Twenty-eight thousand children on primary care psychology waiting lists. In some areas they are waiting up to 13 years.
Unbelievable, ineffable; a reservoir of human suffering and missed opportunities, bursting, every day. Primary care psychology is simply overwhelmed. Why has this happened and what can be done?
Primary care is the front line of health services, the first point of contact; it is where most health care happens. Primary care psychologists practise across disability, mental health, medical problems, maternal and child care, rehabilitation, older people and palliative care.
Our widely agreed national health policy – Sláintecare – is committed to providing more services in the community, to prevent and respond quickly to health problems as they arise. The clear reluctance to adequately resource this gives rise to the misguided rhetoric that positions health as a cost that needs to be contained, rather than an investment opportunity for personal and national prosperity.
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Primary care psychologists were at the forefront of the nation’s psychosocial response to Covid-19, leading community teams, integrating different service offerings and providing a tiered approach to access services. The monthly psychology advice (drop-in) clinics, which are open to everyone to walk in to, help people manage difficulties and prevent escalation. They are innovative and nimble, designed to meet people where they are.
But more and more people across the entire age range are seeking the services of primary care psychologists.
The National Access Policy allocates people to services on the basis of the complexity of their presentation. When it was implemented, this produced a massive increase in referrals to primary care, but no increase in psychologists.
It’s a common misconception that less “severe” presentations are necessarily easier to treat – on the contrary, they can sometimes be much more challenging. Originally, primary care was supposed to provide relatively focused and time-limited services. But now many people require continuous support, and primary care has to absorb what hospital or other specialised services don’t, can’t or won’t manage.
The demand for psychological assessments for autism and assessment of need has also exploded. Again, primary care psychologists have been at the forefront of championing such service innovations.
The increased load of assessment has in turn become overwhelming, with many public services now referring these to the private sector.
No more waiting, constraining or embargoing; it’s time to invest in our psychological health
Psychologists leave for the private sector, mostly undertaking assessments - further increasing waiting times for interventions in the public sector, which again increases the sense of being overwhelmed, boosting the attractiveness of private practice, where you can have more control over your pace of work and mental health.
For those who stick it out, tenaciously committed to providing equitable public services, the situation worsens, as waiting lists lengthen. Some areas have few psychologists, others none at all.
Geographical disparities exist in access to psychological services and what they can offer.
Amid all this, it’s hardly credible that political pressure for cost containment has created an embargo on recruiting staff into these services.
We need psychologists offering alternative ways of providing services; including less intensive digital services
Oireachtas committees are packed with fulminating politicians but the resources to recruit into unfilled existing psychology posts are not provided, nor for the increased scale of training places required. Other than the Department of Education funding a new training programme in educational psychology in Maynooth University, the response from the Department of Health and Health Service Executive (HSE) has been piecemeal and unambitious.
There is nothing that can’t be fixed in primary care psychology services. But we need something entirely different in ambition, scale and in approach. Five years after a report recommending the establishment of a national psychology placement office was completed, it remains to be funded. This modest strategic investment would co-ordinate and identify new placements, allowing more and more widely dispersed training placements across the country.
We don’t only need more psychologists, but a workforce plan for psychological services to be provided in different ways – not always one-to-one. We need psychologists offering alternative ways of providing services; including less intensive digital services (as we did in Covid-19), more assistant psychologists on permanent contracts so this can become a career grade, and more sharing of psychology with other professions, so that they are much more psychologically-minded, and not always needing to refer to psychology.
Psychological Society of Ireland (PSI) and the Heads of Psychological Services in Ireland (HPSI) must facilitate truly innovative change, eschewing the shackles of protective practice and professional boundaries. Psychologists have a profound responsibility to respond to the population level challenge (as in Covid), not only focusing myopically on the person in front of them.
The HSE should establish a national clinical programme for primary care psychology, a clinical lead and advisory group including the broad range of stakeholders, such as Jigsaw, Pieta House and others. The programme should develop a national model of service, just as the other national clinical programmes have.
Without a co-ordinating and guiding model of service, a programme and voice at the top table of the HSE, primary care psychology will remain forever overwhelmed and under-resourced, staffed by a dwindling workforce, providing variable services, and increasingly none at all in more areas. Waiting lists will lengthen, and the toll of avoidable suffering deepen.
Primary care psychology addresses many of the conditions that lose opportunities for both individual wellbeing and productivity for the state.
A European survey led by Oxford University and published in the journal Globalization & Health explored the “fiscal multiplier”; the financial impact a government investment has on the economy. On average, for every euro spent by the Government across the public sector, it produces a further €1.16 in the economy. For health, it is an impressive €4.30. That’s a great investment in wellbeing, in a productive workforce and ultimately in a competitive economy.
Primary care psychology can pay for itself if given the chance. No more waiting, constraining or embargoing; it’s time to invest in our psychological health.
Mac MacLachlan is professor of Psychology & Social Inclusion and Co-Director of the ALL Institute, Maynooth University
