BMA Publication for NHS Modernisation Agency, NHS National Institute of Health in England and Department of Health. 2004.

Response from the Society of Clinical Psychiatrists

SUMMARY and CONCLUSIONS

1. This Society sees the consultant physician-in-psychological medicine role as having a fourfold function.

(a) Foremost is that of lead clinician director and provider in terms of diagnosis (only registered medical practitioners are systemically trained in this most important function) and overall clinical care and needs of the individual patient as is spelt out already in Government and legal accountability. Fudging of this position and denial of legitimate authority within any multi -disciplinary-team (MDT) damages the competence of team goal of best patient care and minimising danger for patients and public.

(b) An inseparable teaching function related to other doctors in training and the MDT.

(c) An evidence-based research component for him/her self and their team.

(d) Lead manager, facilitator, initiator and developer of team healthcare policies. This too requires recognition, not denial, by non-medical managers of the limitations of line management authority in NHS healthcare policy decision making as has existed in the past and now. The current authority situation since Griffith (1983) borders on the ridiculous as regular systemic failures in NHS care colour our daily newspaper headlines.

2. The practice, which has recently occurred in primary care psychiatry, of referral by GPs of patients to a secondary care team rather than a named consultant carries danger not only for the individual patient but medico-legal hazard for the referring family doctor. This is not merely a ‘view' but a GMC backed legal requirement. It applies across the board in healthcare including mental disorder and illness for purposes of protecting patients' treatment standards and safety.

These observations could apply to any consultant in any medical specialty. Organic changes in consultant role require to be discussed in a reality based setting along with resource implications.

Some Observations by the Society of Clinical Psychiatrists.

3. Introduction . We welcome the opportunity to comment on New Roles for Psychiatrists (undated) and gleaned from the document that it represents a distillation of views and opinions expressed at two national conferences held in March and April 2003. We note that delegates were drawn from medical practitioners in psychiatry, nursing, management, occupational therapists, psychologists, user groups, general practitioners, academics, social work and civil servants. Given the disparate nature of this group's focus on new roles for psychiatrists, it is perhaps understandable that the report's most cogent point (which we support) is that it raises more questions than solutions to the clarification of the psychiatrist's role: and we would add for other members of the multidisciplinary team (MDT) also. It is therefore important to clarify current medical professional, ethical and legal responsibilities and accountability in relation to patient overall care vis-à-vis other team members. The role played by resource constraints and other associated politically driven diktat, as distinct from clearly identified patient service need, in distorting doctors role is not addressed. This is a serious omission.

4. The Society agrees with Dr Louis Appleby that the model of consultant psychiatrist of recent years which has seen such exodus of experienced staff from the NHS cannot continue (p5). But of the consultants we canvassed none agreed with his proffered solution. They tended to see this as, understandably perhaps, the product of Government thinking reflected in his National Director for Mental Health role.

5. Although user groups are listed amongst conferences' delegates we feel that, overall, the report is too little patient centred: that there is insufficient emphasis on the patient who is ill or believes himself/herself to be ill and attends a doctor to receive help. It is the unit of patient and doctor that is kernel to all else, in terms of healthcare and treatment, that may follow. The reason it is the doctor and not any other member of the MDT is that he/she is the only one holistically trained in the competencies of full medical history taking, patient examination, investigation, diagnosis and treatment.

These attributes are achieved through a long training encompassing the basic science, anatomy and physiology, pathology, medicine and surgery, obstetrics and gynaecology, embracing the biopsychosocial model of patient care. That is not an exhaustive list and specialism , entailing further years of training is added. The rigours of registration with the General Medical Council (GMC) have to be observed. Proper patient treatment, care and safety, demand nothing less. We find it alarming that mental illness (as distinct from vague ‘mental health problems') and the importance of diagnosis in determining appropriate therapeutic response(s) are not referred to clearly in a document titled New Roles for Psychiatrists. Neither is the impact on consultant role of multi-site patient placement examined.

6. It is for these outlined reasons that patients attend registered medical practitioners and rightly expect to receive the most correct diagnosis and treatment – answers to what is troubling them, whether physical or psychological. A comorbidity mix is far from uncommon. This of course does not guarantee that the patient will receive the most accurate diagnosis and wholly satisfactory treatment from that doctor (just as taking one's legal problems to a lawyer does not guarantee a completely successful outcome). It does mean, all things being equal, that the physician (or surgeon) discipline offers the greatest possibility of best patient treatment, care and general satisfaction because of his/her uniquely fitting training. This satisfaction may be delivered wholly by, in this special context, the physician in psychological medicine. It might involve referral, following examination and diagnosis, to another consultant in a different specialty, or a decision to involve another member or members of the MDT or perhaps decide there is need for hospitalisation. Psychiatrists have long recognised, and promoted, the value of the MDT. Only a foolish doctor would not.

7.That MDT member may be a nurse, psychologist, social worker, occupational therapist, etc. or a combination of care and treatment providers, guided principally by that patient's individual identified need and available family and social support. Local resources, in an NHS setting (including lack of appropriate ones), would of course impinge on a decision as to whether hospital admission or other possible patient placement was indicated and feasible. Best practise and the GMC rightly insist however that a doctor must ensure that in referring a patient to another medical practitioner colleague or a member of the MDT, that such person is adequately qualified and competent to carry out that delegated care for that patient. The practice, which has recently occurred in primary care psychiatry, of referral by GPs of patients to a team rather than a named consultant carries danger for the individual patient and medico-legal hazard for the referring family doctor. This is not merely a ‘view' but a GMC backed legal requirement. It applies across the board in healthcare including mental disorder and illness for the purpose of protecting patient treatment standards and patient safety.

8.The statement (p8) that it is the chief executive rather than the consultant who is ultimately responsible for an NHS trust patient's care is about as relevant as stating that the minister for health or the prime minister is so responsible. It is frankly risible in the healthcare workplace were it not a further suggested undermining of consultant direct patient accountability by a false suggestion that the consultant is thereby somehow less legally accountable, less responsible. In cold legal terms that responsibility for overall patient care remains quite unchanged.

9. An illustrative case in point occurred in November 2000 , with the Commission for Health Improvement's inquiry into Garland 's Hospital run by North Lakeland NHS Trust in Carlisle , Cumbria . There was a catalogue of “degrading and cruel” practices (nursing practices and failures affecting older patients) because of a “systematic failure of management”, claimed the report. Many readers will be aware of the quite dreadful abuse suffered by those unfortunate older mentally ill patients. The trust's chairman was deservedly dismissed. Nothing can or should be said to whitewash this whole tragic situation for patients and their loved ones. There was also strong criticism of the consultant psychiatrist, as the professional responsible for those patients who were abused. He responded , perhaps surprisingly, that he was made to feel like a visitor on his own ward and that he was not aware of the abuse. But the commission said it was “deeply disturbed” by the consultant's “lack of awareness” and “passive acceptance” of being treated in this way. “This reflects an inadequate sense of medical accountability in so senior a figure.” To our best knowledge no further action was taken against him. Nevertheless he was the only member of the MDT who was publicly named. But assuming the Commission's observations on the consultant are correct it behoves us to look more closely at his defence: that he “felt like a visitor on his own ward”.

The Commission is right to emphasise consultant accountability. Working for Patients (1989) reiterated... “The key role of consultants in the NHS in terms of their 24 hour responsibility for patient care. It is they who are the leaders of clinical teams, responsible for all aspects of the clinical care of the patients under their charge.” It could hardly be clearer. It is not the “Team” that is called to account. There can be no retreat for a consultant into words that attempt to diffuse responsibility with “we the team are all responsible”. It is unjust that despite the abuses which occurred in Garland 's Hospital ‘Team' responsibility in terms of naming abusing staff, appeared to have evaporated. It is now quite commonplace for team members to appear unaware of the chain of clinical authority and accountability. There is also a need to clarify that authority and authoritativeness as necessary components in running any business or service. These are not synonymous with authoritarianism which is unacceptable in any organisation, as is elaborated immediately below. Even football teams have a captain and amongst the civil servant bureaucracy their status is guarded zealously by such trappings as the size of their desks and offices. The only structured authority that bothers most doctors is that which enables them to treat patients effectively and without danger in that process.

10. In the NHS of recent years the most basic tenet of general management systems theory - that those charged with leadership, accountability and responsibility must also be given commensurate authority to enable them discharge their duties effectively - is lately honoured more in the breach than the observance. Essential medical authority has been systematically undermined by politically inspired initiatives, notably by Griffith NHS management report (1983) . Entrenchment of this erosion was solidified by Working for Patients (of which more below). The accountability and responsibilities remains unchanged, as needs must. No other professional group within the medical team has the necessary training, experience and skills to justify being entrusted with such leadership, accountability and responsibility. (Here the term consultant is used to describe those Registered Medical Practitioners with specialist experience and seniority as has been the case up to very recently in the NHS when titles such as consultant nurse and consultant clinical psychologist have appeared. This development has introduced an element of confusion in both patients' and general public mind about qualifications ,skills and responsibility).

11. Any government ‘modernisation', ‘reorganisation' ie changes imposed upon already well recognised patient (and public) safe medical practice, needs to be seen against the background of organically accumulated best practice since 1858 (when the GMC was formed). Such non-organic politically driven changes in healthcare delivery carry with them the distinct possibility of danger for patients, and in the context of mental illness, danger for the general public as well. Closure of older mental hospitals, for instance, has reduced mental hospital bed numbers alarmingly, and in an uncontrolled fashion. and has forced psychiatrists to discharge patients earlier than clinically appropriate. As MP, Dr Evan Harris, observed two years ago, the mentally ill are ‘facing a double whammy of cuts to community care budgets and cuts to hospital beds'and this is despite alleged extra funding and despite national service framework. Some stark statistics: psychiatric bed numbers shrank from 150,000 in 1955 to 41,800 in 1994 to 337,650 in 1996 to 34,214 in 2001-2002 the last year when figures were available. We do not consider that the vast bed reduction can be justified by advances in treatment. Furthermore, with the abolition of Community Health Councils which had powers to ask for answers to pertinent questions about local resources such as current bed numbers, that avenue is now closed and without a satisfactory replacement. These trends have impacted hugely on standards of patient treatment and care and also inevitably on the role and responsibilities of physician specialists too. That these issues are vital is borne out by the evidence collected by the Zeto Trust and other sources. It is remarkable that in closing older mental hospitals, that modern purpose -built replacement was exceptional and where it did happen bed numbers were drastically reduced as above statistics underscore.

This occurred despite the older mental hospitals' frequently extensive grounds. These in too many instances were rezoned for extensive and expensive private domestic housing projects. There is little or no evidence that the proceeds from such large land sale were hypothecated for mental health services. The community buildings appointed to substitute have too often been hand–me-down dispersed accommodation. Such marked failure of drive and vision has not occurred in the general hospital setting to anything like the same extent. Multi-site responsibility for mental health patients thereby became commonplace but the problematic consequences for patient care standards were ill-addressed.

12. Role changes have affected all consultants in the NHS and not only psychiatrists. Changes can be divided into (a) intra-professional – eg advances in treatment and their integration into day to day clinical practise for patient benefit and (b) extra-professional ie (for doctors working in the NHS) government driven changes as to how doctors, including psychiatrists, carry out their most important function; ensuring best possible, and safe, patient treatment and care. The Report however sees that ‘their (psychiatrist) function in administering the social institution of (mental) illness has been an integral part of the processes of services and the dynamics of multidisciplinary teams.'(p8) This is a model of muddled expression. The ‘models of leadership' described merely underscore the point that there are different styles of leadership which to an extent are related to different consultant personality profiles. However, inevitably there remains a bottom line of doctor authority, responsibility and accountability in accordance with the rule of law aimed at securing safe and effective treatment and care detailed above. Any proposed role change should adequately consider the medical, ethical, legal and moral aspects of best patient care while, of course, not ignoring cost implications.

13 .It cannot be over emphasised that consultants have for many decades worked within and greatly valued their teams. To do otherwise would be to court professional suicide. This applies to all medical specialties but perhaps is especially appreciated by psychiatrists who have contributed so much in research and practise to an understanding of group dynamics. Despite this history and legacy the recent tendency to suggest that psychiatrists must be prepared to work within teams is to say the least odd, when such has been the norm in the memory of most living practioners

14. The 'medical model'. Although psychiatrists are primarily physicians with a specialist interest in psychological medicine, surprisingly perhaps, the 'medical model' has in recent years sometimes taken on almost a pejorative connotation when used in the context of clinical psychiatry: hints of its being an excessively narrow approach to patient care; of doctors being patronising to patients, lacking in humane consideration. This is unfortunate, misleading and untrue: unfortunate in that persons needing psychiatric treatment may be less persuaded thereby to avail of its help, and misleading simply because it is false. We wish to make clear, we do not contend that doctors are humans embodying virtue only, but we do most strongly submit, that the medical model is the broadest, and most informed evidence based model of human care. A medical training embraces considerations of the biopsychosocial being beyond the breadth of competence of any other discipline within the spectrum of caring professions. While rarely there may be reason to criticise the individual medical man or woman, there is less for criticing the model. We strongly support the personal physician perspective for psychiatrists which Professor Andrew Sims has elaborated elsewhere. Neither is it mere serendipity that has had the medical profession generate the most influential psychotherapists – from Freud, Jung ,and Adler to Beck .

15. Those who criticise the medical model allege a lack of warmth, an emotional coldness towards patients: that doctors treat diseases rather than people. This is to confuse emotional control with coldness. The former is essential in the clinical practice of any medical discipline in order that the doctor may function optimally in the best interest of patients and that judgement is not clouded by excessive emotional involvement.

Doctors endorse this necessity, when they entrust the treatment of own-family to a non-relative colleague for all but minor illnesses. Loss of emotional control whether in the extremes of the surgical theatre or intensive psychotherapy consultation, no matter how well meant, represents poor professional competence more than compassion for patients. What could be more humane than say coronary bypass surgery for a long suffering coronary stenosis patient - or electroplexy for a suicidal endogenously depressed patient ? Let us remember also that ultimate in caring, the hospice concept, so nobly promoted by Dame Cicely Saunders, a registered medical practitioner, is squarely within that mistakenly occasionally maligned medical model. Doctors are at least as aware as other members of society of the value of human kindness and warmth. They are also aware of the limitations of these worthy human attributes in alone attempting to address essential diagnosis and treatment.

16 .NEW ROLES FOR PSYCHIATRISTS(p9)has identified Griffith 1 as having introduced a ‘tension between management and professional supervision'. This suggests that tension was not present prior to Griffith (a supermarket manager) aggressive business line management in 1983. In fact tension between senior medical staff and management/administration has existed since NHS inception. Such tension was both inevitable and not without benefit to service development. But that Griffith-style aggressive line management which was unilaterally and politically determined undermined the necessary confident sapiential authority of doctors is inadequately analysed.

17 .Prior to Griffith, management would not have closed a hospital ward summarily against the advice of responsible consultant medical staff. After Griffith this became not uncommon practice securing huge bed reduction and therefore cost savings. Essentially medical influence was frustrated and patient care standards inevitably dipped. In psychiatry large mental hospital closures were effected prematurely. Medical advice on essential replacement resources (by the medical originators of psychiatric care in the community) in terms of ensuring adequate community services were in place before patients were discharged as happened in large numbers into a community, was ignored. ‘Bed and Breakfast' placements have been too readily the inexpensive (to government not patients) and inadequate substitute for proper treatment and care in the community. The Society considers that this continuing situation, apart from the stresses created by insensitive implementation of ‘community care' has intensified the problem of stigmatising mentally ill and disordered people and that this continues to this day.

18 .At the time(1983) of Griffith , perhaps too few doctors understood the profound consequences of line management introduction into the NHS for the profession. Even fewer non-medical managers were prepared to acknowledge the contradictions inherent in its introduction into the hospital/secondary care clinical workplace. Steele, a non-medical lecturer at the Department of Social Administration, University of Manchester examined the concept of line management, with general managers providing the impetus to manage an organisation. In this theoretical model the board of directors has overall control of the business, looking at overall strategy, including hiring and firing general managers. The unit manager is then responsible for the day to day running of the business and short-term production decisions. Within the unit a supervisor supervises the foreman, who oversees the workers at the end of the assembly line where the final product emerges. A hierarchy of control is practised. Once "production" levels - the hospital - are reached however the line management analogy becomes confused. Even if the NHS has the hospital general manager who will be responsible for day-to-day running of the hospital he (Steele) noted that there are already supervisors and foremen in the service department to ensure the efficient running of departments like catering, laundries, portering , etc but these are merely support activities to the hospital main activity, the care of patients. He stated "this is where any NHS line management system (and therefore the theory) runs into trouble, because those on the shop floor who commit resources and make decisions on their use are the major determinants in the system and not the minor ones envisaged in a traditional line management structure. Not only do clinicians not fit easily into the mould of line management, but, avers Steele, their nonconformity is buttressed by arguments about clinical freedom, which turn the concept of line management on its head”.

19. Curiously, in 1985, even as government proclaimed the virtues of management culture's putative beneficial impact on the NHS with its deliberate sidelining of doctors' influence on new NHS healthcare policy, the Association for Public Policy Analysis and Management's own journal published a monograph by Etzioni suggesting the medical model as especially suited to grappling with policy decisions (healthcare systems were not specifically addressed here though undoubtedly qualify for inclusion) for complex systems " since it combines practical knowledge with the findings of numerous analytic disciplines, and includes procedure for dealing with high uncertainty".

20. Be that as it may the effect of Griffiths and Working for Patients was massive morale reduction among doctors which has impacted severely on doctors' essential authority without, of course, reducing their responsibilities and accountability.

21. The new mental health Bill promises to deliver even more operational problems for the role of the psychiatrist.

22. Reconciliation of best patient care and developing consultant role is likely to be more constructively achieved by initially small subspecialty committee consultant deliberation followed by plenary consultant group submission as a possible general way forward for each and/or all subspecialties. Furthermore we suggest that such an exercise be conducted initially with representatives of, and under, the BMA, HCSA and this Society (with of course appropriate input from the Royal College of Psychiatrists) since matters discussed are likely to impact significantly on terms and condition of service. The membership of such task force should, we submit, remain with medical representative bodies while submissions from other individuals and bodies would be welcomed.

Dr Dermot J Ward, Chairman
Society of Clinical Psychiatrists

November 2004