Taking on the management: training specialist registrars in child and adolescent psychiatry

The proposal that management training should be integral to the training of all doctors, including psychiatrists, is not new (Gadd, 1990). The Child and Adolescent Psychiatry Specialist Advisory Sub-Committee (CAPSAC) training guidelines (1999) recognise that future consultants will need sufficient management skills to be leaders in service development as well as effective clinicians, and outline the knowledge and experience to be gained during higher professional training (Box 1). This paper describes the Yorkshire scheme's approach to supporting trainees to achieve these objectives and highlights the need to engage trainees, trainers and managers in taking forward this important agenda.

Box 1. Learning objectives in management, audit and information technology proposed by the Child and Adolescent Psychiatry Specialist Advisory Sub-Committee

1. • Understanding of relevant organisational structures and processes relevant to delivery of a CAMHS (e.g. within the NHS, other agencies, delivery of postgraduate and undergraduate training, GMC, Royal College of Psychiatrists)

2. • Understanding of service planning, effective use of resources, ability to generate short- and long-term strategy and relate to day-to-day activities

3. • Use of information to inform service development and audit

4. • Understand principles of clinical governance, risk management and accountability

5. • Familiarity with recruitment, equal opportunities and appraisal and the need for continuing professional development for all professionals in the multidisciplinary team

6. • Development of team leadership skills and effective working with other professionals

7. • An ability to maintain appropriate clinical records and communicate effectively with other professionals

8. • Effective self-management: time management, self-presentation, ethical awareness and use of initiative

CAMHS, Child and adolescent mental health service; GMC, General Medical Council

Need for leadership

The NHS Plan (Department of Health, 2000) stresses the need to develop leadership within all professions if modernisation and the redesign of services are to be achieved. Clinical governance (Department of Health, 1998) and the drive to improve the quality of health services are dependent on effective working between clinicians and managers.

Although management as a component of training for specialist registrars is well recognised, new consultants consistently report that this is the area of their work for which they feel most unprepared (Houghton et al, 2002). Where new consultants have gained management experience during their training, this was seen as helpful, but generally a result of the actions of individual consultants rather than a planned component of training.

A survey of the training experiences and attitudes of higher specialist trainees in child and adolescent psychiatry (Smart & Cottrell, 2000) found that 17% were unlikely to have the opportunity to shadow a manager during their training and 13% would not be involved in the planning of services. The majority of trainees, however, recognised management training as essential.

The Yorkshire Child and Adolescent Psychiatry Higher Training Scheme has worked over the last 7 years with all specialist registrars and scheme trainers to ensure that management knowledge and experience becomes an integral and routine aspect of training.

Starting point

In 1998 the training committee sent out a questionnaire to the 17 trainers and 14 trainees on the Yorkshire Child and Adolescent Psychiatry Scheme. This aimed to identify attitudes towards management training, the availability of management experiences on the scheme and to identify development needs. The questionnaire was completed and returned by all trainers and trainees.

Trainees appeared keen to gain understanding of the relevance of management to their future clinical practice and for management to become more meaningful and included in their training. They were asking for improved understanding of the day-to-day running of children's mental health services, including structures, business planning, finance and how and where decisions are made. Future survival as a consultant on a day-to-day basis was a major concern.

The consultant trainers unanimously endorsed the proposal that management should be included in trainees’ training plans but appeared unsure of their own contribution. Many thought that they would have little to offer a trainee, not viewing themselves as undertaking management tasks or having expertise to share. Even those trainers with formal management roles were not used to routinely engaging trainees in this aspect of their work.

As a result of the questionnaire, a number of suggestions were made to improve training. These findings continue to underpin the scheme's overall approach to management training.

Moving on

The approach to management training was formalised following a half-day workshop (Hewson & Wright, 2002). Local trainers and trainees came together to develop proposals for how the scheme could support all trainees to meet the management learning objectives proposed by CAPSAC and to consider the results of the earlier survey (Box 2).

It was agreed that management training would need to be promoted across the scheme by including management experience in the educational objectives for each trainee agreed at the beginning of a new clinical placement. Progress would be reviewed mid-year at the annual placement visit undertaken by the programme director or their deputy, and management achievements would be included in the annual record of in-training assessment (RITA). In addition trainees would be expected to attend the local generic management training available to trainees across all the specialties (Box 3).

Box 2. Initial proposals identified in the scheme survey and/or workshop

1. • Management introduced early in training

2. • Appropriate involvement in clinical teams and service development

3. • Shadowing arrangements in placements facilitated by trainer

4. • Opportunities to discuss management issues in supervision

5. • Undertake a small supervised management project

6. • Identified placements providing in-depth management experience

7. • Generic management courses run by the deanery to become mandatory

8. • Include management in the academic programme

9. • Combine theory and practice to make management meaningful

10. • Directed reading, skill sessions, role-play.

Box 3. Key components of generic management courses

1. • Management and leadership

2. • Mentoring, appraisal, interview skills

3. • Effective team-working

4. • Managing change

5. • Time management

6. • Preventing and managing stress

7. • Negotiating skills

8. • Managing meetings.

However, the survey and workshop identified key areas likely to require a more systematic approach to management training for trainees in child and adolescent psychiatry than that provided either by generic management courses or experience in clinical placements. These included understanding the relevance of inter-agency planning to child and adolescent psychiatry, the forces shaping demand for child and adolescent mental health services (CAMHS) and government and local policy for children's services. It was agreed to develop management seminars that would run two to three times a year and be included in the academic programme.

Management seminars: an evaluation

During 2001, the scheme's lead trainer for management (L.H.) and a lead trainee (S.H.) planned the content, style and format of these new seminars (Box 4). These have now been in place since January 2002. The content has focused on topics considered to be relevant to CAMHS and the future role of child and adolescent psychiatrists (Box 5).

Box 4. Structure and style of management seminars

1. • 2-3 half-day seminars a year

2. • Trainee to work with lead trainer to plan seminars

3. • Include regular update on‘hot issues’ (e.g. new government guidance)

4. • Focus on CAMHS rather than generic management

5. • Trainees to present accessible papers

6. • Trainees share practical management experience from placements

7. • Invite speakers, including CAMHS managers and consultants

8. • Discussion-based learning.

Box 5. Content of the first four management seminars

1. • Historical context of CAMHS

2. • Management experience of a recently appointed consultant

3. • CAMHS structures and operational management

4. • Where is the consultant voice in decision-making?

5. • Modernisation in CAMHS and the wider NHS, including user views

6. • CAMHS in a multi-agency context

7. • Multi-agency working in practice: the rhetoric and the reality

8. • Management responsibilities of the consultant.

Box 6. Characteristics of trainees eligible to attend management seminars from January to July 2003 (n=15)

Age range 32-41 years Median age 35 years

Sex Female:14 Male:1

Training pattern Flexible trainees: 7 Full-time: 8

Time in training 0-12 months:1 13-34 months:1 25-36 months: 5 > 36 months: 8

Trainee still on scheme at evaluation 9 remained in training, 6 had left the scheme

An evaluation was carried out following the first four seminars to ensure that these were on the right track and to ensure ownership by the group. A questionnaire was sent to all specialist registrars who had been eligible to attend any of the seminars (n=15). The characteristics of this trainee group are summarised according to age, gender and time in training (Box 6).

Fourteen trainees (93%) returned the feedback form. The median number of seminars attended was two (50%). Although full attendance is expected, all absences were understandable, being the result of sick leave, annual leave, maternity leave or undertaking a locum post. Trainees were asked to rate the style, relevance and trainee involvement in the seminars. The evaluation showed that the seminars appear highly valued by the trainees (Box 7).

Box 7. Feedback on management seminars by trainees (November 2003) ¹

Median score

1. • How relevant have you found the topics covered in the seminar? 5

2. • How appropriate have the papers and written material been? 5

3. • How beneficial has it been for trainees to summarise and present papers? 5

4. • How useful has it been to discuss examples of local services? 4

5. • How valuable have you found opportunities for free discussion? 5

6. • How adequate has trainee involvement in planning and organisation of seminars been? 4

7. • Do you feel trainee participation in the sessions has been sufficiently valued? 4

8. • How helpful have the seminars been in enhancing your understanding of the wider organisational context of CAMHS? 4

9. • How useful have the seminars been in developing your understanding of the possible management roles of a consultant in child and adolescent psychiatry? 4

   1. A 5-point Likert scale was used where 1=not at all and 5=extremely.

Trainees were given an opportunity to advise on how to improve the seminars. The most consistent request was for more trainers to attend the sessions and outside speakers to be invited so as to ensure a broad perspective. Trainees suggested that final-year trainees should take a specific lead in the planning and delivery of seminars. These recommendations are being addressed. A commissioner and service manager have been included in seminars and there are now plans to include a CAMHS regional development worker. Engaging trainees early continues to be considered important so as to develop understanding throughout training rather than management training simply being an exercise prior to a consultant interview.

Discussion

Child and adolescent mental health services are undergoing significant change and development which is likely to continue for the foreseeable future. The Children's National Service Framework presents a challenging multi-agency vision for children's services (Department of Education and Skills, 2004) requiring whole-system change to achieve better outcomes for children and young people. The new standards for CAMHS will be delivered over the next 10 years. Trainees today will start their consultant careers in services which are taking on these development challenges.

It is well recognised that tensions can exist between doctors and managers (Davies et al, 2003). Getting Better? - A Report on the NHS (Commission for Health Improvement, 2003) identifies the difficulty of securing doctors’ interest in management, particularly those working in mental health, but reports that services do better when doctors get involved in management. Poor relations between doctors and managers can damage services to patients and impede improvements. This has led to a recommendation that developing doctors’ understanding of the organisation of healthcare and the role of management is essential at the earliest opportunity (NHS Confederation, 2003).

Box 8. Types of management experience undertaken in placements

1. • Shadow a senior manager in the trust (e.g. trust board or executive to gain understanding of decision-making structures and processes)

2. • Meet with the financial lead for the service to gain understanding of the financial constraints and opportunities of the service

3. • Attend service or directorate clinical governance meetings and lead a small project supervised by trainer or service clinical lead

4. • Follow through a service reprovision or restructure

5. • Lead the development of a service clinical protocol

6. • Take part in the development of a bid for local or national resources

7. • Take part in a review of service (e.g. compared with NICE guidelines)

8. • Shadow multi-agency partnership meetings

9. • Follow through the development of a multi-agency initiative (e.g. CAMHS input to looked after children or the youth offending team)

10. • Attend meetings with commissioners to gain understanding of the agreed approach to managing a service-level agreement.

NICE, National Institute for Clinical Excellence.

Box 9. Key components of management training on the orkshire scheme

1. • Systematic approach for all trainees

2. • Training across the 3 years of training

3. • Identified management objectives in each placement

4. • Generic management courses as mandatory

5. • Service development issues included during supervision

6. • Service development seminars included in the academic programme

7. • Identified lead trainer for management training

8. • Involvement of the trainees and trainers in ongoing development and evaluation

Future consultants in child and adolescent psychiatry will need to work within increasingly complex management and accountability frameworks (Reder, 2003). They will need to contribute to service development through job planning and clinical governance with an understanding that service priorities are increasingly set by national policy, multi-agency joint commissioning and the expectations of users and the general public. Higher training programmes should ensure that future consultants are prepared for this.

The scheme's annual audit of training has confirmed that all trainees now have management objectives. Many of these include shadowing managers or the consultant trainer and discussing service development during supervision (Box 8). The undertaking of a management project has been less consistent. Organisational change and the move away from business planning to multi-agency commissioning appears to have made the direct involvement of trainees in management projects more difficult. As clinical governance, access and choice increasingly drive service improvement, specialist registrars and their trainers should consider engaging with managers through this agenda.

Conclusion

Generic management courses for doctors provide valuable training but tend to focus on general aspects of management common to all specialties in medicine rather than more specific areas of interest to future child and adolescent psychiatrists.

The Yorkshire scheme has introduced a systematic approach (Box 9) to management training. This is now recognised as an integral part of training for all higher trainees in child and adolescent psychiatry in Yorkshire. Specialist registrar training schemes in other areas may benefit from similar developments.

Declaration of interest

None.