Modernising medical careers: an opportunity for psychiatry?

Medical training in the United Kingdom is generally regarded as being of a high standard. The Royal College of Psychiatrists provides well-managed structured training programmes, with clear expectations placed on educational supervisors and programme directors for supervision and support systems. Successive London Deanery surveys of trainees’ satisfaction across all medical and surgical specialties have found that trainees in psychiatric posts are among the most satisfied with their training. Systematic evaluation of psychiatric training over 3 years in one Deanery demonstrated continuing improvements over time (Herzberg & Paice, 2002). Despite this, the proportion of UK graduates registering an early career interest in psychiatry remains disappointingly low. A survey of doctors who graduated from UK medical schools between 1961 and 1975 found that only 4% had opted for a career in psychiatry (Brook, 1983). Lambert et al (2001) found that only 3.9% of 5366 graduates who qualified in 1993 and 1996 from UK medical schools stated a career preference for psychiatry in their pre-registration house officer (PRHO) year. The most recent London Deanery survey (Paice & Aitken, 2003) showed that only 4.3% of 370 PRHOs working in North London indicated that psychiatry was their intended specialty. Furthermore, there is a constant high vacancy rate for consultant level posts. Consultant vacancies in the UK have run at about 12% for many years (Royal College of Psychiatrists, 2002; Pidd, 2003).

Why are medical graduates not pursuing a career in psychiatry? Sixth-form students have positive views of the specialty, and it has been suggested that poor information and prejudice within medical schools may be deterring people from entering the specialty (Maidment et al, 2003).

In 2002 the Department of Health published a consultation report Unfinished Business — Proposals for the Reform of the Senior House Officer Grade (Department of Health, 2002). The responses to this from the four Health Ministers in the UK resulted in the proposals published as Modernising Medical Careers (Department of Health, 2003). These proposals were designed to ensure that ‘the end product of the training process, whether a Hospital Doctor or a General Practitioner, should be a high-quality, well-trained and accredited doctor who can deliver the care and treatment to patients in the modern NHS’. The key principles guiding this change include:

1. • Doctors will be better prepared to work in multiprofessional teams.

2. • Structured programmes will be developed that are competency-assessed against defined standards and meet UK-wide curricula.

3. • Training programmes should be trainee-centred and flexible. They should aim to meet the individual learning needs of both UK-trained doctors and doctors from overseas and should include programmes supporting academic, research and teaching skills.

4. • Doctors should be enabled to take on more responsibility progressively as their skills and competencies develop.

5. • Training should be supported by appropriately trained trainers and career advice should be available throughout training.

6. • The new training programmes and support structures should be quality-assured.

The new training process will be based on the creation of foundation programmes. It is planned that these will be in place for all newly qualified medical graduates from August 2005. The Postgraduate Deaneries throughout the UK have been charged with the task of creating 2-year foundation programmes. The first foundation year (FY1) will be equivalent to the current PRHO year. Psychiatry is included in a number of innovative PRHO rotations around the country, although the majority of the PRHO posts nationally are in medical and surgical specialties. Evaluation of psychiatric PRHO posts has shown that these can make a valuable contribution to the PRHO year (Herzberg et al, 2003).

Foundation year two (FY2) programmes are now being developed through Deanery pilots. The key outcomes of these programmes are to produce doctors who have robust skills in acute medicine, and can recognise and manage sick patients; have well developed generic professional skills; have had experience in a range of specialties; and have successfully undergone competency-based assessment. Given these outcomes, psychiatry should benefit from the entry of doctors who have had a chance to develop their general clinical and professional skills before entering basic specialist training programmes. For doctors wishing to work in non-psychiatric specialties, the practice of high-quality acute medicine and surgery requires skills in the recognition and management of acute psychiatric illness and an understanding of patients’ psychological reactions to acute illness and stress.

In London, we have asked National Health Service (NHS) trusts to identify posts that might usefully contribute to FY2 programmes. In an effort to avoid disrupting current basic specialist training programmes, we have asked NHS trusts to identify non-career-grade and non-training-grade posts (e.g. trust grade doctor posts) and also accredited senior house officer (SHO) posts that are not part of a rotational training scheme. The dramatic increase in trust grade doctor numbers in acute trusts across the country (in an attempt by the service to meet New Deal and European Working Time Directive requirements) have not to date had a major impact on mental health trusts, limiting the number of trust grade doctor posts available in mental health trusts to incorporate into FY2 programmes. However, in September 2003 the Department of Health allowed a further 500 locally-funded SHO posts to be created in psychiatry across English Deaneries. Although psychiatrists can understandably claim that all of these training posts are needed to produce sufficient post-membership SHOs to fill the vacant specialist registrar posts, we would argue that allowing some of these posts to become incorporated into FY2 programmes would increase the exposure that new graduates have to psychiatry. In the long-term, more people might be attracted to the specialty if they had passed through a Modernising Medical Careers programme with a mental health component. In London, the programmes are being organised by acute trusts, and we hope that they will work with mental health trust partners to produce comprehensive programmes. Pilot programmes in 10 acute trusts in London will start in August 2004. The detailed programmes will vary from trust to trust, but have in common a period in an accident and emergency department or equivalent experience and will generally incorporate exposure to two or more other specialties. Clinical training will be supported by an academic programme incorporating some interprofessional learning. This programme will introduce trainees to basic clinical governance issues in the NHS, and we hope that trainees will become involved in audit projects at this early stage.

Deaneries will need to provide more FY2 programmes than there are PRHO posts in order to allow room for qualified graduates from the European Union and other countries to gain access to this early structured training. The psychiatric SHO posts in FY2 will enable new graduates who might not otherwise do so to gain experience of psychiatry; some will be attracted to the specialty and consider it seriously as a career option, especially given the high rates of satisfaction with psychiatric training posts reported by trainees. Even if individuals undertaking these posts do not enter psychiatry, there will still be a gain for the specialty in the increased number of doctors trained in mental health skills. We see this as a ‘ win-win’ position for psychiatry.

Declaration of interest

The three authors are employed by the London Deanery, which is required to implement Modernising Medical Careers programmes.