The Reality of Low-Intensity Care: Experiences of a Former HIP
By an anonymous NZ Psychologist
“The purpose of the associate psychologist role is for these graduates to work with lower intensity patients, under supervision, to free up and allow registered psychologists to focus on more complex cases.” - Mental Health Minister Matt Doocey
The government recently proposed an “Associate Psychologist” role, prompting outrage from psychologists across New Zealand. “Change is hard,” Mental Health Minister Matt Doocey responds, overlooking the multitude of concerns we have. Why are we concerned? As a profession we care about public safety, and the safeguarding of the protected title of psychologist. From our perspective, the Associate Psychologist role is not only a challenge to public safety, but it does not seem to fit within our current health system as is. And some of that problem is the conflicting messages, referring to the role as working at “low intensity” or “low level”. Not only is there a difference between the two, but the system doesn’t always match up with reality.
I’m a registered psychologist, and as a new graduate I began working as a Health Improvement Practitioner, or “HIP”. I was one of the earlier recruits before the model began rolling out across the country. A Health Improvement Practitioner, in theory, promotes access to mental health care and supports GPs with their work. HIPs are based in GP clinics, are free to visit, and have a brief 30 minute session with someone focusing on delivering practical skills. I will preface my experience by saying my time in this role was overall positive, with great opportunities for learning and in general it is regarded as helpful by patients receiving the service. The role was designed to be delivered at a lower intensity based on the stepped model of care.
The stepped model of healthcare
Our health system in New Zealand is organised as a stepped model of care.
1) Primary
If you had a minor injury or health issue causing you some discomfort, you would see your usual GP. Your doctor would then treat you accordingly, perhaps follow up with you at some point to review your progress. This is the primary care level of support.
2) Secondary
If however you had a health issue that required further investigation or assessment by a specialist, you may be referred to an outpatient clinic at a hospital. The doctors you might see here have titles like cardiologist, or oncologist and this is considered a secondary level of care.
3) Tertiary
And finally, if you had a serious health issue requiring urgent medical care, you would likely be admitted to inpatient care at a hospital - this is a tertiary level of care.
Mental health care in New Zealand follows the same structure; if you are managing well you might just see your GP or HIP for support, perhaps even read some self help books or attend a support group (low intensity). When you start to struggle more with your mental health, your GP may refer you for therapy or counselling (high intensity). If you are extremely distressed or have very complex mental health challenges, you may need to be referred to secondary care. Of course, just like with a physical health issue, if you have the resources you may choose to pay for private mental healthcare.
While this system makes lots of sense in theory, it doesn’t always flow so smoothly. For example, sometimes people may not realise they have a mental health problem that needs a higher level of care - so they might not see their doctor until they have really deteriorated. Or, concerns around being treated differently by society for having mental health issues may deter people from disclosing symptoms to the GP, or calling the Crisis Team. And sometimes, the language used by healthcare professions simply does not align with cultural worldviews and practices. There is still much work to be done to correct inequity in healthcare and ensure culturally safe practice for tangata whenua in Aotearoa.
The HIP role
The HIP role is designed to sit in the primary care space, and was originally developed in the United States under the title “Behavioural Health Consultant” (BHC). The role was created by psychologists and developed for psychologists to assist doctors to care for their patients. In summary, the idea was that BHCs can take on some of the non-medical work a doctor often completes. For example, they can work on stress which may be underlying someone with high blood pressure. Or, they could support somebody with mild symptoms of depression to improve their mood. As their title suggests, they can also provide consultation to doctors or other team members, such as coaching breathing techniques for managing anxiety. In essence, the role itself is designed to relieve strain on the medical system - by helping doctors focus on medicine, and ideally seeing people before their problems become more serious. HIPs don’t provide therapy, but they do provide brief bits of support, and can often be seen on the same day a patient sees their GP. You could say they are designed to see people needing a “low level” of support.
Here in New Zealand, registered health practitioners from a variety of professions can work as HIPs. There are Occupational Therapists, Mental Health Nurses, Social Workers, Alcohol & Drug counsellors, all working in this role. I am not privy to the reasons the role was opened up to other professions, but we are fortunate to have our colleagues as HIPs and doing excellent work to support the health system.
The reality: opening the floodgates
As a new graduate psychologist, I had completed my degree and 4 years of postgraduate study before I started the HIP role. When I began training, the organisation Te Pou were responsible for providing training and accreditation to be a HIP. This involved several stages of classroom style learning, being shadowed by HIP trainers, and finally being endorsed as a qualified independent HIP after 6 months. Basically, not only were you required to have prior qualifications and registration as a health practitioner, but you were also coached to ensure a good understanding of the role and that you were practicing safely as a HIP.
With all of this training and experience, there were times as a new graduate I dealt with challenging and complex issues. In theory I was seeing people who needed a simple strategy or two. In reality, I saw complex mental health issues such as psychosis and bipolar disorder. I saw patients who were imminently suicidal. And I saw cases where there were statutory concerns for the safety of a young person. These are all very challenging presentations for a new graduate to manage, even with 7-8 years of study. While I was supervised by a more experienced psychologist, my supervisor was not always available to swoop in and support me on the job.
The boundaries of our clinical responsibility were sometimes blurry. Theoretically as we were not the responsible clinicians and there to assist the doctors, we could hand back to GPs for responsibility over risk. Realistically, our GP colleagues were already stretched and did not always regard us as having a consultant role - resulting in challenges accepting the handover back. I often acquiesced, submitted referrals and liaised with the Crisis Team myself, despite it not technically being my duty. But as a capable clinician seeing how busy my GP colleagues were, and of course how much the patient needed urgent support, I felt it was the right thing to do. I believe many of my HIP colleagues also did the same. Thus the role did not always match the original parameters of the job description.
While I acknowledge that perhaps my presence was ultimately helpful and hopefully led to some positive change for whaiora I supported, this should clarify why training Associate Psychologists with less experience and expecting “low level” presentations may do more harm than good. When I worked outside of my defined role as a HIP, I was still working within my scope as a registered psychologist and had adequate training to recognise when something was beyond my skill level.
As psychologists part of our responsibility to the public is recognising where something is beyond our competence to treat, and supporting the process to access more appropriate care so we do not cause harm. For an AP without as much clinical knowledge, it may be difficult to identify these criteria. Thus it relies heavily on a system which accurately triages people waiting to see a psychologist, and significant oversight by a clinical supervisor. This brings us to the existing challenges in healthcare.
The current challenges, and those yet to come
The issues I experienced as a HIP were symptomatic of the overall challenges faced by the healthcare workforce in New Zealand. While in theory I should not have seen high risk or complex patients, GPs are currently under pressure to see more and more people each day. In some cases they may be restricted to see patients only for 10-15 minutes, giving limited time to carefully uncover mental health symptoms or assess risk. The demand for healthcare is greater than supply, and it’s showing. People are waiting for appointments to see their doctor for a week or more, or wait for hours at walk in clinics. The reason is not that the system is uncaring, it’s because there are not enough doctors to meet the demand. We know that many of our GP colleagues will be retiring in the next few decades, and that promise of better pay overseas is alluring for many health professionals working in New Zealand. For many patients that become our clients, their journey through the mental health system starts with their GP. And in the decades to come, if the primary health system is struggling, the rest of the health system will suffer too.
For psychologists in public health, the result is that we do not see people the way the stepped care model is designed to work. There is a real risk of “Associate Psychologists” seeing people too complex for them, and sometimes there is no way of knowing before stepping into the room. The effects on the HIP workforce are noticeable; there is a high turnover in the role. From my observations in the role, most HIPs remain in the job for an average of 1.5 years. Most of my original training cohort are no longer in the role. Not only are they seeing a mixture of complexity, but they are also bound by productivity expectations to see 8-10 patients on an 8hr day. There’s no wonder people don’t stay long in the job.
Similarities with the “Associate Psychologist” role
Research into a comparable AP role in the UK draws similar commentary to what I experienced during my time as a HIP. For instance, they note issues such as being pushed to complete tasks outside of their scope. The clinician often needs to educate other staff, which can be a challenging task particularly for new graduates. It involves maintaining strong boundaries at a time where you are also eager to please and be as helpful as possible. An AP wrote on Reddit of their experience in the UK:
“The service had 24 APs managing the phone lines, very very limited clinical support for active crisis management and resolutions - we were often left to manage suicidal patients or highly abusive members of the community … In my experience, most services struggle to find an appropriate place for APs, as we lack self-fulfilling clinical judgment … and experience.”
Such a role would be challenging even for an experienced psychologist, and yet APs were put in highly stressful situations beyond their clinical skill level.
As a HIP I was often pushed on the boundaries of my scope, and I sometimes felt reluctant to push back and thus damage my relationships with the clinic team. Similarly, one AP writes on a Reddit thread about the pressure to perform:
“It definitely feels to me like being an AP is put on a pedestal, and knowing that many people would take my position in a heartbeat makes me feel a pressure to be brilliant in a role that is essentially low responsibility and low pay.”
A related issue is that some APs reported there was not much of a difference between the work they did, and the work completed by fully qualified psychologists - resulting in dissatisfaction with the role. In a conversation on an online forum Reddit, one user said:
“It can be a really jarring experience, because some APs are utterly overwhelmed with [complex] work, and others are left feeling entirely unsatiated. It’s a by-product of being both well-qualified and unqualified for the kind of work we do I think.”
Final thoughts
So you might have wondered while reading this, how would APs be any different to HIPs? From what we know about APs, the government have said they plan for the role to be closely supervised by clinical psychologists and working with “low intensity” patients. Yet we can question, what does this actually mean? And unless the overall health system changes, where do they fit in? How do we define a “low level” and how do we make sure they see such presentations? How closely will they be supervised, and what is being done to retain senior psychologists? How can we make sure they aren’t burnt out and leave the profession after a year? Why couldn’t these tasks be completed by other existing, competent health practitioners?
To those with a psychology degree feeling discouraged by the process to enter a formal training programme - I would advise don’t give up, to keep applying, and avoid the AP programmes at all costs. The safeguarding of the psychologist title is there for a reason - not just to protect the public, but to protect you.
