NewWays ofWorking and psychiatric trainees

This paper aims to consider postgraduate psychiatric training in the context of New Ways of Working for psychiatrists in England. It summarises the impact of recent changes in postgraduate training and the major training implications of New Ways of Working. Finally, it outlines some broad principles that need to be considered for training when implementing New Ways of Working locally. Postgraduate psychiatric training is currently at a unique juncture. It is undergoing a complete overhaul with the implementation of Modernising Medical Careers (MMC) and the new Royal College of Psychiatrists’ curriculum (Royal College of Psychiatrists, 2006) approved by the Postgraduate Medical Education and Training Board (PMETB). At the same time, the working practices of consultant psychiatrists are being reviewed under the aegis of the New Ways of Working initiative (Department of Health, 2005). This presents the profession with a distinctive opportunity to work together to develop a seamless system that will train doctors to be competent consultants to multidisciplinary teams. Doubts have been raised about the effects of New Ways of Working on the future of service provision, patient care and the psychiatric profession as a whole (Gee, 2007). However, to our knowledge, the impact on psychiatric training has not been reviewed.


Recent changes in psychiatric training
Before considering how the implementation of New Ways of Working impacts on training it is important to mention other recent imminent changes in relation to psychiatric training.

European Working Time Directive
The recent reduction of working hours to 56 hours per week, and the further planned reduction to 48 hours in 2009, significantly reduces the quantity of experience gained by trainees (Mason et al, 2006).This places significant emphasis on having a competency-based framework to ensure that each trainee gains adequate breadth of experience and competence without relying on having to spend 'enough' time in a clinical setting.

National Service Framework and National Health Service Plan teams
With the implementation of the National Service Framework for Mental Health (Department of Health, 1999) and the National Health Service (NHS) Plan (Department of Health, 2000) new working practices were established.Clinical exposure for trainees has changed following the introduction of single points of entry and the new specialist teams, including crisis resolution and home treatment teams, early intervention in psychosis teams, and assertive outreach teams.Changes have occurred not just in the quantity of clinical exposure, as a lot of the tasks traditionally carried out by trainees are now carried out by other professionals, but also in its quality, as trainees now see fewer new and emergency cases independently.

Modernising Medical Careers and Postgraduate Medical Education and Training Board
The introduction of MMC's Specialty Registrar runthrough grade and the PMETB-approved competencybased curriculum developed by the Royal College of Psychiatrists (Royal College of Psychiatrists, 2006) should ensure that at the end of training all trainees have acquired the skills necessary to work as a consultant psychiatrist.This framework could not only be used to identify and overcome any training gaps for overseas trainees but also define the skills of those UK-trained psychiatrists who emigrate to work in diverse healthcare environments.

New Ways of Working and postgraduate psychiatric trainees
The implementation of New Ways of Working has two main implications for trainees.First, the role at the endpoint of training (i.e.consultant psychiatrist) will be different in the future.The new curriculum therefore needs to be regularly reviewed, especially in the areas of management, leadership and supervision of colleagues, to ensure that postgraduate training is in line with contemporary and future clinical practices.Second, the traditional training model where the trainee undertakes, under supervision, the range of clinical activities that their consultant would normally perform is under threat.As traditional consultant roles become redundant we will need to consider mechanisms for retaining the broad range of experiences required by trainees, so that future consultants are competent both to deal with the most difficult and complex cases and provide supervision to other colleagues.
The role of the consultant will vary across the country from one multidisciplinary team to the next.The clinical responsibilities of trainees within each team should therefore be specifically considered and clearly defined alongside the evolving role of the consultant at the time of local service reorganisation and not simply be added on as an afterthought.Managers, local trainees, college tutors, consultants and multidisciplinary team members should all be engaged very early on in the discussions about changing service and training models at a local level.

Local considerations
There are some general principles that must be considered locally when reviewing the role of trainees within a team.(Please note: potential specialty-specific issues may need separate consideration that is beyond the scope of this paper).

Working in partnership with service users and carers
Trainees are enthusiastic for user involvement in education (Vijayakrishnan et al, 2006).Recent policy developments including the National Service Framework for Mental Health (Department of Health, 1999) have emphasised the importance of user and carer involvement in mental health services at various levels (e.g.Department of Health, 2001).It is now mandatory for psychiatric trainees to receive training directly from those having mental health problems and their carers.Further work is essential in this area as involvement of patients and carers in training development and delivery is beneficial for patients, carers and trainees alike (Masters et al, 2002;Ikkos, 2003;Walters et al, 2003;Tew et al, 2004), as it helps ensuring that trainees are competent in delivering a truly person-centered care.

Exposure to non-complex cases
With the expanded roles of other professionals promoted by the New Ways of Working initiative, the consultant psychiatrist may see fewer 'routine' patients in the outpatient clinic setting as their skills will be concentrated on those with more complex problems.However, seeing newly referred and follow-up patients in out-patient clinics remains an essential source of experience for psychiatric trainees.Without learning how to assess, formulate, investigate and manage simple cases it is impossible to learn how to manage complex ones.

Emergency assessments and out-of-hours working
In order to gain competencies in the assessment and management of the full range of psychiatric presentations, trainees require exposure to emergency assessments and involvement in out-of-hours working.The introduction of crisis resolution teams, accident and emergency liaison teams and the expanded role of other professionals potentially reduces the involvement of psychiatric trainees in the assessment and management of patients in emergency settings.Supervised independent and joint decision-making at appropriate stages of training should be encouraged and incorporated into the team-working framework.

Multidisciplinary working
There is a consistent emphasis on multidisciplinary work in the New Ways of Working (Department of Health, 2005).The role of the consultant psychiatrist within multidisciplinary teams, as prescribed in the New Ways of Working programme, is to advise other professionals and to be directly involved with the most complex cases.In order to prepare for this role, trainees need to be more involved in multidisciplinary assessments and follow-up.During core training the trainee may be expected to observe and learn from other members of the team.A more experienced trainee may take on a lead role, and at an advanced level the trainee could provide advice and guidance (i.e.consultation) to the team under the supervision of the consultant.

Care coordination
Trainees need to be competent in care coordination as this is a central aspect of delivering mental health services.A recent review of care coordination under the Care Programme Approach has highlighted the need for developing national competencies and training for this role (Department of Health, 2006).Taking on and fully understanding the role of the care coordinator for complex cases would be a valuable training experience in preparing future consultants for their advisory position to care coordinators and would fulfill competencies of care plan formulation and implementation as outlined in the new College curriculum (Royal College of Psychiatrists, 2006).

Use of consultant's time for training
As other members of the team take on some of the tasks traditionally performed by consultants, a portion of the New Ways of Working consultant's additional time should be devoted to revive and promote the traditional apprentice model.This is particularly relevant for those in higher training as it would allow the trainee to spend more time with the consultant to gain competencies in both the management of complex clinical cases and the supervision of multidisciplinary colleagues in managing such cases.

Allocation of training posts
Attention is required to ensure that trainees have a wellrounded training experience.Training posts should be allocated on the basis of each individual's training needs to ensure that by the end of their training they have gained a complete range of experience and competencies.This will involve trainees working with a variety of different teams (e.g.in-patient, community, crisis resolution, home treatment, early intervention team, etc).

Conclusion
New Ways of Working is dramatically changing the way mental health services are being delivered.Simultaneously, MMC and the PMETB are having a similar effect on postgraduate psychiatric training.Early and active engagement with the process is required at a national level by the Royal College of Psychiatrists and the New Ways of Working steering groups, at a regional level by the postgraduate schools of psychiatry, and at a local level by the trust management, trainers and trainees.It is imperative that all involved in these changes work together to ensure that high-quality training today produces 'fit for purpose', high-quality consultant psychiatrists tomorrow.

Declaration of interest
At the time of writing, A.M. was the chair and O.W. the vice-chair of the Psychiatric Trainees' Committee of the College.C.O. and P.H. were members of the Psychiatric Trainees' Committee.J.M. and P.H. have represented trainees on the national steering group for New Ways of Working.