Submission of the Irish College of Psychiatrists
to the National Taskforce on Medical Staffing
JANUARY 2003
1. Psychiatric Specialities and Services
2. Additional Anticipated Constraints on Consultant Psychiatrists’ Time
3. Suggested Steps to Address the European Union Directive on a 48 Hour Working Week
4. Model Psychiatric Service for an Area with a Population of 350,000
5. Impact of the 48 Hour Directive on the Two Pilot Sites
This paper deals with the impact of the EU Working Time Directive on the delivery of Psychiatric services in Ireland. It is in addition to our short submission of August 1st 2002. We wish to supply the Taskforce with this further information to aid it in understanding the delivery of psychiatric services, the type of services, and the patients who receive these services.
Psychiatry has the third largest number (after all surgical specialties and medical specialties) of approved consultants of any specialty in Ireland. There are 274 Comhairle approved consultant posts as of 1/01/03. The number of NCHDs in psychiatry at the end of October 2002 was 440, including 46 senior registrars. It is divided into four main specialties (each recognized by the Medical Council’s Specialty Register), with a number of sub specialties.The first section of the paper is a general description of psychiatry, its patients and its services. This will inform the Taskforce of the differences between psychiatry and other acute clinical specialties. It gives an outline of how services are delivered to patients and their families, and the problems that psychiatrists and psychiatric teams encounter in their work. It covers four main areas of psychiatry: General Adult Psychiatry, Learning Disability Psychiatry, Child & Adolescent Psychiatry and Old Age Psychiatry. It also stresses the chronicity of some of the major mental illnesses and the importance of having continuity of care for patients and their families.
The second section highlights additional factors that will impact on service delivery and manpower planning for psychiatry in the very near future. These include the new Mental Health Act, Competence Assurance and the proposed Criminal Insanity Bill.
The next section deals with general proposals for psychiatry on how to adapt to the new Working Time Directive. Suggestions here include consultants working in teams, extended hours services and vastly enhanced multidisciplinary teams.
The final two sections deal with an ideal psychiatric service for a mixed urban and rural population of 350,000 under the EU Working Time Directive. Proposals are put forward to deal with the impact of the directive whilst also improving service delivery. Suggestions are made regarding the required number of consultant and NCHD staff for such a service.
Finally, this service model is briefly applied to the two pilot site areas and their present service structures and manpower.
From the meeting held with the Taskforce in October it is clear that a more centralised health service is being suggested, with one large centre per population of 350,000. It must be stressed that the model as described by the Taskforce is at odds with all present planning and policy documents, and future planning for psychiatry. The centralisation of medical and surgical services brings about an improvement in patient care through having sophisticated tests and diagnostic equipment all on one site. In addition it improves quality of care by having surgeons and physicians specialised in specific areas available to diagnose and treat patients available on the same site.
In psychiatry, this model is contrary to the current practice. It would envisage the building of a large acute mental health hospital with 120-150 beds in approximately a dozen regions throughout the country. This could only serve to increase stigma, remove patients from their community and family supports, and discourage integration back into the community. It would frustrate comprehensive and integrated treatment plans for individuals. It would also reduce the efficiency of consultants, as more time would be spent travelling between this one inpatient centre and their local sector base and outpatient clinic. Therefore, considerable flexibility and imagination will be required to fit psychiatry - the third largest of all medical specialties - into the overall model for dealing with the proposed 48-hour week.
Details of all documents and publications referred to in the text are listed in Appendix A.
The main specialties and sub specialties are:
General adult psychiatry and its sub specialties form the bulk of the consultant numbers with 170 approved consultant posts; 5 in forensic, 7 in liaison, 5 in rehabilitation, 6 in substance misuse and 152 in general adult. General adult psychiatry deals with patients from 16 years of age. When a psychiatric illness develops before the age of 65 the patient usually remains under the care of the general adult psychiatrist beyond the age of 65. If it develops after 65 years of age, an old age psychiatrist (if one has been appointed in that area) cares for the patient.
The main disorders dealt with are schizophrenia, mood disorders, alcohol abuse, anxiety disorders and personality disorders. These disorders present a number of unique difficulties. Firstly, the more severe illnesses often develop in late teens and early twenties and can be lifelong in duration. Secondly, in the more severe illnesses, the patients may have no insight into their illnesses and may require involuntary treatment under the appropriate legislation. If a patient requires to be admitted to hospital involuntarily, the teams will need to work closely with family of the patient to ensure optimal care.
For these reasons many patients may have contact with their local service for considerable parts of their life. The care for these individuals is provided across a spectrum of facilities, as set out in the next section below on organisation of services.
Often patients require the input from a number of aspects of the service at one time. The team members, according to their skills and training, implement different aspects of the treatment plan with the patient and family members. For example, a person suffering with schizophrenia may be an inpatient but also starts to attend the rehabilitation centre from the inpatient facility on a daily basis prior to discharge. Ideally there would be occupational therapists, nurses, and psychologists based there to implement a program appropriate to the patient’s needs. At the same time the social worker is providing support and education to the person’s family about the illness and how best to ensure that their family member remains well and in contact with the services. The community nurse is linking with the patient and family and rehabilitation services to ensure a smooth transfer from inpatient to outpatient care.
Upon discharge the patient attends the rehabilitation service, attends outpatients to see their doctor and is seen at home by the community nurse to ensure all is progressing well. There may also be a requirement for the patient to spend a period of time in the services residential accommodation if their rehabilitation needs so require. The role of the community nurse and other community based outreach services are especially important if the patient has been an involuntary inpatient and still retains little insight into their illness and the need for treatment.
Therefore, psychiatry requires a long-term involvement with patients and an assertive follow up and treatment regime delivered in hospital as well as a range of community settings.
Organisation of Services
General adult psychiatrists
are usually responsible for a set geographical area and deliver psychiatric
care to all those within the area. A multidisciplinary team consisting of doctors,
nurses, social workers, psychologists and occupational therapists ideally provides
this care. The physical component of the service consists of acute inpatient
beds, acute day hospitals, assertive home care services, day centres, rehabilitation
centres, high, medium and low support hostels and outpatient clinics. Outpatient
clinics are usually held in local health centres in the local geographical sector
of the consultant. The principles of the structure and delivery of services
are set out in the document, "Planning for the Future".
Presently acute inpatient services are provided in a mixture of settings. Some units are stand-alone acute units, some are part of older psychiatric hospitals, and others are part of acute general hospitals.
Outside of the larger urban areas there is approximately one psychiatric service per county. The average catchment area population served by each service is approximately 140,000. Individual consultants service populations for a sector of between 20,000 and 50,000. The recommended population is 25-30,000. One consultant has responsibility for patients throughout all aspects of the service.
Close working relationships between consultants in the different sub specialties (where they exist) are required as patients often move through and present to these specialties at some stage of their illness.
There is very limited development of sub specialization in general adult psychiatry. In the majority of services specialized liaison, rehabilitation, substance misuse, or forensic services are not available and require urgent development. Where these services do not exist, it falls upon the local general adult service to fill the gap. In addition to this there is still considerable under-funding of manpower in general adult psychiatry as evidenced by some consultants caring for populations twice the recommended size.
NCHDs
The ratio of consultants
to NCHDs in general adult psychiatry is approximately 1:2. There are approximately
28 senior registrars in general adult and its sub specialties. They cannot partake
in the first on call rota. NCHDs work an average of 66 hours per week.
On Call Out of Hours
Work
Psychiatry is not a "blue
light" specialty and the need for a consultant to be on site after normal
working hours is limited. There is a very flat on call structure in psychiatry
with either an SHO or registrar first on call to the acute unit. They cover
the inpatients, any assessments requested by general practitioners or the A+E
department and "walk in" patients, either new to the service or current
attendees of the service. They would also be available to nursing staff in the
hostels for advice and would frequently take telephone calls from patients or
their relatives.
The consultant would form the next layer of staff on call. It would be usual for consultants to attend the hospital each weekend day to do a ward round of new admissions and any problematic patients. During weekday nights, consultants would attend approximately every second or third night to review patients or to complete "temporary certificates" under the 1945 Mental Treatment Act. There would be frequent contact with the NCHD on call to discuss assessments of patients and their need for admission, as well as the needs of current inpatients. There would be very little impact on the admission rate to psychiatric units if a consultant were on site. Most admissions after normal hours are for patients who are acutely unwell or at risk of self-harm and need a period of observation and assessment.
Psychiatry of Old Age is a psychiatric speciality concerned with mental disorders arising anew in old age. There are 21 approved consultant posts in Old Age Psychiatry. The two broad groups of people for which the service has responsibility are:
Organisation
of Services
Old Age Psychiatry services
are based on the principle of domiciliary assessment of elderly people referred
to the service with actual or suspected mental health problems. The service
is provided by a multidisciplinary team lead by a consultant psychiatrist and
aims to treat and manage mental disorders in old age by maintaining the person
at home and providing appropriate treatment in that setting. This may at times
be augmented by attendance at a day hospital for a finite period. Only those
with the most severe illness such as a severe depression are admitted to the
acute psychiatric unit within the service for treatment. The long stay role
is confined to people with dementia who have severe behavioural problems associated
with dementia which are not amenable to treatment. This care is provided in
a psychiatric setting in which the nursing care is provided by qualified psychiatric
nurses.
NCHDs
The ratio for consultants
to NCHDs is approximately 1:1.5. There are 5 senior registrar posts approved
in this specialty. NCHDs in this area usually take part in the general on call
rota for the catchment area and this covers both general adult and old age patients.
On Call Out of Hours
Work
Consultants in old age
usually take part in the general on call rota for the catchment area covering
general and old age patients. Some are available at all times for admissions
to their inpatient units. There may be options to have a separate on call rota
for old age services in a health board area if sufficient consultants are appointed.
Child and Adolescent Psychiatry is a speciality that looks after the assessment, diagnosis and treatment of many different disorders that present in childhood. Child Psychiatry Services are provided for the under 16 age group in most health boards and under in others in Ireland. There are 48 approved consultant posts in Child and Adolescent Psychiatry.
Disorders seen by Child and Adolescent Psychiatry are many and varied. Examples include assessment of suicidal children, depressive disorders, bipolar mood disorders, early onset psychosis, adolescent adjustment difficulties, anorexia nervosa, attention deficit hyperactivity disorder, toddler behaviour problems, autism, separation anxiety disorders, school phobias, obsessive-compulsive disorders and many other neurotic disorders of childhood. Children with conduct disorder and oppositional defiant disorder are also referred to child and adolescent psychiatry for assessment. Because of the nature of childhood and developmental changes etc, children are seen in their family context. Diagnoses are usually made across a number of axes to take the global picture into account. This includes psychiatric diagnosis, specific developmental difficulties, level of intelligence, contribution of medical conditions and psychosocial circumstances.
Generally speaking the Child and Adolescent Psychiatry Services, while they have increased and improved dramatically over the last number of years, are still at an early stage of development. Further issues that need to be looked at in relation to development of services would be the issues of specialisation e.g. forensic service, substance misuse etc. These are services that might be provided on a regional basis or by developing special interest posts. Learning disability is another area of Child Psychiatry that is being developed as well as services for those with autism.
Organisation of
Services
Consultant led multidisciplinary
teams provide Child and Adolescent Psychiatry. Over 95% of the work is done
on an out patient basis at community-based clinics. Location of clinics is varied.
In some Health Board Areas they are totally separate from all other clinics
or health services. Some are located in General Hospitals. Some work is also
done in Community Health Centres. Largely the services are provided in the community
catchment area basis along the same lines as adult psychiatry. General hospitals
with paediatric units or paediatric hospitals usually have a liaison or a Child
and Adolescent Psychiatric Service. Consultants who have a sessional commitment
to the hospital usually provide this.
NCHDs
The ratio for consultants
to NCHDs is approximately 1:1. There are 15 senior registrars. All Child and
Adolescent Psychiatric teams should have an NCHD. The situation at present in
Ireland is that the majority of Child and Adolescent consultants only have one
NCHD. Some in fact have no NCHD and the services are largely consultant provided.
On Call Out of Hours
Work
For the purposes of accreditation
of training NCHDs in Child and Adolescent Psychiatry must work on an on call
rota. Where the critical mass of child and Adolescent Psychiatry Services is
large enough they work as first on call for Child and Adolescent Psychiatry
only. For example in the Dublin area the NCHDs on call provide an on call service
for the in patient unit and any community out patients who run into crisis out
of hours. In other areas e.g. outside Dublin, NCHDs may work on the adult psychiatry
rota and first on call cover for child and adolescent psychiatry is provided
from there.
Inpatient Services
for Child and Adolescent Psychiatry
Inpatient services for Child
and Adolescent Psychiatry are rare at present. There is a recognised need for
more in patient units. These usually operate as a tertiary service and would
be run by a consultant led multidisciplinary team. The Child Psychiatry NCHDs
on call in the service would usually provide services to inpatient units. At
present there are only in patient units in Dublin and Galway.
Day Hospital Services
There is a recognised need
for day hospital programmes in Child Psychiatry for all age groups. There is
one adolescent day hospital in Dublin. There are day programmes that run for
younger children and some of the larger services in Dublin and Galway, for example
therapeutic pre school groups. There is a need in some cases to provide Domiciliary
and assertive out reach work.
16- 17 year olds
There is no definitive
direction as to how the services for 16– 17 year olds will progress. The Department
of Health and Children are expected to report on this matter in the near future.
The view of the Irish College of Psychiatrists is that Adolescent Services need
to be developed for 13-17 year olds.
LEARNING DISABILITY PSYCHIATRY
Learning disability psychiatry deals with those people who have a moderate or severe learning disability. It has been developed by the religious orders and voluntary services and is not health board or catchment area based. There is a mixture of long stay, residential and community services. There are 30 approved consultant posts in Learning Disability, 20 in adult and 10 in child.
NCHDs
The ratio here is less
then one NCHD per consultant. There are two senior registrars in this area.
On Call Out of Hours Work
NCHDs do call from home for the learning disability services. Some NCHDs may be involved in the local general adult on call rota. Some services have consultants as the first layer of on call.
The implementation of the new Mental Health Act has begun with the establishment of the new Mental Health Commission. When the rest of the Act is fully implemented over the next one to two years, there will be a considerable extra workload involved for consultant psychiatrists. The Irish College of Psychiatrists has worked out that the equivalent of at least 15–20 extra consultant’s posts will be required in General Adult Psychiatry alone to ensure the smooth functioning of the Act. This is because all involuntary patients will require an independent consultant to review them within 14 days. Also, all of these reviews will then have to be presented to an independent tribunal, with another independent consultant psychiatrist being a member of this. There will also be a significant increase in consultants’ administrative workload to ensure the smooth functioning of the Act.
In addition, all patients who have been on medication for more than three months and who are unable or unwilling to give consent for continued treatment will require review every three months by an independent psychiatrist.
An additional impact of the Act will be a requirement for two consultant psychiatrists to be on-call for each service. This is because of the new method for changing a voluntary inpatient to an involuntary inpatient as outlined in the Act. The new method will involve a patient who is deemed to require certification being independently assessed by another consultant from within the catchment area service. The second consultant will be required to make a full assessment of the patient and decide whether they need certification or can remain as a voluntary patient.
For this section of the Act to function effectively, there will need to be two consultant psychiatrists on-call at all times. If a consultant is on-call and their own patient requires to be changed to an involuntary status, they must arrange that a second consultant assess the patient within a period of 24 hours. If the patient must be assessed at a weekend and there was no other consultant available, it would be impossible to implement the full provisions of the Act.
In addition to the Mental Health Act, the introduction of Competence Assurance will affect all consultants, with the requirement to have a set number of hours dedicated to continuous professional development and education will impact on service delivery. From January of 2003 50% of all psychiatrists on the Specialist Register will have to partake in Competence Assurance. This consists of educational activities undertaken personally, within the local service, or externally. This will take consultants away from clinical duties for a certain number of hours each week. This must be factored in to the development of services and future consultant manpower requirements.
This bill is presently passing through the Oireachtas and should become law shortly. It provides for, amongst other things, the diversion of offenders to psychiatric hospitals from the courts for assessment regarding fitness to plead. It also allows for the placement of convicted offenders, who are found not guilty by reason insanity, in local psychiatric units. Previously this work was carried out by the National Forensic Service in its base in the Central Mental Hospital or its clinics in prisons.
Whilst the bill is a welcome development and would bring our laws in this area up to date, it is anticipated that it will result in a significantly increased workload for local catchment services and the psychiatrists who work there.
Before examining the ideal psychiatric service for a population of 350,000 and the implications of the EU directive on that service, the College has proposed some general themes and solutions to the 48 hour week and a consultant provided service for psychiatry. These can be applied to the manpower numbers and structures discussed in the following chapter on an ideal service for a population of 350,000.
Presently, NCHDs in psychiatry work an average of 66 hours per week. This compares to the average for all NCHDs of 77 hours per week. The majority of these on call hours are delivered on-site. With the implementation of a 48 hour week, this will mean that NCHDs will work a maximum of 4 week days and one week night on-call ( 4 x 8 = 32 + 16 = 48). They may also work 3 week days and one weekend day on-call ( 3 x 8 = 24 + 24 = 48). Therefore, NCHDs would be available for an average of 3.5 working days per week. When their in-house and external training commitments are taken into account, this reduces to approximately 2.5 days or half a working week. This is based on present working agreements for NCHDs and does not include shift working.
As outlined in our previous letter to the Taskforce and in the first section of this submission, psychiatry has the lowest ratio of NCHDs to consultants of all acute hospital specialities that deliver inpatient and outpatient services. Psychiatry is presently the most consultant delivered of all acute clinical specialties. In psychiatry there are 1.6 NCHDs to every consultant, compared to 2 NCHDs in Obstetrics & Gynaecology, 2.5 in Medicine, 2.7 in Paediatrics and approximately 3 in surgery. Within these specialities that have a higher ratio, it would be possible to ensure that NCHDs are on-site at all times by establishing a roster amongst the NCHDs attached to each consultant team. However, in psychiatry due to the low ratio of NCHDs, there will be a gap of at least two days per team in psychiatry where an NCHD would not be available.
Options to address this deficit in the supply of clinical services to patients by the introduction of a 48-hour week, could be addressed in psychiatry by implementing the following ideas.
Firstly, there will need to be considerable increase in the number of consultants to ensure a consultant provided service and also to cover the gap in service left by the reduction of NCHD working hours. This must be in addition to the increasing of consultant numbers required by present policy documents and to ensure the full implementation of the Mental Health Act, Criminal Insanity Bill and Competence Assurance. Alongside increasing consultant numbers, there should be a minimum increase in NCHD numbers to try and ensure that the ratio drops down to at least one consultant to one NCHD. This will ensure a more consultant provided service and a better career structure for NCHDs.
Previous recommendations have been made by the Irish College of Psychiatrists (as outlined in our document – The Future of Irish Psychiatry) and other submissions to Comhairle na nOspideal. These call for increases in the number of consultants in the areas of Child and Adolescent Psychiatry, Old Age Psychiatry, Forensic Psychiatry, Liaison Psychiatry, Rehabilitation Psychiatry and Substance Misuse Psychiatry as well as Adult Psychiatry. By ensuring the full range of specialties are available to the public, it will ensure that people are seen quickly by the relevant service and are not occupying clinical time in other branches of the psychiatric service through inappropriate referrals or through lack of the appropriate service. As well as the increase in specialties, there will naturally be a need for considerable increase in the availability and number of general adult consultants available as they carry out the bulk of the service provision at present and will also be required to undertake the bulk of the changes required by the new Mental Health Act.
Along with the increase in consultants, it is suggested that having consultants working in teams, as opposed to being individual practitioners in charge of a team and a case load of patients, would be beneficial in ensuring a consultant provided service and continuity of care to patients. Such teams therefore may consist of a minimum of two Consultant Psychiatrists along with two NCHDs, Psychiatric Social Workers, Psychologists, Community Nurses and Occupational Therapists. This would ensure that there would be more medical staff available through the provision of rosters to ensure cover at all times and also to ensure continuity of care of patients who are under the care of such teams. It would enable consultants to specialise in specific areas and thereby provide a better service to patients and also prevent "burnout" in consultants. Presently, consultants in General Adult Psychiatry provide a generalist service to their sector population without any ability to specialise or develop specific clinical interests.
Another option in dealing with the impact of the 48 hour week would be to try and reduce the out of hours or on-call demands of the psychiatric services. This can be divided into two areas. Firstly, there are those patients who are already inpatients in psychiatric units and require medical input out of hours while they are inpatients. This can be broken down into medical or surgical intervention for acute medical problems or injuries sustained, and into psychiatric interventions. Secondly, there are those patients who are referred to Accident and Emergency Departments or directly to standalone psychiatric units for assessment because of self-harm or acute psychiatric illness.
By implementing a fully comprehensive assertive community service that operates for extended hours and is available at weekends, it would be envisaged that a considerable amount of the acute presentations to Accident and Emergency Departments services out of hours could be avoided. The provision of such services have already been proposed in the "We Have No Beds" document published by the Eastern Health Board and the Health Research Board. It found that 50% of all acute psychiatric beds were blocked due to the lack of development of community services (including psychiatric hostels) and the lack of extended hours services. It also pointed to the underdevelopment of Rehabilitation Psychiatry, Liaison Psychiatry, and integrated psychiatric services for the homeless. The Inspector of Mental Hospitals and new Chairman of the Mental Health Commission are both strong advocates of enhanced community Mental Health Teams covering extended hours. However, for this to succeed it would require a considerable amount of resources and must be backed up by a strong inpatient base with the full range of facilities including regional medium secure units, high support, medium support and low support hostels, acute day hospitals and day centres. Also, it must be fully staffed with community psychiatric nurses, psychiatric social workers, psychologists and occupational therapists in addition to medical staff.
Some services have already implemented community services along the lines of those described. The degree of success is clearly related to the amount of resources available to the teams, and where it has been fully resourced, it has brought about a considerable reduction in out of hours use of the service and inappropriate use of the Accident and Emergency Department. In those services that have not been adequately resourced, there are frequent on call difficulties, as the service cannot meet the needs of patients. It only takes under resourcing of one of the areas in the service to cause a backup in the service. Invariably, it is the acute inpatient beds that take the brunt of any such blockage.
If such teams were in place throughout the country and adequately resourced, it would reduce the use of the out of hour’s services and therefore the use of medical staff outside the normal working hours. Such Teams would work extended hours up to approximately 8 pm weekdays and would be available for at least half a working day each weekend day. Therefore, there would be fewer presentations to Accident and Emergency Departments of an acute psychiatric nature. If this were to occur it may be possible to manage acute psychiatric on-call service on a regional rather than on a local basis. A Liaison Psychiatry service with NCHDs and consultant cover, who could assess and manage patients and refer them on the following day to their appropriate local services, would staff this. The NCHDs for this on call service could be drawn from the NCHD complement of all the psychiatric units in the area covered by the Accident and Emergency Department. This would aid in reducing the amount of on site on call duty of NCHDs by increasing the number on the rota. Local in patient units would be covered by NCHDs on call off site and therefore would not fall under the 48-hour week directive.
It is vital to stress that in psychiatry, continuity of care is extremely important as patients often have a chronic enduring illness and they and their families have built up a close relationship with Teams and services over the years. Whether such regional on-call services would be acceptable to patients and families is uncertain.
In designing the psychiatric service for a population of 350,000 the principles of Planning for the Future are adhered to. This population area is considered to be an urban rural mix and is made up of 3 psychiatric services each working with catchment area populations of approximately 120,000 (90 -160,000). There are a number of important assumptions understood in the design of this service.
They are as follows:-
These assumptions, along with the documents listed in the Appendix A, form the basis of many of the structures, plans and aspirations for Psychiatric Services in Ireland. All of these are assumed to be part of the models outlined below.
The population numbers, consultant numbers, and NCHD numbers discussed in the models are drawn from the documents as listed in Appendix A.
The detailed calculations of the NCHDs’ rotas, their hours and of consultants required to bridge the gap in clinical time are not included here. They are available if required.
The recent Health Strategy also specifically mentioned a review of Planning for the Future promised to update Mental Health Policy. It is proposed to establish an expert group to review the current situation and set out future policy. Also, the recent part implementation of the Mental Health Act 2001, with the setting up of the Mental Health Commission, will further evolve Mental Health Policy. It is extremely unlikely that there will be any move away from community based services, and it is envisaged that both these bodies will encourage and plan for further community based treatments and services for patients with mental health difficulties. In fact, the Irish College of Psychiatrists recently met the CEO and Chairman of the Mental Health Commission and it was clear from our discussions that the Commission will plan and work toward a further development of community psychiatry.
If the service was to move along the lines of the medical and surgical services as proposed in these initial stages by the Taskforce, it would require the building of new Psychiatric hospitals with approximately 120 – 150 acute beds in each region of 350,000 people. Such a policy would naturally be unacceptable and retrograde.
Apart from the staffing complement, which will be discussed below, there is a need for a physical infrastructure for each catchment area as outlined in Planning for the Future.
This will consist of:
One local acute unit in each of the three catchment areas and a complement of day hospitals, day centres and community residences. Each local acute unit will also have facilities for Psychiatry of Old Age inpatients. One of the local acute units will be located within the main regional hospital or the population base. Other physical infrastructure includes inpatient facilities for children and further inpatient facilities for adolescents. There is also a requirement for a psychiatric intensive care unit for the region. This would be a secure unit that specialises in the care of severely ill psychiatric patients who would present great difficulties if they were managed in a local low secure unit. At present there is no service between the local low secure catchment area units and the National Forensic Service based in the Central Mental Hospital in Dundrum. All of these units would ideally be located within the campus of the main regional hospital. This would facilitate on-call arrangements.
Each of the local units would ideally be attached to the local hospital that under the plan would operate as an arm of the main regional hospital. It would not be an acute, medical or surgical facility but would provide a minor injury clinic between 9 and 5. There would be no non-elective admissions to this hospital. In each local psychiatric unit all acute admissions would be referred through the appropriate psychiatric team involved with a patient’s care. There would be no accident and emergency or walk in assessment facility within the psychiatric unit. Ideally any new referrals of an acute nature would be referred by the general practitioner to the appropriate psychiatric team and assessed in the community or in the sector headquarters of each team. If an individual presented acutely to the regional accident and emergency unit they would be assessed by the liaison psychiatric team and then transferred to the appropriate local service depending on their needs.
Ethos of Service
The service would be based around multi-disciplinary teams as outlined in Planning for the Future and as discussed above. Ideally these teams would consist of one to three consultants having responsibility for a set population of patients. They would work with a number of non-consultant hospital doctors, psychiatric nurses, psychiatric social workers, psychologists and occupational therapists. Service would be very much community based with outpatient attendances in local sector headquarters and the bulk of acute care being delivered in the community. Ideally, there would be a community service available seven days a week for nine to ten hours a day. This would also facilitate a reduction in demands on the on-call service.
Consultant Staffing
In the discussion of consultant staffing for all specialities in psychiatry these staffing numbers include provision for internal annual leave and study leave, provision for teaching and tutors’ responsibility, provision for a Clinical Director within each service. No provision for individual time for Continuing Professional Development or time to ensure full implementation of the new Mental Health Act is made as these demands have yet to be fully clarified.
The following figures are based on present criteria which includes at least one NCHD per consultant and do not include provision for the 48 hour week.
Based on the criteria of The Future of Irish Psychiatry in its recent update, the consultant staffing complements for a population of 350,000 would be as follows:
General Adult Psychiatry 17
Child & Adolescent Psychiatry 22
Incl: Autism (2)
Mild Learning Disability/C & A Psychiatry (3)
Adolescent Psychiatry (5)
General C & A Psychiatry (12)
Liaison Psychiatry 2
Eating Disorder Psychiatry 0.5
Psychotherapy 4
Forensic Psychiatry 2
Old Age Psychiatry 4
Rehabilitation Psychiatry 1.5
Substance Abuse Psychiatry 2
Learning Disability Psychiatry 4
General Adult Psychiatry for Homeless Persons 1
Total 60
Further detail on Old Age Psychiatry needs for a consultant provided service for a population of 350,000, (30,000 aged over 65) is provided by the Old Age section of the College in Appendix B.
There are approximately 274 approved consultant psychiatrist posts in Ireland at January 1st 2003. This gives approximately 24 consultants per population of 350,000. This gives a clear indication of the current under resourcing of psychiatry and manpower in psychiatry in Ireland. There is a significant shortfall of 36 from the ideal consultant number of 60. This requires a 150% increase from the present consultant numbers.
Presently each consultant would work with approximately one NCHD. As of October 2002 there are 440 NCHDs in psychiatry in Ireland for a population of 3.9 million. This gives an average of approximately 40 NCHDs per population of 350,000. Assuming there is no increase in NCHDs, this gives a complement of 40 NCHDs to undertake an on-call rota in each region. The provision of 60 consultant psychiatrists under the present criteria as specified above (which excludes provision for the 48 hour week) will therefore have to be increased depending on the shortfall of medical time and cover due to the implementation of the 48 hour week.
NCHD on-call Rota for Population of 350,000
Due to the development of psychiatry in recent years and the thrust towards more community delivered care there are some difficulties in devising an on-call rota in a system where all other acute specialties are being centralised.
To cover a psychiatric service for this population there would be a number of centres to cover:
Ideally there would be three physical structures in which all of these would be located.
Two local acute units would be located in the community attached to local general non-acute hospitals. The third local unit and all other facilities would ideally be located on the campus of the major regional hospital.
Therefore, the on-call would be as follows:
Each acute local unit would be covered by off site on-call and there would be no emergency or acute assessments, as these would all be diverted to the appropriate team Monday to Friday 9 a.m. – 6 p.m. At weekends a multi-disciplinary team available 9 a.m. – 6 p.m., and a doctor on-call off site, would see them. Outside these hours, the off site on-call for the unit provided by the NCHDs would be only to cover those inpatients in the local acute psychiatric unit and their psychiatric needs. It would not deal with any emergency assessment.
Emergency assessments outside of these hours would be seen at the regional Accident and Emergency Unit by the on site on call psychiatric service there.
The child, adolescent, learning disability, forensic and substance abuse units could all be covered by NCHDs from within each specialty on-call off site. If these were located on the campus of the regional hospital, they would be covered for emergencies by the two psychiatric NCHDs on-call on site.
It is envisaged that the major regional hospital would require two NCHDs in psychiatry to be on call on site outside normal working hours to cover the accident and emergency department for acute psychiatric referrals and assessments. They would also provide on site on call cover to all the on-site psychiatric units (adult, old age, adolescent, child and the psychiatric intensive care unit) within the regional hospital campus with consultants on call off site for each of these specialties.
As discussed in the previous section, only the implementation of comprehensive multidisciplinary teams, extended hours services, adequate consultant staff in all specialties and clear referral polices would bring about a reduction in demand for the on call service, thereby reducing the amount of on site on call and the number of NCHDs required to be on call on site. If this did not occur more then 2 NCHDs may need to be on call on site.
Therefore, there will be a pool of NCHDs throughout the region who would do off-site on-call for each of their local units or specialty units but they would all form a larger pool from which there would be two NCHDs on-call on site outside of 9 – 5 at the regional hospital, its accident and emergency and attached psychiatry unit.
Attempting to staff such a rota gives a requirement of approximately 50 to 58 NCHDs for a region of 350,000. This envisages that each off site NCHD covering the 2 local units removed from the regional unit would work on-site for approximately 6 hours of the 16-hour on-call period. The two NCHDs in the regional hospital would be on site continually for their shift. The NCHDs off site at weekends for the 2 local units would probably work 6 – 8 hours on site in each 24-hour period. The Forensic Unit located in the regional hospital may require an NCHD to be on-site at all hours given the severity of illness and risk attached to such in-patients.
The number of NCHDs required as specified above also includes both provision for study leave and annual leave. No provision is made for sick leave or maternity leave.
The reference period of 13 weeks for the 48 hour week rota gives some flexibility in adjusting rosters and rotas for those who work on-call off site and who may work excessive hours for a period within the reference period. Therefore, balancing hours over the period should be easily manageable. As calculated above, there are approximately 40 NCHDs on average for a population of 350,000 in Ireland at present. This leaves a shortfall of 15 NCHDs plus or minus three. With 40 NCHDs, and including annual leave and study leave, NCHDs will do on site on-call approximately once every two weeks. The off site on-call will occur at a more frequent rate. There may also be need to make provision for the fact that NCHDs could be based in local units removed from the regional unit and may require travelling time to be built into their schedule if they do the acute on site on-call in the regional unit at some distance from their residence and normal work place. As the longest work period on site is 13 hours, there will need to be at least 10 NCHDs rostered for each weekend on call on site for the regional hospital. At least 2 will need to be available for each weeknight on call on site in the regional hospital. These NCHDs will not be available for their normal work hours the day of and the day after on site on call.
Consultants from General Adult and Old Age will be on-call for each of their local units. Consultants from the other specialties would be on call for their respective regional units and would be available to the NCHDs for specialist advice and assessment if required. The on-call structure in psychiatry is flat with just two layers of call. There is a consultant and then an NCHD. The vast majority of assessments and difficulties in psychiatry do not require a consultant to attend immediately. If such urgency exists it is usually due to an urgent physical problem, which would be dealt with by medical or surgical teams. Also the provision under the new Mental Health Act is for a 24-hour period of assessment for anyone who is admitted involuntarily and therefore there is no compulsion on consultants to attend out of hours unless such a period occurs at weekends. However, it should be noted that within the new Act, as mentioned above, there will be a provision for two consultants to be on call for each unit at any one time due to the new requirements for change of status from voluntary to involuntary patients.
Psychiatry is not considered to be one of the ‘blue light’ specialties and the need for consultants being on site out of hours on a routine basis is not considered necessary. The only area where this may really occur is in the Accident & Emergency Department out of hours where acutely unwell people may present. This could be handled by off site on-call consultants, as is the case at present. It may also be a necessity to build a small acute psychiatric observation unit attached to the psychiatric department of the regional hospital for patients who present at night but would be from the catchment area of either of the two removed acute local units. They would need to be admitted for a period of time until they were fit for transfer to their acute local unit. Provisions would need to be made as to consultant responsibility for such patients until their admission to their appropriate local unit. It would also be important to ensure that strict guidelines and policies are in place for the local units that no acute assessments or walk-in assessments are undertaken at the unit out of hours.
There is a gap therefore in the number of NCHDs at present (40) and the number required to staff the above NCHD rota (50-58). Given the assumption that was mentioned in the introduction, there is to be no increase in NCHD numbers, this gap must be filled by extra consultant staffing.
With a shortfall of NCHDs of approximately 14 plus or minus 4, it is estimated that the consultant numbers would require to be increased by another 15 to 20 from the above proposed number of 60. This again includes all provisions for annual leave, study leave, teaching and administrative responsibilities.
Therefore, consultant numbers for a population of 350,000 would be 75-80. Present numbers average approximately 24. This would be a tripling from present numbers. Psychiatry would then have a ratio of approximately two consultants to one NCHD.
The extra 15-20 consultants would be distributed proportionately amongst the specialties as outlined in the recommended number of 60 consultants per population of 350,000.
One of the important considerations about the present ratio of consultants in psychiatry of one consultant to 1.6 NCHDs is that the NCHDs work approximately 66 hours at present and reducing this to 48 hours would leave large gaps in the service. This is because each consultant works with one to two NCHDs and removing one of these from clinical duties at any one time reduces medical staffing by up to 50%. In other specialties with large numbers of NCHDs they may be able to roster them so that there is a constant number of NCHDs available at any one time. This is not the case in psychiatry and will often leave the service that has been provided by two to three people being provided by one consultant. Therefore it is imperative that the changes brought about by the EU directive would be addressed by the provision of an adequate number of consultant psychiatrists.
At present the psychiatric service in the East Coast Area Health Board covers a population of approximately 365,000 people. This is higher than the actual population of the East Coast Area Health Board. This is because part of the South Western Area Health Board extends right along the southern border of the river Liffey into Ringsend. This area was part of the Vergemount psychiatric services under the old Eastern Health Board. This population is still covered by the psychiatric services of the East Coast Area Health Board based in Vergemount, though it is part of the South Western Area Health Board. This accounts for the higher psychiatric population in the area compared to the health board population.
The East Coast Area Health Board has 34 approved consultant posts. However, within the East Coast Area Health Board these numbers include the provision of 5 Forensic Consultants in the Central Mental Hospital. The Central Mental Hospital provides a national service and therefore it is estimated that only 0.5 of one of these posts is available directly to the East Coast Area Health Board. Also, within St. Vincent’s Hospital there are two posts - one a professorial post, one a consultant post, that are attached to the non-catchment area services of St. Vincent’s Hospital. If one takes away the non-catchment area and professorial duties from this it will leave approximately one post available for catchment duties. Therefore, in real terms there are approximately 29 consultants available for the population of the East Coast Area Health Board.
The Mid Western Health Board covers a population of approximately 340,000.
At present the Mid Western Health Board has 22 approved consultant posts as of January 2003.
To achieve the norms under The Future of Irish Psychiatry of 60, the Mid Western Health Board would require an increase of 38 consultants and the East Coast Area Health Board an increase of 31 consultants.
If one adds the extra consultants required to make up for the gap in medical services due to the 48 hour directive and to provide a consultant provided service, the Mid Western Health Board requires an extra 55 consultants +/- 3 and the East Coast Area Health Board an extra 48 consultants +/- 3.
In the East Coast Area Health Board there are approximately 40 NCHDs at present. This number does not take into account the number of NCHDs working in the Central Mental Hospital as they would only be providing services to Dundrum and its own internal on site on call. Also a small deduction is made for the NCHDs in St. Vincent’s Hospital who do not provide direct catchment area services. This number is in line with the national average for a population of 350,000.
The Mid Western Area Health Board has approximately 30 NCHDs at present, which is below the national average of 40. Therefore the Mid Western Area Health Board would require an even further increase in consultants above the 55 stated above if it were to remain at its present NCHD level of 30 following the introduction of the EU 48 hour directive.
In conclusion, given the assumption of the provisions laid out in the beginning of this document, these figures give an approximate guide to the requirements of psychiatry and consultant and NCHD manpower following the implementation of the EU Working Time Directive. It also provides for an alteration in the structure of work with consultants working in teams delivering care through a strongly enhanced multi-disciplinary team and being able to deliver this care in the structure of good community services and facilities.
These consultant manpower requirements will provide for a NCHD to consultant ratio of 2:1. Such a ratio would enable a consultant provided service for psychiatry. By also working in teams of consultants it would also ensure continuity of care for patients, which is of paramount importance in psychiatry.
The Future of Psychiatry in Ireland; a report for Comhairle na n-Ospidéal by the Irish Division of the Royal College of Psychiatrists, 1998.
Update to the Future of Psychiatry in Ireland; prepared by the Irish College of Psychiatrists 2002.
Postgraduate Medical & Dental Board NCHD Census; October 2002.
Comhairle na n-Ospidéal 8th Report, December 1995 – December 2000.
Census 2002 Preliminary Report, Central Statistics Office.
Consultant Staffing; Comhairle na n-Ospidéal January 2002.
Comhairle na n-Ospidéal Minutes of Monthly Meetings regarding New Approved Consultant Posts, 2002.
Postgraduate Medical & Dental Board 4th Report 1996 – 2002.
Quality & Fairness, A Health System for You, Health Strategy; Department of Health & Children, 2001.
Inspector of Mental Hospitals Report, 2001.
The Psychiatric Services - Planning for the Future, Report of a Study Group on the Development of Psychiatric Services, Department of Health & Children, 1984.
Rationale
In a consultant provided Old Age Psychiatry service the majority of assessments of patients referred by their GPs or by consultant colleagues in General Hospitals would be carried out by the.
Junior staff for training purposes would carry out some assessments and this would be under the close supervision of the responsible consultant.
The service would be able to expand to include two new areas:
Each consultant would be able to develop an area of expertise to expand the range of treatment options available to patients.
In such a population 5% of people suffer from dementia, 13% with depression and smaller numbers with other disorders such as schizophrenia, delusional disorder, anxiety related problems and alcohol abuse. There are also likely to be up to 150 people with pre-senile dementia.
An established service would generate about 600 referrals per year with 2/3 of patients requiring to be seen at home and 1/3 in the general hospital setting. Whether seen at home or in hospital, each would require the same comprehensive psychiatric assessment, which includes cognitive aspects. Such assessments are time consuming requiring 1-1 ½ hours plus travelling time. Time is also required for discussion of the case with the referring doctor, compilation of a report and setting up adequate management. The time required for follow up is variable and depends on the nature and severity of the patient’s problem. However, much of this is carried out by community mental health nurses who have specialised in Psychiatry of Old Age.
It is proposed
that a consultant provided service be developed by deploying four wholetime
equivalent consultants for a catchment area of 30,000 65 + population. The document
"Specialist Psychiatric Services for Elderly People – A Proposal for the
Development of Services in Ireland (Irish College of Psychiatrists 1998)"
recommends 1 consultant per 10,000 over 65 years so the recommendation of four
consultants for 30,000 for a consultant provided rather than a consultant led
service is not excessive. However, it would only be successful if the full multidisciplinary
team and physical resources are available.
Four wholetime equivalent consultants would provide for:-
One consultant would be designated Clinical Director and have responsibility for the overall management of the service and for planning and development within the service in close consultation with consultant colleagues. Ring fenced time would be required for this task. The service as a whole would operate as a single team with shared staff and facilities. In particular, no additional junior doctors would be required and in some instances it may be possible to reduce junior doctor numbers if an additional consultant is appointed. Current service activity demonstrates minimal out of hours contact by patients so an extended day or weekend community psychiatric nursing service is not required. The reason for this is that the proactive community outreach ethos of the service means difficulties are energetically responded to before they become emergencies and families feel well supported.
The efficient working of the service would depend on the development and maintenance of good working relationships between the consultants who would move to working co-operatively within a single team. This differs from the usual arrangement in psychiatry whereby one consultant leads one team. It would bring many benefits to patients to be under the direct clinical care of fully trained specialists with areas of special interest. Likewise consultants would benefit from the support offered by close working relationships with colleagues, easy opportunities to discuss cases with a fellow consultant in Old Age Psychiatry and facilitate the taking of annual and other leave. It would enable the activities, which will be required for competence assurance to take place. It would also allow for the development by each consultant of an area of special expertise thereby providing a better service for patients and enhancing professional life for consultants.
Compiled by Dr Brendan Cassidy, Hon. Secretary, Irish College of Psychiatrists