You work in the independent sector for at least for part of your working week, but have you decided where within the sector you are positioning yourself? Let me tell you about where I find myself, with a view to perhaps prompting you to some reflections on your own situation.
Nowadays I count myself fortunate that I work entirely within independent practice, and that the bulk of my clients pay for themselves directly. I’d like to claim this was all part of my business plan back in 1991, when I founded my practice here on Anglesey, but serendipity has played the greater part. I never imagined that I, an English southerner, would spend most of my working life here in North Wales. The fact is that a work promotion for my partner had bought us, two monoglot English speakers, to the most Welsh speaking part of North Wales. Welsh Government policy is committed to providing bilingual services through bilingual employees, so it really was just as well that I came here intending to work in independent practice!
In the early years of my practice I was seeing quite a few people from employee assistance schemes. It was useful to have these referrals, given that I wasn’t well known in the area. However EAPS tend to offer workplace counselling rather than psychotherapy, and are often neither modality specific, nor outcome orientated. Consequently the remuneration isn’t great. I let this work go as other work began to come in.
I circulated GPs regularly from the start, but with very little effect in the early days. I suspect GPs receive promotional materials of all sorts and they are maybe inclined to wait and see if new practitioners develop a name for themselves before starting to make referrals. They certainly refer in quite large numbers now, but I think it probably took nearly ten years for that to start to happen.
Did you notice that “I think”, last sentence, previous paragraph? It tells you that I don’t know, because I didn’t keep good practice statistics. Learn from my mistakes, dear reader! Make sure you ask every client how they heard about you, and tabulate the information so you can notice changes and trends. Promote your services to potential referrers, who might then refer several clients each, rather than promoting yourself to individual potential clients.
In the last ten years I have tended to see more clients referred by healthcare insurance agencies and solicitors. These folk want CBT or EMDR specifically. They refer on the basis of a report they have commissioned for an individual client, and usually written by a psychiatrist or sometimes a clinical psychologist. The NICE Guidelines made a huge difference when they first came out. Nowadays treatment recommendations invariably follow NICE Guidelines. The main benefit of working for agencies is that they make referrals for a decent number of sessions, usually between 6 and 20. Depending on the agency, the office support may be provided purely by admin people; or by nurses, occupational therapists; or people with degrees in sports psychology, so any clinical support is pretty limited. All these agencies have their own suite of forms, and many of them are badly designed. For example, one is often asked to supply the same set of contact details on every form, despite a case reference number having been supplied. Then there are those agencies which are trying to go paperless. This would be fine if their online recording systems didn’t crash, causing you to lose all your work. Completing the admin can take as long as your clinical work with the client so what seem like quite generous fees don’t translate into quite such good hourly rates.
You will recall a period a few years ago when there were lots of “No win, no fee” advertisements. At this time, PTSD and Adjustment Disorder vied with back pain and whiplash injuries as the referral justification of choice for those clients and solicitors who were looking to play the system. I’m glad to say that the industry has been tightened up more recently. Spurious referrals seem to be far fewer now. A less happy consequence of this tightening up is that the agencies are having to tighten their belts. Consequently, they often try to wriggle out of paying for last minute cancellations, especially for the first meeting. Those relatively few clients who are trying to play the system are the ones most likely to cancel or fail to attend, and this is most likely at their first meeting. I have always refused to work with agencies whose contracts excuse them from covering last minute cancellations and DNAs and I urge you to do the same. The people with the most control over attendance are the clients themselves, and then the clients’ solicitors and health care agencies. I don’t see any justification for those of us with the least control to be the ones who bear the cost. There is no doubt that I have lost business as a result of making this stand on last minute cancellations. There again, my attendance rate is very high. My ever-increasing number of fee-paying clients has more than compensated for any lost agency work.
It took me five to ten years to build up to a full time practice. I was fortunate to have a partner who was earning a good income, and to earn money myself delivering some (non-therapy related) training during this time. After twenty-five years of consulting in the same small village on Anglesey, most of my clients are self-funding. They come by word of mouth or GP recommendation. I like working with people who are paying for my time. As Freud observed, the fee is part of the cure. Nobody pays for something unless they want it. Self-funding promotes self-responsibility and a willingness to engage, and not just on the part of the clients either! I cannot tell you how many supervisees have told me that they feel obliged to work that bit harder with their private clients, as opposed to NHS or funded clients because, “well, they are paying for themselves after all”.
So, where in the marketplace do you belong? You will do better if you tailor your service delivery and how you promote your practice with a specific section of the independent sector in mind. Please post your comments and share your experiences.
CBT Psychotherapist in independent practice on Anglesey.
You can follow Adam on Twitter @Adam_May_CBT