‘We now fit the system to the person’

Sarah Rutter, Dr Angela Busuttil and Mike Rennoldson have dared to imagine a progressive (perhaps utopian?) future, written from the perspective of a new graduate, and they invite you come along with them…

I graduated in 2020, the first of the Covid-19 generation of young people in the UK whose education and futures were shaped by experience of the pandemic. Whilst that time was bleak, looking back it's possible to see the start of important change. I'm not talking about the sort of dramatic changes that happen in a crisis, then fade when it passes. I'm talking about sustainable shifts that have momentum and grow. Here are some of the most positive and important changes to affect clinical health psychology in the last 20 years.

Preventative behavioural health services

From the perspective of 2040, the expense and loss of quality of life resulting from treating ill health mainly after it has occurred seems absurd. It took a pandemic with very uneven effects to make health inequality a hot political issue. The power of public favour for the NHS helped immeasurably. Politicians saw the value of shifting to invest in the health promotion and prevention approach we have today. Waiting for the vaccine forced us to address issues that contributed to poor Covid-19 outcomes, including obesity and long-term health conditions. It also challenged us to reconsider and address cultural diversity and lifespan issues in relation to health, as older adults and citizens from BAME backgrounds were disproportionately affected.

Now, enjoying the fruits of investment, we have early years support for children, and preventative behavioural health services co-led by psychologists and other health professionals. Life expectancy is increasing again, due to reduced health inequality. In hospitals, we see fewer people of working age with complex multi-morbidities. The physical and psychological burden of living with chronic disease linked to lifestyle is reducing. With an expanded psychological professions resource, we actually aspire to meet psychological need for everybody with physical health problems, rather than just tackling the tip of the iceberg.

Psychology became everyone's business

The concern for the mental health of frontline workers during the pandemic assisted the gradual de-stigmatisation of mental health in society. As the world recovered from Covid-19, the impact of trauma was brought into the general consciousness, and appreciation of this influenced a redesign of certain services. Distress is now understood as an expected response to adverse events, with recognition that healthcare professionals (HCP's) are regularly exposed to situations that can be traumatising. Psychologists took a lead in embedding trauma theory into healthcare delivery. Reflective practice is now considered integral to staff wellbeing, and therefore optimum care provision, and there are cascade models of support (psychologists supporting team leaders to support their teams) across healthcare. Trauma-informed approaches became a reality for long-term health conditions where there are high levels of adversity and distress; historical and current. Within this, there is the acknowledgement of complex dynamics that can manifest in service user and HCP relationships and the association with health outcomes. Psychological consultation is now commonplace in relation to these issues.

Post-qualification training in psychological skills is essential for the continued registration of all HCP's. Psychology has become everyone's business, and is so well-rooted that stepped care models are rarely explicitly referenced. The revised post-Covid-19 NHS Long term plan (2020) required employment of psychologists in every hospital and community setting. The BPS worked across divisions and networks to achieve strategic influence and assessment and intervention became meaningfully bio-psychosocial. In mental health services, physical health is given appropriate attention and we have seen morbidity and mortality rates significantly improve. As a trainee, prior to 2020, I noted psychology was often an afterthought in care discussions. Half remembered, fading in and out of the awareness of my hospital colleagues. Unlike my supervisor then, I don't need to campaign to keep psychological wellbeing of patients and staff in the spotlight – it's part of the fabric of everything we do. There is much less reactive involvement with the expectation that a crisis can be fixed. We no longer require that 'magic wand' to prove our worth.

Training changed

Training for psychologists now is unrecognisable. Back then there was talk of developing skills and competencies across specialties, and inter-professional learning, yet it seemed that clinical health psychology was an optional extra; sporadic and inconsistent. Physical health placements are now mandatory. Did we really claim to have expertise in a bio-psychosocial approach without experience in physical health settings?

Now, my trainees come on placement already well-versed in clinical health psychology. They are much more knowledgeable than me regarding responding to psychological and physical health interactions and apply this across a range of needs (e.g. intellectual disabilities, complex mental health problems). Additionally, when working within specialist physical health services, their enhanced understanding of health encompasses reciprocal associations between a whole range of factors. This means that MDT understandings consistently include broader factors such as early trauma, quality of relationships and support networks (personal and healthcare) and sexual health, function and satisfaction.

Personalised healthcare

I remember the 2020s as a time of talk and excitement about personalised medicine, but not much change. People were still treated by the category that seemed to fit them best (or not) as far as I could tell. With personalised care developments, you could say that medicine caught up with psychology, as we prided ourselves on individual formulations. However, the kind of psychology we do today is qualitatively different. We're using and actively contributing to research from areas which integrate physical and mental health, such as psychoneuroimmunology, and the gut micobiome, which informs our work. We are becoming truly inter-disciplinary and in 2040 we balance 'No Health without Mental health' equally with 'No Mental Health without Health'.

Covid-19 also taught us about our ability to adapt when necessary, and we offer flexible services to all who use them. Technology continues to be a central feature to healthcare delivery, particularly for those with busy lives. This has freed up space for teams to provide more traditional face-to-face care for those who require in the room connection, and might need extra time due to complex needs. We now fit the system to the person.

Final thoughts

Looking back, it remains important to remember the devastation that Covid-19 brought to so many. Perhaps the way we pay tribute to those who are bereaved or forever affected is to balance this with development for the greater good, including our health system. Covid-19 highlighted the importance of relationships, human connection and created some perspective shifts. It made us aware of vulnerability; our own, that of people we care about and of our planet. Our shared understanding of loss, self-sacrifice and celebrating the small stuff bonded communities and seemed to alter the general conscience. Ultimately, it helped us take better care of our world and of each other.

-  Dr Sarah Rutter is Chair of the British Psychological Society's HIV and Sexual Health Faculty, and a clinical psychologist in HIV at North Manchester General Hospital.
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-  Dr Angela Busuttil is Consultant Clinical Psychologist and Clinical Health Psychology Services Clinical Lead, Primary Care and Wellbeing, Sussex Partnership NHS Foundation Trust; and BPS DCP Chair Faculty of Clinical Health Psychology.
[email protected]

-  Mike Rennoldson is a Senior Lecturer at Nottingham Trent University
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Artwork: Collage by Andrea Watts (City University, London)
Using collage as a creative coaching tool had always meant working with clients face to face with the materials. So, the challenge for Andréa during Covid-19 was to transition her arts-based methodology online, without losing the power of images to unlock unconscious thinking. Discover how she accomplished it at thepsychologist.bps.org.uk/rich-visual-language