A View on Senior Registrar Training in General Adult Psychiatry

1. The development of community psychiatric nursing services has been of benefit to patients, has assisted in the development of community psychiatry and may have reduced pressure on hospital resources. These services should be maintained and expanded. This expansion should be monitored to ensure that the expected benefits can be demonstrated. 2. There is a need to consider the development of 24-hour, seven days a week CPN services. Evaluation of such developments is important to show whether the increased commitment is justified. 3. At present the CPN should be a member of the psychiatric team, but in the future if numbers increase it may be possible for CPNs also to be members of primary care teams. The value of CPNs working as members of primary care teams requires evaluation. 4. There is need for further experimentation and no one pattern of CPN service can at this stage be seen as ideal. 5. The training of psychiatric nurses should become increasingly community-orientated. Shorter courses should be made available so that all CPNs have some formal training. 6. Psychiatric nurses working with in-patients and day patients should have the opportunity to follow up patients in the community when continuity of care or other factors make this desirable. 7. The expansion of CPN services should not be so rapid that it depletes hospital in-patient services of staff and so endangers the care of the chronically ill. 8. There should be a degree of specialization in CPN work and evaluation studies should be made comparing 'specialist' and 'generic' services.

1.The development of community psychiatric nursing services has been of benefit to patients, has assisted in the development of community psychiatry and may have reduced pressure on hospital resources.These services should be maintained and expanded.This expansion should be monitored to ensure that the expected benefits can be demonstrated.2. There is a need to consider the development of 24-hour, seven days a week CPN services.Evaluation of such developments is important to show whether the increased commitment is justified.3.At present the CPN should be a member of the psychiatric team, but in the future if numbers increase it may be possible for CPNs also to be members of primary care teams.The value of CPNs working as members of primary care teams requires evaluation.4.There is need for further experimentation and no one pattern of CPN service can at this stage be seen as ideal.

A View on Senior Registrar Training in General Adult Psychiatry
By ROBERT FIELDSEND, Senior Registrar, Warneford Hospital, Oxford Pre-Membership training tends to concentrate on the acquisition of knowledge and gaining clinical experience, especially in the assessment of patients.In postgraduate training the learning of various management skills, the development of special interests and filling gaps in previous training are the primary tasks.Theoretical learning through books and journals alone is insufficient in these areas.Opportunities must be available for the senior registrar to use his clinical time to achieve satisfactory training.If the senior registrar's position is largely supernumerary this is easily achieved; however, this happy situation is a rarity.
In preparing for consultantship, the higher trainee needs to develop team management and administrative skills, become accustomed to working in a supervisory capacity, increase his teaching experience, and be able to initiate and carry through changes in the institution or service he is providing.Most clinical placements of over one year should be able to give this experience; acting for a consultant on leave is not adequate training.As well as receiving advice and guidance the trainee needs the opportunity to have a reasonably free hand in a particular area, e.g.altering a ward culture, run ning a liaison service, setting up supervision and training for particular staff members.It is possible that in a non-teach ing hospital there may be less constraint on such activities.In practice it is important that the consultant should be flexible and interested in helping the trainee with these skills which are all too often only acquired through trial and error.
Another important training experience is the development of special interests.Most consultant posts are now adver tised with a special interest, or such an interest is encouraged.A trainee's day release can easily be taken up with a research project, leaving little time for other interests.Many rotations are entirely through general psychiatric posts, so that the availability of specialized experience is limi ted.A great many trainees will want to develop skills in psychotherapy and forensic psychiatry without going through a sub-specialty training scheme.A substantial part of any rotation needs to be used for this purpose, either by releasing the trainee for more than one day per week or by specific periods within the rotation.In my view, priority needs to be given to the development of interests other than research if we are to produce consultants with informed enthusiasms.It is the use of such interests which is one way of producing expansions of service in hospitals where the trainee becomes a consultant.
A third area of lesser importance is to fill gaps left by a particular registrar training experience, e.g. in alcoholism, rehabilitation or liaison psychiatry.It is obvious from the above description of senior registrar training that any train ing programme will need to some extent to be tailored to individual needs.
Many factors militate against the trainee's individual needs being adequately met.Senior registrars differ widely in their needs partly as a result of varied registrar training.It is certainly possible to become a consultant with little or no experience in important areas such as psychogeriatrics, rehabilitation or psychotherapy.Clinical loads are often heavy, and in addition the trainee often finds himself cover ing for either the registrar or consultant on leave (for over four months in a year).The consultant may expect his senior registrar to act within a well-defined job description, allow ing no flexibility for individual needs.The trainee may be reluctant to press for changes in his post for fear of alienat ing a potential referee for a consultant post.Clinical loads are not easily re-allocated without resentment.Clinical tutors have a responsibility to help trainees in consultation with individual consultants and also to review with the trainee what his training needs are at the beginning of a rotation so that a definite plan may be made.In addition rotations must be organized for the trainee and not for administrative con venience.
At present many rotation schemes involve only general psychiatric placements with day release for special study.In my view this is inadequate for development of special interests or skills and has arisen out of trying to fit existing posts into a rotational scheme.To develop a system where posts of several months can be used for special need, or where less clinical input is expected in some attachments, depends on the goodwill of the consultants, who may have to be without a senior registrar for long periods.Again, such changes are unlikely to take place without the active involve ment of clinical tutors.
The organization of senior registrar rotations has developed in different ways over the last few years in different areas.Clockwise rotation between several jobs (sometimes including specialty posts), rotation between a non-teaching and a teaching hospital (often both general adult jobs), flexible movement between a variety of jobs and rotations including a choice of special interest periods (e.g.psychotherapy, forensic psychiatry) are examples.In many areas senior registrars have little influence on how rotations are set up, and one suspects that where rotations are more flexible senior registrars have been better organized to press their views.
Based on the points I have put forward, I conclude that the ideal senior registrar scheme would consist of one long placement of 18 months to learn team management and related skills, and several other placements of variable length (six to twelve months) for the development of special interests and the correcting of any obvious dÃ©ficiencesin pre vious training.
There is no obvious way of measuring the effectiveness of senior registrar training (such as the Membership examina tion in a registrar's education) and there is therefore a danger of complacency.Do different schemes produce more or less trainee satisfaction?Do trainees' expectations fit the Royal College's guidelines?Regional meetings of senior registrars can help to generate change, and trainees and tutors should take note of how other schemes operate.It is too easy for a dissatisfied registrar to escape into consultancy or into dreaming of becoming a consultant.Are you getting the training you feel you require?

Henderson lives!
Dr Gerard Vaughn, Minister for Health, said in the House of Commons on 3 July that the Henderson Hospital would not close, He commented that it had a 'vital role to play in the community' and that it would be a disgrace if it were allowed to close.As an exceptional measure, the runn ing costs of the hospital over the next two years would be met from the Region's allocation of funds for secure treat ment.Costs of the hospital would be kept under regular review.