Part-time training and working for male and female psychiatrists

Part-time training and working have become popular acceptable options for both male and female psychiatrists, regardless of age. There are a number of reasons for this, the most common being family commitments such as those to children or elderly relatives, but also including personal ill health, wanting to reduce stress and prevent burn-out, wanting to pursue different priorities, portfolio-working or simply trying to achieve a better quality of life. The importance of providing flexible working patterns has been emphasised by the Department of Health (1998) in Working Together – Securing a Quality Workforce for the NHS.

Although most doctors who work flexibly are women, it is important that child care is not seen as the only legitimate reason for wanting to work part-time, as otherwise doctors who want to work flexibly for other reasons may be unfairly penalised. Male doctors often work very long and stressful hours and may also wish for a better balance between their home and working life and to take on more child care responsibilities, and the culture is slowly changing to accommodate this. This is likely to mean that there will be less resentment of part-time workers and less stigma attached to part-time working, and more realistic sharing of domestic responsibilities and equality between the genders. Male psychiatrists also seem to be increasingly attracted to the possibility of working flexibly as they approach retirement. At present, as the Equal Opportunities Commission has recently pointed out, men who work part-time may be legally discriminated against as they are unable to claim indirect discrimination under the 1975 Sex Discrimination Act. This provides a premise for women to argue that a policy, for example, loss of mental health officer status for part-time workers, indirectly discriminates against them as the vast majority of part-time psychiatrists are women.

Attitudes and cultures are changing and a large number of psychiatrists now train or work part-time, although the indications are that many more would like to do so but have not been able to organise it. Many psychiatrists believe that it is now easier to fill a part-time consultant post than a full-time post, and in areas where there is a shortage of applicants, trusts are much more inclined to be flexible. However, some organisations still have conditions that seem to have been designed when working women made up only a small part of the NHS workforce. A survey of trusts in the West Midlands showed that 41% had no plans to develop a flexible working policy; although this does not necessarily mean that they do not support flexible working it is likely to indicate in some cases that its development is a low priority (Harvey et al, 1998). The same survey also identified the continuing reluctance of some senior medical staff to accept flexible working, and this attitude should be discouraged.

Given the present national shortage of psychiatrists and the fact that an ever higher proportion of doctors are women, it is important to offer flexibility in the workplace to recruit and retain staff: the main reason for doctors leaving medicine early in their careers is the long hours of work (Harvey et al, 1998). Flexible working offers other advantages to the employer such as: access to different skills, for example, two sets of skills in the case of job-sharing; possibly less absenteeism for domestic reasons; increased employee satisfaction and commitment; and a more balanced workforce in terms of male and female doctors. Disadvantages to the employer are few, and are probably limited to slightly increased administration and some increased costs – for example, funding an overlap session for job sharers or covering study leave (part-timers should have the same opportunities for continuing professional development as full-timers).

In addition, offering flexible working promotes equality, as able individuals who have commitments that prevent them from working full-time would otherwise not have the opportunity to achieve senior positions within their organisation.

Flexible training

Historical development

Formal flexible training first became available in 1969 with the HM (69) 6 notice (cited in Clay, 1998) offering the option of part-time training. The training opportunity was specifically aimed at women with domestic commitments, but except for the setting up of some posts in the Oxford area, the scheme was not greatly used.

In 1979, the scheme was focused on senior registrar training, and it was left to individual regions to set up other posts in the junior grades, at their own discretion. Candidates had to enter a national competition to get ‘manpower approval’. There was an average delay of 18 months for funding to become available.

Implementation for other grades improved with the introduction in 1991 of a new scheme for career registrars. Funding and manpower were organised centrally and interviews took place locally. Further administrative changes allocated responsibility for funding for flexible training in all grades to the postgraduate deans. The introduction of the specialist registrar (SpR) grade, through the Calman reforms, integrated appointments for flexible training with the appointment system of full-time trainees. The deaneries make local arrangements for other grades. Since then, the recruitment criteria for part-time training programmes have been the same as those for full-time – which provides a fair system for the flexible trainees to apply in open competition.

How to apply

Preliminary fact-finding

It is advisable to make inquiries and gather information, in confidence if appropriate, 6–12 months before the planned start date, particularly as funding may not be immediately available. The key people are:

1. • the associate dean for flexible training

2. • the regional advisor

3. • the programme director

4. • the lead consultant for flexible training (available in some regions)

5. • the flexible training tutor (available in large training schemes)

6. • other flexible trainees

7. • consultants in the speciality

8. • the Royal College of Psychiatrists' Sub-Dean for Flexible Training.

The Flexible Training: Thames Regions booklet (Goldberg, 1998) highlights the following points:

1. • flexible trainees must fulfil the eligibility criteria (as will be discussed below) for this pattern of training

2. • flexible trainees must be of equivalent calibre to full-time trainees

3. • the part-time posts must be comparable with full-time posts save only that the training in them will take longer to complete.

The booklet also contains useful checklists and guidance on how to join the scheme. It notes that candidates should be made aware that flexible training is not a soft option, as it entails lower pay and longer time to completion. Furthermore, it should be noted that part-time training is not a way to avoid some parts of training or gain access to others.

Eligibility for flexible training

Eligibility criteria are set in the European Union Council Directive 93/16-/EEC of 5 April 1993 for cases when training on a full-time basis would not be possible for well-founded individual reasons. The responsibility to determine eligibility for part-time training rests with the postgraduate dean's department. Given that there is a limited budget, priority criteria may need to be considered.

The Thames Region places applicants in two categories for funding priority. Category 1 includes:

1. • doctors, men or women, looking after young children

2. • doctors caring for a disabled relative/partner

3. • doctors with a disability

4. • doctors with recognised religious commitments.

Category 2 deals with well-founded individual reasons connected with professional or personal development. It includes:

1. • doctors in a substantive career job wishing to retrain in another speciality or wishing to complete their specialist training

2. • doctors wishing to pursue further studies, e.g. psychotherapy training, management studies, art courses

3. • doctors undertaking other paid or unpaid work, e.g. as medical officers, for the Department of Health or for groups such as Victims of Medical Torture.

It is the responsibility of the postgraduate dean (associate dean) for flexible training to ascertain what constitutes well-founded individual reasons, usually by way of an informal interview.

Funding

The postgraduate dean holds funding and it covers study leave, travelling expenses and 100% of the flexible trainee's basic salary. The employing trust is responsible for the additional duty hours payments.

Once eligibility is agreed, the flexible training programme may be undertaken in:

1. • a supernumerary post, fully funded from the flexible training budget created for the individual trainee

2. • a substantive post, with agreement to work reduced sessions, funded by the trust

3. • a job share, where the funding of the full-time job will be split and be paid by the trust, any ‘overlap’ sessions being funded by the flexible training budget

4. • a substantive part-time training post (a recent innovation, set up in the North-West Region, reported by Harvey et al, 1998) – currently only at senior house officer grade, but there is a possibility of extending this to SpR grade in the future.

The supernumerary post arrangement remains the preferred option for trainees. It is also popular with consultants, as it provides additional manpower for the service. The disadvantage is that of a general increase in the demand for flexible training within a limited budget, which may result in long delays until funding becomes available. The Thames Deanery (Goldberg & Paice, 1997) has suggested the job-share option as a preferred alternative. It has the advantage of providing funding, manpower and educational approval immediately and some trainees report greater satisfaction at being in a substantive post, rather than being ‘an extra’. The disadvantage is that it may not be easy to implement, owing to practical difficulties in identifying an appropriate job-share partner. The creation of part-time substantive posts is an encouraging initiative. The great advantage is that funding, manpower and educational approval are connected to the post, rather than to the trainee, as is the case with a supernumerary part-time post.

Appointment to grade

Entry is judged on merit alone in open competition by formal interview. Under Equal Opportunities legislation, the candidate is not expected to disclose to the appointments committee the intention to train flexibly, although some candidates may prefer open disclosure. The applicant is expected to disclose the intention to train flexibly when a job is offered. Provided that the plans have been discussed, in confidence and in advance, with the associate dean, it is likely that funding has been organised. If there is a delay in identifying funding, the trainee may decide to continue working flexibly at his or her present grade until a suitable SpR programme becomes available. In these cases, a National Training Number (NTN) will be reserved for the successful candidate. Another possibility is to opt for a period of full-time training until a flexible placement is organised.

Educational approval

The EC Directive 75/636 requires that part-time training should be equivalent in content and duration to that of a full-time programme, including on-call experience. An interruption of training for up to 3 months, for example, owing to maternity leave or a period of illness, may be considered within the training period.

It is required for flexible trainees to have an educationally approved programme of training before starting in post (Boxes 1 and 2). In the case of higher training, the full programme is essential in order to calculate a provisional Certificat e of Completion of Specialist Training (CCST) date. Details of the first two placements must be submitted and an outline of the remainder. A timetable for the first placement must be enclosed that should include, in the case of SpR training, sessions for research and special interest. It should be noted that special interest sessions are not a requirement, as the longer period of training for flexible trainees often results in them having a wider range of job placements than full-time doctors. Any significant amendments to the approved programme, such as change of sessions, change of placement or a period of maternity leave, must be presented for approval.

Box 1 Sample of Royal College of Psychiatrists' letter accompanying the Higher Specialist Training Committee's application form for approval of flexible higher training progammes

1. • Dear Doctor,

2. • Re: Educational Approval of Flexible Higher Training Programmes

3. • A copy of the HSTC's application form for approval of flexible higher training programmes is enclosed. Flexible trainees are required to have an educationally approved programme of training before they can commence in post. The form must be submitted by the relevant training programme director or the flexible training programme director/tutor (if such exists in the Deanery) but must also be signed by the trainee.

4. • In line with the Specialist Medical Qualifications Order (1995, amended 1997), training undertaken on a part-time basis must be equivalent in duration and content to that of full-time SpRs. It is therefore essential that a full programme of training is identified before a trainee commences in post so that a provisional CCST date may be calculated. This is particularly important for flexible trainees, as experience has shown that a number have applied for their CCST only to discover that they are short of the required duration of training. Details of CCST requirements are given in the HSTC Handbook (March 1998).

5. • Details of the first two placements must be given in the programme and an outline of the remainder. A timetable for the first placement must be submitted. This should include sessions for research and for special interest, although the latter is not a requirement for flexible trainees, whose longer period of training often enables them to occupy a greater range of placements than their full-time colleagues. Any significant amendments to an approved programme must be submitted for approval (e.g. a change of placement, number of sessions or a period of maternity leave).

6. • Applications for approval of flexible training programmes are dealt with as quickly as possible but it is always helpful if the covering letter from the Training Programme Director/Flexible Training Tutor can indicate if an early start date is planned.

7. • If you require clarification of the above, or have any other queries relating to flexible training, please do not hesitate to contact me.

8. • Yours sincerely,

9. • Jane Smith

10. • Senior Postgraduate Education Administrator

Box 2 Sample application form

HIGHER SPECIALIST TRAINING COMMITTEE

Application for Approval of Flexible Higher Training Programmes in Psychiatry

This application must be submitted before by the Training Programme Director, and receive educational approval, before the SpR commences in post. The following information is required before applications can be considered by the relevant Specialist Advisory Sub-Committee. This form must be submitted together with the trainee's CV, a timetable for the first placement and a covering letter from the training programme director.

THE APPLICANT

Please supply the following details about the trainee on whose behalf this application is submitted:

Name of trainee:

NTN:

MRCPsych date:

Provisional CCST date: ¹

CCST specialty(ies): ²

Endorsement: ³

Previous higher training, if any (please state specialty and duration):

THE SCHEME

Please supply the following information about the scheme the trainee will be joining:

Name of scheme:

Region:

Training Programme Director:

Speciality:

Total number of approved placements in this scheme:

Total number of trainees (full time, research, lecturer and flexible):

How many sessions will this trainee work:

1. (i) in total?

2. (ii) in a clinical placement?

3. (iii) in research?

4. (iv) other? (please specify)

Notes

1. 1. 12 months @ 5 sessions = 6 months WTE, @ 6 sessions = 7.2 months WTE, @ 7 sessions = 8.4 months, @ 8 sessions = 9.6 months

2. 2. General adult psychiatry/old age psychiatry/child and adolescent psychiatry/psychiatry of learning disability/forensic psychiatry/psychotherapy

3. 3. Substance misuse psychiatry/rehabilitation psychiatry/liaison psychiatry

It has been suggested (Clay, 1998) that the pro rata arrangement is a limitation of the scheme, as there is general agreement that the learning and experience gained by part-time trainees in their longer placements clearly exceeds that of full-time trainees. Under the Calman reforms, trainees who have reached their CCST are given the 6-month ‘grace period’ that applies to full-time doctors to find a consultant job. Although it has been argued that a ‘pro rata grace period’ may be fairer, a recent study (Etchegoyen et al, 2001) found that most trainees had no difficulty in obtaining a consultant job shortly after accreditation.

Support structures

These include regional and local arrangements and those made by the College. Most regions have now an associate dean for flexible training. The Thames Region, which includes a third of trainees nationally, has pioneered the appointment of lead consultants for flexible training to liaise between the flexible training office and the speciality training committee and programme directors. Responsibilities include providing an informed opinion on matters concerning flexible training, approving eligibility of flexible trainees when appropriate and advising trainees on flexible training opportunities and practical considerations associated with this. The advisory and liaison role may involve advocacy on behalf of the trainee if difficulties occur. The arrangement appears to be working well. A local tutor for flexible training may be available in large schemes. An important aspect of the role is to ensure that each individual has a realistic timetable that includes clinical work, regular educational supervision, research, audit, management and special interest.

The role of the College's Advisor for Flexible Training has now been amalgamated with the role of Sub-Dean for Flexible Training. This is a welcome development that facilitates the processing and approval of training programmes. In addition, the Sub-Dean chairs the Flexible Training and Working Group, which is an alternative source of support and advise for trainees.

Attitudes and perception of training

Norcliffe & Finlan's national survey of flexible trainees (1999) had a very good response rate of 70%, indicating the high level of interest and motivation of the 797 respondents. The great majority of trainees were women in higher specialist training, with family commitments. Difficulties reported included working more than the contracted hours, heavy clinical workload, difficulties in fitting in on-call commitments with child care arrangements, missing important meetings, problems in completing research and feeling marginalised and perceived as of lower status than full-time colleagues. In spite of these problems, 91% of respondents said they would recommend flexible training, 2% would not and 7% were not sure. The overall view was that part-time training was the only way to combine work with a family life.

Dean et al's (1999) national survey examined trainee SpRs' perceptions of flexible training in psychiatry. Of the 135 respondents (63% response rate), the great majority found the quality of their training to be high and were positive about the opportunity to train part-time. Problems reported included restricted training opportunities compared with full-time colleagues, perceived lack of status, limited time available to find consultant jobs on accreditation and a relative lack of part-time consultant jobs. Seventy-five per cent of trainees wished to work in part-time consultant jobs in order to continue to care for their families. Additional findings suggested that flexible training had helped to keep doctors in the workforce: 28% would have chosen not to work at all and 25% would have chosen non-medical work if part-time opportunities had not been available.

Career development

Etchegoyen et al's (2001) Thames Region survey of 32 flexible trainees' progress into the consultant grade indicated that most (72%) who wished to work part-time found consultant jobs to suit their needs almost immediately after accreditation. However, there was a limited range of part-time academic opportunities. Difficulties reported included workload, lack of administrative and junior staff support and problems in accessing CPD.

The way forward

The demand for flexible training is increasing in all specialities. Goldberg (1997) reported an over 30% increase across all grades and specialities in the previous 2 years. NHS Executive figures for July 1996 showed 8% of doctors across all specialities training flexibly, with 14% training flexibly in psychiatry (of those, 45% were in the psychotherapy subspeciality and 13% in adult mental illness). Nationally, there is wide variation in the uptake of flexible training in psychiatry, ranging from 3.5 to 26% of doctors training flexibly. Goldberg (1997) and Clay (1998) suggest several reasons for this, including the availability of funding to support part-time training, reluctance of local trusts to fund the additional duty hours, degree of commitment of key people at local and regional level and demand from the trainees themselves.

Flexible training is now a well-established option alongside full-time training. There is general agreement that it offers good-quality training and it attracts doctors of high calibre and motivation. Clearly, there are also challenges and difficulties to be addressed, including funding bodies that consider flexible training an inferior option. As the demand for flexible training opportunities is likely to outweigh the budget available, alternatives may need to be considered. Goldberg & Paice (1997) have pioneered the job-share option in the Thames Region. Harvey et al (1998) describe a practical initiative, “Don't Waste Doctors”, to establish less than full-time substantive posts (LFTPs) in the North-West Region, funded by the trust.

There is evidence to suggest that there are still entrenched attitudes in some senior sectors that view flexible training as a second-class option and show reluctance towards implementing flexible working arrangements in the workplace (NHS Management Executive, 1993; Hamilton et al, 2000). It has also been argued that there are additional costs in employing doctors working part-time. However, it is suggested that employing highly motivated and well-trained doctors may result in savings by increasing retention, hence reducing recruitment costs, and by increasing cover, which reduces the expense of locum cover.

Gibson (1997) contends that part-time working should be seen in the context of a portfolio career. She argues that working part-time brings greater fulfilment, humanity and a better understanding of patients and the real world.

In conclusion, flexible training is considered overall to be a positive opportunity that plays a significant role in retaining doctors in the workforce.

Flexible working

It can sometimes be very difficult for psychiatrists to find part-time work as consultants as most posts are advertised as full-time or maximum part-time – although increasingly posts are being advertised in a way that suggests that those unable to work full-time will be considered. Even if this is not the case, with a little patience and persistence it should be possible, but candidates may need to initiate the idea themselves. There are many ways of working flexibly, including having a part-time contract, job-sharing or developing a portfolio career and there is no set pattern for doing so. Whichever way is chosen, flexibility in approach is essential – for example, a part-time employee may occasionally need to come in on an extra day for a particular meeting, but if so there should be the opportunity to take time off in lieu. Other ways of working flexibly, such as flexitime, term-time working, working from home or unpaid sabbaticals, are still very uncommon in medicine.

There are obviously many advantages to working flexibly and inevitably a few disadvantages such as reduced pay, difficulties with time-management and continuity and, sometimes, problems with status. Reduced pay is often seen as being particularly unfair to those part-time doctors who work 40 hours a week or more if their on-call commitments are included, but still earn less than a full-time salary because on-call is paid at a lower rate. In addition, these first 40 hours may not all be counted as pensionable, as on-call commitments are not automatically pensionable, and part-time doctors may not accrue as much eligible service as their hours might suggest. The biggest disadvantage is probably the loss of mental health officer status and its pension advantages for those psychiatrists who would otherwise be entitled to it, but this is now being addressed. Another common problem is that trusts expect part-time staff to be available at all times, particularly for non-clinical activities such as teaching and meetings. This should be discouraged and staff should be contacted in their time off at home only in an emergency. The disadvantage of job insecurity no longer applies, as the requirement to work at least 16 hours a week to have continuity of employment has been abolished.

Part-time working

Part-time working is probably the most common way of working flexibly, and it simply refers to being offered or negotiating a contract that is less than the full-time equivalent of their colleagues. In medicine, a part-time doctor may well work 40 hours a week or more owing to the on-call component of a post. Traditionally, part-time doctors have usually included less senior grades than consultant level (apart from the maximum part-time contract), but there is now much more opportunity to work part-time at any level. Although most posts are advertised as full-time, any post should be regarded as suitable for part-time working or job-sharing, and this can be discussed with the trust involved and should not deter any doctor from applying for any post. If a full-time post is being applied for part-time, it is important to ensure that the job-plan is rewritten to reflect the reduced time commitment, as this will not necessarily occur automatically. It is possible to end up trying to do a whole job in half the time. It is not uncommon for part-timers to fail to complete their work within their paid sessions and regularly work extra unpaid sessions; the main reason for this is usually unrealistic contracts. Fixed sessions and commitments should be reduced proportionately and someone else employed or contracted to do part of the work. Advice can be taken from organisations such as the British Medical Association (BMA).

Job-sharing

Job-sharing refers to the now commonplace situation where two people share one full-time job, usually (but not necessarily) each doing half the job and usually providing cover for the other. This commonly includes clinical cover and communication such as giving feedback from meetings. Clinical, managerial and administrative duties are all shared, and the partners usually share an office. Clinical case-load can be divided pro rata, with each having his or her own case-load or by task, for example in-patient, day hospital, community or out-patient work (divided responsibility). This type of job-share is probably the most common in medicine. Alternatively, both partners can share all tasks interchangeably with no division of duties (shared responsibility). Occasionally job-sharers work in completely different areas or departments (unrelated responsibility).

Job-sharing allows for the possibility of working part-time in an environment where part-time work may otherwise not be possible. It can mean fewer problems with continuity than other part-time posts, especially if partners work alternate days, although more unusual splits such as alternate weeks are also possible. There is also better cover than there is in full-time posts when one partner is on sick leave, as the other partner is still there part of the time. This may also be true of annual leave, although ideally job-sharing partners ought to be able to take annual leave together if they so choose. The difficulty here is finding a suitable job-sharing partner and this can be done by word of mouth, contacting the post-graduate dean or applying to join a job-share register such as the Royal College of Psychiatrists' National Flexible Working Register. This is run by the Women in Psychiatry Special Interest Group, which puts potential job-sharers in touch with each other. Partners should apply together for posts that interest them, although it is probably best to make detailed plans about the post and discuss them with their potential employer prior to interview. They should present articles on job-sharing and examples of successful job-sharers in the field if the employer is new to the concept. Alternatively, a full-time employee may want to share his or her existing post, which may then be advertised. Either way, each sharer should have a contract stating how the job is to be divided by key tasks and time. There should be provision in the contract for eventualities such as one partner leaving, for example, an undertaking by the management to re-advertise that part of the job for an adequate time or to offer the sessions to the remaining partner. Pay and benefits such as leave and bank holidays should be shared pro rata. Ideally, there should be an extra session to allow both partners to overlap and have adequate hand-over time, but this is not always provided and the telephone and a handover book may need to be used instead. Alternatively, one can negotiate overlapping for half a day, and cover being provided by a third colleague for the remaining half-day.

Conclusion

Whichever way of working flexibly is chosen, there is now a great deal of information available from many sources, including postgraduate deans, human resources departments, the BMA, the Royal College of Psychiatrists, the Equal Opportunities Commission, the Maternity Alliance and organisations such as New Ways to Work. Many of these, including the BMA and some of the deaneries, also run job-share registers. Although there is no absolute legal right to work part-time, employers must demonstrate that they have taken a request seriously and risk being taken to an Industrial Tribunal if this is not done. It is also helpful where possible to support flexible working policies by appropriate related practice such as provision of a crèche.