New Ways not working? Psychiatrists’ attitudes

AIMS AND METHOD A questionnaire survey of general adult psychiatric consultants and 
specialist registrars in the West Midlands was conducted to examine attitudes 
towards New Ways of Working (NWW) for psychiatrists; these were measured using 
a 5-point Likert scale. Participants were also asked about their own 
experiences of NWW. The data were analysed using Mann–Whitney U -test. RESULTS The response rate was 31.2%. Attitudes were generally negative, 
particularly regarding the effect on patient care, the erosion of the 
professional role of the consultant and effect on quality of work life. The 
attitudes of those who did not have any direct experience of working to the 
NWW models were more negative than those who had direct experience of NWW. CLINICAL IMPLICATIONS There are significant concerns about NWW among consultants and specialist 
registrars. There is a need for further debate and research with regard to the 
proposals.

The Department of Health guidance New Ways of Working for Psychiatrists (NWW) sets out fundamental changes in the role of consultants and how they interface with other mental health professionals. 1 The drivers included consultant dissatisfaction with excessive workloads and concerns about workforce planning, in terms of both recruitment and retention of psychiatrists.
The proposals do not reflect a single service model or structure that has to be adopted, but suggest ways of changing the culture and roles within teams to use skills in a more productive way. 2 These include a move towards reduced case loads, with consultants taking on a consultative role within the multidisciplinary team and seeing only patients with more complex and severe illness. This will take place through the delegation of tasks to other members of the team and developing roles within the multidisciplinary team, such as appointing advanced practitioners. There will also be a move from the traditional 'sector psychiatrist' model to more specialised teams, for example those focusing solely on in-patient care and specialised community mental health teams.
Despite the proposals being developed by psychiatrists themselves, NWW has been met with a mixed response from the profession. Of five comments that were posted in response to the College website feature, 'Diary of a new ways of working consultant psychiatrist', all were negative or raised serious concerns about the proposals. 3 Issues that have been raised regarding NWW include: lack of evidence that the changes will benefit patients; loss of continuity of care; the erosion of the professional role of the consultant into one of 'technician' ; de-skilling of psychiatrists; difficulty with delegation of tasks; the suspicion that trusts will use the changes to replace consultants with cheaper alternatives; a negative impact on psychiatric training and reduced job satisfaction. [4][5][6] Given these reservations, it is surprising that there are no existing studies that have examined the wider views of psychiatrists regarding NWW.
We aimed to: . examine the attitudes towards NWW of general adult consultants and specialist registrars working in the West Midlands; . evaluate whether attitudes differed depending on experience of working to the models proposed in NWW; . evaluate whether attitudes differed between consultants and specialist registrars.

Method
Design We conducted a cross-sectional questionnaire survey of all general adult consultants and specialist registrars working in the West Midlands Deanery across eight trusts. A list of potential participants was generated from a database held by Birmingham and Solihull Mental Health NHS Trust Postgraduate Medical Education Administrator. The questionnaires were sent by email and returned by email or post. The questionnaire was sent out on one further occasion 8 weeks later with a view to recruiting additional participants.

Questionnaire
The questionnaire asked for information such as gender, experience (years) and name of trust. We then asked whether or not the participant's trust had adopted any of the changes in NWW and if so, how their job had been affected and whether their work life had improved as a result. Participants rated their attitude towards 12 statements about NWW on a 5-point Likert scale (ranging from 'strongly disagree' to 'strongly agree'). They were also invited to give their written comments about NWW. The questionnaire was anonymous.

Analysis
The data were entered into the statistical package SPSS version 12 for Windows and a Mann-Whitney U-test was performed to establish any statistically significant differences in attitudes between two pairs of subgroups: . those whose jobs had been directly affected by NWW v. those whose jobs had not been affected by NWW . specialist registrars v. consultants.
For each comparison, a further analysis was performed by collapsing the 5-point scale into a 3-point scale.
In the consultant group, the male:female ratio was 25:12 and in the specialist registrar group it was 3:5. Years of experience working as a consultant psychiatrist ranged from 1 to 27 (mean = 11.7 years), and as a specialist registrar from 1 to 7 (mean = 2.5 years).

Experience of NWW
Twenty-one participants (39.6%) said that their trust had adopted or partly adopted NWW. Within three trusts the answers were conflicting, with some respondents saying that NWW had been adopted and others saying it had not.
Of the 21 participants who said they worked for a trust that had adopted NWW, 4 (19.0%) said they (or their consultant) were working in a purely consultative role; 11 (52.4%) said they were working in a functionalised team for out-patients only and 6 (28.6%) said the changes were yet to affect their job (values do not add up to 100% as more than one option could be selected). Five people (23.8%) felt their work life had improved as a result of NWW, 4 (19.0%) said their work life had not improved, 9 (42.9%) were not sure and 3 (14.3%) gave no response.
Attitudes towards NWW Table 1 shows the distribution of opinions to the 12 statements about NWW. No statistically significant differences in attitudes were found between the specialist registrar and the consultant group on analysis using both the 5-and 3-point scales. The comparison of those whose jobs had been directly affected by NWW with those whose jobs had not been affected showed that there were statistically significant differences in attitudes on four of the items. Those whose job had changed were more likely to agree with the statements: 'NWW will lead to increased job satisfaction' (Mann-Whitney U = 165.5, Z = 71.925, P = 0.026 (3-point scale)); 'NWW will lead to enhanced quality of care for patients' (Mann-Whitney U = 164.5, Z = 72.315, P = 0.021 (3-point scale)); and 'NWW will be better for patients' (Mann-Whitney U = 156.0, Z = 72.512, P = 0.012 (5-point and 3-point scale)). Those whose job had not changed were more likely to agree with the statement 'NWW will lead to lack of continuity of patient care' (Mann-Whitney U = 178.0, Z = -2.011, P = 0.044 (3-point scale)).

Comments
Written comments about NWW were given by 19 of the 53 respondents, almost all of them consultants. These are summarised in Table 2.

Discussion
Our study revealed that attitudes towards NWW among consultants and specialist registrars in the West Midlands were generally negative. Although those who had direct experience of working to NWW models tended to have more favourable attitudes than those with no direct experience, this effect was modest, with statistical significance only being demonstrated on 4 of the 12 items. Some respondents were unclear whether or not their trust had adopted NWW. This may reflect underlying confusion about the essence of NWW due to the multifaceted nature of the proposals and their overlap with some of the changes already introduced through another government policy (e.g. the introduction of some functionalised teams in the National Service Framework for Mental Health 7 ).
Dale & Milner New Ways not working? original papers The increasing loss of one-to-one patient contact which is progressively coming along, the increasing de-professionalisation of the consultant role with a clear strategy to disempower medical consultants and in a field where everybody can do everything, does not inspire one with confidence for the future of the profession.' 'It might save money and reduce the job opportunities for psychiatrists.' 'It will weaken the role of consultants.' 'For an external view look on the GP forum in www.doctors.net -their comments on already reduced psychiatric services and difficulty getting hold of a psychiatrist are particularly scathing.' 'Danger of narrowing of skills repertoire and burn out of consultants' Improvement in work life 'If it will reduce personal workload and burn-out, then it appears attractive -just acting in a consultative role and dealing with a few complex cases.' 'The one thing that has improved work life was the recruitment of an associate specialist to each of the consultant teams, covering on-call rota out of hours. Second, the crisis team and hospital nurse liaison team have reduced the unnecessary assessments that were taking place both within and outside of normal working hours. I am not sure that any of these developments were connected with New Ways of Working.' 'Good points: less pressure.' '[Work life has improved] a little, in terms of reducing some pressure on sector consultants. However, case load numbers are still high.' Impact on patient care 'I believe some of the new functionalised teams benefit patients and enhance care, but in-patient consultants will not. Again, some teams such as assertive outreach [teams] improve continuity of care but in-patient consultants reduce continuity.' 'There is as yet no clear evidence that patient care improved. If this existed, then I would be more eagerly embracing the model.' 'I am very ambivalent about NWW and can't see many benefits for patients.' '[It will] possibly compromise care depending on the skills of the people doing the bulk of the work.' 'It should have been focused around improving standards of care rather than making life easier for consultants.' 'The New Ways of Working will only be successful, if all care coordinators are adequately trained and also have manageable case loads. It will be disastrous for patients, if care coordinators are also not adequately supervised.' 'Continuity of care could be lost.' 'Bad points: more fragmentation of care can be difficult and precipitate crises.' Suspicion of abuse by trusts 'It is being seen by the managers as a way of cutting costs by reducing medical staff numbers with perhaps a small increase in CPN numbers. We do not have a document yet but this has been expressed to us in ''confidential briefings''.' Local implementation of NWW 'NWW is multifaceted and needs to be flexible and agreed locally before implementation.' 'I think each individual trust's circumstances and resources will ultimately decide the best way forward.' The mixture of issues in NWW There will be pros and cons to the new system just as there were with the old system.' '[There is] a mixture of issues and feelings.'

Main concerns about NWW
The survey reflected wider concerns that have been expressed about NWW. For instance, the majority of the sample (73.5%) agreed or strongly agreed that the changes would lead to lack of continuity of care for patients. Most (51.0%) felt that the role of the consultant would be weakened, a view also expressed in many of the respondents' comments ( Table 2). The majority (56.6%) felt that NWW would not encourage new trainees into psychiatry. Indeed, concerns have been raised that NWW will have a negative impact on psychiatric training by restricting the range of clinical experiences that trainees are exposed to. One of the main drivers behind NWW was to improve the working lives of consultants. However, our respondents were sceptical about this and less than a quarter of the participants whose jobs had changed through NWW stated that their work life had improved as a result. The proposals outlined in NWW were developed in areas where patient numbers were particularly high and placing a significant burden on consultants. It may be that the models are not readily transferable to areas without these difficulties.

Limitations
The survey had a relatively low response rate and small sample size. This made statistical analysis of the data difficult and reduced the generalisability of the results. It is probable that those with strong opinions about NWW were more likely to respond to the questionnaire. This responder bias may explain the predominantly negative attitudes of the group. It is likely that trusts will have different approaches to the implementation of NWW, and our study did not account for this. The findings should be interpreted with these factors in mind.

Conclusions
New Ways of Working has far-reaching implications for consultants, patients, mental health teams and the way they interface with other agencies. Despite its limitations, this survey has revealed significant concerns about NWW among some consultants and specialist registrars. It highlights the need for ongoing examination into the impact of NWW and invites further debate on this issue. Trusts will need to examine their own individual resources and service requirements before adopting NWW. They must also work closely with psychiatrists and other agencies so that any changes that are adopted are both satisfactory to consultants and do not compromise patient care.