INTRODUCTION The main aim of this essay is to critically evaluate a chosen counselling service. The essay will begin by briefly describing the counselling service, outlining its aims and objectives. Then, using Donabedians (1980) model, it will go on to discuss and critically evaluate the structure, process and outcome of the service which will be backed up by relevant supporting evidence. Following a final conclusion the essay will end with a personal reflective analysis. Evaluation enables researchers to assess a service to determine whether that service reaches its targets and/or purposes, but most importantly to asses whether the service is beneficial to its clients (Berk & Rossi, 1998). Newton (2002) suggests that ?it is important for counsellors to evaluate their work as an ongoing process through evaluation, in which the client participates, to understand where their interventions are appropriate or where a different approach may be more effective?, (pg. 85). Previous research of counselling evaluations have possibly failed to recognise client?s views, which is important as this examines how clients want to be helped and how they consider to have been helped, which helps counsellors to improve their service (McLeod, 1995). According to Wolfe, Dryden and Strawbridge (2003), there are three types of evaluation which are service audit, quality assurance and evaluation. Service audit looks at certain aspects of the service to check whether they are meeting targets for example, clients being seen within a certain time of being referred etc. Quality assurance assists in maintaining high standards of the service such as room settings etc. Finally, evaluation, which has two main categories: formative and summative. Formative evaluations feedback continuously to inform and modify the service as it develops which is especially useful for enhancing new services, whereas summative evaluations are more useful for evaluating existing services to summarise how the service is doing at that time, (Barkham and Barker, 2003). Donabedian (1980) combined all three types of evaluation and developed the structure-process-outcome model. Structure looks at the physical resources available inside and outside of the service for example, parking, access, staff etc. Process looks at how the service is being delivered such as models of therapy used, how referrals work etc. and outcome assesses how effective and efficient the service is. Parsley and Corrigan (1999) suggest that Donabedians (1980) model is satisfactory for services which have a distinct structural, process and outcome criteria. MAIN BODY The service being evaluated is a large primary care NHS counselling service which has been operating locally across Middlesbrough for around 6 years. Barkham and Barker (2003) state that regardless of the size of the organisation, ?the central principals of evaluation apply to all types of service, including one-person operations? (pg. 93), therefore Donabedians (1980) model is perfect for the task in question. Before the interview had taken place it was thought to be a good idea to research the organisation, however, the website only gave out limited information. A letter was then composed by the group (see appendix 1), followed by a phone call to arrange an interview. Questions (see appendix 2) were based around Donabedians? (1980) structure, process, outcome model. The aim of any service is the desired outcomes and their objectives are what specify how their aims are to be achieved. In this case the aim of the service is to offer an effective and efficient counselling service to a wide range of clients which will be achieved by staff meetings and supervision to assure that the counsellors are working effectively. This will also be achieved via client satisfaction questionnaires which are adopted into the service annual reports to measure outcomes. STRUCTURE According to Donabedian (1980), structure refers to the ?
physical, human and financial resources available? within the service. This includes location, car parking facilities, disabled access, staff, etc. Structure is very important as it looks at how well the service is organised. If the organisation of a service is not fully developed, some new organisational structure is necessary to recruit resources and develop professionalism in the attempt to improve performance, (Donabedian, 1996). The interview took place in the administration building with the head of the counselling department and so interviewers did not see any of the buildings where the actual counselling took place. As the interviewers did not visit any of the GP surgeries where the primary care counsellors worked from, it is difficult to describe the how well they are all situated. Whether or not they are signposted and easily accessible will remain unknown, as will equipment and facilities etc., however, the interviewee was asked lots of questions to try to cover as much as possible. The interviewee informed interviewers that all GP surgeries had adequate car parking and disabled access. Since this was not seen first hand, the information given is trusted to be correct. Upkeep and maintenance of the GP surgeries is the responsibility of the GPs themselves and nothing to do with the counselling service or counselling staff. When questioned about the website the interviewee explained that as patients are referred, anyone requiring information would need to either ring up or gather leaflets about the service. The primary care trusts within the NHS are responsible for the funding of the service within the GPs surgery with 1 hour of counselling being allocated per 1,000 populations. So, for example if a surgery had 10,000 patients, they would receive only 10 hours of a counsellor?s time per week, which seems awfully limited for such vast amount of patients. Staff are recruited via advertising externally as well as internally. Applicants must possess the correct qualifications and also fit the job description (see appendix 3) and person specification requirements (see appendix 4). Suitable candidates will then be subject to an interview and an enhanced criminal record bureau check before being hired. All counselling staff must possess specific qualifications and training with a minimum of 450 hours worth of core theory and training skills as well as 120 hours worth of supervised clinical practice (see appendix 4). This adheres with BACP/BAC (1997) standards. Clients using the service are of various backgrounds, ages, gender and ethnicity, the latter of which will be discussed later. Clients come with all kinds of problems ranging from depression, anxiety, relationship issues, bereavement and childhood issues etc, which will also be discussed later. There are 7 full time paid members of staff within the service (including the manager) who provide counselling into 52% of the hours that are available in Middlesbrough. Any other counsellors are employed directly by the GPs themselves. Staff roles are to provide an effective and efficient counselling service to their clients. There are no volunteer workers on the team. All staff are given supervision at a ratio recommended by the BACP and the BAC (1997) which is 1 hour supervision per 8 hours contact at basic grade, and 1 hour supervision to 25 hours contact at senior grade. The purpose of supervision is for the counsellor to develop their skills, knowledge and awareness as well as to help improve client-therapist relationships (Wosket, 2004). Continued professional development is also very important for gaining personal and professional skills and qualities. Donabedian (1996) suggests that quality assurance within health care can provide new opportunities for personal self expression and growth. The counselling service has a training requirement log which consists of 8 annual pieces of mandatory training (see appendix 5).
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Personal development planning is also a necessary requirement and staffs meet up 3 times per year to ensure that this is being updated. According to research carried out on counsellors/therapists by Vallence (2004), ?all participants reported that professional development and supervision impacted their clients positively, some in a general way adding to their experience, knowledge, confidence and monitoring of competence, some commented on supervision helping them develop congruency and building confidence to challenge?. The interviewee explained that since personal therapy is no longer part of the BACP accreditation criteria, it is no longer required as part of the person specification within their service, unless of course, the individual chooses to do it. However, there seems to be many valid reasons for personal therapy such as increasing therapist effectiveness and awareness, easing stressful work situations by offloading certain stresses. It could also put the therapist into the client?s shoes which may help them to become more sensitive to the needs of their clients, this is to mention but a few valid points. According to Macran and Shapiro (1998) personal therapy is a very important and perhaps necessary requirement for therapists. Another study by Macran, Stiles and Smith (1999) on personal therapy found that ?participants translated their experiences as clients into skills and attitudes used in their practice and so by experiencing helpful conditions in their own therapy, participants seemed better able to provide them for their clients? (pg. 419). Although Garfield and Bergin (1971) found negative results with therapists receiving personal therapy, the positive studies seem to outweigh the negative. Aside from the debate on personal therapy and the limited amount of counsellor time per week, the structure of the service seems to be very professional. PROCESS Process looks at how the service is being delivered, for example how referrals are carried out, client assessments, models of therapy used etc. Donabedian (1996) believed that the first step in the process of quality assurance is for performance to be improved. The way that this service works is that clients are referred directly to the counsellor through their GP. Although the interviewee stated that there are guidelines for this procedure, she did not elaborate on this. If the GP is unsure of where to refer the client they would then refer them to the counsellor for a client assessment to look at what treatment or therapy would be most appropriate to meet the needs of that client. After a client assessment has taken place the counsellor will then either treat them or refer them on to a secondary source such as a specialist psychotherapy unit or crisis team for more serious longer term problems. This is a fully confidential procedure and breach of confidentiality is taken very seriously unless that breach was necessary, such as clients being in danger or endangering others. Waiting time after referral can take anything from 2 - 20 weeks depending on the surgery, how many referrals that surgery receives and how much the service is used. This could possibly be detrimental to a client who desperately needs someone to talk to. Counselling sessions are on a one to one basis and generally last for 50 minutes per session. However, a cognitive behavioural session may last for up to 90 minutes. The number of sessions was not stated, however this would probably vary depending on each individual client and the extent of their problem. According to McLeod (1995) ?counselling is more likely to be short term with clients seeking coping strategies rather than fundamental personal change? (pg. 192). Clients may be put onto 2-4 week review sessions towards the end of therapy but once therapy has ceased, clients are fully discharged. If a client wishes to be seen again they have to go back to their GP to be re-referred, and hence back to the waiting list. The counsellors predominantly use a humanistic approach such as person centred therapy or an integrated model depending on how much experience and training they have. Some staff have psychodynamic training, some have cognitive behavioural therapy training and some have biographical counselling training. Since problems of the clients vary so much person centred therapy is appropriate as it is non-directional and can be applied to a wide range of problems. Rogers (1942) discussed about how powerful the non-directional therapeutic relationship can be and states that this ?allows the client to gain an understanding of himself to a degree which enables him to take positive steps in the light of his new orientation? (pg. 18). However, Bergin and Garfield (1994) found that positive effects of therapy were from a more directive approach. This again may well depend upon the individual. Since not all clients respond equally to the same approach, therapy is generally fitted around the needs of the clients, integrating other models where appropriate. According to Feltham and Horton, (2004) there is no single approach to integrating counselling therapies and it seems that therapists are beginning to broaden their range of techniques in order to suit a wider range of clients. However, McLeod (1998) argues that therapists must feel secure enough with their own approach before integrating others, which affirms what the interviewee had stated about integration being used by their counsellors depending on their level of experience and training. As far as integrating multicultural approaches, one of the mandatory training requirements for counsellors is equality and diversity training (see appendix 5). It is apparent that people from different cultures may not share the same world views as one another which could cause problems. However, Spangenberg (2003) suggests that Rogers (1942) person centred counselling is cross-culturally suitable and that such obstacles can be overcome using this approach. Health and safety of counsellors is an important matter and as well as staff being issued with panic alarms, they are required to practice break away training which is also mandatory (see appendix 5). Reeves, Wheeler and Bowl (2004) believe that assessing risk and safety is a fundamental consideration for counsellor training. It seems that waiting time lets down the process of the service, this will be discussed in the outcome section. OUTCOME Evaluation of a service assesses whether targets and aims are being met. It also looks at the impact of the service on clients and the community. Donabedian (1982) suggests that an outcome is the anticipated improvement or change looked for when applying health-related interventions. As no target figures where discussed by the interviewee, it is difficult to assess whether the service is meeting financial aims. However, other areas of the service can be evaluated. Client outcomes are measured via patient satisfaction questionnaires and although no evidence was produced, the interviewee stated that according to the questionnaires, clients benefit from the counselling. However, clients may find it difficult to express dissatisfaction when completing questionnaires (Nguyen, Attkisson, & Stegner, 1983). Many researchers (such as Berk & Rossi, 1998; Newton, 2002; McLeod, 1995 & Donabedian, 1980) agree that client satisfaction is of utmost importance when evaluating quality of care and Donabedian (1980) suggests that it is an important tool for research, administration and planning. Although Avis, Bond and Arthur (1995) agree that patient satisfaction is important, they argue that more of a qualitative method of research would allow clients more freedom of expression when it came to their perceptions and experiences of the counselling service.
Although clients seemed to benefit from the service, it was apparent that there were concerns about how long they had to wait before seeing a counsellor. Average waiting times for primary care counselling are said to be between 2-10 weeks (Trusler, Doherty, Mullin, Grant & McBride, 2006). Waiting times for this service ranges from 2 - 20 weeks which was recognised by the interviewee as an issue, however, as each surgery is only allocated a weekly average of 10 hours of counselling per 10,000 patients, this may be difficult to overcome. Staff supervision assures that the counsellors are working as effectively and efficiently as possible and 3 annual meetings ensure that continued professional development plans are updated via the mandatory training log. As a counsellors own beliefs and values can affect their approach to the counselling process, this needs to be taken into account. Although it has been suggested that counsellors should be neutral to the values of their clients, Patterson (1989) argues that as values vary so much from person to person as well across cultures, it is not necessarily the values that are the issue, but rather the way in which those values are dealt with. For example, if a counsellor had been subject to domestic violence and had a client who was going through a similar situation, it may be difficult for the counsellor not to impose their values and beliefs upon that client. It seems that under such circumstances, personal therapy may come in useful, however, as this is no longer a person specification within the service (as mentioned earlier), then problems may arise due to this. In conclusion to this essay/evaluation, it seems that the services major downfall is the waiting time which is a shame because without an increase of funding from the primary care trust to employ more staff, there is very little that can be done about it. However, it is suffice to state that the service is achieving their stated aim which is to provide an effective and efficient service to a wide range of clients. However, without target figures, as mentioned, it is difficult to assess whether the service meets financial aims. REFLEXIVE ANALYSIS Each individual person has their own values and opinions and although there may have been 4 researchers evaluating this particular service, there will probably be 4 quite different interpretations. Reflexive analysis is where researchers ?engage in explicit, self-aware analysis of their own role? (Finlay, 2002, pg. 531). It describes how the researchers own characteristics could have influenced their approach to the evaluation of the service. In this particular case, the researcher may have been a little bias as she is a counselling psychology student and therefore views counselling in a positive light, however, negative aspects of the service were also recognised. The overall service was found to be very professional and effective, which may also reflect on the researchers? positive bias. The realisation that it can be extremely difficult to achieve certain targets, such as reduction of waiting times, especially when funding is out of the hands of the counsellors themselves, must be very frustrating. This activity has taught the researcher a lot, not only about evaluating a service but also about professionalism. For example, writing a professional letter to a professional organisation, structuring a professional set of questions and finally conducting a professional interview. It has given the researcher confidence in her ability to participate well in a group as well as individually. Most importantly it has given her a much clearer insight of how a service is organised and how much work goes on behind the scenes to try to continuously improve performance within that service. And although Donabedian (1988) states that we know much about assessing quality, he also suggests that much more remains to be known.