Growth in independent hospitals. An opportunity for training beyond the NHS

The UK independent psychiatric hospitals sector has grown significantly in recent years. The arrival of community care and the closure by the National Health Service (NHS) of the county asylums led to overload of local NHS hospitals from the 1970s onwards. The resulting demand facilitated the

Growth in independent hospitals. An opportunity for training beyond the NHS The UK independent psychiatric hospitals sector has grown significantly in recent years. The arrival of community care and the closure by the National Health Service (NHS) of the county asylums led to overload of local NHS hospitals from the 1970s onwards. The resulting demand facilitated the expansion of the several private and voluntary sector providers. In the past 5 years many new commercial entrants have appeared, with rapid development of services covering many localities and specialties. It is estimated that around 250 independent mental health hospitals (exclusive of care homes) are registered with the Healthcare Commission, providing around 8000 beds (Laing & Buisson, 2006). Over 80% of these beds are purchased by the NHS (Healthcare Commission, 2006;Laing & Buisson, 2006); the rest are mostly funded under private medical insurance.
Provision in the sector ranges across open and secure care in mental health, with services for learning disability, brain injury, acute, longer-term and rehabilitation treatments. Many of the country's most highly specialised and secure psychiatric care pathways are found in the independent sector. In some subspecialties, this is the main national provision, for instance longerterm medium and low secure care, women's services, learning disability, forensic, brain injury, autistic spectrum, secure services for adolescents, older people, the deaf, people with Huntington's disease, etc. The sector also contributes toward care in personality disorder, forensic addictions, and sex-offender services.
There is little hard data on how many psychiatrists work in the independent sector, but the authors estimate the number of directly employed medical staff (including part-time staff) at around 400, with visiting NHS or retired psychiatrists raising the number into thousands. The latter have 'practising privileges', a contracted piecework form of engagement recognised by the Healthcare Commission.
The consultants employed by most providers, and nearly all of those visiting the mental health independent sector, are on the Specialist Register, with some eligible to apply for inclusion owing to past experience or training. Many were previously accredited by the Royal College of Psychiatrists as trainers working in the NHS, and have therefore experience of supervising specialist registrars. However, the College rules concerning trainers outside the NHS sector remain unclear and close cooperation between the College and the independent sector is needed here (Sugarman & Nimmagadda, 2007).
Psychiatrists working in registered independent hospitals frequently express their wish to offer placements to trainees. Admittedly, there is wide support from many independent sector providers to students (of nursing, social work, psychology, occupational therapy and others) from local universities in terms of work and study placements (e.g. St Andrew's in Northampton trains significant numbers of professionals [in nursing, psychology, occupational therapy, social work, physiotherapy, speech and language therapy, dietetics, also police] in close collaboration with the University of Northampton and six other major universities in the region; there are similar arrangements in smaller hospitals in the Priory, Partnerships In Care and other groups). Still, support for psychiatrist trainees is scarce. Doctors in training appear equally rare in the medical and surgical independent sector, where a 'junior doctor' title is given to resident medical officers, a non-training grade.
With psychiatry's move to the community, the independent sector may be the only opportunity for higher specialist trainees to access specialist or longer-term inpatient settings. These facilities have enormous training potential, but as they are not run by the NHS, they are generally not considered for trainees' placements and thus specialist registrars in almost every area of psychiatry are missing out on unique and accessible learning experiences. Such training has benefits for patients, trainees and consultants alike as it fosters a learning environment with cross-fertilisation of good clinical practice. Understanding the independent sector will be important for future NHS consultants who will refer patients, review placements and progress, and arrange transfers from or to the independent sector. Most future NHS psychiatrists will face this responsibility at some time.

Current situation
Individual placements for doctors-in-training occur but only occasionally in independent sector services (e.g. senior house officer's training posts in some Priory hospitals, specialist registrar attachments at St Andrew's and Priory hospitals), mostly as 'special interest sessions', time-limited or one-off attachments -typically arranged with the agreement of the relevant clinical tutor or training programme director, and often initiated by an enthusiastic trainee. One of the authors sought special interest experience in a medium secure forensic learning disability placement, unavailable within the local training programme. By a modular approach to training, she obtained a 10-week 'out of programme experience' with the local deanery and College approval. This was agreed prior to the implementation of the new Postgraduate Medical Education and Training Board (PMETB) 'out of programme experience procedures' (Postgraduate Medical Education and Training Board, 2007). This was a successful placement and a valuable training opportunity which was unavailable within local NHS services.
More recently, with the PMETB approving all postgraduate training posts and programmes in the UK, an out of programme experience must also be prospectively approved this way. If this experience is to count towards the award of a Certificate of Completion of Training (CCT), PMETB needs to be reassured that the local deanery and the College support the post and that it fulfils PMETB quality requirements. There is a risk that these new criteria will reduce rather than enhance specialist trainee access to independent sector services. In addition, the move to the new specialist training grade may be reducing the quality of job plans and flexibility for special interest sessions (Royal College of Psychiatrists, 2007), further increasing the difficulties in gaining valuable independent sector experience.
There are only one or two examples of substantive specialist training places in the independent sector known to the authors (i.e. the Priory and St Andrew's hospitals mentioned above). The underlying challenge may be one of funding and the perception that scarce NHS training resources must be protected. Monies for the costs of trainees' employment and education are increasingly ringfenced and are usually divided between NHS trusts and the local deanery. However, independent sector providers, keen to have the valued input of trainees, are very likely to agree to fund such posts.
The challenge for the future There is a deeper question behind the concerns about resources^what are trainees being trained for? Is it to provide a junior workforce for NHS providers and an inhouse pool of potential consultants? Or is it to deliver the best care for patients, by giving them a choice of providers? As most independent sector patients are also NHS patients (and all, as tax payers, fund training), surely we should place trainees in all quality services which provide primarily for NHS patients. The independent sector and NHS should be collaborating to find ways to rotate trainee doctors through the different settings and ensure that they are getting the range of training they need. This is an important task for the College, with its central role in setting standards in psychiatric services and training, to champion the value of the breadth of training.
Independent sector training may attract trainees to become consultants outside of the NHS, but an increased number of training places should also boost the number of trainees available for NHS consultant posts. So not only are psychiatric trainees missing out on valuable training in independent sector services, but psychiatric services as a whole are missing out on this. Surely commissioners should demand of the independent sector not only that it provides patient care but also that it provides training for the workforce.
The government has increasingly supported the movement of some aspects of medical care into the independent sector (Department of Health, 2007). However, experience with the Independent Sector Treatment Centres suggests that satisfactory results may require better integration with the NHS, especially as regards training opportunities for junior doctors.
There are significant changes occurring in medical training at present -with reports of doctors in training unable to find work. This may be an ideal opportunity for the independent sector to contribute additional training opportunities. Looking beyond the UK, this has already happened. It is routine in many other countries to train psychiatrists in private hospitals. For example, in Australia, training programmes have been developed integrating public and private sector placements. This was initiated as a result of the recognition that trainees were no longer being exposed to an appropriate range of cases solely within the public sector. There is a call for this to develop further because of the discrepancy between increasing numbers of medical graduates and the inadequate number of training posts available within the public sector (Australian Private Hospitals Association, 2007).
In the UK, the solution is likely to be based on substantive training schemes outside of the NHS. This would allow many smaller independent sector providers to contribute, whereas larger providers may act as organising and teaching centres in their own right or work in partnership with the deaneries and postgraduate schools. Independent teaching hospitals are an exciting prospect for the future, in which psychiatry could be the leader.
It is essential to find new ways to work together to benefit both trainees and patients. The Royal College of Psychiatrists could (e.g. via the Academy of Medical of Royal Colleges and directly) influence PMETB and the deaneries in this respect. The College has also a key role in changing the attitudes of psychiatrists who currently develop and organise training. A clear statement of positive intent may be highly effective in breaking down barriers, and creating a base on which we can build a training system for the future.