Dr Gianatta Rands Dr John Lowe

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Psychiatry and the Foundation Programme

• Dr Gianatta RandsDr John Lowe
• Royal College of Psychiatrists

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Shall Cinderella go to the Ball?

• The Future of Psychiatry in the Foundation
  Schools of
• the UK.
• John Lowe and Gianetta Rands

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Intro

• 3 Questions
• What does psychiatry want?
• Does it deserve to get what it wants?
• Is it getting it?
• Some Stories
• 3 Surveys
• Structure and Design
• Paper based survey of Foundation Programme
  Curriculum and associated documents
• Actual Delivery
• Questionnaire survey of Specialty Schools
• Questionnaire survey of Foundation Schools
• Conclusion and Way Forward

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Carl Jung
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Cinderella
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So what does psychiatry want from the FP?

• All Tomorrows Doctors will have achieved the
  psychological and psychiatric competencies
  essential for the safe and effective practice of
  medicine with the living patient.
• All doctors who are Striving for Excellence and a
  career in psychiatry will receive adequate
  experience and support during their Foundation
  Years.

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Does psychiatry deserve to get what it wants from
the FP?

• We ARE a medical specialty (Craddock et al 2008)
• There are a lot of us
• 3,231 NHS Consultant Psychiatrists (DoH 2004) vs
  33,674 in all specialties (DoH 2006)
• 10 of Consultant Workforce
• 450 CT programmes in 2008
• We are a growing group
• Consultant no.s increased 46.5 1997 - 2004 vs
  4.6 all specialties
• We spend a lot of NHS money in increasing
  amounts
• Over 8b 2006/7 (10 of total NHS budget)
• Innovative EB Service Models
• CRT, EIPT, AOT
• High Achievers
• Research and National Targets
• Prizes to be won
• Psychological and psychiatric competency deficits
  in the medical profession as a whole
• Known longstanding recruitment shortfall
  (Goldacre 2005)
• Historically made up for by Overseas recruitment
  - now severely curtailed
• New uk med schools
• Early post grad experience a known important
  determinant for uk grads

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Survey of Heads of Psychiatry Schools in England,
2008/9

• Arose because of concerns about recruitment to
  Psychiatry Specialty training since MMC
• Electronic questionnaire to HoSs
• Replies from 13/13 Deaneries
• 1388 HT posts, (6 sub-specialties)
• 1498 CT posts
• Ratio 11.08 ideal!
• HTs General 667, OAP 232, CAP
  214,
• For 126, LD 88, PT - 51

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Results of HoS survey continued

• 1498 CTs - approx 500 p.a.(DH estimate 450)
• FYs lt 1.
• Some overlap with FP survey, but Comments
  included
• no tasters
• Two Deaneries knew of 3 FY2s each going on to
  Psychiatry specialty training
• loss of overseas trainees will decimate
  recruitment to psychiatry
• Why not ask about GPVTS posts?

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Is Psychiatry currently getting what it wants
from the FP?

• Anecdote - no?
• Data
• Design
• Curriculum - yes!
• Rough Guide and Portfolio - yes?
• Operational Framework - no?
• Delivery
• Posts - no!
• Tasters - no?
• Teaching and Mentoring etc - ?
• Outcomes
• Competencies - ?
• Recruitment - no!

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Design
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Curriculum - yes
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Curriculum - yes

• Psychiatry in the FP Curriculum
• Well represented prominent, relevant and
  comprehensive inclusion
• Examples
• Section 4 Syllabus and competencies
• p50 History taking Consider the impact of
• physical problems on psychological and social
  well-being
• physical illness presenting with psychiatric
  symptoms
• psychiatric illness presenting with physical
  symptoms
• psychological/social distress on physical
  symptoms (somatisation)
• family dynamics
• p52 Examination
• Patterns of clinical signs including mental state.

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Curriculum - yes

• Section 7.0 Recognition and management of acutely
  ill patient
• p103 (x) Understands and applies the principles
  of managing a patient following self-harm.
• undertakes a focused history, including
  psychosocial causes requiring social services or
  police intervention
• recognises the need for involvement of mental
  health or more experienced personnel
• does a mental state assessment
• demonstrates an awareness of child protection
  concerns where appropriate.
• performs a risk assessment and anticipates
  necessary steps to minimise current and future
  risks to patient
• initiates referral to mental health services
  where appropriate.

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Curriculum -yes

• (xi) p103 Understands and applies the principles
  of managing a patient with an acute confusional
  state or psychosis.
• recognises diagnostic features of psychosis and
  acute confusional states
• discusses safe administration of anti-psychotic
  drugs, including the risks of sedation
• knows the provisions of mental health legislation
  and can apply them appropriately.
• safely administers anti-psychotic drugs
• considers underlying causes of acute confusional
  state or psychosis.

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Rough Guide and Portfolio -?
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Dilution and Loss of Quality Assurance

• Keyword sample search using psych comparing
  Curriculum with Rough Guide and Portfolio
• Page for page the Curriculum is 5 X more likely
  to refer to psychiatry in the context of
  acquiring clinical competencies than the Rough
  Guide or the Portfolio.
• Lack of specific reference to psychiatric
  competencies in key parts of documentation
• WBATs
• Summary of Evidence eg Hx Ex.
• Signing Off

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Operational Framework

• Refs to psychiatry - 1 (stand alone 4 month F2
  academic placements)
• Refs to GP - 26
• No specific representation advised or mention re
  Boards or Faculties cf GP
• No Joint Working Group

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Delivery
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Survey of Foundation Schools in England 2008/9

• 21 Foundation Schools in England
• Email questionnaire to all FS Directors/Managers
• 6 Questions
• How many F1 programmes?
• How many F2 programmes?
• How many F1 placements (4 month equivalent) in
  psychiatry?
• How many F2 placements (4month equivalent) in
  psychiatry?
• How many tasters in psychiatry?
• How many graduates go on to a career in
  psychiatry?

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Results

• 19 Foundation Schools responded
• 5371 F1 progs 5148 F2 progs
• 150 (0.9) F1 posts are in psychiatry
• 318 (2.1) F2 posts are in psychiatry
• Tasters nk (4FSs had data)
• Progress to CT nk (6FSs had data)

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Benchmarks for Numbers of Psychiatry FP placements

• Target 1 - competency
• All FPTs offered placement in psychiatry
• 17 of all FP placements
• 5 met
• Target 2 - equity
• Matching of FP stream to CT stream (450 CT1 Psych
  posts 2009)
• 8 of all FP placements
• 10 met
• Target 3 - career
• Matching of FP placements to CT1 posts (450)
• 468 FP placements
• 100 met

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Outcomes
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Outcomes

• Foundation Competencies in Psychiatry
• Unclear if these are being met or how despite
  mass signing off
• Lack of specific quality assurance measures and
  targeted management, although structures mostly
  in place eg WBATs, Summary of Evidence, Signing
  Off, or planned eg. FS Boards and FP Faculties
• Reasons to be concerned eg nos of posts
• Recruitment
• Remains difficult in terms of attracting uk
  graduates
• Overall Impact of FP, New Medical Schools and
  reduction in Overseas Recruitment difficult to
  predict and as yet unclear.

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The Take Away Message

• More posts esp F1
• ?How many
• Up to 95 more
• Joint Working Groups
• Modelled on GP
• National, Regional and Local levels
• College, Specialty Schools and Faculties of
  Mental Health Trusts
• UK Foundation Programme, Foundation Schools and
  Faculties of Acute Trusts
• Targets and management
• More research and monitoring

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And finally .