© 2008 The Royal College of Psychiatrists
Education and training |
New Ways of Working and psychiatric trainees
Hampshire Partnership NHS Trust, Gosport War Memorial Hospital, Gosport, PO12 3PW, email: doctmalik{at}hotmail.com
Highfield Adolescent Unit, Warneford Hospital, Oxford
East Glade Centre, Sheffield
Northern Deanery
Queen Elizabeth Psychiatric Hospital, Birmingham
At the time of writing, A.M. was the chair and O.W. the vice-chair of the Psychiatric Trainees’ Committee of the College. C.O. and P.H. were members of the Psychiatric Trainees’ Committee. J.M. and P.H. have represented trainees on the national steering group for New Ways of Working.
This paper aims to consider postgraduate psychiatric training in the context of New Ways of Working for psychiatrists in England. It summarises the impact of recent changes in postgraduate training and the major training implications of New Ways of Working. Finally, it outlines some broad principles that need to be considered for training when implementing New Ways of Working locally.
Postgraduate psychiatric training is currently at a unique juncture. It is undergoing a complete overhaul with the implementation of Modernising Medical Careers (MMC) and the new Royal College of Psychiatrists’ curriculum (Royal College of Psychiatrists, 2006) approved by the Postgraduate Medical Education and Training Board (PMETB). At the same time, the working practices of consultant psychiatrists are being reviewed under the aegis of the New Ways of Working initiative (Department of Health, 2005). This presents the profession with a distinctive opportunity to work together to develop a seamless system that will train doctors to be competent consultants to multidisciplinary teams. Doubts have been raised about the effects of New Ways of Working on the future of service provision, patient care and the psychiatric profession as a whole (Gee, 2007). However, to our knowledge, the impact on psychiatric training has not been reviewed.
Recent changes in psychiatric training
Before considering how the implementation of New Ways of Working impacts on training it is important to mention other recent imminent changes in relation to psychiatric training.
European Working Time Directive
The recent reduction of working hours to 56 hours per week, and the further
planned reduction to 48 hours in 2009, significantly reduces the quantity of
experience gained by trainees (Mason et
al, 2006). This places significant emphasis on having a
competency-based framework to ensure that each trainee gains adequate breadth
of experience and competence without relying on having to spend
‘enough’ time in a clinical setting.
National Service Framework and National Health Service Plan teams
With the implementation of the National Service Framework for Mental Health
(Department of Health, 1999)
and the National Health Service (NHS) Plan
(Department of Health, 2000)
new working practices were established. Clinical exposure for trainees has
changed following the introduction of single points of entry and the new
specialist teams, including crisis resolution and home treatment teams, early
intervention in psychosis teams, and assertive outreach teams. Changes have
occurred not just in the quantity of clinical exposure, as a lot of the tasks
traditionally carried out by trainees are now carried out by other
professionals, but also in its quality, as trainees now see fewer new and
emergency cases independently.
Modernising Medical Careers and Postgraduate Medical Education and Training Board
The introduction of MMC’s Specialty Registrar run-through grade and
the PMETB-approved competency-based curriculum developed by the Royal College
of Psychiatrists (Royal College of
Psychiatrists, 2006) should ensure that at the end of training all
trainees have acquired the skills necessary to work as a consultant
psychiatrist. This framework could not only be used to identify and overcome
any training gaps for overseas trainees but also define the skills of those
UK-trained psychiatrists who emigrate to work in diverse healthcare
environments.
New Ways of Working and postgraduate psychiatric trainees
The implementation of New Ways of Working has two main implications for trainees. First, the role at the endpoint of training (i.e. consultant psychiatrist) will be different in the future. The new curriculum therefore needs to be regularly reviewed, especially in the areas of management, leadership and supervision of colleagues, to ensure that postgraduate training is in line with contemporary and future clinical practices. Second, the traditional training model where the trainee undertakes, under supervision, the range of clinical activities that their consultant would normally perform is under threat. As traditional consultant roles become redundant we will need to consider mechanisms for retaining the broad range of experiences required by trainees, so that future consultants are competent both to deal with the most difficult and complex cases and provide supervision to other colleagues.
The role of the consultant will vary across the country from one multidisciplinary team to the next. The clinical responsibilities of trainees within each team should therefore be specifically considered and clearly defined alongside the evolving role of the consultant at the time of local service reorganisation and not simply be added on as an afterthought. Managers, local trainees, college tutors, consultants and multidisciplinary team members should all be engaged very early on in the discussions about changing service and training models at alocal level.
Local considerations
There are some general principles that must be considered locally when reviewing the role of trainees within a team. (Please note: potential specialty-specific issues may need separate consideration that is beyond the scope of this paper).
Working in partnership with service users and carers
Trainees are enthusiastic for user involvement in education
(Vijayakrishnan et al,
2006). Recent policy developments including the National Service
Framework for Mental Health (Department of
Health, 1999) have emphasised the importance of user and carer
involvement in mental health services at various levels (e.g.
Department of Health, 2001). It
is now mandatory for psychiatric trainees to receive training directly from
those having mental health problems and their carers. Further work is
essential in this area as involvement of patients and carers in training
development and delivery is beneficial for patients, carers and trainees alike
(Masters et al, 2002;
Ikkos, 2003;
Walters et al, 2003;
Tew et al, 2004), as
it helps ensuring that trainees are competent in delivering a truly
person-centered care.
Exposure to non-complex cases
With the expanded roles of other professionals promoted by the New Ways of
Working initiative, the consultant psychiatrist may see fewer
‘routine’ patients in the out-patient clinic setting as their
skills will be concentrated on those with more complex problems. However,
seeing newly referred and follow-up patients in out-patient clinics remains an
essential source of experience for psychiatric trainees. Without learning how
to assess, formulate, investigate and manage simple cases it is impossible to
learn how to manage complex ones.
Emergency assessments and out-of-hours working
In order to gain competencies in the assessment and management of the full
range of psychiatric presentations, trainees require exposure to emergency
assessments and involvement in out-of-hours working. The introduction of
crisis resolution teams, accident and emergency liaison teams and the expanded
role of other professionals potentially reduces the involvement of psychiatric
trainees in the assessment and management of patients in emergency settings.
Supervised independent and joint decision-making at appropriate stages of
training should be encouraged and incorporated into the team-working
framework.
Multidisciplinary working
There is a consistent emphasis on multidisciplinary work in the New Ways of
Working (Department of Health,
2005). The role of the consultant psychiatrist within
multidisciplinary teams, as prescribed in the New Ways of Working programme,
is to advise other professionals and to be directly involved with the most
complex cases. In order to prepare for this role, trainees need to be more
involved in multidisciplinary assessments and follow-up. During core training
the trainee may be expected to observe and learn from other members of the
team. A more experienced trainee may take on a lead role, and at an advanced
level the trainee could provide advice and guidance (i.e. consultation) to the
team under the supervision of the consultant.
Care coordination
Trainees need to be competent in care coordination as this is a central
aspect of delivering mental health services. A recent review of care
coordination under the Care Programme Approach has highlighted the need for
developing national competencies and training for this role
(Department of Health, 2006).
Taking on and fully understanding the role of the care coordinator for complex
cases would be a valuable training experience in preparing future consultants
for their advisory position to care coordinators and would fulfill
competencies of care plan formulation and implementation as outlined in the
new College curriculum (Royal College of
Psychiatrists, 2006).
Use of consultant’s time for training
As other members of the team take on some of the tasks traditionally
performed by consultants, a portion of the New Ways of Working
consultant’s additional time should be devoted to revive and promote the
traditional apprentice model. This is particularly relevant for those in
higher training as it would allow the trainee to spend more time with the
consultant to gain competencies in both the management of complex clinical
cases and the supervision of multidisciplinary colleagues in managing such
cases.
Allocation of training posts
Attention is required to ensure that trainees have a well-rounded training
experience. Training posts should be allocated on the basis of each
individual’s training needs to ensure that by the end of their training
they have gained a complete range of experience and competencies. This will
involve trainees working with a variety of different teams (e.g. in-patient,
community, crisis resolution, home treatment, early intervention team,
etc).
Conclusion
New Ways of Working is dramatically changing the way mental health services are being delivered. Simultaneously, MMC and the PMETB are having a similar effect on postgraduate psychiatric training. Early and active engagement with the process is required at a national level by the Royal College of Psychiatrists and the New Ways of Working steering groups, at a regional level by the postgraduate schools of psychiatry, and at a local level by the trust management, trainers and trainees. It is imperative that all involved in these changes work together to ensure that high-quality training today produces ‘fit for purpose’, high-quality consultant psychiatrists tomorrow.
References
- DEPARTMENT OF HEALTH (1999) The National Service Framework for Mental Health: Modern Standards and Service Models. Department of Health.
- DEPARTMENT OF HEALTH (2000) The NHS Plan: A Plan For Investment, A Plan for Reform. Department of Health.
- DEPARTMENT OF HEALTH (2001) Involving Patients and the Public in Healthcare: A Discussion Document. Department of Health.
- DEPARTMENT OF HEALTH (2005) New Ways of Working for Psychiatrists: Enhancing Effective, Person-Centred Services Through New Ways of Working in Multidisciplinary and Multiagency Contexts. Department of Health.
- DEPARTMENT OF HEALTH (2006) Reviewing the Care Programme Approach 2006: A Consultation Document. Department of Health.
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