Setting up stall in the market place: psychotherapy in a state health service

Public sector psychotherapy differs from private practice in its explicit responsibility for a population. This has major implications, with the need to ration a scarce resource inevitably affecting clinical practice. De facto rationing has existed within the National Health Service (NHS) for years, and the ‘unconscious’ processes involved must be made explicit if NHS psychotherapists are to deal with their broader responsibilities, and influence current changes in the Health Service. Resource issues and the related psychological conflicts shape clinical practice and thus theoretical concepts. The effects on practice could be seen as a series of unhappy compromises, or a stimulus to the creative development of a specific NHS psychotherapy, as envisaged by Sigmund Freud.