Independent CBT practitioners and the thorny issue of fee schedules. How much is not enough?
Deliberating on the financial precariousness of providing psychological treatment as an independent CBT practitioner is something many of us will have reflected on before making the decision to cease being an employee . For those of you took the leap before the 2007 credit crunch which then became a full financial meltdown which then turned into a global recession you will no doubt have felt the effects of the worst recession since the second world war both on your practice and your wallet. Actually if you’ve been around that long and continue to ‘thrive’ (Clarkism) we salute you.
Nonetheless, we have been aware of the recent trend by some health insurance companies of capping or downgrading the fees offered to service providers. The bottom line is clear and it seems non-negotiable. Accept the fee offered or jog on. We have also been made aware of a ‘no compete clause’ demand from a therapy clinic looking to recruit CBT therapists which means that anyone signing up must desist from seeing other private patients. This example of restrictive practice removes at one stroke the central benefit of self-employment, i.e. autonomy and appears to be justified on the grounds of the ‘significant’ benefits offered to those that decide to sign up.
For many in the UK self-employment has become a way of escaping harmful or unsatisfying workplace experiences whilst trying to gain back some control and self-respect. The anecdotal evidence heard from our IPSIG colleagues is that private practice is viewed similarly – a route out of a mental health service delivery system that is too often experienced as demoralising and restrictive. The obvious danger of signing up to a business model that prescribes your supervision and training needs and prevents you from seeing other patients is that you are likely to find yourself in exactly the same situation from which you had tried to escape in the first place.
In the UK self -employment is at its highest level since records began almost 40 years ago. According to a report by the Office for National Statistics, “ There are 4.6 million people working for themselves, with the proportion of the total workforce self-employed at 15% compared with 13% in 2008, and 8.7% in 1975. Fewer people left self-employment over the last five years than at any period in the last 20 years, with the ONS suggesting that they might have struggled to find an alternative job during the downturn. It also pointed to the increasing number of people choosing to work for themselves beyond the state pension age of 65”.
However, wages for many have stagnated or seen a fall . Indeed, David Blanchflower, Professor of Economics at Dartmouth College, claims there is no evidence of meaningful growth in real wages taking hold soon. Blanchflower says that, “the rise of self-employment, now making up 15 percent of the UK workforce, has contributed to economic stagnation, as the group typically earn less than waged and salaried workers.”. Blanchflower’s report, co-authored with Stephen Machin, Professor of economics at University College London, also identifies, “falling trade union membership and collective bargaining power as contributing factors”. Furthermore he points out the hazards in no uncertain terms,” Self-employment conveys considerable risks, not least when there are large amounts of labour market slack. Of people who were self-employed in 2009, 23 per cent were no longer so in 2014. There is some evidence that when the self-employed fail, as many do, they lose their jobs, their houses that they used to finance their work, and sometimes even their marriages. Around half of employees say they want to be self-employed; fortunately, most don’t take the leap”.
We have no data on the number of IP’s who attempt self- employment or the trajectory of that decision but we can be pretty sure that the trend towards fee capping and the enforced fee schedules rolled out by the major health insurance companies and some larger private psychotherapy businesses will have consequences for the lone practitioner. One of these is likely to be the undercutting of fees by competing organisations with practitioners having to make a decision about whether to accept terms and conditions or deprive themselves of a revenue stream.
BUPA introduced a cap some years ago and more recently AXA PPP have followed suit. Interestingly the schedule of fees offered by some health insurance companies is slightly more than the fees set by CBT Therapists themselves which may surprise those who harbour the fantasy that independent practitioners are mercilessly money motivated. What we are though is vulnerable to market forces. We work independently and rely on our personal networks and special interest groups for information on what is happening in the health care industry. It is therefore in our best interests to come together and share information regarding financial practice issues as this will allow us to provide co-ordinated feedback to stakeholders when they do their market review. Accessibility to high quality CBT provision in the NHS is insufficient . The services IP’s offer are invaluable to the patients we treat. Don’t let anyone tell you you’re not worth it.