The postgraduate deans commission training to speciality standards set by the Medical Royal Colleges. The Royal College of Psychiatrists has published clear guidance on the standards expected for basic and higher professional training (Royal College of Psychiatrists, 1998, 1999), and these guidelines are updated regularly. Additionally, in the NHS professionals are re-defining and extending their traditional roles, and this has major implications for workforce development, which will need to be supported by multi-professional training (Department of Health, 2000).
At the time of the study, the North Thames deanery was responsible for training approximately a sixth of the psychiatric trainees in the UK. We reviewed psychiatric training on all sites in North Thames in 1996-1997 (Reference Herzberg, Fergus and PaceHerzberg et al, 1999) and found that, despite a high level of satisfaction expressed by trainees, deficiencies in educational and safety standards were found. Trusts and trainers were made aware of these deficiencies by immediate feedback and a written report. A subsequent cycle of visits was carried out in 1999-2000 to see whether improvement had occurred.
Method
Training sites visited in the first survey were revisited. College tutors provided information on a structured questionnaire about the staffing levels, general characteristics of their NHS trusts and their training programmes. The questionnaire was identical to that used in the previous cycle of visits in 1996-1997. Additionally, structured interviews were carried out with senior house officers (SHOs) and specialist registrars (SpRs) on each site. The interviews lasted approximately half an hour per group and the responses were entered onto a form.
Results
All 43 psychiatric training sites in North Thames were revisited. Of 374 SHOs on the deans' database, 237 (63%) were interviewed, and of 161 SpRs 101 (63%) were interviewed. Our experience is that the number of trainees available for interview at any time is approximately 12-15% less than the full establishment, because of leave or vacancies (Paice et al, Reference Paice, West and Cooper1997, Reference Paice, Aitken and Cowan2000). The true response rate was therefore over 75% for each group. Tables 1 and 2 compare key findings on the 1996-1997 visits with those of the 1999-2000 visits.
Educational findings over a 3-year period
| GPVTS posts without community sessions | Comprehensive induction programme | ECT supervision satisfactory | Multi-professional case conferences | Multi-professional audit meetings | Bleep-free local training programme | |
|---|---|---|---|---|---|---|
| 1996-1997 | 9/18 (50%) | 27/40 (68%) | 10/29 (34%) | 24/40 (60%) | 29/37 (78%) | 15/43 (35%) |
| 1999-2000 | 3/24 (12%) | 42/43 (98%) | 19/26 (73%) | 28/43 (65%) | 26/36 (72%) | 28/43 (65%) |
Availability of psychotherapy supervision over a 3-year period
| Dynamic psychotherapy | Cognitive—behavioural psychotherapy | Family therapy | |
|---|---|---|---|
| 1996-1997 | 37/42 (88%) | 39/43 (91%) | 31/43 (72%) |
| 1999-2000 | 41/43 (95%) | 42/43 (98%) | 32/43 (74%) |
General practitioner vocational training scheme posts
The percentage of general practitioner (GP) vocational training scheme posts without community sessions decreased from 9/18 to 3/24 (Table 1). In 1999-2000, nine offered one session, five offered two sessions and the rest offered between three and five community-based sessions.
Induction
More departments offered comprehensive induction programmes (Table 1). In 1999-2000 induction occurred on 42 sites, lasting a mean of 2.6 half-day sessions (range 0.5-6 sessions).
Electroconvulsive therapy
In 1999-2000 an electroconvulsive therapy (ECT) induction session occurred on 34 (94%) sites where trainees were expected to participate in the ECT rota, an identical finding to the first survey. However, ECT supervision was deemed satisfactory in over twice as many units in 1999-2000 as in the previous study (Table 1).
Training meetings and supervision
There has been little change in trainees' ability to access multi-professional training over this period. Table 1 sets out some key educational findings in the two periods surveyed. There was little change in trainees' access to case conferences, with regular multi-professional input between the two surveys. Journal clubs remained largely medical events and on 41 sites where these were run in 1999-2000, only 11 had multi-professional input, compared with 8 in 1996-1997. Audit meetings were slightly less likely to be multi-professional over the two periods surveyed.
In 1999-2000 trainees on two sites complained of difficulty in attending the local training programme on a regular basis, compared with similar difficulties for trainees on six sites in 1996-1997. However, marked improvements have occurred in the provision of ‘bleep-free’ local training time (see Table 1). Interviews with SHOs identified nine posts in which supervision was stated to be unsatisfactory and discussions with SpRs revealed three posts with poor supervision. Supervision in psychotherapy was widely available (see Table 2), with modest increases in availability of supervision in major modalities across the deanery area.
Workload issues — 1999-2000
SHOs described the on-call rota as satisfactory on 29 sites. They felt that the general daytime workload in their posts were satisfactory on 36 sites. Twenty-three SHOs reported that in at least one post they were expected to carry out inappropriate duties (routine filing, phlebotomy or portering). SHOs graded their overall group view of the quality of their satisfaction with posts as average on seven, good on 26 and excellent on three sites.
SpRs in psychiatry carry out non-resident on-call duties. On all 34 sites where SpRs were interviewed, their daytime workload was deemed satisfactory. On three sites SpRs complained of inappropriate duties. SpR's overall satisfaction with posts was graded poor on one site, good on 20 and excellent on seven.
Discussion
It is clear that the majority of trainees were satisfied with the training in their posts, but there remains scope for improvement in several areas. The deanery has been pressing to improve the quality of the training experience offered to GP vocational training schemes to ensure that the experience reflects a suitable clinical case-load and setting mix for primary care. The number of posts offering more than one community oriented session has risen since the 1996-1997 visits but generally the hospital—community balance remains inappropriately skewed to secondary care. There is a constant tension between the need to improve training experience for GPs and the need for NHS trusts to ensure that wards are covered.
Induction arrangements have improved in the study period. Similarly, comprehensive arrangements occur on the majority of sites where ECT is given. The Royal College of Psychiatrists is now inspecting ECT facilities and training and accrediting clinics. It remains a matter of concern that on seven (27%) sites supervision is unsatisfactory. Feedback received at deanery visits indicates that this is often because the consultant responsible for the service is timetabled to be off site when treatment is being given. Phlebotomy services are often poor on isolated community sites away from the general hospital. We know from feedback that many NHS trusts are addressing this issue by training nurses to assist in this task.
The Department of Health document, A Health Service of all the Talents (Department of Health, 2000), has emphasised the importance of multi-professional training in the service setting. Unfortunately, the majority of trainees in this study had little access to meetings in which they could share knowledge and discuss and debate issues with other health professionals. However, this may be partially explained by the fact that doctors have traditionally enjoyed easier access to protected study leave time and money than other professional groups. However, there are also doubts raised about the value of multi-professional learning. Frankly, there is a dearth of studies assessing multi-professional training in secondary care. However, in primary care Mann et al (Reference Mann, Viscount and Cogdon1996) have shown benefits in collaborative working by delivering a multi-professional heart health programme to doctors and other health and social care professionals, and in undergraduate courses similar benefits have been described (Reference Wahlstrom, Sanden and HammarWahlstrom et al, 1997; Reference Parsell, Spalding and BlighParsell et al, 1998). For a review of this topic see Herzberg (Reference Herzberg1999). Psychiatrists face a significant challenge to ensure that trainees have access to educational programmes that promote learning of core skills, attitudes and knowledge necessary for practice in the speciality, but also promote shared learning with other clinical health professionals.
This study demonstrates that psychiatric training had improved over a 3-year period in one deanery, but there will need to be a considerable amount of work undertaken to meet the challenges of the new NHS training agenda.
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