Service innovations

On-call work in general adult and old age psychiatry can be a daunting experience for specialist registrars, particularly at the beginning of their higher specialist training. The nature of the work is urgent and unpredictable, and it is done during unsociable hours and in isolated circumstances. It may be the first time that specialist registrars are exposed to work involving the provisions of the Mental Health Act 1983 and it may also be the first time that they have worked away from a hospital site. In a survey of stress in psychiatrists working in the Wessex region (Rathod et al, 2000), two-thirds of the respondents identified out-of-hours on-call duties as causing moderate to extreme stress. This was the highest scoring variable in the study. A study conducted in Manchester examining sources of stress, psychological distress and burn-out in psychiatrists (Guthrie et al, 1999) also identified on-call work as a significant cause. The stress associated with being on-call was significantly greater in junior doctors than in consultants. We also suggest that on-call work has become more stressful in recent years.

Other studies of psychiatrists have referred to the importance of peer support in reducing stress and the advantages of forming groups to provide mutual support as well as a forum for education and discussion (Benbow & Jolley, 1999). The Health and Safety Executive are currently very concerned with the issue of work-related stress and are considering strategies to tackle the problem (Health and Safety Executive, 2002). Draft management standards against which employers can measure their performance in preventing work-related stress have been developed, and these are currently being piloted and evaluated (Health and Safety Executive, 2003).

Background

The Senior On-call Group was originally set up to provide support for specialist registrars at a time when two separate senior on-call rotas merged (Portsmouth City and Havant & Petersfield, with Fareham & Gosport). This led to a significant increase in the geographical area and population covered by the on-call service and to an increase in the amount of on-call duties requiring cover by specialist registrars and non-consultant career grade doctors (NCCGs). The on-call service covers a population of approximately 550 000 persons. Full-time specialist registrars work a 1 in 10 rota and provide emergency out-of-hours cover for both general adult psychiatry and old age psychiatry. Two further on-call consultants (one general adult and one old age psychiatry) are available to provide advice if required.

Membership

The Senior On-call Group is open to all psychiatrists who participate in the senior on-call rota as well as representatives from the nurse-led out-of-hours assessment and support team and the mental health liaison and deliberate self-harm assessment service team. Other professionals, such as the Mental Health Act coordinator, are invited to attend if there are specific issues that need to be discussed. All psychiatrists are approved under section 12 of the Mental Health Act 1983 and consist of consultants, specialist registrars and NCCGs. Locum post-holders are invited to attend. The number of people attending the monthly meetings varies but is usually about 8-12. Each meeting, which lasts about 1 hour, is chaired by one of the specialist registrars, and the minutes are circulated to all members of the group. To facilitate attendance, the meetings are held during working hours immediately prior to (and on the same site as) a business meeting attended by the same group of psychiatrists.

Functions

The objective of the group is to provide a supportive forum for discussion about on-call issues and dilemmas. It provides a representative body of opinion regarding such matters. It therefore has an important role in specialist registrar training and in the continuing professional development of other doctors. It also ensures that the quality of the out-of-hours service provided is optimised by the identification of problem areas and the initiation of appropriate changes.

The monthly meeting comprises factual exchange of information between professionals and agencies as well as discussion of any concerns or difficulties that have arisen during the previous month. Where necessary, action can be taken to clarify unresolved issues or to address areas of concern by speaking informally to relevant agencies or professionals or by writing more formally if appropriate. The group is a point of contact enabling pertinent information to be directed to all those delivering on-call services. It also provides members with a valuable opportunity to meet other professionals and agencies involved in the delivery of the service.

Common themes

A wide variety of issues, both clinical and managerial, are discussed. Roles, responsibilities and referral procedures are clarified. Any concerns about the smooth running of the multiprofessional and interagency services can be discussed face-to-face on a regular basis. Some issues are discussed more frequently than others (Box 1).

Benefits of the group

Clinical implications

Discussion within the group allows several viewpoints to be aired, illustrating that there is seldom a single correct answer to on-call dilemmas but rather a range of acceptable management choices. This exposure to the different clinical and patient management styles of senior colleagues is instructive. Discussion of difficult clinical problems may relieve the anxiety experienced by junior doctors, who may lack other suitable opportunities to discuss these issues, providing an important addition to the weekly session with the specialist registrar’s own educational supervisor.

An additional benefit of the group is that it ensures contact between specialist registrars and consultants from different trusts, many of whom would not otherwise meet during the course of their work. Such contacts help to ensure the smooth running of the on-call service by facilitating information-sharing and networking.

Handbook

The group identified a need for a handbook containing information about all aspects of on-call work for senior doctors, and one has now been printed and distributed. It is given to all new doctors joining the first on-call rota (substantive and locum). The book outlines the roles and responsibilities of the on-call senior doctor, and provides useful information about the on-call system, procedures for working with the other nonmedical teams involved, and clarification of the referral and admission procedures.

Box 1. Common themes discussed at Senior On-call Group meetings

• Referral and assessment/admission policies

• Use of the Mental Health Act 1983 and Mental Health Act assessments

• Capacity and consent

• Liaison assessments

• Routes for assessment and placement of patients requiring treatment by other services (forensic, learning disability, and child and adolescent psychiatry)

• Personal safety

• Clarification of the role of the specialist registrar and responsibilities on-call (and the interface with the role of the senior house officer on-call)

Conclusions

The Senior On-call Group is a valuable source of education and support for specialist registrars. It also plays a part in the continuing professional development of the other doctors on the rota. It enables regular discussion and problem solving about a wide range of issues that arises during the first on-call duties, and has an important role in reducing the stress associated with on-call work. In addition to the group’s training role, meetings have benefits including the facilitation of communication and networking among professionals and agencies, and optimising the smooth running of the service. We have found the group to be a welcome and positive addition to our training, and would recommend that other rotations consider implementing a similar system.