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Current state of integrated care: An opportunity in England

Posted By David Humphreys, Monday, December 4, 2017

A recent article in Context, the house magazine of the Association of Family Therapy (AFT), raises questions about the future of family therapy as an accredited profession in the UK. A variety of threats to the profession are described, which include a lack of clarity about what the family therapists do and with which client groups. The recognition and accreditation by AFT of the systemic practitioner role. This can be achieved with the completion of the first two years i.e. intermediate level, of the four-year family therapy training.


AFT argue that they are responding to an increase in intermediate level training being provided by private, voluntary and NHS providers. This is attractive to organizations because training can be delivered in house to existing staff, who can be skilled up for specific projects. Further the nature of the requirements permit the two years to be delivered in one.  


 There has been a reduction in the numbers on qualifying training courses and several courses have moved to bi-annual intakes. In recent years one private training provider, Kensington Consultation Centre (KCC) closed because of financial issues. There is also some suggestion that universities providing qualifying level training are losing money on these courses. This in a climate where those same organizations have closed other courses because of insufficient numbers.


There would seem to be many reasons for the changes, including the ways that the NHS and Social Services departments have responded to several years of having to make efficiency savings. They are the major employers of family therapists in the UK, the majority of whom are employed in children’s services. In a bid to buy more, with less, many of them have adopted a re-banding strategy. An example of how this works can be seen in a large mental health trust of 3000+ staff close to London.  A layer of middle managers was removed, and their tasks were given to senior clinicians below them, requiring them in turn to reduce their clinical caseload by passing it down and so on. At the same time a new grade of clinician was created, with a lower level of training, using manualised approaches to work with less complex clients, and being supervised by the senior clinicians.  The economics are straightforward depending on grading you can buy 2.5 -3 junior clinicians for one middle manager.


It could be argued that one of the effects of these strategies might be to increase the demand for qualified family therapists as supervisors. This might be the case, but to ensure compliance that would require a binding agreement that systemic practitioners could only be supervised by qualified family therapists.  That doesn’t exist; and already that role is often fulfilled by other clinicians such as clinical or counseling psychologists, who may have completed a systemic element in their training. All of this would support the argument that the profession may be facing a serious reduction in numbers of qualified practitioners and an associated reduction in dedicated posts.


Into this bleak description of the future, maybe consideration needs to be given to current developments in the NHS, and where most of the resources are being allocated. One of these is primary care; the launch in 2015 by NHS England of the Vanguard project; initially establishing 23 trial sites. These are Multi-Speciality Community Providers and Primary and Acute Care systems, trialling integrated care structures. They are bringing together physical and mental health treatment in a variety of structures including within GP practices.  These are large sites serving big populations providing primary physical and mental health care, and outreach secondary services. They are looking to collaborative integrated primary care models in the US, such Intermountain Healthcare and Southcentral Foundation for ideas and inspiration. In 2017 there are over 50 trial sites with a variety of models and configurations across the country. Recent feedback is very interesting.


These developments would seem to offer a potential demand for mental health clinicians skilled in relational working, trained to think about and engage with the network and system at an organisational, team, familial and individual level, aiming to build collaborative working across disciplines. Family therapists would seem to be well placed to meet these demands.


Primary care has not historically been a place of employment for family therapists, there are a number of reasons for this. The first is that the majority of family therapists were, as previously mentioned employed in secondary children’s services in dedicated posts. Until 10 years ago mental health provision in primary care was inconsistent and of variable quality. There was little guidance offered to GPs about the variety of therapeutic modalities and the most effective evidence based treatments. At the same time secondary services especially for people with mild to moderate depression and anxiety disorders were very sparse and often non-existent. The combined effect was an increasing untreated population of adults, with many GP’s trying to treat people with medication and informal supportive counseling.


This changed 10 years ago, when following the publication of the Depression report,  teams of CBT therapists were established across England contracting with GP practices to provide time limited evidence based treatments. Although they are based in secondary care, they see some people in the primary care setting.   Interestingly in the original report family therapists had been identified as one of the professions to be trained to work in primary care, regrettably it didn’t happen.  One of the reasons may be that when in the 1990’s, Susan McDaniel and others in the US, described a Medical Family Therapy role working in primary care. It was dismissed by some in the UK family therapy establishment, on the basis that they were already using that approach in secondary care had been for 40 years.  


Whilst acknowledging that it wasn’t used in primary care, maybe the time has come to take another look at MFT and consider the possibilities that might be created in the Vanguard sites, it is not too late. The Vanguard sites provide the opportunity to implement change, MFT provides a model to learn from and Family Therapists have the professionalism and the motivation to drive the change to integrated care.


David Humphreys, MSc., is a registered family therapist working in a primary care practice in Hertfordshire in the UK. He is a 2016 Winston Churchill Fellow and visiting lecturer at the University of Hertfordshire. 

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