BJPsych Bulletin
New Ways of Working: time to get off the fence
Christine Vize, Stephen Humphries, Janet Brandling, Willm Mistral

New Ways of Working is about developing new, enhanced and changed roles for mental health staff, and redesigning systems and processes to support staff to deliver effective, person-centred care in a way that is personally, financially and organisationally sustainable. It is about developing capable teams attuned to the needs of their users, supported by good systems (particularly information systems) and adequate resources, embedded within a values-driven organisational culture with leadership and effective team working modelled at all levels. New Ways of Working is what it says – new ways of working – rather than a single service model or structure that has to be adopted. It recognises that services catering for the different types of needs of service users across their lifespan and differing demographics and geography will need different configurations to manage their task most effectively. However, the underlying principles relating to using the skills of the workforce in the most productive way are common. It is about achieving cultural change; a shift in the way teams think about themselves, the skills of the individuals within them, and the reasons they are there. However, cultural change is difficult to achieve and it is difficult to measure the extent to which it has been achieved.

New Ways of Working is producing some encouraging results, but it also faces significant challenges. Its strength is that it is being driven by practitioners themselves who can see its potential for enhancing the quality of care and for empowering service users and carers. Its weaknesses are that it can be seen as an optional extra rather than integral to the provision of efficient effective services, it can be used as the scape goat for service cuts, and opponents can always raise the spectre of risk to argue against change.

Role of the psychiatrist

In mental health services psychiatrists themselves have driven forward changes to their role. Kennedy & Griffiths (2001) analysed the problems of working in the ‘traditional’ way, which resulted in burgeoning case-loads and seemingly limitless responsibility. The College Research Unit found high levels of work-related dissatisfaction and burnout among psychiatrists (Pajak et al, 2003). The national conferences of 2003 in Swindon and Newcastle organised with the College and the British Medical Association were group catharses for psychiatrists struggling with expanding roles and trusts haemorrhaging cash in locum costs, as recruitment and retention reached crisis point (National Working Group on New Roles for Psychiatrists, 2004). Increasing demands for clinical governance came at the same time as a reduction in the service availability of doctors in training, and a period of intense organisational restructuring. Psychiatrists have come a long way in the past 4 or 5 years, and New Ways of Working has contributed to the improvement in their lot, alongside the new consultant contract and job planning, investment in mental health services and the rolling out of the national service frameworks. The message has got through that case-loads of 300 are neither desirable, necessary nor safe.

Service users and carers value the ability to see a consultant when they need to because clinics are not booked months ahead with ‘routine follow-ups’, and colleagues welcome the opportunity to discuss clinical problems with the consultant in a collaborative approach rather than simply handing the problem over for a ‘medical review’. Wards with dedicated in-patient consultants are benefiting from the leadership and consistency of approach they bring. New types of workers have taken on more support work and freed up qualified staff, some of whom have formally extended their skills, for example in prescribing, with the encouragement of consultants, who must be supervisors and examiners to enable this to happen. Multidisciplinary assessment can save clinical time as well as provide more consistent standards and high service user satisfaction.

Distributed responsibility

The General Medical Council has explicitly recognised that consultant psychiatrists work in teams with a model of distributed responsibility, and they are not responsible for the care provided by other members of the team (Care Services Improvement Partnership et al, 2005). The College and National Health Service (NHS) employers have for the first time produced joint guidance on the employment of consultants (Care Services Improvement Partnership, 2005), and recruitment and retention have improved. Job planning is being used to drive changes in working practices. All over the country, consultant psychiatrists are involved in service redesign, often generating the initial ideas and leading the process. The third national progress report on New Ways of Working, New Ways of Working for Everyone (Care Services Improvement Partnership, 2007), with its predecessors (National Institute of Mental Health in England et al, 2004; Care Services Improvement Partnership et al, 2005) provide a wealth of background information and examples of innovative practice, supplemented by a dedicated website ( Teams are increasingly taking responsibility for what they provide and how they provide it – it is of course true that they have to. Whether the myriad influences on how a team works, and will work in the future – with performance management, Payment by Results, patient choice, Increasing Access to Psychological Therapies, Foundation Trusts, contestability and plurality of provision, Practice-based Commissioning, the Care Programme Approach review, the Common Assessment Framework, the Mental Health Act 2007 – are seen as an opportunity or a threat is a matter of opinion. What is certain is that no team will be able to stay still in the midst of it all. Psychiatry, as a profession, cannot afford to stand still, and moreover needs to be in the vanguard of change. Psychiatrists were one of the biggest single drivers for New Ways of Working, and must not lose the initiative.

Off the fence

Psychiatrists, led by the College, need to comprehensively endorse and support New Ways of Working and its implementation. It is not about a few misguided psychiatrists naively selling their profession short and hastening its demise; it is the opposite – it is part of the survival strategy for psychiatry. Skill-mix reviews and cost improvement plans have been commonplace for some time and will become more so. If psychiatrists try to cling to what they perceive as a ‘unique selling point’ – whether it be legal powers, prescribing or diagnosis – the need for psychiatrists will diminish as the world moves on, driven not only by the need for value for money, but by patient demands and expectations. We cannot afford to be turning out psychiatrists who, at the end of their training, have a solid academic grounding but little awareness of the complexity of the systems within which they will be operating, and therefore lacking in the skills to adapt and thrive, and help others to develop within it. We need to promote training that includes leadership skills and values-based practice, a degree of technological and managerial competence and the ability to understand and work in complex systems, alongside the knowledge and evidence base. This will produce psychiatrists for whom New Ways of Working is the natural way of working, who approach their work with flexibility, expect to develop new skills throughout their careers, and who will have the capacity to not just survive, but flourish. In order to get the training right, we must redefine the role of the psychiatrist so that we know what we are aiming for, to move away from a focus on skills on which there is no longer a monopoly, towards a more holistic definition of a role that encompasses the full scope of the work in which psychiatrists could be involved. In common with all other branches of medicine, the subject area becomes increasingly complex, and more unmet need becomes apparent. There are many opportunities to both broaden what can be offered in terms of direct clinical work, training, governance and prevention, and to deepen knowledge of particular aspects of the subject. If they take the initiative and help lead modernisation, psychiatrists will define for themselves a more secure professional identity within the new NHS, as masters of a range of skills and a body of knowledge that they can use to help patients and train and develop other clinicians. This could make psychiatrists an important part of most teams, an essential element of many and a desirable component of all.