Shortly after taking up my appointment as National Director for Mental Health, I convened a working group of consultant psychiatrists to consider how to involve psychiatrists more in the current process of changing mental health services. This was in recognition of the fact that, while psychiatrists are central to modernising services, their skills and experience are insufficiently used. It is one of the most frequent complaints that I hear from clinicians.

This paper summarises the conclusions and proposals of the group. First, it proposed the appointment of a ‘consultant adviser’ in every local service; with dedicated time for service development, linked to National Service Framework (NSF) local implementation teams. The consultant adviser will have no managerial responsibility and will reflect the perspective of front-line clinical practice on how a local service puts current policies into effect. Similar posts at the regional level will help to coordinate the work of consultant advisers.

Second, the group supported the abolition of the current system of local homicide inquiries on the grounds that they are a key factor in increasing occupational stress. Third, the group proposed that the Department of Health and the Royal College of Psychiatrists should work jointly to increase the consultant workforce and reduce vacancies.

Summary of discussion

The group considered three questions:

1. • Were psychiatrists well informed about the content of the NSF and the NHS Plan?

2. • Were they sufficiently involved in the process of effecting and monitoring change in clinical services?

3. • What were the features of clinical practice that made it difficult for psychiatrists to play a full role in service development?

Most consultant psychiatrists are aware of the general content of these two key policy documents (NSF and NHS Plan). However, knowledge of their details varies widely. Dissemination of the main points could be improved as current channels of communication, for example, through trust chief executives or journals, tend to be slow and tend not to highlight the points of greatest interest to medical staff. The wide press coverage of the launch of the NHS Plan gave little attention to the mental health aspects. The general principles of the NSF were broadly accepted but there were concerns that the specific clinical initiatives in the NHS Plan could disrupt the existing good practice of community mental health teams.

For several years psychiatrists have felt marginalised by the process of service development and performance management. This is resented by clinicians, who feel that their experience, knowledge, responsibility and awareness of the strengths and weaknesses of a local service are not being recognised or adequately exploited. It also has the effect that services develop in ways that do not reflect the priorities of clinical staff working at the front line, or of the people for whom they provide a service - patients, carers, general practitioners and others.

The role of the consultant psychiatrist, particularly in adult psychiatry, is increasingly complex, difficult and stressful. Adult psychiatrists lack a clearly defined role that is accepted by service managers and that places clinical practice at its core. They often feel overwhelmed by multiple demands, with administrative tasks competing with urgent clinical duties. The vital role of training future mental health professionals can become impossible. Many adult psychiatrists feel that specialist services are selective about the patients they will treat, leaving them to be responsible for the most intractable clinical problems.

There is a lack of flexibility and progresson in career pathways. Many adult psychiatrists lack a sub-speciality interest and the pressures of their clinical role make it difficult for them to take on new roles or training.

Staff shortages and concern over resources in general make the work of all clinical staff more difficult.

There are high levels of stress in health professionals. In mental health, stress in consultant psychiatrists can be made worse by the lack of structured support from peers or team members. Many psychiatrists in training do not learn about successful team working. Junior psychiatrists who are supervised by a stressed and disillusioned consultant may leave the speciality.

Although there is a problem of burnout among clinical staff, the solution should not be for senior consultant psychiatrists to move away from a clinical role. Instead, the pressures of the job should be addressed. This could be done through providing support and training in team leadership and by making the consultant's role more rewarding clinically. How this would be achieved might vary for each individual. For some it would mean the development of sub-speciality interests or training on areas other than the treatment of severe mental illness and the containment of high risk.

Clinical practice is characterised by substantial pressure of work but evidence shows that in itself this does not need to be stressful. One problem is that there is a lack of reward for doing the job well.

In particular, occupational stress in health professionals is linked to fear of litigation. Consultants in adult psychiatry fear that they will be held responsible for the actions of the patients, such as acts of violence, over which they may have no control. This fear has been greatly exacerbated by the current system of homicide inquiries.

Conclusions and proposals

In every local service a consultant adviser should be appointed. The consultant adviser would work closely with his or her local implementation team (responsible for putting the NSF/NHS Plan into practice). He/she will foster the active engagement of senior clinicians in NSF and NHS Plan implementation. He/she will ensure that the priorities, strengths and weaknesses of the local clinical service are taken into account and will therefore have close links with clinical staff of all disciplines, including psychiatrist colleagues. He/she will differ from a clinical director in having no managerial responsibilities. The consultant adviser will be expected to be aware of successful clinical innovations in other services and to receive training in leadership skills. He/she will have links with clinical governance leads, service managers, the regional College executive and local user/carer groups.

The consultant adviser should be released from clinical duties for 1 day per week (or equivalent). A number of services already have a consultant in an advisory role but this initiative will ensure that dedicated time is available to carry it out. One day per week is 20% of a consultant's time - in an average service, defined by the local implementation team, this is less than 2% of consultant time overall.

The consultant adviser should be nominated by local consultant psychiatrists. Ideally, the consultant adviser will carry out these duties in relation to one local service, either at trust or health authority level, depending on local service configuration. However, there may need to be some local flexibility so that he/she does not have to relate to several local implementation teams.

The appointment of a consultant adviser at local service level should be reflected in a similar position at regional level. At the moment, consultant psychiatrists may relate to regional offices in a variety of capacities, either as regional NSF champion, lead clinician or as a member of a regional modernisation board. In some regions, there is no lead psychiatrist. The important point is that every region should have a practising consultant psychiatrist who advises on clinical service development and who is consulted by regional office staff. The precise title and the other duties of the post are less critical, as long as the central function is presenting the clinical perspective.

A network of consultant advisers should be established with close working links to the regional clinical lead and two-way links to the National Director for Mental Health. The regional clinical leads should also form a national network linked to the National Director. At all levels, it will be important for there to be strong links with the College and its representatives.

There is a need to define the role of the consultant general adult psychiatrist, with emphasis on clinical practice, but taking account of the problems listed above, including lack of flexibility in clinical role, the importance of team working, etc. The College Faculty of General and Community Psychiatry has recently prepared a document on this, which should form the basis of individual job plans. Job plans should be as specific as possible and should give a true reflection of the time required for both clinical and non-clinical duties.

The College and Department of Health should work to increase the number of specialist registrars and senior house officers (SHOs), including psychiatry SHOs who are training to be general practitioners.

The working group supported personal development plans. Flexible career development should allow consultants to train in sub-specialities while remaining primarily in general adult psychiatry, and to change sub-specialities over time. Priority areas for continuing professional development should include team working and areas of major policy development. Team working should also be promoted as part of the training experience of junior psychiatrists.

There should be better dissemination of policy initiatives and a number of ways of achieving this now need to be considered:

1. • A policy information page on the College website.

2. • The MRCPsych exam to include questions on key policies.

3. • The consultant adviser should have a dissemination role.

There was support for current work in the Department of Health on new outcome measures for mental health services. These would cover local and national outcomes and focus on mortality, morbidity, quality of life and user/carer satisfaction. Local services would be able to use these outcomes as a way of demonstrating the benefits of their services.

A broader system for identifying and disseminating good clinical practice needs to be established. This should go beyond the current system of Beacon Awards, so that good local practice receives proper recognition.

There should be changes to the current system of local homicide inquiries. The NHS is likely to set up new systems for detecting and responding to adverse incidents in line with the Chief Medical Officer's report An Organisation with a Memory (Department of Health, 2000). New NHS-wide structures should cover adverse incidents in mental health, including homicide.

Follow-up actions

Since the working group reported, all trusts have been asked to appoint a consultant adviser. Clinical leads have been identified in each region. A new working group has been established, with Department of Health and College representation, to address problems in the recruitment and retention of psychiatrists. The mental health branch in the Department of Health continues to contribute to putting An Organisation With a Memory into practice.

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