Meeting of the Central Executive Committee
of the RoyalCollege of Psychiatrists
on 08 December 2009 /

Draft Minutes

Morning session: Service reconfiguration

CEC received the following documents:

  • Themes from redesign survey (CEC 161/09)
  • Leading the NHS workforce through to recovery: NHS Employers’ briefing (CEC 162/09)
  • Example of strategic planning consultation for working age adult services (CEC 163/09)

Members broke into three groups to identify issues and challenges arising from different service models. Problems noted included:

  • Discontinuity of care/too many interfaces and barriers (inclusion/exclusion criteria/thresholds)
  • Waste/repetition of effort
  • Turf wars
  • Plundering of staff from CMHT to specialist teams
  • CMHTs left to do the ‘messy work’ (e.g. MHA work)
  • Difficult to apply model in rural/small populations
  • Training problems – e.g. difficult to produce well-rounded career progression because of specialisation
  • Eligibility criteria unilaterally decided
  • Fragmentation is bad for patients and staff
  • Battles between inpatient and community team consultants
  • Bizarre and fragmented set-ups in rural/small areas due to money only being available for new team start-ups
  • Too many teams (e.g. CRHT) set up without consultant psychiatrists
  • Inappropriate referral to CRHTs by GPs
  • Thresholds for specialist services (e.g. liaison/mother-and-baby) too high
  • Consultants in CRHTs taking on patients even though they haven’t ever seen them
  • Waste due to multiple assessments at each ‘gateway’, resulting in patients becoming more ill the more they move around
  • CMHTs have become the ‘dumping ground’ for some patients, often those with complex needs that overlap different specialties, and therefore are ineligible for some services (i.e. ‘not unwell enough’)
  • Under-specialisation of inpatient care, and lack of outcome for people in inpatient care

What could a new service look like, and what might it provide?

  • Specialist functions within CMHT in one building, thereby reducing managerial tiers
  • Maintain specialist functions within generic teams
  • Good clinical care – benefits of EIS and AO are essential to good practice
  • Clear pathways – continuity of care
  • Front-load decision-making - the consultant should conduct the initial assessment and rely on a well resourced and skilled team to deal with.
  • CMHT to cover most pathways for most patients
  • Specialities should not be able to say ‘no’ but have a variety of ways of saying ‘yes’
  • Proportion of specialist teams’ time should be spent working with the generalist services (consult with, train, up-skill the services of the general team)
  • No specialist team should be able to establish terms of reference without collaboration with the general team
  • Co-terminosity with social work
  • Medics are key and need to avoid marginalisation, and hold clinical responsibility for patients
  • Need to work with other MH professionals to agree appropriate models in different localities
  • Fidelity to one model is a very bad idea – local flexibility and interpretation is crucial
  • CMHTs organised around GP clusters
  • Single point of access for GPs but need access to consultant as well – this model only failed before because the CMHT was under-resourced; if resourced properly, it could work
  • Standards to be created re access/timeframes (audited)
  • New service would be based on research about what patients want (too often this is overlooked). For example, do patients really want to see two consultants (inpatient and community)? Do patients really want to see one consultant and one nurse?
  • Evidence-based interventions
  • Respectful attitude
  • Recovery-focused
  • Use the locality model
  • Able to deal with dual diagnosis etc
  • Able to treat those who are not necessarily the people with the most severe mental illnesses, but sometimes those with the more complex needs.
  • Consultants available for GPs to contact (24-hr on-call shift system for psychiatrists to ensure that – at least in urban areas – there is always a psychiatrist available for sign-posting and advice)
  • Services available to deal with ‘softer’ mental health problems
  • Service would keep data on outcomes and quality measures
  • Services would focus higher resources on those most in need

Problems with integrated model; alternative models of care

  • Putting everything back into CMHTs risks all the effort being put into crisis work, with the danger that services like rehabilitation are not done properly
  • Some Scottish services have rebadged themselves, becoming semi-autonomous (but still based around functional teams), resulting in better continuity of care

What are the problems relating to psychiatry, and what does the College/scoping group need to do to address them?

  • Scoping group needs to work with other representative bodies (RCN, BPS, RCGP etc.) to ensure that GPs and other professional groups are on board with any service redesign or restructure.
  • Psychiatrists have failed to persuade colleagues of their own worth
  • Psychiatrists have over-devolved care to nurses
  • College lacks influence; stronger lead needed from the College, using the evidence base (e.g. minimum pricing on alcohol; public mental health general)
  • College statements need to have explicit principles stating that services should be led by patients’ needs – this would avoid turf wars
  • Psychiatry needs a ‘back-fill’ model (as, for example, nursing has) so that psychiatrists’ absence can be covered
  • Psychiatry needs to clarify sensible specialties
  • Psychiatry needs to develop examples of good practice
  • Scoping group must ensure that any protocol of change must contain a positive message of simplification; past experience has shown that change creates greater complexity.
  • Need to be very politically and strategically astute because the upcoming financial constraints may make services vulnerable give there is a drive to simplify structures. It needs to be stressed that simplification is not at the expense of skills that each specialised team possess.
  • There needs to be greater identification and articulation of the triggers that may cause a patient to be moved between services.
  • Peer group and management practices and interactions within a team are very important. Workforce development is critical.
  • Any redesign needs to focus on care across the ages
  • Important to minimise boundaries as this will lead to less discrimination.
  • Must address care needs for the over 65, as they are often requiring different models of care, for example a patient suffering with dementia and chronic physical problems.
  • College will need to work out how to address continued Government support for specialised teams model
  • College needs to support GPs, as they undertake substantial amount of high-end mental health work
  • Need to avoid the NWW model – this model risks deskilling psychiatrists as they are trained only to deal with very complex cases rather than less serious mental health problems.
  • College should show a lead on encouraging the use of technology (e.g. video conferencing) to make better use of resources

Afternoon session

Item / Action
1 / Present
There were members (including alternates) present. The President took the Chair.
In attendance
There were members of College staff in attendance.
2 / Apologies
Apologies were received from members.
3 / Obituary
The Registrar read the obituaries
4 / Minutes of the meeting on 16 10 09
The minutes of the meeting on 16 October 2009 (CEC 164/09) were approved.
5 / Matters arising
Improving the College finances
Dr Khoosal told members that he and Dr Holloway had prioritized the suggestions made for improving the College finances. They suggested that the highest priority items should be addressed within the next 12 months, medium within 18 months, and others over the longer term. The higher priority items were those with the lowest cost and quickest return. The prioritized list would be taken forward by the Officers in conjunction with Dr Holloway and Dr Khoosal. / For Officers’ action
Renaming the specialty of psychotherapy
Dr Mace told members that he was in discussion with the GMC about the possibility of re-naming the specialty of psychotherapy ‘medical psychotherapy’. He would report back. / CM to report ad hoc
6 / Items from Faculties, Sections and Divisions
Review of the work of the Divisions
Dr Holloway presented the review of the work of the Divisions (CEC 165/09). She explained that the document sought to answer the question of what would be involved if the Divisions wrote their own remit, and how could they best serve it? The President invited the Faculties and Sections to focus on the recommendations and consider whether they gave rise to any tension points or overlap: The Chief Executive would consider possible workforce and financial implications. / Comments from F/S invited
VC to look at workforce/financial implications
For Feb CEC
Questions for parliamentary candidates
Members would discuss possible questions for parliamentary candidates at the February meeting of CEC / For Feb CEC
Financial matters for F/S/D
Business plans for 2010 were now being submitted by all F/S/D. Chairs commented that while useful, these documents were long and complex for those not trained in finance to complete. The Treasurer agreed to organise a workshop for F/S/D Finance Officers and managers to discuss how to simplify the forms.
Faculties expressed concern that costs would increase as employers became increasingly unwilling to pay travel and subsistence costs. The President commented that all the members of the AoMRC were experiencing similar difficulties: he would discuss the matter with Sir Liam Donaldson. / GI/PT to organise workshop
DB to discuss costs with AoMRC
7
7.1 / President’s items
New Horizons
The Registrar noted that the Cabinet Office had launched four documents including New Horizons (see 10.5 below). The President invited members to maintain a watching brief on developments and keep him informed.
7.2 / The Role of the consultant psychiatrist
The President told members that he was currently producing the final draft of his document on the role of the consultant psychiatrist in contemporary mental health services. It would be available from the College web site in the New Year. / DB to put R&R doc on website when finalised
7.3 / Levels of prescribing in elderly care homes
The President told members that the Health Foundation had given funding for a researcher to work across the College, the RCP and the RCGP to look into patterns of prescribing in elderly care homes. The project was initially funded for 12 months, but might be extended.
8
8.1 / Dean’s items
Workplace based assessments
The Dean told members that ETSC was keeping the newly-introduced Workplace Based Assessments under review. It had been suggested that they should be more formative, and less summative, and this would be implemented: Faculties had been invited to generate model assessments for their specialties, and to draft a short guide for assessors on what they should expect from a candidate. The scoring system had also been simplified (to 3 scores: not achieved, achieved with gaps, fully achieved). He invited comments from CEC. / Comments invited
9
9.1 / Treasurer’s items
College investment portfolio
The President welcomed Philip Payne, from Barclays Wealth Management (the College’s investment managers). Mr Payne presented his report on the performance of the College’s investment portfolio and the outlook for the next 12 months. He explained that while the benchmark investments had outperformed the portfolio in the past 12 months, it was expected that active management would provide a better long-term return. The College’s investment objectives were to hold a balanced portfolio at a medium to high level of risk. Certain categories of investment were excluded, such as companies which sold armaments or alcohol. The Treasurer would review the College’s instructions on excluded investment and would update them if required. / GI to check investment instructions
9.2 / Sharing Project Costs
CEC received for information a summary of information from other Colleges about the sources of their income (CEC 166/09)
9.3 / Financial agreement with CCQI
The Treasurer told CEC that the Director of the CCQI (Dr Lelliott) and the College Director of Finance (Mr Taylor) had worked together to set out the financial arrangements for the CCQI. Directly attributable costs had been listed, and one-third of the College’s insurance and audit costs would be included. The formula would cover both Development Fund contributions and College overheads.
10
10.1 / Registrar’s items
Membership of Standing committees
Members received for information the membership lists for the Standing Committees of CEC (CEC 167/09)
10.2 / Supporting medical managers who are not Medical Directors
Dr Frank Holloway introduced this report which drew upon the outcomes oftwo focus groups which had considered how the College could best support and develop members who were medical managers but not Medical Directors (CEC 168/09). He explained that there was significant commonality of tasks and skill sets for the different managerial roles, but no common training.It appeared that the College might have a valuable role in training and development, and in facilitating networking. Members noted that training would have to accommodate areas where the senior manager of a team might not be a psychiatrist, as could happen in the more complex areas of commissioning. A proposal for a short-life working group to take the recommendations forward, with draft remit and anticipated budget, was attached as appendix 3 of the document.
CEC supported the proposal to set up a working group and suggested that the title thereof should reflect a slightly wider remit, that is to include psychiatrists with management responsibilities but not necessarily formal management roles. / FH to take forward
10.3 / CQC briefing
CEC received for information the CQC briefing ‘A call for the better management of serious untoward incidents’ (CEC 169/09).
10.4 / Violence and psychosis
The Registrar told CEC about a project recently undertaken by the Public Education Committee to provide specific training to College members so that they could act as local media experts when a homicide occurred which was linked to serious mental illness. This had been effective in creating a group to provide balanced input to media reports. She invited suggestions for other topics which would benefit from similar training and input. / Suggestions invited
10.5 / Work, recovery and inclusion
The Registrar drew CEC’s attention to the four documents recently published by the Cabinet Office Social Exclusion Task Force:
  • New Horizons: a shared vision for mental health
  • Realising ambitions: better employment support for people with a mental health condition
  • Working our way to better mental health: a framework for action
  • Work, recovery and inclusion: employment support for people in contact with secondary mental health services
All available from the Cabinet Office web site:
10.6 / High Court decision on NHS Trusts declaring income from private patients
The Registrar drew members’ attention to the recent decision by the High Court that Monitor (the NHS regulator) had ‘misdirected itself in law’ when applying the statutory cap on what health service foundation trusts could earn from private patient work. Monitor would be working on clarifying the rules and providing clearer guidelines about what should be included within the relevant income stream.
10.7 / Unlicensed doctors
The Registrar told members that the President had written to the BMA to seek their opinion on the issue of unlicensed doctors working for Tribunals. The BMA had indicated that they would not dispute the GMC’s view that it would be the responsibility of employers to decide whether or not to employ a doctor who was registered but not licensed. The GMC considered that accountability was maintained by registration.
Members discussed some of the issues. It was agreed that patients should have access to the highest standard of decision making, and it could be unfair in situations such as Tribunal hearings for one party to be represented by a doctor with up-to-date validation and the other not. There was concern that the practice could provide a basis for argument that it was not necessary for doctors to be validated for some other areas of work as well.
The Registrar noted that the College had been directly asked to become involved in developing a training curriculum for these doctors. CEC accepted that it would be better to remain engaged and to support members by ensuring that training was appropriate, but made it clear that training was not an acceptable replacement for licensing, and the College view should be that all employed doctors should be both registered and validated.
CEC acknowledged that it was likely that unlicensed doctors would be employed. It agreed that no formal statement for or against should be issued at this point. The College should seek the view of the National Director for Mental Health and invite comment from the user and carers’ fora as next steps. / SB to report ad hoc
11
11.1 / Chief Executive’s items
College committees
CEC received for information a list of the College’s current active committees (CEC 170/09). The Chief Executive noted that the Finance Management Committee had suggested that significant savings would be made if each committee reduced the number of meetings by one per year. / Invite committees to consider reducing number of meetings
11.2 / Information Governance
(this item was postponed to the next meeting) / For Feb CEC
11.3 / College Strategic Plan
(this item was postponed to the next meeting) / For Feb CEC
11.4 / Changes to the CRU structure
CEC received for information a diagram showing changes to the organisational structure of the College Research Unit (CEC 174/09)
12 / Committees and Boards
International Advisory Committee
CEC received for information the annual report of the International Advisory Committee (CEC 175/09)
Programmes and meetings
Dr Miller (Director of Conferences) presented the programme for the College’s International Conference 2010 (CEC 178/09) together with an introductory memorandum (CEC 176/09) and the budget (CEC 177/09). She noted that the conference was now stronger and more streamlined, with a topic-based approach, and a clear separation from F/S/D Residential Meetings.
The anticipated daily delegate fee would be £220. This took into account both the higher cost of venue hire and reduced sponsorship income. It was anticipated that the costs for the 2011 conference, and therefore fees, would be lower.
14 / Any other business
(there was no other business)
15 / Future meeting dates
2010
  • 05 February
  • 09 April
  • 11 June
  • 16 July
  • 20 August (provisional)
  • 01 October
  • 03 December

Consultations (CEC179/09*C)