New Ways of Working for Psychiatry

March 2009

Dr. Christine Vize
Consultant Psychiatrist,
Oxfordshire and Buckinghamshire Mental Health Foundation Trust
Cotswold House Marlborough Eating Disorders Unit,
Savernake Hospital, Marlborough, Wiltshire SN8 3HL
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1. Why Psychiatrists wanted change

New Ways of Working was given a big impetus in mental health by psychiatrists, who felt that their jobs were becoming undoable due to the increasing breadth of their responsibilities. In the early years of the millennium there were recruitment and retention problems in psychiatry as a result which in some areas reached crisis point, with the widespread use of agency locum staff adversely affecting budgets as well as continuity of care.

When the National Steering Group for NWW was established, it had two subgroups, a Psychiatrists’ subgroup (looking at issues pertaining to them, rather than with a membership exclusively of them) and a Cross Boundary subgroup, looking at issues across disciplines. The Psychiatrists’ subgroup continued meeting until March 2007, by which time it was felt that the emphasis had shifted towards the need to look at all aspects of team and multidisciplinary working, as psychiatrists could not change their role without the other members of the team also having to change the way they worked. The group therefore ceased meeting just before the conference to launch new Ways of Working for Everyone in April 2007. The Psychiatrists subgroup was chaired latterly by myself and Steve Humphries, who were practising psychiatrists as well as being members of the NIMHE National Workforce Programme, and Professor Richard Williams representing the Royal College of Psychiatrists.

Over the past 18 months the Royal College of Psychiatrists has had a steering group on New Ways of Working, which reported to the English Policy Committee, and was chaired initially by Peter Kennedy and latterly by Sally Pidd. This was an opportunity for members of the college to meet with members of the National Workforce Programme including service users and carers. The last planned meeting of this group was held in January 2009.

2. Psychiatrists and Progress

Numbers of Psychiatrists

Over the past 10 years there has been a dramatic increase in both the head count and the number of whole time equivalent psychiatrists (2206 to 3624 wte). Recruitment and retention have improved markedly over the past five years and the spend on agency locums has been brought under control.

Do-able jobs

The ‘Red Book’ which contained ‘College norms’ for all types of consultant post, was replaced by the Joint Guidance on the Employment of Consultant Psychiatrists, which in turn is now being revised and reissued (April 2009). This represented the first time that the College and employers had collaborated in thinking through what the role of the consultant psychiatrist should be and how it should be defined in job descriptions. It recognises that the role cannot be defined by numbers, but needs to be thought through in relation to the roles of the rest of the team, and the resources available in the local system, as well as recognising that different areas will have different ways of operating services depending on geography, morbidity, the choice of other services and other indicators of service user and carer need. The guidance therefore discusses the importance of job planning in ensuring doable jobs for consultants which also deploy their skills most effectively.

Distributed responsibility

In 2005 the GMC recognised the different way in which psychiatrists operate in the context of their multidisciplinary teams, and issued guidance to supplement that in Good Medical Practice. Further details can be found in the Guidance on Responsibility and Accountability on the website, which has hyperlinks to all the relevant source materials. Consultant psychiatrists no longer have to worry about feeling, or being, responsible for everything that happens to the patients being cared for by their team, even if they had not seen the patient. The GMC guidance makes it clear that psychiatrists are not responsible for work being carried out by other members of the team. The current guidance documents explain the NWW model of distributed , rather than delegated, responsibility.

Effective input

Many psychiatrists used to feel overwhelmed by the sheer numbers of outpatient appointments that they seemed to be expected to carry out. In many cases patients had been returning routinely to see a psychiatrist for many years, without the added value of this intervention being discussed. As the practice of ‘handing over’ such cases from one SHO to another every six month became less common because it was unsatisfactory for patients and trainees, a greater proportion of the work fell to consultants, whose clinics were then booked up so far in advance that they could not respond swiftly to urgent requests to see someone. NWW has helped to move away from that model to one where the input of the most experienced and senior members of the team, like the consultant psychiatrist, is targeted towards where it will be of most benefit or where it is most needed, for example in very complex formulations. In turn psychiatrists practising in this way can respond to requests to see people when they need to be seen.

Focused leadership

Consultant psychiatrists are often clinical leaders in their teams, but NWW emphasises that they may not be the only leader, and that this needs to be a position for which the leader is suited, rather than one which comes with perceived status or is the exclusive preserve of one profession. NWW encourages teams to be explicit about their members’ roles, including leadership roles, as confusion can result from assumptions being made. Some teams have been reorganised to provide more focused leadership; for example where a consultant psychiatrist works exclusively in an inpatient setting, s/he and the ward manager will generally offer joint leadership to the ward. There have been many drivers for the so-called ‘functional specialisation’ model apart from NWW however, in particular the reduction in inpatient beds that has occurred everywhere as a result of the effective deployment of crisis and home treatment teams. As the bed base has reduced, having sometimes 8 consultant psychiatrists with patients on a 20 bed ward has no longer been a tenable model.

3. Psychiatrists and Challenges

The Role of the Psychiatrist

This is the biggest single worry of those who have concerns about NWW. They assert that the ‘giving away’ of aspects of the traditional consultant psychiatrist’s role, will result in a future role that is ill defined and therefore less attractive, and which can more easily be substituted by other professions if cost savings need to be made or recruitment is difficult. In turn they fear that this substitution will lead to a ‘dumbing down’ of the service offered to patients.

It is worth pointing out again that it was because of psychiatrists’ concerns that they had too much to do, that NWW got such an impetus in the first place, and also that the numbers of psychiatrists have gone up a lot. It is likely that this trend will not continue, but this will be due to the overall economic settlement for the NHS and mental health, and because it was such a large increase that it could never have been sustained for ever. Attracting enough medical graduates into psychiatry has long been a challenge and remains so, and the availability of more jobs will make this more obvious. There is a challenge to define the role in a way that emphasises the many opportunities being a NWW psychiatrist provides, including those which are an inherent part of professionalism such as teams being supported and empowered to improve and develop.

Psychiatry as a Medical Specialty

A debate about the need to ‘re-establish’ psychiatry’s identity as a branch of medicine, has recently become entangled in debates about NWW, because of the concern to redefine the role of the psychiatrist. NWW has been about how teams work together to provide a better service to their users and carers; it has never been about what a psychiatrist must or must not do in respect of individuals. It has made no comment on the need for investigations and tests, for example, neither would it presume to do so. What it has talked about is psychiatrists not seeing every patient. NWW argues that psychiatrists have to target their skills appropriately, and that seeing every patient , or trying to, does not leave time for this and in most community teams is simply not possible to do in a meaningful way. In order to facilitate the best use of the psychiatrist’s skills, commissioners and providers need to think about more sophisticated measures of their performance than activity figures, as this approach disregards quality and outcomes.

Training for a NWW Psychiatrist post

Concerns have been expressed that if consultant psychiatrists are dealing only with the most complex cases, how will trainees learn about more straightforward management in ordered to gain the experience they need? More thought needs to be given about how other members of the team can contribute to the training of psychiatrists (and vice versa), so that they not only gain broad experience, but also understand better than their predecessors may have done, what the roles of the other members of the team are and how they all fit together.

The evidence for NWW

‘What is the evidence for NWW?’ is a common question. NWW is about a cultural change in how we think about how teams work together, so how does one measure cultural change in the NHS? And what was the evidence for ‘Old Ways of Working?’ There is evidence of more doable jobs, more choice for service users, and better outcomes – but these things refer to individual services or teams, where NWW has been set up as a project and before and after measures have been taken, and no set of circumstances in one team ever exactly mirror another. Often the changes have been gradual, and have not been set up to be evaluated or compared. The striving for evidence in a form that does not exist can encourage people to think NWW is one model or style of service, which it is not, and elevate it beyond the arena of common sense and a pragmatic approach to quality of service delivery, which it is.

4. The future

The other professions with which we work are embracing NWW and the opportunities to improve the fit of team skills and user and carer needs. In all other branches of medicine, and in other public services, there are examples of new and extended roles. Service users and carers are looking to exercise choice. All these developments will continue irrespective of where psychiatry as a profession positions itself.

Psychiatrists need to work with their multidisciplinary colleagues and managers to determine how NWW can help them improve the services they work in. When the lag period is over, and the economic downturn really hits public services, NWW will help, not to dumb down provision, but to ensure that the best use is made of the skills of all members of the team, including psychiatrists, and that teams are working with efficient processes that can also be flexible enough to respond to individual need.

The Next Stage Review champions clinical leadership at all levels. It is hoped that by having doable jobs, agreed by a job planning process, psychiatrists will be able to take advantage of opportunities to apply for other leadership positions to contribute to the next stage of mental health service reform.