Examination of current mental health policy reveals two divergent trends: on the one hand, a drive towards quality improvement, transparency and accountability through clinical governance, with an emphasis on patients' and carers' rights, expectations and involvement in care planning and service evaluation; and on the other, an increasingly paternalistic trend towards central Government control, with an expansion of custodial care at the expense of personal and clinical freedom. At the same time that home treatment is being advocated to spare patients the unpleasantness of in-patient admission, the realities of resource allocation show that finances are being poured into the forensic services ahead of all else. Public protection is seen as the principal motivation behind the proposed legislation to reform the Mental Health Act (Reference ZigmondZigmond, 2001), now enshrined in the White Paper Reforming the Mental Health Act (Department of Health, 2000), with the pendulum swinging so far from the individual's freedom that there are concerns as to whether it will breach the Human Rights Act (Reference LeungLeung, 2001).

Concern about the proposed legislation is widespread. Campbell (Reference Campbell2001) cites complaints from a number of local service user organisations that ‘the viability of their work is being undermined by an atmosphere favouring custodial approaches’.

The College has responded to the Government's proposals in depth, with considerable concern about fundamental aspects such as the broadened definition of mental disorder, the detrimental effect of a coercive service on patients' willingness to seek help and the role of the new tribunals (Reference ZigmondZigmond, 2001).

In a letter to the BMJ, Crawford et al (Reference Crawford, Hopkins and Thomas2001) reported a survey of all consultant psychiatrists in England and Wales, which focused on the plans for preventative detention of people with severe personality disorder. Only 20% of the 44% who responded supported the proposed legislation.

In the context of the current recruitment crisis in psychiatry, the prospect of an increasingly custodial role for consultant psychiatrists may have a detrimental impact on attracting doctors into the specialty, or discourage trainees from choosing a career in general adult psychiatry. The views of trainees in psychiatry are, therefore, of critical importance, not only to the future implementation of a new Act but also to the viability of future plans for the development and modernisation of mental health services in the UK.

Method

Within a week of a well-attended professorial lecture summarising the proposed legislative changes, a postal questionnaire was sent to all 33 specialist registrars (SpRs) on the Wessex Higher Training Scheme preparing a Certificate of Completion of Specialist Training (CCST) in general adult or old age psychiatry. Respondents were asked to agree or disagree with 10 items identified as potential areas of concern regarding the legislative proposals. Views on how consultants will be affected by the proposed legislation and altered perceptions of their own future career in the light of the Government's plans were investigated in 11 further questions. Space was given for free comment.

Results

Of 33 questionnaires sent out, 28 were returned, with 26 completed, giving a viable response rate of 79%. (One person felt (s)he had insufficient knowledge to answer the questionnaire and one was returned blank.)

Concerns about proposed changes

Trainees' responses to a 10-item list of potential concerns regarding the proposed legislative changes are presented in Table 1.

Table 1. Trainees' concerns about the content of the White Paper (n=26)

Question	Answered yes (%)	Answered no (%)	Did not answer (%)
Do you think there are major flaws in the proposed legislation that suggest it needs redrafting in important areas?	23 (89)		3 (11)
Are you concerned about any of the following:
adequacy of medical work force resources to meet the demands of the new legislation	26 (100)
loss of exclusion criteria (e.g. substance misuse)	22 (85)	3 (11)	1 (4)
loss of treatability criterion?	22 (85)	3 (11)	1 (4)
extension of approved social worker role to other professionals	11 (42)	14 (54)	1 (4)
potential loss of approved social worker involvement	19 (73)	6 (23)	1 (4)
introduction of behaviour management as a reason to detain	20 (77)	5 (19)	1 (4)
inclusion of clinical psychologists as clinical supervisor	8 (31)	17 (65)	1 (4)
introduction of community treatment option	5 (19)	20 (77)	1 (4)
practicality of community treatment powers	21 (81)	4 (15)	1 (4)

Perceptions of how consultants will be affected by the proposed legislation

Trainees' responses are given in Table 2. Of the 18 (69%) whose overall impression of the legislation was unfavourable, 7 had a full house of negative answers to all the itemised concerns and 4 gave only one positive answer; that is, of those who had an unfavourable impression, 11 (42% of all respondents) had an extremely unfavourable impression. Of these, 7 (64%) were preparing a single CCST in general adult psychiatry.

Table 2. Trainees' perceptions of the impact of the proposals on consultants' daily work (n=26)

Question	Agreed (%)	Disagreed (%)	Did not answer (%)
Imagining its effect on your future working life as a consultant, is your view of the proposed legislation:
favourable	13 (50)	12 (46)	1 (4)
unfavourable	18 (69)	3 (12)	5 (19)
Do you think it will be:
a big improvement	0 (0)	25 (96)	1 (4)
burdensome	21 (81)	1 (4)	4 (15)
helpful	0 (0)	22 (85)	4 (15)
adding to stress	20 (77)		1 (4)
reducing stress	5 (19)
adding to workload	23 (88)		1 (4)
reducing workload	2 (8)
Do you think the proposed legislation will adversely affect your:
clinical freedom	17 (65)	8 (31)	1 (4)
morale	15 (58)	11 (42)	0 (0)
time spent on paperwork	23 (88)	3 (12)	0 (0)
relationships with patients	12 (46)	13 (50)	1 (4)

Effects of proposals on views of their future careers

After learning of the proposed legislation, 16 (62%) had a more negative perception of their future career. For this subgroup of 16, further details of the negative impact of the proposed legislation are given in Table 3.

Table 3. Responses from those with negative perceptions of future career (n=16)

	Agreed (%)	Disagreed (%)	Did not answer (%)
Has the proposed legislation caused you to:
view general adult psychiatry less favourably than before	16 (100)
perceive private practice more favourably	7 (44)	9 (56)
think of giving up NHS psychiatry	8 (50)	7 (44)	1 (6)
want to change your specialist registrar training plans	3 (19)	12 (75)	1 (6)

Of the 7 (44% of the subgroup) who viewed private practice more favourably, 6 (86%) were preparing a single CCST in general adult psychiatry, as were 6 of the 8 (50% of the subgroup) who had thought about giving up NHS psychiatry. Analysis of all respondents shows that 6 out of the 12 trainees (50%) preparing a single CCST in general adult psychiatry viewed private practice more favourably in the context of the proposed legislation and an overlapping 6 (50%) had thought about giving up NHS psychiatry. Four of these trainees agreed with both items, in contrast to only one who was not preparing a single CCST in general adult psychiatry. They represent 15.4% of the total study sample.

In addition to 3 (18.8%) who had considered changing their SpR plans, a further 3 (18.8%) spontaneously mentioned they were less concerned because they were preparing dual accreditation.

Discussion

This survey attracted a good response rate, but the sample size is small. The majority of respondents held an unfavourable view of the proposals. The results accord with the general concern within the profession about the

White Paper, although there is very little published statistical evidence with which to make detailed comparison. However, the level of concern (one-quarter of respondents) about the introduction of compulsory treatment in the community is much lower than the two-thirds majority who rejected it outright at a recent debate on the subject in February 2000 (Reference Pinfold and BindmanPinfold & Bindman, 2001).

The areas of highest concern deal with the practicalities of implementing the proposals, especially adequacy of resources and the burden of extra work. Ethical considerations involved in the changed definition of mental disorder and the treatability issue, which lie at the heart of the legislative framework that underpins psychiatric practice, also proved to be major concerns. No respondent thought the new legislation would be helpful or an improvement.

A substantial minority of SpRs were sufficiently adversely affected by the implications of the proposed legislation to consider career alternatives. Trainees planning a career in general adult psychiatry were more likely to give negative responses and to have considered opting out.

Conclusion

The proposals in the White Paper were viewed negatively by the majority of future consultant psychiatrists in this sample, with particular concern expressed about the practicalities of implementation and ethical considerations. The results indicate a potential negative impact of the legislation on the recruitment and retention of senior medical staff, especially in general adult psychiatry. This could, in turn, add to the significant adverse effect of the current workforce shortage on the development and delivery of services.

Declaration of interest

None.