It was with much conflict that I attended an information evening for therapists by a social enterprise called Get Stable on Tuesday.
On the one hand, here is a company whose aim is to widen people’s access to psychological therapies beyond the CBT hegemony currently held in place by NICE guidelines. Adult Psychological Therapies is an area of the NHS being opened up to delivery by ‘any qualified provider’ (AQP). Get Stables’s main objective is to make it possible for people seeking therapy to be referred to private practitioners by their GP. As a therapist in private practice, my attraction to this idea is clear.
On the other hand, the legislation that has made this possible is the much-maligned Health and Social Care Act 2010-12; a bill so steeped in Fecklessness and Lose that Health Secretary Andrew Lansley defied FOI legislation to prevent publication of its risk register during its passage through Parliament. An early draft of the Health Bill risk register has now been leaked, confirming pretty much every argument against a Bill opposed by the majority of the medical profession. It’s probably clear where I stand on this issue.
So you can imagine the conflict; here is a company, aiming to deliver the kind of access to therapy I think people need to have, made possible by legislation I have actively campaigned against. Never had it been any clearer: I am a private psychotherapist; I am a private sector interest!
I remain opposed to the opening up of the NHS to ‘external markets’, and consider the term ‘any qualified provider’ to be an act of misdirection. It is clearly intended to play on most people’s assumption that ‘qualified’ means ‘good’, while in fact, ‘qualified’ simply means ‘meets the criteria’. As the manager of a small charity pointed out to me a few weeks ago, one of the qualifying criteria in tendering for service delivery is often that the organisation demonstrates a minimum annual turnover, or minimum level of reserve capital. So there are ways of ensuring that the ‘any’ qualified provider criteria are skewed towards, say, organisations that have paid your political party lots of money, or on whose Boards you can expect to sit.
That said, the starting point in gestalt therapy is to make contact with the actual situation and respond accordingly. The Health Bill has passed, ‘the markets’ are mobilising, and I find myself living in interesting times. So…
Who is Get Stable?
Although I asked at the end, I’m still unclear on the governance arrangements of Get Stable. Which doesn’t sound like an interesting thing to be concerned with but is, I think, very important.
The language of Get Stable is one of therapists as partners. The problem with that language is that, to me, partnership implies a more or less equal power relationship. However, Get Stable is a limited company, not a co-operative or collective, so while therapists may be referred to as partners, that doesn’t empower anyone to make organisational decisions; the Board will retain that authority.
That said, Get Stable isn’t (or at least doesn’t seem to be) a shadowy corporation moving in to snaffle up NHS goodies. Benjamin Fry, Get Stable’s founder, gave a very warm and personal account of his motivation for setting the company up, grounded in his own experience of trying to get therapeutic support through the NHS. If Get Stable is successful in its bid, I would like to see it move to a co-operative set up with charitable status.
The following is my understanding of what’s happening, so I’d appreciate it if any factual errors or mis-interpretations could be pointed out in comments.
Delivery of adult psychological therapies will be opened up to tender on 4th April. Any organisation that meets the AQP requirements will be able to put in a bid, with the bidding process closing 24th April. This is Get Stable’s initial window of opportunity.
PCTs are being dissolved, and their place taken by larger clusters, aligned to Local Authority boundaries. Get Stable is bidding in relation to the Bristol, North Somerset, and South Gloucestershire (BNSSG) cluster. This made some of the presentation confusing for me, as Ben mostly referred to how ‘Bristol’ would be doing things; I’m assuming that he was using Bristol as shorthand for the BNSSG cluster.
The BNSSG cluster appears to be the first in the country to be interested in commissioning an adult psychological therapies service that isn’t simply IAPT v2. Rather, the cluster is apparently open to the possibility of tapping into modalities beyond the prescription of NICE guidelines.
The referral process
In Benjamin Fry’s ideal world, Get Stable has successfully been awarded the tender for delivering adult psychological therapies in the BNSSG cluster. The journey from suffering to recovery goes something like this:
You go to your GP. You might have already self-assessed using Get Stable’s website, or you might not know what’s wrong. Your GP agrees or assesses that you need therapy. You then use Get Stable’s website to choose a therapist, using therapist profiles to decide who is right for you. Your GP refers you to that therapist, you make contact to arrange an initial meeting, and off you go.
Essentially, the process is pretty much the same as finding a private therapist, but with your GP as gatekeeper (s/he will hold the money), and Get Stable providing the background administration and quality assurance (only qualified and accredited practitioners can sign up).
This maximises choice on the part of the person seeking therapy in a way that is designed to reassure commissioners that what Get Stable will make available meets the same standards as what is already available in the NHS. It means that therapists who have chosen not to accredit, or who have sought alternative accreditation paths (such as the peer-review system of the Independent Practitioners Network) are unlikely to benefit from this system.
If this model is successful, then I would expect to see organisations like BACP and UKCP grow in strength, especially if this model spread to other clusters. Further, I would expect some degree of ‘therapist immigration’ as therapists outside the cluster area travel into the area, specifically to tap into this referral process. Especially if neighbouring clusters are commissioning services that essentially replicate the current IAPT provision.
I experience a lot of excitement as I make initial contact with these possibilities because it certainly looks like the kind of access to therapy I would like everyone to have. As a private practitioner, I hold a conflict between wanting to support people on the one hand, and needing to make a living on the other. Consequently, I have to acknowledge that my fees are beyond the reach of a large number of people.
Clearly, the Get Stable vision is one in which people can get, through their GP, the same access to therapy that only people with the means to pay can currently enjoy.
Money money money
At one point, I wondered to myself whether we were all going to be asked to pay some money into some kind of pyramid scheme-esque therapy racket. Amusingly, that thought was followed by Ben drawing a pyramid on the flipchart as a visual aid. He was explaining the logic behind Get Stable’s funding model, so far as it exists (the pyramid didn’t detail the funding by the way, it detailed the hierarchy from IAPT (top) down to self-certified therapists (bottom) from the commissioning perspective).
The understanding I’ve come away with is this:
Each person referred by a GP would have an amount of money associated with them. That money is only released to Get Stable when a successful outcome is achieved. A successful outcome in Get Stable’s model is achieving ‘recovery’ as defined by CORE (regular readers will be remembering my post on the Gestalt CORE project at this point). CORE is a way of measuring the impact of therapy in order to allow quantitative assessment of service provision.
This is a murky area of the model for many reasons, and is the main dampening factor on my excitement.
Ben’s argument is that, in order to meet the needs of the commissioners that will be deciding which bids are successful, Get Stable need to minimise the financial risk to the cluster. The NHS already uses CORE to measure the strength of a wide range of services (hence the logic behind the Gestalt CORE Project). Nothing reduces financial risk more than ‘no win, no fee’, so if ‘win’ is defined in terms the NHS already considers definitive, a major hurdle is, theoretically, overcome.
Further, by applying existing NHS standards as sign up requirements for therapists, Get Stable can argue that they are safe in the same way that NHS services were safe. Qualified and accredited therapists provide therapy in the NHS already, so Get Stable isn’t exposing people to anything they wouldn’t already be able to find in the NHS nationally.
The rub for me as a therapist comes in a number of places.
First, CORE methodology consists of a long list of measures at the start and end of therapy, and a shorter list of measures in every other session. So some therapy time must be given over to filling in CORE forms.
Second, it remains unclear to me what happens in terms of payment in the instances where: the person referred doesn’t show up; the person referred comes for assessment and we end up not working together; the person referred disengages from therapy before the agreed end date. My current reasoning is that, in these cases, no money will come from the cluster to Get Stable because there is no ‘win’ (recovery, in CORE language).
Third, suppose I’m seeing two people and see both through to an agreed ending; the CORE scores for one indicates recovery, the scores for the other indicate non-recovery (either no movement in scores or not enough). My current reasoning is that Get Stable receives money for the person with recovery scores but no money for the person with non-recovery scores.
Get Stable has asserted that it will take money centrally from commissioners and re-distribute to partner therapists so that everyone gets paid for their time. If I’ve understood correctly, and money only comes to Get Stable when a recovery score is achieved, then a bizarre economy is created in which the money gained through people with recovery scores subsidises the people without recovery scores. I find it hard to see how that could average out at a decent level of fee for each individual therapist (though a caveat here would be that the money available per person isn’t known yet so no one can crunch any numbers!).
Fourth, I’m unclear on this but assume that the money allocated per referral is a fixed amount, creating an environment that is better suited to brief therapy. If the money per person is fixed, then the money:session ration clearly reduces with every session, creating an incentive to take as few sessions as possible.
While this appears to be a good thing (and Fritz Perls was very opposed to the idea of spending years in therapy), it fails to take into account that people need to move at their own speed. In the case of depression, for example, a depression that is highly situational is more likely to pass more quickly than a depression that is rooted in long-standing problems.
So a further nuance to the therapeutic economy becomes people with simpler therapeutic situations subsidise people with more complex therapeutic situations.
If the money available per person is flexible subject to assessment of complexity and time needed; and/or if there is a ‘basic + commission’ model where Get Stable get a standard payment at the start, and an additional, recovery-linked payment at the end, then much (though not all) of that bizarre economy will be mitigated.
Overall impact on therapy provision
From the perspective of someone seeking therapy through their GP, this model provides a wider choice than currently exists, and I think that is a good thing. Having received my own therapy purely through the private sector, I would have a very hard time being allocated to someone by my GP
From the perspective of the commissioning group, this model clearly transfers all the financial risk away from the commissioners and onto the practitioner. At the same time, it ensures that only private practitioners who meet the current NHS standards for therapy provision are available for referral. I’m not a commissioner, but the no win no fee & NHS standard equivalency logic seems to me to stand a good chance of being appealing.
From my perspective as a practitioner… I don’t particularly like the risk of not getting paid for my time. Get Stable seem to be wanting to use the bizarre economy I’ve described to ensure that everyone gets paid for their time. In which case, I suspect the bigger risk is that the average therapeutic fee will fall below what practitioners currently get privately. Get Stable quoted an expected average fee of £45; given that no numbers are available, I’m assuming that to be an air-plucked number meant to attract an initial wave of therapists to sign up.
Overall, I see the impact as being largely determined by how much money is available for each person referred, and what proportion of that money is dependent on hitting the win of recovery scores.
In the worst case, therapists adapt to a therapeutic economy that is skewed towards people who are more ‘responsive to treatment’ and have ‘simpler presentations’ because these are the most ideal conditions for a speedy journey towards statistical recovery.
In the best case, therapists have the freedom to give each person the time they need, and the discipline of CORE assessment supports practitioners in developing a more sophisticated ability to assess likely therapeutic timeframes.
I suspect there’s a bell curve in this, with ‘available funding’ along the x axis, and ‘therapeutic efficiency’ along the y axis. Whilst it’s obvious that too little money leads to poor conditions for therapy, I do also think that too much money does the same.
That said, I doubt we have to worry about too much money being made available!
In closing, I’m aware that there are many nuances and aspects to this that I haven’t discussed, not least of which being whether the very idea of quantifying a ‘no win no fee’ approach with CORE is good, bad, or meh.
What I’ve stuck to for this post is an immediate remembrance of and response to Tuesday’s meeting; it’s my hope that some discussion will take place in the comments, especially among people who attended the meeting.
My current position is that I think Get Stable is basically a good idea in need of the numbers necessary for financial modelling. I can’t see any real loss involved for a therapist wanting to give this a try by experimenting with making three or four slots available on a one year trial basis to assess whether it works.
I wish Ben Fry and his team the best of luck with the bidding process!