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The Tavistock Clinic, North Cumbria Mental Health and Learning Disabilities Trust, Carleton Clinic, Cumwhinton Road, Carlisle, Cumbria CA1 3SX
Newcastle General Hospital, Newcastle upon Tyne
Abstract
AIMS AND METHOD
To explore the role of the consultant psychiatrist using an observational approach. Five consultant psychiatrists were shadowed by a trained observer. Observations were subjected to a qualitative analysis based on a grounded theory approach.
RESULTS
Six themes emerged as being significant; these were administration and secretarial support; training aspects of the role; clinical activity; the referral process; supervision, support and continuing professional development; and organisational systems.
CLINICAL IMPLICATIONS
The results indicated significant difficulties in the role of the consultant psychiatrist and the need for change. Any change in this role would have an effect on the roles of other professionals and on the whole system in which they work.
The Changing Workforce Programme, a part of the National Health Service (NHS) Modernisation Agency, has the task of exploring new ways of working and of helping to develop new roles, with the aims of responding better to the needs of service users, increasing job satisfaction and retaining staff. A particular aspect of its work is to address the crisis in medical staffing in psychiatry, particularly the shortage of consultant psychiatrists. These issues have been highlighted in a report by the Royal College of Psychiatrists (2001) and by Kennedy & Griffiths (2001). The Changing Workforce Programme undertook this study within the mental health pilot sites to obtain detailed information about ‘a day in the life of a consultant psychiatrist’, in an attempt to look at what the consultant’s role is now and how consultants might want to change it.
Method
The investigation took the form of a small qualitative study, using grounded analysis, of five consultant psychiatrists. Information was collected by means of a brief questionnaire, followed by observation and formal, non-structured interviews. We are aware that the observation or shadowing process of one role can only offer a snapshot of the role and the organisation. The observers were informed ‘outsiders’, i.e. they had a background in the NHS as mental health professionals, but were not part of the departments being observed. The study comprised eight stages:
Negotiating entry
One consultant volunteered to participate from each of five Changing
Workforce Programme mental health pilot sites, providing a self-selected
sample. Three were consultants in general adult psychiatry (one in an
inner-city teaching hospital and two in hospitals with combined urban and
rural catchment areas) and two were consultants in old age psychiatry in
inner-city teaching hospitals. We asked each consultant to consider four
questions prior to the observation period:
The first consultant was observed over a 5-day period to test the study design. The other consultants were observed for 1 day only, on a date negotiated between the observer and the consultant. All the consultants provided a copy of their timetable in addition to completing the questionnaire.
Consent
Guidance was taken from the Department of Health. Ethical consent was not
required, as the observation process did not impinge on patient care. Verbal
consent was obtained from each consultant and the role of the observer
explained to all staff and patients involved.
Contract
Prior to the start of the project, discussion took place about how
information would be used and made anonymous. Guidelines were agreed about
whom the information belonged to, with whom it could be shared and the
clinician’s right to edit it.
Observation
The observers recorded all information related to task, activity and role,
asking questions for clarification purposes. In addition, each
consultant’s medical secretary was interviewed for 30 min, to obtain a
fuller picture of the consultant’s role. At the end of the observation
period there was a 30 min debriefing period, allowing the participating
consultant an opportunity to reflect on the observation process and to discuss
any issues that had arisen.
Report
The report was composed of a brief description of the consultant’s
job situation and the main themes observed.
Follow-up interview
The interview took place 1-2 weeks after the consultant had received the
report. The interview enabled in-depth discussion of the report to take place
and changes to be made to it where necessary.
Coding and collating
The Changing Workforce Programme team gave each interaction a code and
these were collated into emergent themes.
Final report
The final report included information about the context within which each
consultant worked, the questionnaire, the timetables and the time log from the
observation period, and a full report on the data collected. Feedback from the
consultants was incorporated into the final report and added to the data.
Comparisons were made between consultants working in different geographical
areas and different specialties.
Results
The main themes that emerged were administration and secretarial support; training aspects of the role; clinical activity; the referral process; supervision, support and continuing professional development; and organisational systems.
Administration and secretarial support
Each consultant spent 4-8 h per week on administrative tasks. Some of these
tasks were appropriate for consultants, but some were not and could have been
performed by a competent personal assistant. Some consultants felt guilty and
responsible for the high work-loads imposed on their secretaries. There were
additional compounding factors such as poor information and media technology
systems and unclear roles for lower-grade administration and clerical
staff.
Training aspects of the role
Each consultant had some involvement in training junior doctors. The
consultants working in the teaching hospitals had more time allocated to
teaching and supervising junior doctors. One consultant had the role of
college tutor, but owing to a large clinical case-load was unable to fulfil
this role in its entirety, leading to stress in the individual concerned.
Consultant support for junior doctors varied widely. The consultants who worked with a specialist registrar had more time to spend on organisational tasks such as leading new projects and initiating change.
Clinical activity
The consultants observed had appointments with 30-50 patients per week.
These included in-patients, out-patients, day patients and new referrals.
Where there were fewer junior doctors the consultants had a far higher number
of patients; these consultants would have liked to reduce their case-loads but
found it difficult to do so. There were complex issues highlighted around the
accountability of responsible medical officers
(Kennedy & Griffiths,
2002). Consultants who had large case-loads were providing a
good-quality service to their patients but were frustrated by their lack of
time for involvement in organisational strategy, and their experience and
leadership skills seemed not to be used effectively by the organisation.
Referral process
The referral pathways varied enormously, from referrals entering the system
in a haphazard way, to a system in which all newly referred patients were seen
by a consultant psychiatrist for their initial assessment. This variation
depended on the consultant’s individual preferences and feelings of
anxiety and uncertainty about other professionals’ ability to do initial
assessments. This was related to the uncertainty about the exact
responsibilities of the consultant, including the confusion over responsible
medical officer status. The consultants’ thoughts about changing the
system ranged from anxieties about the skills and competencies of other
professionals to the length of wait a patient might have if not referred
directly to the consultant. Two of the consultants seemed to be filling voids
in their service. One consultant seemed to be part of an effective
multidisciplinary team where referred patients had a single point of entry to
the system, were discussed by the team as a whole and allocated to the most
appropriate member of staff for initial assessment. The whole team then
discussed the assessment. In this team the consultant was observed to have a
consultative role, seeing the more complex cases, and offering containment and
clinical management.
It was unclear whether members of the multidisciplinary teams understood each other’s skills and competencies and the lines of accountability and expectations seemed unclear in some teams.
Two of the consultants had concerns about record-keeping and patients’ case notes; they made a good case for a single multidisciplinary record.
Supervision, support and continuing professional development
The consultants who were working in the hospitals with combined urban and
rural catchment areas seemed more isolated with less support than the
consultants working in the large teaching hospitals. Access to support,
mentorship and continuing professional development (CPD) varied for each
consultant. Access to support, mentorship and CPD was better for consultants
who were part of a team, whereas the more isolated consultants seemed to be
unable to make space for CPD. In addition, even if the consultant timetabled a
space for CPD or supervision, this was often lost owing to the demands of
clinical work and other unplanned activity. Access to study leave varied, but
consultants working with a large peer group found taking this leave easier
because cover was available.
Organisational systems
In all areas there seemed to be a shortage of services, such as
psychological therapies, and of staff, such as psychiatric liaison nurses,
community nurses, occupational therapists, clinical nurse specialists and
nurse consultants. Many teams and services were being developed across
primary, secondary and tertiary care, and how all these systems interact is
confusing to all involved — particularly the patients. Greater role
clarity and flexibility, improved care pathways and effective management would
lead to improvements in the use of existing resources.
Discussion
This is the only study that has explored consultant roles in the NHS from an observational position. The observational method highlights issues that are not always reported by individuals themselves. Despite the small sample of consultants, the study showed wide variations in practice.
The consultant role differed from that of other professionals in that consultants seem to be positioned on the boundary of all professional groups and at the interface between primary, secondary and tertiary care. They were observed to take a broad view of the patient and the treatment options available. The assessment they offered was specific to their role, in that it included physical, neuropsychological, psychological, psychosocial and pharmacological aspects. They were able to explore diagnosis by ordering specific investigations, prescribing and managing medication regimens.
All the participating consultants found the space to reflect on their role in their organisation useful, and the majority went on to make some changes to their role. What is evident is that consultants cannot change their role effectively in isolation. Changes to the consultant’s role would result in changes to all the other professionals’ ways of working, including those at the primary care level. A whole systems approach to changing roles is essential.
Areas in need of review and change
It is unacceptable that medical secretaries are over-worked and that
consultants feel guilty and responsible for this. Our study suggests that two
secretarial roles are required: one would involve typing and answering the
frequent telephone calls about patient appointments and clinics; the other
would be that of a personal assistant, to perform the more complex tasks.
Some consultants were reviewing patients in out-patient clinics but doubted the value of these reviews. A review of out-patient services in relation to consultant contact would be beneficial. Regular routine follow-up could be achieved in other ways, for example by the general practitioner or another professional, or through e-mail or telephone contact.
Observations of multidisciplinary team and community mental health team meetings suggested that a review of the process of how these teams function might be useful. There seemed to be many assumptions about the roles of each member of the teams and a lack of knowledge about each other’s skills and competencies. In addition, it seemed that role development at primary care level, such as specialist general practitioners or mental health practitioners, would enable consultants to deal with the more complex cases, acting in a truly consultative role when required.
The stressed consultant is often seen as having a personal problem in need of therapy. This personalises the difficulties encountered in the role. If consultants are encouraged to take the therapy option when the organisational structures are not in place to support the role, the individual continues to carry the dysfunction, when this might be more appropriately explored in an organisational context. It would be preferable to have a structure that offered consultants mentorship, clinical supervision, management supervision and leadership training. Consultants have not been offered good management in the past, and from this study it was clear that there is an absence of management of their role. A comprehensive appraisal system is now in place for all medical staff. This should lead to professional development and identification of problematic areas of the consultant role.
The more experienced the consultants, the more effectively they managed the tasks and boundaries in their role. Two of the consultants took up strong leadership positions in terms of service development and strategic management.
It seems that a cohesive and progressive role development plan would be helpful to support the consultant. There are particular concerns for the consultant working in isolation, and a need for the early identification of signs of stress and professional burnout. These findings endorse the Royal College of Psychiatrists’ proposal to offer mentorship to all newly appointed consultants (Dean, 2002). This complexity of change requires a thoughtful change process and will include changes at a national level, including clarification of a consultant’s responsibility/accountability.
Future steps
Since this work was completed, a National Steering Group has been
established, chaired by the President of the Royal College of Psychiatrists
and the Director of Workforce Planning at the National Institute for Mental
Health in England (NIMHE), to look at roles and service provision across the
mental health services. An interim report is now available on the work of this
group
(http://www.nimhe.org.uk/whatshapp/item_display_publications.asp?id=706).
As part of the Changing Workforce Programme and independent initiatives, several pilot sites linked to the NIMHE areas have been established where clusters of consultants are designing changes to roles and services. The authors of this paper, who have links with the National Steering Group, would like to hear from any groups of consultants who are proposing role changes.
Acknowledgments
The authors thank the consultants who took part in the ‘shadowing’ process for the wealth of information they provided and their enthusiasm towards the work, and Siobhan Chadwick of the Changing Workforce Programme.
References
DEAN, A. (2002) The Role of a Mentor for Newly-Appointed Consultants. London: Royal College of Psychiatrists (http://www.rcpsych.ac.uk/traindev/tutors/mentorsAug02.pdf).
KENNEDY, P. & GRIFFITHS, H. (2001) General
psychiatrists discovering new roles for new era... and removing work stress.
British Journal of Psychiatry,
179, 283
-285.
KENNEDY, P. & GRIFFITHS, H. (2002) What does
‘responsible medical officer’ mean in a modern mental health
service? Psychiatric Bulletin,
26, 205
-208.
ROYAL COLLEGE OF PSYCHIATRISTS (2001) Roles and Responsibilities of a Consultant in General Psychiatry. Council Report CR94. London: Royal College of Psychiatrists.
This article has been cited by other articles:
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  R. Mason and H. Hayes Telephone peer supervision and surviving as an isolated consultant Psychiatr. Bull., June 1, 2007; 31(6): 215 - 217. [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
