firstly a 47 item questionnaire was produced and distributed to Clinical Psychologists and non-clinicians such as managers, commissioners and Chief Executives (see section 4.2). The aim of this was to gain an indication of what differing groups perceived as priorities and what percentage of Clinical Psychologists were perceived to be delivering on these different areas. The key findings from this survey were: General agreement between Clinicians and non-clinicians regarding priorities in all sections with the exception of section B (Treatment offering). Some indications of differences in perspectives were noted with clinicians rating clinical skills higher and non-clinicians rating access more importantly. Supporting other professionals and working with complex cases were agreed priorities. Respones suggested that there may be a lack of understanding from nonclinicians regarding certain areas i.e. reflective practice. Non-clinicians generally rated the percentage of Clinical Psychologists delivering on these items as lower than clinicians rated. On 19 out of 47 items the difference between the two groups was statistically significantly different (p>0.05). Following the questionnaire 14 in-depth interviews were conducted again with a mix of clinicians and non-clinicians such as Chief Executives, commissioners, managers and clinicians with specialist roles (see section 4.1). The main findings from these interviews are presented below: Breadth and depth of Clinical Psychologists roles was highlighted. Valued roles in terms of supporting other professionals and working with complexity. The need to engage with all stakeholders. Consideration of how best to engage with and influence commissioners. Variability in terms of perception of what value the profession adds. Lack of clarity regarding the role of Clinical Psychologists, expectations of different grades and the need to clarify what exactly Clinical Psychologists can and can not do. Issues were raised regarding integration and isolation of the profession from other team members. Variability in terms of quality and individual capabilities. Issues regarding training and how prepared newly qualified staff are to meet expectations. The diversity of settings in which Clinical Psychologist work and issues relating to specific specialties were also highlighted.

3 Both the questionnaire survey and the interviews have identified a variety of issues for the profession. The findings; provide an insight into customers needs, have helped to identify some Unique Selling Points (USP) and have contributed to a SWOT analysis for the profession (see section 5). The next phase of this project is to develop a strategy document to address the many issues identified. This is expected to include guidance documentation for the profession to raise awareness of these issues and develop plans to ensure the continuing development of Clinical Psychology services. In addition it is also planned to develop information for dissemination to customers to assist in addressing issues regarding the misconceptions, lack of understanding and varying expectations customers have about Clinical Psychology. It is also planned to hold a further workshop to look at the implementation of documentation and recommendations. Page 1 of 63

4 CONTENTS Understanding Customer Needs of Clinical Psychology Services - DCP The approach used to this project produced a large amount of information. In order to assist the reader summary boxes setting out key issues are presented through out the document, page numbers for these summary boxes are included in the contents page. Page 2 of 63 Page 1. INTRODUCTION OBJECTIVE PROJECT METHOD About Marketing.. 6 About Marketing Strategies...7 Research Methodology 8-10 Phase 1: Questionnaire Survey..8 Phase 1: Demographics...8 Figure 1: Bar chart of geographical distribution of respondents 9 Table 1: Table showing grading of participants..9 Phase 2: Interviews PROJECT FINDINGS Phase 1 findings Section A: Training, Education and Professional Support..10 Table 2: Key results from Section A 11 Table 3: Top five ranked items for clinicians and non-clinicians.11 Additional comments..11 Key messages from section A Section B: Treatment Offering.12 Table 4: Key results from section B.12 Table 5: Top five ranked items for clinicians and non-clinicians.13 Additional comments..13 Key messages from Section B Section C: Competence...14 Table 6: Key results from Section C 14 Table 7: Top three ranked items for clinicians and non-clinicians..15 Additional comments..15 Key messages for section C Section D: Efficiency and Effectiveness 15 Table 8: Key results for Section D...16 Table 9: Top three ranked items for clinicians and non-clinicians..16 Additional comments..16 Key messages Section D Section E: Organisational Contribution.16 Table 10: Key results from Section E.17 Table 11: Top five ranked items for clinicians and non-clinicians..17 Additional comments.17 Key messages Section E Phase 2: Findings.18 Figure 2: Superordinate and subordinate themes Theme 1: Roles and Expectations..20 Direct treatment.20

5 Indirect role.20 Research and Audit..20 Supervision 20 Teaching..20 Leadership..20 Team Work.21 Consultation 21 Service Development 21 Organisational Level.21 Theme 1 summary Theme 2: Different Grades..22 Pre qualified grades..22 Lower qualified grades.22 Senior grades.22 Training...23 Awareness 23 Local variation 23 Theme 2 summary Theme 3: Strengths..24 Breadth 24 Training...24 Team Work.24 Research 24 Support / supervision / teaching.25 Organisational contribution.25 Value 25 Quality.25 Theme 3 summary Theme 4: Weaknesses 26 Comparisons with other professions.26 Adapting to changes.26 Lack of perceived clarity regarding roles and expectations...26 Addressing diversity..27 Integration / isolation.27 Outcomes 28 Value 28 Access.28 Variable quality..29 Training...29 Theme 4 summary Theme 5: The Future 29 Specialism vs generic roles.30 Move from disciplines to modalities 30 Greater clarification of development of roles 30 Research 31 Engaging stakeholders 31 Training...32 Outcomes..33 Threats 33 Staffing levels.34 Organisational issues 34 National institute for health and clinical excellence.35 Value 35 Theme 5 summary 35 Page 3 of 63

6 4.2.6 Theme 6: Issues Within Specialties 36 Adult mental health secondary and primary care 36 CAMHS...36 Forensics 37 learning disabilities 37 Early intervention...37 Older adults 37 Theme 6 summary SUMMARY Identification of Customer Needs Unique Selling Point of Clinical Psychologists SWOT analysis RECOMMENDATIONS 40 Appendix.50 Page 4 of 63

7 1. INTRODUCTION Clinical Psychologists, like much of the NHS, have to adapt to new ways of working, with new roles and demands placed upon them as the NHS undergoes further modernisation. Key factors affecting the profession of Clinical Psychology are: the developing role of psychological therapies affecting physical health the Layard inquiry into Depression 1 the NICE Guidance on the Treatment of Depression 2 the demands for evidence based practice the changes demanded of mental health services through stronger commissioning the development of Practice Based Commissioning the development of NHS Foundation Trusts a need for the public to be treated as valuable customers a growth in the number of people attending University the New Ways of Working programme for professions in the mental health field increased contestability in the provision of services and contracting and the growth of non statutory provision One of the major challenges of this new environment is that services and professionals that may have traditionally operated without having practice questioned increasingly have to demonstrate the value and benefit of their services and skills. This has forced a paradigm shift whereby a new understanding of how to operate in these new quasicommercial environments is a prerequisite for success. In this regard Clinical Psychologists are no different to many other professions. It is however possible that despite the rigorous clinical training that Psychologists have to undergo many are left unprepared to face this new commercial reality. In addition, as a result of the introduction of Agenda for Change and the relative higher banding of Clinical Psychologists there is possibly greater pressure upon the profession to demonstrate that they are providing value for money. In order to help the profession of Clinical Psychologists prepare to meet these challenges in a proactive way, the Division of Clinical Psychologists of the British Psychological Society have been pulling together a body of evidence to demonstrate the value of Clinical Psychologists. Alongside this work is a recognition that the profession needs to consider how it could best meet its customers (i.e. the needs of the people who can influence the purchase or development of psychological services, such as commissioners and senior managers) needs whilst at the same time ensuring the continued success of the profession. This required treating the profession as a business and by surveying both internal (Clinical Psychologists) views and those of key 1 The Depression Report: A New Deal for Depression and Anxiety Disorders. Report by The Centre for Economic Performance s Mental Health Policy Group, Clinical Guideline 23. Depression: management of depression in primary and secondary care. Issue date: December 2004 Page 5 of 63

8 stakeholders in positions of influence, to use the information gained to inform the development of a marketing strategy. In order to facilitate this development, Mental Health Strategies were charged with project managing and providing oversight to production of a report that would enable the profession to better understand the challenges it faces. 2. OBJECTIVE There is one overriding objective for this project, which is to secure an understanding of customers needs to underpin the development of a Marketing Strategy for the Division of Clinical Psychologists. A key element of this will be to consider what value the profession adds. In order to facilitate this Mental Health Strategies (MHS) provided a Project Management and guidance function. Part of this role was to provide a template for the final document and development of a project plan so that key milestones are met on time and to specification. A further aspect is to suggest or recommend further steps for the profession to take in the light of forthcoming information. Reporting to Tim Cate and the wider Division of Clinical Psychology, Nick Moor was assisted by Mark Bradley, Trainee Clinical Psychologist who operated as archivist/ librarian and research assistant. 3. PROJECT METHOD About Marketing Marketing methods have traditionally been applied to businesses so that through the exchange of money or goods customers have their needs met, and the supplier s business grows and increases market share. Marketing has been variously described as: an organizational function and a set of processes for creating, communicating, and delivering value to customers and for managing customer relationships in ways that benefit the organization and its stakeholders and Human activity directed at satisfying needs and wants through exchange processes" In popular usage, "marketing" is the promotion of products, especially advertising and branding. However, the term also has a wider meaning which recognizes that marketing is customer centred. Organisations which are market-focused, or customer-focused, determine potential customers desires, and then build the product or service around them. This will include much more than the product offered, but also the way in which it is offered (including customer service ) and the price. In this way, marketing can be seen to underpin the whole organisations efforts and strategic approach to win business. Page 6 of 63

9 Marketing theory and practice is justified in the belief that customers use a product/service because they have a need, or because a product/service has a perceived benefit. This is not to say that innovation is stifled, but the onus is clearly on the supplier to demonstrate the benefits of their product so that the customer has their needs met, rather than use an alternative or competing product or service. This may all sound too commercial, and feel alien in a profession traditionally found in a statutory public sector organisation. But, many of the challenges inherent in the new commercial environment within the NHS revolve around the need for professions and services to understand the market forces at work and to demonstrate the value and benefit of their product to the customer, whereas perhaps in the past this was much less of a requirement and the customer bought services because they were advised to do so by experts. What is clear is that in this new environment a new approach is required, adopting many of the techniques and strategies used by more commercial organisations and to adapt them to suit the professions needs, so that the Division of Clinical Psychology, will have in effect a marketing strategy. About Marketing Strategies Within any Marketing Strategy there are some clear requirements. These are outlined below: 1. an understanding of the organisation/ profession (Strengths, Weaknesses, Opportunities and Threats) 2. an understanding of the unique selling proposition (USP) 3. an understanding of the benefits of the products or services offered 4. an understanding of the market (external factors such as Political, Environmental/ Economic, Social and Technological) 5. an understanding of the customers and their needs 6. an understanding of the competition and their strengths, weaknesses, opportunities and threats 7. a description of how to position the products or services (Price, Place, Promotion, Product) 8. a definition of the marketing approaches to be used including Market Penetration, Market Development, Product Development or Diversification 9. a method to evaluate the success of the approaches proposed In order to gain information to inform this strategy a two phase approach was used. Phase one consisted of a survey of clinicians (Clinical Psychologists) and non-clinicians which produced a mix of qualitative and quantitative data. In phase two semi structured interviews were conducted with key individuals to gain more in-depth information, and provide insight into both the current needs of customers, and the perceived strengths, weaknesses, opportunities and threats faced by the profession. Page 7 of 63

10 Research Methodology The methodology used for both phase one and phase two are presented within this section. Phase 1: Questionnaire Survey In order to obtain as broader range of views as possible a questionnaire was devised and distributed to Clinical Psychologists, managers, commissioners and chief executives. The aim of this survey was to compare views from clinicians and non-clinicians regarding what the key roles are for Clinical Psychologists and to what extent these are delivered. A modified Delphi approach was used to develop the questionnaire. A large number of potential items were generated, these items where then reviewed in a working group which identified five themes. This resulted in a questionnaire with five separate sets of items with 47 items in total (see appendix 1). Participants were asked to first rank the top five items in each section in terms of importance. Then in the preceding column participants were then asked to rate what percentage of Clinical Psychologists demonstrated these skills or experience. Space was also provided for any additional comments in each section. Basic demographic information was also gathered. Replies could be returned anonymously, however if participants were interested they were invited to provide contact details for any follow up, although clearly it was not possible to interview every person who expressed an interest in further involvement. In terms of distribution, our intention was to both elicit clinician s views, and non-clinicians. Accordingly the survey was sent out electronically via the DCP manager s faculty Special Interest Group to Clinical Psychologists along with a request for members to cascade the survey amongst Clinical Psychologists within their locality. Psychologists were invited to either complete electronically, alternatively contact details were provided to print and post the responses. Contact details for nonclinicians were obtained from standard NHS sources and copies of the survey were posted with an enclosed SAE. Phase 1: Demographics Of the 127 responses 89 were from clinicians and 36 from non-clinicians. In terms of geographical spread figure 1 below shows the regional distribution. Page 8 of 63

11 Figure 1: Bar chart of geographical distribution of respondents 25 Clinician/Non Clinician Clinician Non Clinician Number of respondents North east North West Yorkshire & Humber West Midlands East Midlands East of England South West South East London Region Information regarding respondents Agenda for Change grades was provided for 85% of responders as presented in figure 2 below. Table 1: Table showing Grading of participants Grade Frequency Percentage % % % 8a % 8b % 8c % 8d % % VSM % Missing % Phase 2: Interviews Following on from the survey a number of interviews were conducted to elicit more in depth information regarding views of Clinical Psychology. Individuals at different levels and across different specialties were identified and contacted. Fourteen interviews were conducted using a semi structured interview (SSI) schedule as a guide to open up discussions (see appendix 2). This was based upon themes arsing from the results from the survey in phase one. In terms of participants roles there were; 3 Chief Executives (from foundation and non foundation trusts), 3 Commissioners (of varying levels within PCT s from associate Page 9 of 63

12 director of commissioning to lead commissioners), 1 General Manager and 2 Heads of Psychological services participated, as well as 5 further professionals with a variety of specialist roles and involvement on national projects (with clinical backgrounds in Clinical Psychology or General Practice). Interviews varied in length from ½ an hour to 1 ¾ hours. In order to maintain anonymity individuals names and designations have not been included anywhere within this document. Some interviews were conducted via telephone and some in person. Following interviews notes or audio recordings were transcribed. These transcripts were reviewed and key themes identified which are presented below. 4. PROJECT FINDINGS The findings are presented separately for phase 1 and phase 2 of the project. A large amount of data was produced from this project, the main findings of which are set out below Phase 1. Findings A summary of the results from the survey and analysis of the findings is presented below for each section of the survey. In the tables survey items are presented in the rank order based on clinician s scores (highest to lowest). To allow comparison non-clinician rank scores are included, mean scores are also provided in brackets. The final two columns indicate the average percentage rating for clinicians and nonclinicians respectively. To give an indication of how significant differences between clinicians and non-clinicians were Mann-Whitney U tests were conducted for the rank scores and t-tests were conducted on the percentage scores. In the tables below statistically significant results have been highlighted in red and other results of interest have been highlighted in green. In order to provide a more visual representation of the findings, scatter plots are also included in appendix 3. The numbers within the boxes on the scatter plots correspond to the questionnaire item numbers. Tables including standard deviations are also provided in appendix 4. Some of the more pertinent additional comments from respondents are also included. The main themes for each section are outlined in a summary of key messages at the end of each section Section A: Training, Education and Professional Support This section was intended to elicit views on the most important aspects of Clinical Psychologists training, education and professional support. Within this section there appears to be general agreement in terms of the priority areas for Clinical Psychology input. In terms of the percentage of psychologists perceived to be delivering in these areas in nine out of ten items clinicians rated higher than non-clinicians. Page 10 of 63

13 Table 2: Key results from Section A Question number Section A Items (in clinician rank order) 7. Foundation in abroad range of therapeutic approaches Clinician rank (mean) Non- Clinician rank (mean) Clinician mean % Non- Clinician mean % 1(2.25) 2 (2.22) ** 2. Clinical / expert supervision 2 (2.19) 3 (2.14) * 4. Integration of theory and practice 3 (1.95) 4 (1.83) ** 6. Ability to interpret evidence base 4 (1.93) 1 (2.44) * 10. Produces reflective practitioners 5 (1.58) 5 (1.72) Development of skills to conduct Research 6 (1.36) 8 (1.25) Develops skills to work indirectly 7 (1.34) 5 (1.72) * 3. Supervision of MDT 8 (1.22) 7 (1.3) Intensive post graduate education 9 (1.16) 10 (1.0) Develops supervision skills 10 (0.9) 9 (1.17) * * indicates p > 0.05, ** indicates p > 0.01 Table 3: Top five ranked items for clinicians and non-clinicians from Section A Clinicians Non-Clinicians 1. Foundation in a broad range of 1. Ability to interpret evidence base Therapeutic approaches 2. Clinical / expert supervision 2. Foundation in a broad range of therapeutic approaches 3. Integration of theory and practice 3. Clinical / expert supervision 4. Ability to interpret evidence base 4. Integration of theory and practice 5. Produces reflective practitioners 5. Produces reflective practitioners 5. Develop skills to work indirectly Additional Comments Comments highlight several issues. On item 9 ( Develops skills to work indirectly ) we note: a barrier to this may be interpersonal skills of professionals and working effectively as team members, this may explain low percentage score (non-clinician) Other comments expressed expectations of Clinical Psychologists as follows: Excellent product knowledge is the main requirement (non-clinician) Psychologists are better than most other clinicians but do not spend enough time advising commissioners we can only do indirect / consultation / supervisory work IF we have gained expertise and credibility as clinicians we need that grounding and experience to be observed as credible to be able to act in the other roles Page 11 of 63

14 (clinician) Key messages for Section A. General agreement on ranking the most important aspects of Training, Education and Support by clinicians and non-clinicians Difference in rankings suggests higher emphasis on knowledge by nonclinicians (item 6) For 6 out of 10 items, including the top 4 items, there were statistically significant differences between the ratings of the two groups for the percentage of Clinical Psychologists delivering on these items, with non clinicians rating lower than clinicians. The 2 areas which non clinicians felt the highest percentage of Clinical Psychologists demonstrated were low in non-clinician rankings. This suggests the most common skills within the profession are amongst the least important priorities for non clinicians Section B: Treatment offering Within this section there does appear to be agreement on the top priority, both clinicians and non-clinicians agreed on the importance of offering support to other professionals. The two groups differed on the other priorities highlighting differences in perspectives between clinicians and non-clinicians. Table 4: Key Results from Section B Question Number Section B Items (in clinician rank order) 12. Ability to guide and support other professionals involved Page 12 of 63 Clinician rank (mean) Non- Clinician rank 6. Ability to formulate cases 2 (1.84) 11 (1.28) * 9. Ability to adapt approaches / models to individual patients 5. Assessment skills including psychometrics & risk assessment Clinician mean % Non- Clinician mean % 1 (2.11) 1 (2.33) * (1.73) 9 (1.42) (1.7) 10 (1.3) Can draw upon multiple models 5 (1.39) 2 (2.03) * Ability to manage case load 6 (1.31) 4 (1.89) * ** effectively 13. Monitor and evaluate outcomes 7 (1.25) 6 (1.64) Ability to provide individual Psychotherapy 8 (1.1) 13 (0.75) Research skills to review evidence base for approaches 9 (1.06) 11 (1.28) Evidence base 10 (0.92) 5 (1.67) * Skills & knowledge appreciated by other professionals 11 (0.91) 8 (1.58) Ability to manage and reduce waiting 12 (0.88) 3 (2.0) ** ** lists 2. Access to treatment (out of hours) 13 (0.39) 7 (1.61) ** * indicates p > 0.05, ** indicates p > 0.01

15 Table 5: Top five ranked items for clinicians and non-clinicians Clinicians Non-Clinicians 1. Ability to guide and support other professionals 1. Ability to guide and support other professionals 2. Ability to formulate cases 2. Can draw upon multiple models 3. Ability to adapt approaches / models to individual patients 3. Ability to manage and reduce waiting lists 4. Assessment skills including Psychometrics and risk 4. Ability to manage caseload effectively 5. Can draw upon multiple models 5. Evidence base Additional comments Additional comments in this section presented mixed views, including: managing and reducing waiting lists, out of hours, efficient management of caseloads should be improved, or justified, if it s currently working well. There were differences of opinion amongst clinicians regarding these issues. With some suggesting such issues as: depends, in my mind, importantly on the service structure and setup. Clinicians often get blamed when the system is inadequate to deal with the throughput. Alternatively there was the suggestion that Clinical Psychology should be: seen to offer a more comprehensive understanding of presenting difficulties (individual or systemic problems). Breadth and depth of knowledge is required to offer a more sophisticated formulation and make decisions which allow more efficient use of resources. Page 13 of 63

16 Key messages for Section B. Understanding Customer Needs of Clinical Psychology Services - DCP Differences between the two groups in priorities are highlighted. High priority for clinicians in terms of formulation (item 6) and priorities for non-clinicians emphasizing reductions in waiting lists (item 3). High value placed on ability to draw upon multiple models by non-clinicians (item 8). Perception by non-clinicians that the profession is delivering on some areas not perceived as a high priority i.e. ability to provide individual psychotherapy (item 7). Supporting other professionals agreed as the most important aspect for both clinicians and non clinicians. Out of hours access seen to be more important to non-clinicians than clinicians, but nonetheless not highly rated (item 2). Ability to manage and reduce waiting lists (item 3) and manage caseloads effectively (item 4) are both rated highly by non-clinicians yet are amongst the lowest scores on percentages delivering on these areas for non-clinicians and statistically significantly lower for non-clinicians compared to clinicians. Generally some indication that clinicians rate clinical skills more highly as important, whilst non-clinicians seem be rating access to treatment more importantly Section C: Competence Within this section there was general agreement in terms of priorities regarding supporting other team members with complex cases (item 3) and the use of a range of treatment modalities (item 1). In terms of percentage ratings non-clinicians on the whole rated slightly lower again on most items. Table 6: Key Results from Section C * Non- Clinician Clinician Noni Question Section C Items (in clinician rank rank rank Clinician Clinician n Number order) (mean) (mean) mean % mean % d i 3. Ability to support other members of 1 (2.45) 1 (2.42) * c the team / local health services to a deal with complex cases t 1. Range of modalities of treatment 2 (2.18) 3 (2.19) e 8. Encourages reflective practice 3 (2.0) 7 (1.5) s 6. Enables proliferation of 4 (1.98) 6 (1.78) p > complex cases psychological knowledge 2. Ability to deal effectively with 5 (1.93) 5 (2.05) * 4. Ability to move people back out of 6 (1.81) 4 (2.14) the system into independence. 7. Provides support for other 7 (1.57) 2 (2.31) professionals 5 * 5. Valued by other professionals 8 (1.06) 8 (1.25) * indicates p > 0.05, ** indicates p > 0.01 Page 14 of 63

17 Table 7: Top three ranked items for Clinicians and Non-clinicians Clinicians Non-clinicians 1. Ability support others complex cases 2. Range of modalities of treatment 1. Ability support others complex cases 2. Provides support for other Professionals 3. Encourages reflective practice 3. Range of modalities of treatment Additional comments There were some additional comments regarding roles: Need more psychologists willing to accept clinical leader role and be expert at psychological knowledge of teams (clinician) There were also views expressed by both Clinicians and Non-clinician regarding value and effectiveness: Dealing with complex cases is critical. Highly skilled and expensive resource (psychologists) need to be used to best effect (non-clinician) I think as a profession we still do not always sell our services well enough to other members of the MDT so are not as valued as we could (should) be (clinician). key word for these items is effectiveness (non-clinician). Key messages for Section C Agreement between non-clinicians and clinicians regarding priority of supporting others with complex cases. Having the skills to use multiple models was perceived as important. On an individual or a team basis insufficient clinicians are seen to be delivering in terms of working with complexity (items 2 and 3) by non clinicians. Clinicians perceive they are delivering more in these area. The difference in rankings for item eight, encouraging reflective practice, may point to a lack of understanding from non-clinicians regarding the importance of this within the profession Section D: Efficiency and effectiveness Within this section there was good general agreement in terms of priorities as can be seen in the rankings for both groups. The only difference in priorities in this section is that on item one, high clinical contact time, which clinician s rank first and non-clinicians rank joint third. This may represent a difference in perceived expectations in terms of roles. There are some marked differences in terms of the percentage ratings with relatively large discrepancies between clinician and nonclinician ratings, again clinicians rating higher than non-clinicians. Page 15 of 63

18 Table 8: Key Results for Section D Question Section D Items (in clinician Clinician Number rank order) mean % Clinician rank (mean) Non- Clinician rank (mean) Non- Clinician mean % 1. High clinical contact time 1 (2.57) 3 (2.47) ** 5. Ability to reduce waiting lists 2 (2.42) 1 (3.0) ** 6. Enhances access in terms of 3 (2.36) 2 (2.75) * appointment times and venues 3. Responsive to local needs 4 (2.21) 3 (2.47) ** 2. Offers value for money 5 (2.04) 5 (1.81) ** 4. Clinical Psychologists cost more than other therapists 6 (1.17) 6 (1.36) * indicates p > 0.05, ** indicates p > 0.01 Table 9: Top three ranked items for Clinicians and non-clinicians Clinician Non-Clinician 1. High clinical contact time 1. Ability to reduce waiting lists 2. Ability to reduce waiting lists 2. Enhance access in terms of appointment times and venues 3. Enhance access in terms of 3. high clinical contact time and appointment times and venues responsive to local needs Additional comments Some of the additional comments raised areas in which Clinical Psychologists were perceived to add value or impact: Using a consultation model offering one to one work. This is not just about efficiency and effectiveness, but humane-ness and quality of service provided and quality of working life of other front line workers (clinician). I think we can offer treatment that is not so obviously cost effective with the long term client / complex needs (eg personality disorders) by reducing inpatient admissions, benefit reliance, criminal behaviour (clinician). psychologists need to be more accessible and reduce the need for higher support needs (non-clinician). Key messages Section D General agreement on rankings. The only difference in top priorities were clinician s ranked high clinical contact top and non clinicians prioritised reducing waiting lists. Statistically significant differences in the top five areas in terms of percentage ratings, with non-clinicians rating below clinicians Section E: Organisational contribution As can be seen in table 10 below from the rankings there is general agreement about the priority areas. The main difference between the non-clinicians and clinicians within this section is the greater emphasis Page 16 of 63

19 placed upon these highest rank items as can be seen by the higher mean scores. Of these higher ranked items the mean scores for the percentage of Clinical Psychologists delivering on these areas is variable with similar scores for some items and generally clinicians rating higher again. The largest difference was in terms of item two, contribution to team planning and development. Although not ranked as highly it is interesting that non-clinicians perceive a higher percentage of Clinical Psychologists contributing to wider national policy development. Table 10: Key Results from Section E Question Number Section E Items (in clinician rank order) 4. Ability to contribute to organisational strategic planning 3. Ability to contribute to organisational performance and delivery 7. Ability to contribute to national policy implementation at a local level (e.g. NICE) 2. Ability to contribute to team planning and development 1. Ability to contribute to team performance and delivery 8. Ability to contribute to wider national policy development 9. Ability to contribute to local or wider academic institutions 5. Ability to contribute to primary care mental health services performance and delivery 6. Ability to contribute primary care mental health services planning and development 10. Professional organisational support for planning and development * indicates p > 0.05, ** indicates p > 0.01 Clinician rank Non- Clinician rank Non- Clinician Clinician (mean) (mean) mean % mean % 1 (1.93) 2 (2.53) (1.86) 1 (2.56) * (1.81) 4 (2.22) (1.79) 3 (2.31) ** 5 (1.67) 6 (1.97) ** 6 (1.36) 9 (1.19) (1.27) 9 (1.19) (1.26) 5 (2.08) * * 9 (1.25) 7 (1.89) * (1.0) 8 (1.42) Table 11: Top five ranked items for Clinicians and non-clinicians Clinician Non-Clinician 1. Ability to contribute to organisational 1. Ability to contribute to organisational strategic planning performance and delivery 2. Ability to contribute to organisational performance and delivery 2. Ability to contribute to organisational strategic planning 3. Ability to contribute to national policy Implementation at a local level 3. Ability to contribute to team planning and development 4. Ability to contribute to team Planning 4. Ability to contribute to national policy and development implementation at a national level 5. Ability to contribute to team performance and delivery 5. Ability to contribute to primary care mental health services performance and delivery Additional comments There were mixed views in terms of additional comments in this section: we are able, but not often encouraged or in a position to contribute to the above Page 17 of 63

20 (clinician). There are too few of us to really contribute on these levels as time spent on this level leads to less time in local service delivery and it is those targets that we are then criticised for not achieving (clinician). generally not corporate players, far too frequently operate in isolation from organisational agenda (non-clinician). Key messages Section E Top four priorities the same for both groups but in differing orders Ability to contribute to wider national policy development and local or wider academic institutions were rated as less important by non-clinicians than clinicians. However they perceived a greater percentage of psychologists engaged in these activities, which could indicate that psychologists are seen as working in areas not seen as priorities by non-clinicians Items 5 and 6 (ability to contribute to primary care mental health services development and delivery) ranked less important by clinicians surprising given current context of developing areas (Layard, IAPT). Non-clinicians don t perceive delivering in these areas. Although item 3 was seen important by both groups, greater emphasis was placed on this area from non-clinicians. Items 1 and 2 seen as relatively important by both groups, yet there were statistically significant differences in the perception of Clinical Psychologists delivering in these areas, with non-clinicians rating lower than clinicians Phase 2: Findings From the analysis of the interview transcripts six super-ordinate themes were identified with a number of associated sub-ordinate themes. These themes are outlined below. The order in which themes are presented does not reflect the importance of the theme or the number of references. The main themes were very general and were raised by numerous respondents with different backgrounds and roles, some more specific issues relating to specialities are included in the final theme. Themes have been arranged in an order which appears to be the most logical. In order to highlight certain issues direct quotes from respondents have been included. Identifiable information such as names or roles have not been included in order to maintain the anonymity of participants. Figure 1 below presents the six superordinate themes and associated subordinate themes. Page 18 of 63

21 Figure 2: Superordinate and subordinate themes Theme 1: Roles Theme 2: Different grades Direct treatment Indirect Role: Research and audit Supervision Teaching Leadership Team work Consultation Service development Organisational level Pre qualified grades Lower qualified grades Senior grades Training Awareness Local variations Theme 3: Strengths Breadth Training Team work Research Support / Supervision / Teaching Organisational contribution Value Quality Theme 4: Weaknesses Comparison with other professions Adapting to changes Lack of perceived clarity regarding roles and expectations Addressing diversity Integration / isolation Outcomes Value Access Variable quality Training Theme 5: Future Theme 6: Issues within specialties Specialist vs generic roles Move from disciplines to modalities Greater clarification of roles Research Engage with stakeholders Training Outcomes Threats Staffing levels Organisational role Value Page 19 of 63

22 Theme 1. Roles and expectations: Understanding Customer Needs of Clinical Psychology Services - DCP This section outlines a number of expectation or roles for Clinical Psychologists which are presented below. These various roles will also be explored in more detail in subsequent themes. Clearly depending upon clinical settings and local service configurations there was variable emphasis on differing roles. Direct treatment Although there was varying opinion upon the extent to which Clinical Psychologists should be involved in direct work there was general agreement that direct patient work remains a central role. It was felt that Clinical Psychologists expertise and specialist skills / knowledge play an important role in terms of assessment and formulation. In addition the assessment of risk, the use of psychometrics and the use of an eclectic framework was perceived as valuable. In terms of therapeutic input there was an emphasis upon working with complex presentations with both individuals and more systemically with families. The ability to work eclectically and flexibly in terms of delivering therapy was also recognised. Psychologists give you a unique view through the use of psychometric testing and psychological review on risk assessment and offending behaviour, looking at the individual rather than the illness (non-clinician) Indirect role Research and audit Research and audit was seen a key element and valued as highlighted below. Another key role discussed was that of research in terms of developing new approaches or new ways of delivering existing approaches. Supervision The role Clinical Psychologists can offer in terms of supervision was seen as vital in terms increasing capacity and in the proliferation of psychological knowledge. Supervision was particularly valued in stepped care and early intervention services. Teaching The role of training other professions to deliver psychological interventions as well as training within the profession through input to training courses was highlighted Leadership Respondents identified leadership as a key role in terms of being leaders as part of a team and being leaders with other leaders dividing up roles to match the skills. There Page 20 of 63 As a commissioner I would expect professionals at band seven to be leading teams or managing teams of thirty people. (non-clinician)

23 was an expectation expressed that given the agenda for change bandings of qualified Clinical Psychologists that leadership would be an essential element of their role and yet not perceived to be providing sufficient guidance or influence to other professionals Team work There is obviously overlap between this area and others such as leadership and service development. In terms of respondents there were expectations expressed that Clinical Psychologists will work with teams in a variety of ways: to improve team functioning, recognise problems / issues then promote solutions increase capacity by supporting others with less training, and be involved in process mapping. Working with complex cases is a key role in terms of direct work, but also need to be working with the team on such cases. (clinician) There was also a desire for Clinical Psychologists to engage with and be integrated into teams. Consultation The use of consultation was advocated in a number of specialties, such as primary care and CAMHS. However it was also highlighted that this was not seen as appropriate in all settings where there was an expectation of greater input from Psychologists. The role of providing consultation to other services was seen to be useful in terms of managing referrals again this may not be applicable or seen as a priority role in all settings. In some settings it may also be seen as a way out and avoiding the need for direct contact. Service development Again this area overlaps somewhat with others, such as leadership, team work and research /audit. Roles in this area included developing packages of care, exploiting new technologies / growth areas, team design, process They (Clinical Psychologists) are the ones that highlight the need to think about what we are doing where as some other professions may be more eyes down to the core task and less how can we do this differently. (Non clinician) mapping, audit and evaluation. There was recognition that Clinical Psychologists are well suited to this role in terms of their skills. In some areas it was also felt that Clinical Psychologists can play a role in managing the interface between different specialties the example of learning disabilities and CAMHS was one suggestion. Organisational level There was a suggestion that Clinical Psychologists need to have an awareness of broader organisational aims and ensure that service Page 21 of 63

24 developments related to these aims. There was also the suggestion of possible roles in terms of developing links with commissioners either in terms of informing or advising commissioners, or as suggested by some actually taking on a commissioning role. Theme 1 summary: Issues within this theme highlight the breadth in terms of roles for the profession Key roles and expectations were identified in terms of direct work relating to assessment, adaptation of approaches, adopting an eclectic approach and working with more complex cases Indirectly there were expectations regarding supervision, leadership team working and service evaluation / development Theme 2. Different grades: A recurring issue was the differentiation between different grades of Clinical Psychologists in terms of expectations. The key issues within this theme are presented below Pre-qualified grades In terms of assistant and associate grades there was great variability in terms of the extent they were used if at all. There was a sense that such grades can provide good value, but there were issues regarding the relatively short term nature of employment particularly in terms of assistants. Lower qualified grades There was mixed opinion regarding the expectations and perceived value of Clinical Psychologists particularly on AfC bands 7. Some respondents perceived lower grades as representing good value for money in terms of working directly with clients, interpreting and developing the evidence base and in providing support for teams. There is an expectation that these staff will be fully formed professionals, supervising others and having a high level of expertise. Compared to other professions Clinical Psychologists are becoming uncompetitive at these grades. (Non-clinician) However others had differing views and perceived band 7 Clinical Psychologists as providing poor value. There was some recognition that longer term the contribution increases after a couple of years but there was still an issue as to what exactly can be expected from newly qualified staff; Senior grades There was acknowledgement that Clinical Psychologists on A4C higher band 8 s and 9 posts were focusing upon issues such as Page 22 of 63 Need to ensure higher grades have impact to be cost effective. Average 8c only having an impact upon 4 or 5 staff within services, should be more like 15 to 20 people. (Clinician)

25 organisational change, clinical governance, supervision, service development, training and were perceived to be highly specialist clinicians. However, there was still some concern from some respondents that in some areas the extent of their influence needs to be increased. Training There was some suggestion that in order to address the issues regarding lower qualified grades mentioned above there may be some implications regarding selection and preparation. All grades should be doing variety of indirect roles if not up to taking on leadership roles at lower grades then maybe we need to look at selection process. (non clinician) Awareness Awareness in terms of expectations across differing grades was variable. There was a feeling that A4C had increased awareness. In areas were there was good awareness this was attributed to factors such as the production of a psychology services strategy document and collaborative working practices. Local variation Another key issue raised was that in some areas Clinical Psychologists within comparable services in different localities had been graded differently. This appears to have led to some difficulties and some jobs being considered for re-grading. Theme 2 summary: Questions about the value of the profession across all grades. Need to ensure standardisation around product (quality of clinician produced) and price (salary). Clarification of roles across different bandings and clear expectations. Demonstrating effectiveness in terms of activity and outcomes. Direct comparison between professions focused upon salary and newly qualified Clinical Psychologists entering at band 7 aren t seen to be delivering broad range of skills and duties that other professions are at band 7. Compared to the medical profession, the newly qualified Clinical Psychologist at band 7 ( 27,600) is comparable to the SHO starting salary (5 years medical training, 1 year Junior house officer). Page 23 of 63

26 Theme 3: Strengths: All respondents identified a number of key strengths in terms of Clinical Psychologists. These can be classified into a number of areas presented below. Breadth A key strength identified is the breadth in terms of knowledge and skills and clinical understanding to work across a number of settings, as well as a breadth of abilities to perform in a variety of capacities. It was also highlighted that the breadth of skills was useful in terms of problem solving in complex situations. In addition the In depth knowledge and experience in application of a broad range of psychological theory to wide range of presenting issues, throughout the lifespan. (Clinician) combination of the scientist practitioner model and the reflective practice provides a unique perspective. Training The use of an apprenticeship model is perceived to be positive. Training is considered to be generally good, sophisticated and in-depth. The length of placements relative to some other professions is considered to be beneficial. In addition the generic nature of course is seen to produce clinicians with a range of skills and knowledge. Also training is seen to instil a recognition of the importance of continuing professional development, supervision and self care. It was suggested that this may be a factor in the high retention rates within the profession. Clinical Psychology has good retention rates which can result in good value for money compared to other professions in terms of investment in training. (Clinician) Team work Within some services Clinical Psychologists were perceived to be generally good team players. have an ability to form good relationships with colleagues, managers, and service users and to identify and address relational difficulties informally. (non-clinician) There was a perception that particular strengths of Clinical Psychologists lie in terms of working with teams on complex cases. It was also felt that Clinical Psychologists are often well placed to challenge teams in terms of existing practices. However this was seen to be variable. Research Reference was made to strengths in terms of conducting audits, evaluations, adding to and interpreting the evidence base and supervising the research of others. Can conduct and interpret evidence base, other professionals can do this but not as well as Clinical Psychologists in terms of systematic reviews and Clinical Psychologist s can supervise others research. (non-clinician) Page 24 of 63