Evaluating the Cost-Effectiveness of Counselling in Health Care

Nancy Rowland, Keith Tolley

• Publisher: Routledge
• Year: 2021
• eBook ISBN: 9781317725626
• Topic: Philosophy
• Subtopic: Ancient & Classical Philosophy

Limited resources in health care mean that the value of counselling is decided in a highly competitive economic arena. Keith Tolley and Nancy Rowland have written a practical guide to the basic principles of evaluating cost-effectiveness to enable counsellors and service providers to carry out analysis for themselves. They provide helpful definitions of technical terms and use case studies to demonstrate how to apply the theory in different contexts.

Part I

The principles of economic evaluation

Chapter 1

The economic evaluation of counselling

The relevance of economic evaluation for the NHS

A working definition of counselling

The importance of evaluating counselling

Does counselling work? Research issues

The economic evaluation of counselling

Techniques of economic evaluation

THE RELEVANCE OF ECONOMIC EVALUATION FOR THE NATIONAL HEALTH SERVICE

Economic evaluation is just one part of the overall evaluation of counselling in medical settings, but it is a very important part. In the current climate of change in the NHS and the impact of limited resources, economic analysis plays a powerful role. The present government’s commitment to value for money cannot be doubted. The health service is the largest employer in the state sector with public money of £30 billion provided annually to pay for staff, facilities, equipment and patient care. Demographic trends, the continuing stream of new medical and surgical advances and increasing public expectations are placing ever greater demands on the health services, which because of the existence of cash limited funding, has led to lengthening waiting-lists for non-acute health care. Limited funds raise important issues in relation to the development of counselling services in the allocation of NHS resources.

Health service managers will require information on the costs and outcomes of alternative treatment programmes in order to determine priorities for the use of NHS resources. Without that information, decisions will be made according to other more subjective criteria such as historical precedent, managers’ personal preference, vague notions of public interest, pressure from government and interest groups and demand from doctors and their patients. GP demand for counselling services is widespread; a recent survey of GPs (Sibbald et al. 1993) showed that 80 per cent of GPs surveyed would like on-site counselling services. Many of these doctors are responding to patient pressure. Without evidence of their effectiveness and data on their cost-effectiveness, counselling services may be viewed as peripheral activity deserving of limited funding, or they may continue to develop in an ad hoc fashion, with no reference to planned policy or population need. Sound evidence is crucial in determining whether or not counsellors are employed. An economic analysis has a key facilitating role to play in ensuring that available resources are used efficiently.

Counsellors have been exhorted (Ross 1989) to deal positively and openly with notions of accountability, cost-effectiveness, cost-benefit analysis, performance indicators and the like. This book aims to develop the reader’s knowledge and skills in the economic evaluation of counselling.

A WORKING DEFINITION OF COUNSELLING

While counselling is most commonly perceived as a form of advice giving (a definition irritatingly legitimated by dictionaries (Woolfe et al. 1989)), the term may, in fact, cover a whole range of helping methods from psychotherapy to behaviour modification to befriending or advice giving and counsellors may use any or all of these methods. There is, too, a wide range of helpers involved in counselling with workers from many different professions and volunteers in different settings. The range of clients is even greater, encompassing all humanity and its problems (Bolger 1989). It is no wonder that defining counselling presents problems and that those involved with counselling continually refine definition of the term in light of developments in the counselling field, its theory and practice.

A thorough definition of counselling would involve not only describing counselling and differentiating it from associated activities (such as advice giving), but also addressing the issue of who counsels, the methods used by counsellors and a description of the settings in which counselling takes place. Such an investigation is beyond the scope of this book. For a full review of counselling, the reader would do well to refer to Dryden et al. (1989), which has a useful introductory chapter describing, in detail, the nature and range of counselling practice.

In outlining a working definition of counselling, it is necessary to touch briefly upon two of the major theoretical issues that currently concern those actively involved in the counselling field, issues which reflect the emergence of counselling as a profession, practised by professionals with a Code of Ethics and Practice for Counsellors (British Association for Counselling 1993). Thus the debates on what counselling means to counsellors focus on delineation, definition, inclusion and exclusion. Two such zonal disputes, as Woolfe et al. call them (1989), centre on the boundaries (if any) between counselling and psychotherapy, and the differences between the practice of counselling and the use of counselling skills, for example, ‘Can a nurse who uses counselling skills in her work caring for patients be said to be “counselling”?’ This process of description and definition is an important one and it is to the credit of counsellors and their representative organisation, the British Association for Counselling (BAC), that time and energy is spent attempting clarification (1989a, 1993).

While the BAC and their colleagues in the voluntary and statutory sector are formally attempting to describe and differentiate skills and processes within counselling and psychotherapy under the auspices of the Department of Employment’s Lead Body for Advice, Guidance and Counselling, we will use the terms counselling and psychotherapy interchangeably, believing that in general they overlap more than they diverge. While a broad differentiation might be that psychotherapy tends to deal with deep-seated personal issues and is usually carried out on a longer term basis and in greater depth than counselling, which tends to focus on life problems (Rowland 1992), Einzig points out (1993) that some psychotherapists practise short-term work and some counsellors practise long-term work. If there is a distinction between the two ‘talking cures’ it lies in practical concerns about the nature of training, the settings in which people work, and the problems and issues with which they are typically confronted (Woolfe et al. 1989).

As to the differences between the process of counselling and the use of counselling skills, the BAC maintains that the process of counselling is a complex and highly skilled enterprise which demands training in theory, ethics and practice and an ongoing commitment to personal and professional development on the part of the counsellor, and that this differs from the ‘simple’ use of counselling skills in a variety of helping situations. While those trained as counsellors represent the ‘professional’ end of the counselling spectrum, raising issues of training and accreditation, supervision and standards (Woolfe et al. 1989), there is also a vast array of individuals of paid and voluntary workers whose primary training is not in counselling but who may have had brief training in, or developed expertise in, the use of counselling skills. Thus doctors, teachers and social workers, to name but a few, use counselling skills in their daily work.

Some counsellors might baulk at hearing these helping activities described as ‘counselling’, and it is evident that these ‘helpers’ have varying degrees of experience and expertise. We are not talking about ‘good’ and ‘bad’ counselling; such issues must remain the professional concern of counsellors. However, we would agree with Davis and Fallowfield (1991) in taking the broad view and use the term ‘counselling’ to refer to a range of helping situations, drawing on a base of specialist psychological knowledge and a set of qualities and skills for communicating effectively. This includes those who have developed counselling skills through training or experience but who might have another primary profession such as doctor, teacher, priest and so on; and those who specialise in helping people in emotional distress, such as counsellors, psychotherapists, psychologists and psychiatrists. Therefore, our definition of counselling will include the work done by trained counsellors who help individuals with their ‘problems of living’, whether psychological, emotional, physical or a complex mixture of each, the work done by psychologists who may use counselling skills along with a variety of specialist interventions (occupational testing, behaviour modification and so on) and those who use counselling skills in their professional lives to do their job effectively, such as doctors or nurse therapists. The content of the book will reflect this diversity.

Given the range of psychological interventions which come under the counselling umbrella, it is useful to refer back to the BAC’s Code of Ethics and Practice for Counsellors (1993). As there are individuals whose main job it is to counsel, it seems reasonable to take their view of what they do as our baseline, and to include in our definition of counselling other activities that approximate to the definition of counselling, in the spirit if not in the letter. The BAC defines counselling thus:

The overall aim of counselling is to provide an opportunity for the client to work towards living in a more satisfying and resourceful way. The term ‘counselling’ includes work with individuals, pairs or groups of people, often, but not always, referred to as ‘clients’. The objectives of particular counselling relationships will vary according to the client’s needs. Counselling may be concerned with developmental issues, addressing and resolving specific problems, making decisions, coping with crisis, developing personal insight and knowledge, working through feelings of inner conflict or improving relationships with others. The counsellor’s role is to facilitate the client’s work in ways which respect the client’s values, personal resources and capacity for self-determination.

(British Association for Counselling 1993 3:1)

The Association adds that:

Only when both the user and the recipient explicitly agree to enter into a counselling relationship does it become ‘counselling’ rather than the use of ‘counselling skills’.

(British Association for Counselling 1993 3:2)

Counsellors use a variety of techniques, underpinned by a number of theoretical models with different aims and objectives. Counselling work may be developmental, crisis support, psychotherapeutic, guidance or problem solving. It is a multi-faceted activity which takes place in a variety of settings, for individuals, couples, families and groups. Clients may define themselves in terms of, for example, gender, sexual orientation, ethnic group, age or occupation. Some counsellors have developed special skills (abortion counsellors, bereavement counsellors, cancer counsellors and so on) or work with particular behavioural problems (agoraphobia, drug misuse); other counsellors may utilise a psychodynamic approach to explore and resolve the client’s problems. It may be practised on a paid or voluntary basis within a counselling or other occupational setting, or in private practice. Evaluating counselling presents a challenge to most researchers!

THE IMPORTANCE OF EVALUATING COUNSELLING

Given that counselling and related psychological interventions aim to facilitate improved psychological well-being, it is essential to try to evaluate counselling, its processes and outcomes, to identify what makes for effective counselling and effective counsellors. Questions such as ‘What is counselling?’, ‘Does it work?’, ‘How does it work?’, ‘Who does it work for?’, ‘How much does it cost?’ have relevance for clients, counsellors, employers, researchers and the NHS.

Individual supervision

The most common form of evaluation in Britain is through supervision of the counsellor’s work. Such supervision is considered essential to the ethical practice of counselling. In addressing issues of competence the British Association for Counselling’s Code of Ethics and Practice for Counsellors exhorts them to monitor their counselling work through regular supervision by professionally competent supervisors and be able to account to clients for what they do and why. Counsellors should monitor the limits of their competence and, along with their employers or agencies, they have a responsibility to themselves and their clients to maintain their own effectiveness, resilience and ability to help clients.

BAC suggests that it is difficult if not impossible to be objective about one’s counselling unless there is opportunity to discuss it in confidence with a suitable person. Thus supervision helps the counsellor to evolve practice and in this sense is one aspect of continued training (British Association for Counselling 1987). Counsellor supervision and consultative support refers to a formal arrangement which enables counsellors to discuss their counselling regularly with someone who is experienced and/or qualified in counselling and counselling supervision/consultative support. Its purpose is to ensure the efficacy of the counsellor/client relationship. This involves addressing three main tasks: establishing good standards of practice, developing the counsellor’s knowledge and skills and working with the counsellor’s response to conducting the counselling. Individual or group supervision may involve a system of peer review or may entail a more experienced counsellor supervising a less experienced counsellor. The agenda will be the counselling work and feelings about that work, together with the supervisor’s reactions, comments and confrontations. Exactly what is discussed and how the material is dealt with will vary with different supervisors and counsellors. Supervision is the process by which adequate standards of counselling can be maintained through the continuous assessment of the counsellor’s work (British Association for Counselling 1988). Not only does supervision monitor counselling by providing a setting in which individual counsellors are facilitated in their work, it also operates on an organisational level; the cumulative effect of all individual experiences of supervision pervades the culture within BAC. It assists the development of a culture in which there is an openness to new learning and a personal re-evaluation, as well as an expectation that individual experience will be shared and disseminated (Bond 1990a, b).

The drawbacks...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Illustrations
• Foreword
• Acknowledgements
• How to use this book
• Part I The principles of economic evaluation
• Part II The practice of economic evaluation
• Further help
• References
• Index