Psychologists, Scope of Practice and the power of medical aids

Dear Colleagues
I would like to make a contribution to the current debate regarding the Scope of Practice crisis. Please note that I offer this as a contribution to the debate, it is not in any way intended as a pronouncement on the way forward.
At present there is a huge uproar in Psychology profession as certain medical aids are refusing to reimburse Educational Psychologists at all. This is important. It is not the case that they are refusing to reimburse educational psychologists practising out of the current scope of practice but not at all.

It started with a sms to all POLMED Medical Aid Members issued from their Fraud Division which said that due to irregularities in claims they would no longer reimburse educational psychologists or industrial psychologists (at all). It was unfair because it said it was from the Fraud Division and implied all educational psychologists were practising unethically. POLMED also based their argument on an old Scope of Practice from 2002 (restricts educational psychologists to work with children) and not the more recent one of 2008 (without restriction to children).
It was followed by a letter from PROFMED saying they too would not reimburse educational psychologists or industrial psychologists. And only counselling psychologists, if they are within scope, and only for 4 sessions.

Now KEYHEALTH medical aid has followed suit. More medical aids are making noises, including GEMS.
POLMED has gone further to say that they are going to exclude the following from their medical aid cover:
Aptitude Tests,
IQ Tests,
School Readiness,
Marriage Counselling,
Learning Problems,
Behaviour Problems.

This list effectively cancels out claims for all neuropsychologists, all educational psychologists, all counselling psychologists and much of what clinical psychologists do.

The current crisis facing Educational Psychologists in particular and all psychologists in general, needs to be addressed with thought and strategy. More light, less heat.

The approach to POLMED needs to be separated from that with the HPCSA Board of Psychology.

1. Arguments need to be brief, clear and neutral. (No more than 2 pages when submitted).
2. The argument to be taken up with POLMED need only include the following:
2.1. The email sent to POLMED members was defamatory and suggested that Educational Psychologists have been practicing in a fraudulent and unethical way.
2.2. The Scope of Practice paragraph quoted was invalid. It came from the old 2002 Scope of Practice which restricted educational psychologists to working with children and adolescents (not the current 2011 version). This has seriously misled POLMED members.
2.3. By quoting the Scope of Practice Document out of context and not in conjunction with the Regulation 993 and Regulation R704 (Depart. Of Health, 2008) which deals with the core competencies of clinical, counselling and educational psychologists; the limitations of the Scope of Practice were overstated and misrepresented to POLMED members.
2.4. By acting in bad faith POLMED is restricting the access of thousands of South Africans to psychological services who, without medical aid assistance, cannot afford such services. This constitutes a barrier to mental health services in a country besieged by trauma, stress and emotional difficulties.

3.0 The HPCSA: Board of Psychology
3.1. The HPCSA has a new Board of Psychology. We need consider how we approach this new Board and whether we choose to build bridges or burn them. A fresh respectful approach is more likely to be successful than a hostile attack.

4.0. It might be an idea for Educational Psychologists, Key Stakeholders, Representative Bodies and Training Universities to call for an Extraordinary Meeting with the new Board. The key issues that do need to be raised with the new Board are:

4.1. The current Scope of Practice focuses on the differences between the psychologist registration categories. This is the cause of all the trouble. The emphasis should be on the core competences of psychologists with the specialized skills and scope of each registration category being backgrounded (but acknowledged) e.g. Educational Psychologists are first and foremost psychologists not educationists.

4.2. The unintended consequence of the current Scope of Practice is that the Board no longer regulates the practice of psychologists. Medical Aids now regulate the practice of psychologists and in some cases even police us. The Board has lost control of its own constituents.

4.3. In order for the Board to regain control several changes need to take place:

4.4. We are aware that the previous Board had chosen to put the Scope of Practice issue on the back burner while waiting for the court case from ReLPAG dealing with prior learning to play out in court. We can only hope that the new Board chooses to be proactive and not defensive or reactive with regard to ReLPAG. e.g. Engaging with ReLPAG much like the State President and various universities recently engaged with the students of the country over “Fees must Fall” debate, is a model to consider. If the new Board could undertake to review the value of prior learning, the court case launched by ReLPAG against the Board could potentially be diverted.

4.5. Prior learning does need to be reconsidered in the training and professional development of all psychologists as does scope of practice training and subsequent competence via continuous professional development. This could be done by each psychologist being required to keep a logbook of their areas of competency as evidenced by their CPD activities. e.g. if a psychologist is reported to the Board for practicing out of their Scope of Practice, the Board can evaluate whether they have the appropriate training and subsequent CPD exposure and competence. The Board can then decide whether to sanction the psychologist in question and whether or not a medical aid should reimburse for their services. At present it is the medical aid company who evaluates the competency of psychologists. Not only is this inappropriate, it is a conflict of interests, as their interpretation of skill and competency will always be biased in favour of their profit driven motives.

4.6. Historically some universities trained educational psychologists with a broader approach to Scope of Practice and others with a more narrow scope. Currently, this continues to be the case, but to a lesser extent. This issue in and of itself is not relevant. What is relevant is that all educational psychologists had to submit Individualized Internship Programs which had to be approved and signed off by the HOD’s of their Training Universities and the Education Committee of the Board of Psychology of the HPCSA. Therefore, the Board is legally obliged to recognize their training whether it was broad or narrow as its own Educational Committee approved these internship programs.

4.7. Currently, clinical, educational and counselling psychologists all write the same Board Exam which includes competency in the DSM 5. By the Board’s own examination requirements this implies that these 3 categories of psychologists are competent in diagnosis. The Scope of Practice cannot contradict this.

5.0. It is a good idea for the various training University Departments in Educational Psychology to join forces with their Vice Chancellors to approach the HPCSA Board of Psychology independently and take up the implications of the present Scope of Practice for recruiting future students to train in educational psychology. The present consequences of restricted medical aid reimbursement to educational psychologists, who have few career options outside of private practice, prejudices the viability of their Academic Departments and their capacity to recruit future students. It is imperative that the Board take steps to protect their profession.

6.0. It is essential that Educational Psychologists also tackle the Education Department with regard to developing a career path for Educational Psychologists within the education system. This should not be left to this few Educational Psychologists who work in school settings. If Educational Psychologist posts, Educational Psychology intern posts and Community Psychology Service posts were created within the educational system in parallel fashion to that of Clinical Psychologists in the health system; vast numbers of disadvantaged South African families would have access to psychological services via their local schools. As school buildings are always placed within communities, families would have immediate access to psychological services without the burden of transport costs. The Education Department is struggling with various barriers to learning, including gang related activities, adolescent pregnancies, drug abuse, poverty, crime and violence to name a few. It essential that the Minister of Education be lobbied with regard to the role that educational psychology can play in making a difference within the education system. A systematic, focused and sustained approach undertaken by a dedicated task team needs to tackle the Education Department.

7.0. The role of the Board and the HPCSA is to “protect the public and indirectly the professions”, “by promoting the health of the population, determine standards of professional education and maintaining excellent standards of ethical and professional practice” ( In addition, Section 195 (1) of the Constitution dictates public administration, (which includes the HPCSA and Board of Psychology as organs of the state) must be governed by the democratic values and principles enshrined in the Constitution. We need to call upon the new Board to fulfil this mandate in its entirety and in a manner consistent with our Constitution.

8.0. We in South Africa have a moral obligation to provide psychological services to all South African citizens in need. As matters stand we do not meet the minimum requirement of 5 psychologist per 1000 000 in a developing country. We only have .32 psychologists per 100 000 (Burns, 2011). Given the shortage of psychological resources it is unacceptable to further restrict access to services by creating barriers to educational psychologists.

9.0. I appeal to my clinical psychology colleagues not to be complacent about the current plight of Educational Psychologists. At present some medical aids are not reimbursing certain Counselling and Educational psychologists. It is naive to believe that the money not given to these psychologists will somehow be reserved for Clinical Psychologists. Medical aids are not our allies, they are profit driven businesses. It is only a matter of time before a particular medical aid refuses to reimburse a Clinical Psychologist for being out of scope for treating a child who happens to have a learning problem or an adult with a lifestyle problem that is deemed not to constitute clinical pathology.
I appreciate that when debating these issues feelings run high as psychologists experience a threat to their livelihoods. It is essential that we do not turn on each other but stand together.

Having battled difficult bureaucracies, medical professionals and government officials to recognize the profession of clinical psychology in state hospitals for over 3 decades, I have learnt several important lessons. In particular, I have learnt that we need to stand together, accept that battles like these take time and effort, understand that complacency is fatal, realize that no one else will fight for us, and most importantly recognize that we can be emotional or we can be effective but we cannot be both.

Cora Smith
Adjunct Professor
Chief Clinical Psychologist
Charlotte Maxeke Johannesburg Academic Hospital
Division of Psychology
Department of Psychiatry
School of Clinical Medicine
Faculty of Health Sciences
University of Witwatersrand.