Psychiatric Bulletin (2007) 31: 65-67. doi: 10.1192/pb.bp.106.009811
© 2007 The Royal College of Psychiatrists
Service innovation: psychiatrists on call - the community at night
Laurence Mynors-Wallis
Alderney Community Hospital, Ringwood Road, Parkstone, Poole, Dorset BH12
4NB, email:
laurence.mynorswallis{at}nhs.net
Denise Cope
Alderney Community Hospital, Ringwood Road, Parkstone, Poole
Declaration of interest
L.M.-W. is the Medical Director of Dorset HealthCare NHS Trust and a
general adult psychiatrist. D.C. is Associate Medical Director of Dorset
HealthCare NHS Trust and a consultant in old age psychiatry.
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Introduction
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There have been significant changes in the provision of medical care in
hospitals at night. The initial catalyst for this was the New Deal for Junior
Doctors but more recently the European Working Time Directive requiring
doctors’ hours to be reduced to 56 in 2002 and to 48 by 2009. The
reduced availability of junior doctors in hospitals at night has had a range
of implications, including the necessity to train other health professionals
to do work previously undertaken by doctors and a reduction in the number of
specialist doctors available out of hours. The expectation is that staff in
the hospital at night will be equipped to deal appropriately and safely with
emergency work across specialties, rather than each specialty covering their
own patients.
In psychiatry reducing the working hours of junior doctors and implementing
the Hospital at Night programme (Department
of Health, 2005a) have necessitated review of having
resident junior doctors on call at night and the training of nurse
practitioners to take on some roles of the on-call duty doctor. The extension
of prescribing to nurses and other professionals will facilitate and hasten
this process; prescribing has been a role which it has not been previously
possible to delegate.
Although there have been significant and, in some cases, far-reaching
changes in out-of-hours hospital work, there has been little discussion of the
implications for out-of-hours work in the community and whether the principles
of the Hospital at Night programme apply equally to the community at
night.
This paper sets out the response by a medium-sized specialist mental health
and learning disability trust in Dorset to the challenges of providing safe
and appropriate out-of-hours care in the community, balancing the need to have
satisfactory working hours, not only for training grade doctors but also for
career grade doctors. In meeting this challenge the trust was influenced by
the Royal College of Psychiatrists’ Good Psychiatric Practice
(Royal College of Psychiatrists,
2004). This states that all psychiatrists should be equipped to
deal with emergencies across sub-specialties. In the section on competencies,
Good Psychiatric Practice states that ‘All psychiatrists will
have a common basic understanding of the following specialties: child and
adolescent psychiatry, forensic psychiatry, general adult psychiatry,
psychiatry of learning disability, liaison psychiatry, psychiatry of old age,
psychotherapy and psychiatry of substance misuse. Knowledge and skills in
these areas will need to be maintained and updated. All psychiatrists should
be competent to assess and undertake the immediate management of patients for
whom they have responsibility when on-call over the weekends and in
emergencies.’ The document goes on to state that ‘All
psychiatrists should have skills in the assessment of psychiatric disorder
complicated by or associated with substance misuse and of psychiatric problems
in young people, older people and people with learning disability and skills
in the immediate (short-term) management of these conditions, together with
sufficient knowledge of management strategies and local services to suggest
appropriate care for these conditions and knowledge of the differing ethical
and legal frameworks to ensure appropriate emergency care’.
The trust was also influenced by the emerging proposals from the now
published New Ways of Working for Psychiatrists
(Department of Health,
2005b) and the White Paper Valuing People
(Department of Health, 2001).
New Ways of Working for Psychiatrists gives clear guidance about the
need for trusts to devise job plans for consultant psychiatrists that will
prevent them from becoming burnt out and demoralised through excessive
workloads. Valuing People is clear that ‘a person with learning
disability who has a mental illness should therefore expect to be able to
access services and be treated in the same way as everyone else’.
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Historical on-call arrangements in East Dorset
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In 1993 there were two separate consultant on-call rotas for general adult
and old age services within East Dorset, with consultants on call 1 in 5. In
1996 these rotas merged into one so that there was a single rota covering
patients in learning disability, general adult and old age psychiatry. Child
and adolescent services were covered by a separate rota. The frequency of on
call at this time was 1 in 11 for consultants in general adult, old age and
learning disability psychiatry and 1 in 3 for consultants in child and
adolescent psychiatry. The senior doctor on call was supported by a resident
junior doctor in the main hospital base and a non-resident junior doctor/staff
grade in other peripheral units.
In 2001 an out-of-hours nursing service was established to run alongside
and in parallel with the medical on-call rota, to provide additional support
for existing patients but not to provide assessment of new patients. In 2003
the out-of-hours nursing service was strengthened by the appointment of nurse
practitioners to undertake first-line assessments from the accident and
emergency departments of the two local general hospitals and to take all
hospital calls at night in place of junior doctors who became
non-resident.
In 2003 the trust also appointed 1.5 additional consultant psychiatrists in
child and adolescent mental health services (CAMHS). These new consultants did
not wish to participate in a 1 in 4.5 on-call rota or even a 1 in 6 on-call
rota, which was the projected development for CAMHS within the trust. A
discussion was held with the consultant body as to whether the CAMHS
consultants should join the well-established combined learning disability,
general adult and old age psychiatry on-call rota. It was agreed to trial a
combined senior on-call rota for a period of 6 months.
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Preparation for combined rotas
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Training was given by the child and adolescent consultants to their
consultant colleagues in the management of psychiatric emergencies in
children; in particular, the use of the Children Act 2004, the issues of
capacity and consent in children and the links with social services.
Arrangements were clarified with the paediatric services that all children
under 16 who had taken overdoses would be admitted to a paediatric ward
overnight and reviewed by CAMHS the next day. At weekends, the paediatrician
would make a decision about whether the child needed to be kept in hospital
until the next working day. This decision could be made in conjunction with
the on-call psychiatrist. Arrangements were made for emergency assessments by
the CAMHS team of all children who had been discharged from the general
hospital on the next working day.
Child and adolescent consultants and general adult consultants, in
psychiatry were both anxious about their extended on-call roles. However, the
training reassured anxious colleagues in both adult and child and adolescent
services. All consultants indicated that they would be happy to be contacted
by other colleagues, even if not on call, to provide advice during the trial
period.
At the end of a 6-month trial there was unanimous agreement by consultants
within the trust that the on-call system had been a success and it was
therefore agreed to continue.
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Training grade doctors
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It was discussed initially whether the specialist registrars in general
adult/old age psychiatry and CAMHS should remain on separate rotas. It was
decided not to do this, both because of the College recommendations about
training in the emergency management of other sub-specialties
(Royal College of Psychiatrists,
2004) and because specialist registrars were being trained to be
consultants, and the on-call rota, although iinnovative, might well be adopted
elsewhere. Those specialist registrars obtaining consultant posts in Dorset
would be helped by the experience of on call across the sub-specialties.
Safeguards were incorporated into the system for specialist registrars.
- The specialist registrar should contact the consultant on call for
discussion of the management of all patients aged 15 and under
- The specialist registrar was encouraged to contact the child and adolescent
psychiatrist the next working day for supervision and advice about all
patients under the age of 16 seen out of hours
- Any concerns and difficulties would be discussed in the already established
monthly on-call supervision group between specialist registrars and consultant
psychiatrists.
The system was approved by the Specialist Training Committee in Psychiatry
of the Wessex Deanery. Subsequently inspectors from the Royal College of
Psychiatrists General Adult and Old Age Higher Specialist Training Scheme
expressed concern about such trainees working with children and adolescents
and those with learning disability out of hours. They have recommended that
this aspect of the rota for these trainees ceases.
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Functioning of the new rota
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The new rota has now been running successfully for over 2 years. The
consultant body continue to be supportive of the rota and feel that they have
the necessary skills to manage emergencies as they arise. All new consultants
appointed to the rota in all sub-specialties are given appropriate training
and induction to ensure that they feel equipped to undertake the role of
senior on-call consultant. Feedback from specialist registrars has indicated
that they receive appropriate support and supervision in fulfilling their
on-call duties.
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Discussion
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The change from traditional ways of working always has the potential to
raise anxieties, and in medicine concerns about reduction in standards. We
believe that we have developed an on-call system which both maintains high
standards of psychiatric practice and provides an appropriate work–life
balance for consultant psychiatrists. The system is in line with all relevant
government directives and facilitates achievement of the objectives set out in
Good Psychiatric Practice. Feedback from consultant psychiatrists has
been uniformly positive. Feedback from specialist registrars has indicated
that the on call has been a useful training experience and has been
appropriately supported by training and supervision. There have been no
concerns about clinical practice out of hours. We hope that this system of on
call, which we believe is not replicated elsewhere in the country, provokes
discussion about best practice in out-of-hours psychiatric provision. This
could be a model as to how high standards can be maintained while ensuring
that career grade doctors have satisfactory and enjoyable working lives.
Recruitment and retention of consultant psychiatrists remains an ongoing
problem and improving the quality of a consultant’s working life both in
and out of hours will help address this issue.
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References
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DEPARTMENT OF HEALTH (2001) Valuing People:
A New Strategy for Learning Disability for the 21st Century.
Department of Health.DEPARTMENT OF HEALTH (2005a) The Implementation and
Impact of Hospital at Night Pilot Projects: An Evaluation Report.
Department of Health.
http://www.dh.gov.uk/assetRoot/04/11/79/69/04117969.pdf
DEPARTMENT OF HEALTH (2005b) New Ways of Working for
Psychiatrists: Enhancing Effective Person Centred Services Through New Ways of
Working in Multidisciplinary and Multiagency Contexts. Department of
Health.
http://www.dh.gov.uk/assetRoot/04/12/23/43/04122343.pdf
ROYAL COLLEGE OF PSYCHIATRISTS (2004) Good
Psychiatric Practice (2nd edn) (Council Report CR125). Royal
College of Psychiatrists.
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Introduction
Historical on-call arrangements...