The present and future of higher training

As part of an ongoing educational audit of the pro cess, content, and outcome of higher training in the Mersey Region, the Senior Registrar Tutor (MA-S) and the Psychotherapy Speciality Tutor (MG) organised a whole-day workshop for the senior regis trars, involving them in internal audit as well as pro viding an experience of strategic thinking on the impact of NHS changes on higher training. We modified a package used in industry for strategic planning called the Quick Environmental Scanning Technique (QUEST) (Nanus, 1984). The QUEST process involves two whole-day meetings usually separated by a month which we condensed and adapted to one day, alternating large group discussion with small group work. We report our experience of the workshop which may provide a useful model in strategic thinking and planning for trainees as well as for trainers.

As part of an ongoing educational audit of the pro cess, content, and outcome of higher training in the Mersey Region, the Senior Registrar Tutor (MA-S) and the Psychotherapy Speciality Tutor (MG) organised a whole-day workshop for the senior regis trars, involving them in internal audit as well as pro viding an experience of strategic thinking on the impact of NHS changes on higher training. We modified a package used in industry for strategic planning called the Quick Environmental Scanning Technique (QUEST) (Nanus, 1984). The QUEST process involves two whole-day meetings usually separated by a month which we condensed and adapted to one day, alternating large group discussion with small group work.
We report our experience of the workshop which may provide a useful model in strategic thinking and planning for trainees as well as for trainers.

Stakeholders
The first task was for each group to determine the five most important stakeholders in higher training in the Mersey region, with an emphasis on the understand ing of the concept rather than the content. Two main groups were identified as stakeholders: those with an interest in training and those who controlled resources

Outcome of training
The next task addressed the question 'What willdeter mine the success of higher training in ten years from now?'. The SRs were asked to produce five measures of outcome of training from a stakeholder's viewpoint with the following results.
(a) For trainees, success was determined by satis faction, recognition, as well as freedom from major strains, and a reasonable income. They felt it was important to have mastered a variety of skills to enable them to be flexible and able to cope with future changes. (b) For the providers of training as well as the consumers, i.e. the patients, good performance indicators included good clinical and manage ment skills providing quality care and quality training, as well as outcome indicators such as low litigation rate, and low suicide rate. Another performance indicator was profit ability for the self-governing unit or private institution concerned. (c) The SRs thought that from the trainers', the tutor's and the Postgraduate Dean's point of view the indicators included prestige, good trainees seeking higher office, and continued approval from the JCHPT.

Critical events
A 'brain-storming' exercise provided a list of ten main critical events influencing strategic decisions regarding higher training in the next ten years. The themes were interesting enough to be repeated in full. Group 1 decided to categorise them into external and internal themes. Among the external ones were government policy, expectation of society, require ments of training, local politics, advances in medi cine, disease rates, new fashions, and advances in treatment. Internal events included changes in the people in charge of training as well as change of trainees.
Group 2 lumped external/internal events together and the list included change of government, financial crisis in the NHS, change of role of the professions, competition with other professions such as psychi atric nurses and clinical psychologists, EEC member ship in 1992, outcome of the Gulf War, major slump/recession, loss of leadership and control of money, the change of orientation from hospital to the community, and identifying cures for diseases such as Alzheimer's dementia and schizophrenia.
Group 3 listed population structure changes, increased number of elderly and decreased number of children, the need for new skills, legislation change in consumer expectation, and changes in family structure.
Group 4 listed closure of mental hospitals, Achieving a Balance, privatisation, and medical/ clinical audit. The list often important critical events agreed by the whole group were: EEC 1992, the Gulf War, change of government, privatisation, differ ential pay, renewable 1-3 years contract, restrictions on merit awards, audit, resource management, and changing disease rates and advances in treatment.
The 'Delphi1 exercise: predicting the future This process involved the determination of prob ability of each of these major events ranging from 0 to 100% if it is certain to occur in the next ten years. The groups were also asked to rank all these in their impact on training.
NHS reforms had the highest probability, between 80% and 100%. While the risks for recession were estimated around 25% to 30%, change of govern ment achieved a 50% rating. Merger with the EEC and implications for the influx and efflux of trained doctors were rated 100%. Privatisation varied, as one group put its likelihood at 15% and another at 75%.
Events with the highest impact on training were the NHS reforms, with 75% negative impact and 25% positive impact; privatisation was given a probability of 15% occurring with 90% negative impact.
One group highlighted the critical importance of audit in determining cost-effective varieties of treat ment and how audit of outcome will influence prac tice as well as the role of psychiatry. There was concern for the continuing discrepancy between expectations and demand for health care and avail able resources, with the possibility of a nightmare scenario of a global recession, war, widened gap between the north and south, as well as pollution of the environment, and the implementation of a market-driven NHS, starved of cash.

'Your dreams'
The group was asked "What were your dreams when you started your training in psychiatry and what happened to those dreams?". There were no major disillusionments and most people have experienced reality to reflect their dreams to some degree. Those motivated by social and political concerns felt that their missionary zeal had to be contained and caring goals had to be modified. One main cause of frustration was the pressure to get involved in man agement which is against their major interests and the conflict between being a clinician and manager.

Scenarios
From the interplay of the interaction of critical events, the probability of occurrence and impact on training, the moderators developed four possible scenarios for discussion: business as usual: govern ment driven; choice (money) driven; and the night mare (total privatisation with economic recession) scenarios.

Abou-Saleh and Goepfert
Each group was asked to develop one of these scenarios, describe them and assess their implications for training. The following points emerged.
(a) Lack of management exposure within the scheme. (b) The money/choice driven scenario was seen as a mixed blessing depending on whether it was privatised which was seen as negative or choice driven by the consumer/patient/ general practitioner. The group highlighted the negative aspects of any privatised scheme with examples from the American health care system, with its high costs, low consumer satisfaction and disadvantages for vulnerable groups. (c) Anticipated increase in private practice with a negative impact on training standards. (d) Considerable risk of a two-tier private and public service system. Private services cater for the middle classes with neurotic problems, with no emphasis on training or research. The public sector would cater for the unemployed, disenfranchised underclass, particularly psy chotic illnesses cared for by less well trained doctors. The detailed analysis of strength, weaknesses, opportunities and threats was followed by antici pated training needs to help trainees cope with the future.
The following are a selection of needs/ requirements: negotiating skills -research time psychotherapy supervision -community psychiatry and active rehabilitation management experience available at the level from registrar upwards -multidisciplinary team management leadership skills -joint planning team experience more liaison experience with psychologists and community nurses reviews of training and feedback opportunities regarding quality of supervision from trainer. business skills -time-management allocation of real management projects with supervision -"face the media" skills regular trainer and trainee feedback -experience of interface between NHS and other organisations prescribed procedure for dealing with personal issues of trainees-wide range of psychotherapeutic skills (including family, behavioural and cognitive) training in consultancy skills. At the end of the meeting each participant listed at least one action point for implementation in the immediate future. Examples were the institution of a support group for SRs, shadowing managers/ clinical directors, visits to places of excellence, psychotherapy training, and time management.

The present and future of higher training Comment
There is a clear demand for higher order skills such as management and leadership skills, as well as specialised diagnostic and therapeutic skills which are perceived as potentially saleable in the market place in competition with other professional groups.
The workshop provided an applied experience in learning strategic thinking and planning, an essential component of management training.
This inquiry into the current objectives and methods of higher training in the Mersey region has implications for the aims and objectives as stipulated by the Joint Committee for Higher Psychiatric Training. It might be timely to review knowledge, skills, and attitudes to be attained by senior registrars 281 during their training. Other pertinent questions involve the assessment of quality and quality control of training and its method, criteria for the appoint ment of trainers, including the provision of required training to become a trainer. Most important are the outcome measures for evaluating the effectiveness of higher training. We think it is necessary to reexamine higher psychiatric training vis-Ã¡-vis the new NHS to refine its objectives and concepts of training and treatment methods.