Prescribing Rights

A challenge to the BPS on Prescribing Rights for psychologists.

Pat Harvey writes…

The BPS position on prescribing rights for psychologists is controversial and the Society has not carried out adequate consultation. The communication below has been sent to chairs of Divisions and Faculties, accompanied by the copy of a letter (below) signed by 102 psychologists last October


Letter to Chairs of Divisions and Faculties of the British Psychological Society 20 March 2021

Dear Colleague

I am contacting you in your capacity as an elected office holder of a Division or Faculty within the BPS. I write on behalf of a group of around 20 clinical psychologists who are seriously concerned about the recent BPS decision to recommend to NHS England that some psychologists should have prescribing rights. 

We understand that NHS England will not be taking further action on this matter until the COVID crisis has resolved. The problem that we wish to draw to your attention is that the Division of Clinical Psychology has made little or no attempt to survey its members in a thorough, fair and transparent manner.  We are concerned that you and your members may be unaware of the position that the BPS is now adopting on this crucial issue for our future professional roles. We see this interim period as now giving an important opportunity to conduct a full, accurate and impartial survey of all BPS members, especially those who belong to the Divisions and Faculties that are most likely to be affected. A poll of a small number of counselling psychologists was carried out, but as far as we know, no other Divisions or Faculties have formally consulted with their members. 

To give a brief history: A group of clinical psychologists and service users expressed their concerns about extending prescribing rights in Nov 2019 in an open letter to the BPS. It outlined the many problems with the BPS discussion paper which was used as the basis for further consultation by the BPS Task and Finish group on Prescribing Rights.

Here is further information:  https://www.madintheuk.com/2019/11/prescribing-rights-psychologists-cautious/

No response was ever received to the letter, although the authors were told that it had informed the subsequent discussions. The Task and Finish group on Prescribing Rights then proceeded, in our view on a flawed basis, to further discussion leading to its final conclusion, in which the BPS recommended to NHS England that developing a policy for prescribing rights for some psychologists should be pursued. Along the road to this point, a number of other very serious concerns about biased and misleading information, failure to consult, and extremely poor process, emerged. These were summarised in a letter with over 100 signatories (attached below minus signatures) sent to senior BPS staff on 6 October 2020. Despite chasing this up, the issues raised in this letter have never been directly addressed, and the recommendation went forward. 

In contrast, the ACP (the Association of Clinical Psychologists in the UK) carried out a survey of 439 people and found that the majority (58%) did not want prescribing rights for themselves and also had concerns about other CPs being able to prescribe. They found that 17% want to prescribe themselves, 16% were uncertain and 9% did not want to prescribe themselves but had no concern about other CPs prescribing. 

We have reason to suppose that there are other agendas are driving the current conclusions, but we hope you agree that the overriding priority is to have a fair and transparent discussion in which we can consider what will ultimately be best for clients and service users and for the unique contribution our professions can make.

Please let me know if you would like to discuss this further with one of the core group of 20 clinical psychologists who have been involved in trying to ensure fair process. If you wish to discuss the issue more generally Professor Peter Kinderman has agreed to be contacted via email on profpeterkinderman@gmail.com  If you receive any further feedback from members it would be helpful if you could let me know. 

Best wishes

Pat Harvey Consultant Clinical Psychologist, Psychology and Counselling Service Manager (retired) BPS No. 4810

Copy of email letter sent 6 October 2020 to Hazel McLaughlin, BPS President, copied to Sarb Bajwa, Kathryn Scott and Esther Cohen Tovee. Heading: ‘Urgent expression of concern about prescribing rights consultation process.’ Signed by 102 psychologists.

hazel.mclaughlin@bps.org.uk DCPUKChairDrEstherCohen-Tovee@ntw.nhs.uk Sarb.Bajwa@bps.org.uk Kathryn.Scott@bps.org.uk

Dear Hazel McLaughlin,

We write to express our grave concerns about the proposal to extend prescribing rights to some psychologists, and about the process through which the BPS view is being decided. This decision has the potential to produce major changes in how psychology and the BPS are seen by the general public and in the ways in which psychologists work with people referred to them, as well as how they work alongside other professionals. An open letter to the BPS outlined many other serious concerns, including the growing awareness of overprescription and withdrawal problems in antidepressants, and the overuse and misuse of psychiatric drugs in people with learning disabilities and older adults https://www.madintheuk.com/2019/11/prescribing-rights-psychologists-cautious/ . Equally complex issues are raised by the prospect of prescribing in other proposed settings, all of which deserve careful consideration in their own right.

All of this has serious, undiscussed implications for our core professional roles and independence. Particularly in mental health settings, there is a risk of jeopardising our specialist expertise and the psychological perspective that is so important and already under-represented, thus reducing rather than increasing service user choice. The requirement for prescribing psychologists to use diagnostic categories directly contradicts the DCP Position Statement on Classification (2013) which called for a move away from functional psychiatric diagnosis, and the DCP Good Practice Guidelines on Psychological Formulation (2011), which describe formulation as an alternative to, not an addition to, psychiatric diagnosis. The gravity of the implications in already highly controversial areas, and the strong opinions held on both sides of the argument, demands a thorough consultation process which is open and transparent, balanced and unbiased. It needs to be based on sound methods and evidence and to ensure that BPS members are fully informed about the issues and implications. None of this has happened. This at the very least risks reputational damage to the BPS.

We understand that the Prescribing Rights Task and Finish group is submitting a document to the Practice Board for a final recommendation this week. If the Practice Board agrees, as seems likely, then NHS England will be informed that psychologists want prescribing rights to be extended to some psychologists. Yet there has been no adequate consultation of members. On the contrary, the initial discussion document was mainly based on extremely small numbers and convenience samples from two conferences. The only professional group specifically consulted at this stage was counselling psychologists, in spite of the fact that clinical psychologists are likely to be seriously affected. This document also failed to inform members of many of the issues and evidence relevant to the prescribing rights proposal, as set out in responses to the consultation. What appears to have been the final stage of consultation consisted of a BPS online event which can only be described as a travesty. It was originally set up as a debate between two panels for and against the proposals, so that members could be presented with a wide range of views. Twenty-four hours beforehand, the ‘against’ panel found out that that the format had been changed, on spurious grounds, to a question-and-answer session with members of the task and finish group and one of their nominees (a psychologist prescriber from the US.) As a result, the ‘pro’ discussants outnumbered the ‘anti’ one by five to one.

It is essential that further discussion and consultation takes place, as happened with previous issues. For example, when the clinical supervisor role was first mooted, the DCP conducted a survey garnering 681 responses which were published before any decision was taken. In contrast, this consultation process has been grossly inadequate in the following ways:

  • Lack of adequate discussion across the BPS membership (and indeed psychologists who are not members of the BPS). An informal poll on the UK Clinical Psychology Facebook site resulted, a few hours later, in over 550 people saying they were unaware of the consultation.
  • An initial consultation document based on ‘how’ not ‘whether’ prescribing rights should be granted; was poorly evidenced; and failed to highlight many of the key issues. For example, the article cited to support the likelihood of psychologists of ‘de-prescribing’ (Linda & McGrath, 2017), actually found that on the “last full day of patient care” prescribing psychologists in the US had decreased medications in an average of 2.18 of cases but increased them in an average of 2.93 of cases. In addition, over the previous 12 months, 83% of the patients were given a prescription, only 16.33% were seen for therapy alone, and 29.3% were seen for medication alone (Linda & McGrath, 2017).
  • Failure so far to involve affected divisions, particularly the DCP, which represents the largest group of psychologists in the BPS.
  • Strong opposition from significant numbers of psychologists (as evidenced by the many unanswered concerns raised in the online discussion; the strong reservations expressed on the UK Clinical Psychology Facebook site; and the open letter to the BPS in 2019 https://www.madintheuk.com/2019/11/prescribing-rights-psychologists-cautious/).
  • Failure to involve service users adequately.
  • Lack of clarity about aspects of the proposals (such as the need for supervision by consultant psychiatrists or other medical specialists; the requirement to use a diagnostic framework).
  • Biased representation in the Task and Finish group, as acknowledged by chair of theProfessional Practice Board Alison Clarke in her article in The Psychologist https://thepsychologist.bps.org.uk/volume-33/march-2020/more-debate-prescribing-rights
  • Pressure on members of the Task and Finish group to agree to the proposals.
  • The decision not being taken at the appropriate level of the BPS, given the very major implications for our practice and our professional identity
  • Additional serious questions about the consultation process, including but not limited to:
  • –  the fact that most questions raised by the audience in the online BPS event were aboutconcerns, but only 3 out of 70 were responded to
  • –  the biased public BPS video on prescribing rights, in which only 5 seconds out of 3 and a halfminutes were devoted to possible disadvantages of the proposal
  • –  the marked failure to clarify the process by which the decision would be made – for example, the precise role that the debate, the email responses and the public consultation will play in the outcome.

We are aware that the Task and Finish Group believes it has already considered all the relevant issues. Clearly, not only has appropriate and serious attention to the many issues involved not been given, but also the process of discussion, consultation, dissemination of information to members and others, and decision making has been shockingly poor. We have been contacted by many colleagues, service users and others who are quite rightly deeply concerned. We fear an exodus of these psychologists from the BPS.

We look forward to a very prompt reply to this issue, given that a decision is due to be rushed through this week. We hope to hear that the process has been suspended so that genuine consultation and debate can take place. We will be pleased to provide any further information you may need. Please can you let us know that you have received this letter.

Reference

Linda, W. P., & McGrath, R. E. (2017). The current status of prescribing psychologists: Practice patterns and medical professional evaluations. Professional Psychology: Research and Practice48(1), 38-45.

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