Modernising Medical Careers 1 promised a ‘new dawn’ for medical training in the UK. This included a major expansion and remodelling of the old pre-registration house officer year into a 2-year competency-based foundation programme delivered by the newly formed foundation schools. The purpose of the foundation programme was to deliver a modern and safe platform of generic training for all postgraduate doctors preparatory to clinical specialisation. The programme was based on a foundation curriculum 2 in which psychiatric competencies were comprehensively covered. At the outset, optimism was expressed that there may be opportunities for ‘Cinderella’ specialties such as psychiatry to enhance their representation at postgraduate level. Reference Herzberg, Forrest and Heard3,Reference Brown and Bhugra4 Anecdotally, where foundation posts in psychiatry have been established the feedback has been positive. Reference Boyle, Chaloner, Millward, Rao and Messer5
Five years after the launch of the foundation programme we report a national audit of the establishment of psychiatry in foundation schools. As our primary measure of success we took the number of training posts in psychiatry in the foundation schools. Our target or standard of success was that every foundation doctor should be able to access programmed work-based training in psychiatry delivered via a psychiatric foundation training post.
Method
Between late 2008 and early 2009, using a Royal College of Psychiatrists’ database, we sampled by postal questionnaire the entire population of foundation directors and managers in the foundation schools in England (at the time the database did not include Scotland, Wales or Northern Ireland).
Each school was asked to provide current information on the number of foundation year 1 (FY1) and year 2 (FY2) posts, number of FY1 and FY2 posts in psychiatry, number of foundation doctors in receipt of ‘tasters’ in psychiatry and number of foundation doctors progressing to a specialist training in psychiatry. Simultaneously, we also surveyed all 13 heads of psychiatry specialty schools in England, sending them a questionnaire (Box 1). Three reminders were sent over 6 weeks.
We then compared these data with information about numbers of doctors on specialist registers obtained through a freedom of information request to the General Medical Council (GMC). We did not prospectively define terms but in analysing the data and throughout this paper we used the definitions from Modernising Medical Careers and The Gold Guide 6 as summarised in the Appendix.
Results
Responses were obtained for 21 out of 22 foundation schools in England, with data for one school in Oxford (approximately 450 posts) missing, in the context of a reorganisation of the postgraduate training in NHS South Central Strategic Health Authority. We found a total of 413 foundation posts in psychiatry or 3.5% out of a total of 11 668 posts. There were 121 FY1 posts (2.0%) and 292 FY2 posts (5.1%). The distribution across the different foundation schools is shown in Table 1. Responses to the specific items relating to foundation tasters and progression to psychiatry were sparse and on the whole anecdotal.
TABLE 1 Foundation posts in psychiatry in the foundation schools of England in 2008/2009
| n | n (%) | |||
|---|---|---|---|---|
| Foundation school | FY1 posts | FY2 posts | FY1 posts in psychiatry |
FY2 posts in psychiatry |
| Birmingham | ||||
| Black Country | ||||
| Coventry and Warwick | ||||
| Hereford and Worcestershire | ||||
| Keele (Shropshire and Staffordshire) | 626 | 578 | 22 (3.5) | 27 (4.7) |
| East Anglian | 287 | 287 | 3 (1.0) | 26 (9.1) |
| Leicestershire, Northamptonshire and Rutland | 174 | 166 | 5 (2.9) | 7 (4.2) |
| Mersey Deanery | 314 | 339 | 3 (1.0) | 16 (4.7) |
| North Central Thames | 362 | 315 | 3 (0.8) | 9 (2.9) |
| Trent | 297 | 294 | 8 (2.7) | 9 (3.1) |
| North East Thames | 306 | 306 | 4 (1.3) | 26 (8.5) |
| North West Thames | 299 | 282 | 2 (0.7) | 12 (4.3) |
| North West | 561 | 561 | 15 (2.7) | 19 (3.4) |
| North Yorkshire and East Coast | 181 | 157 | 12 (6.6) | 12 (7.6) |
| Northern Deanery | 389 | 423 | 0 (0) | 19 (4.5) |
| South Central (Oxford data missing) | 303 | 275 | 0 (0) | 22 (8.0) |
| Severn | 299 | 263 | 3 (1.0) | 18 (6.8) |
| South Thames | 874 | 808 | 16 (1.8) | 32 (4.0) |
| Peninsula | 207 | 184 | 3 (1.4) | 10 (5.4) |
| South Yorkshire | 180 | 189 | 15 (8.3) | 18 (9.5) |
| West Yorkshire | 295 | 287 | 7 (2.4) | 10 (3.5) |
| Total | 5954 | 5714 | 121 (2.0) | 292 (5.1) |
| Grand total | 11668 | 413 (3.5) | ||
FY, foundation year.
Box 1 Questionnaire sent to heads of psychiatry specialty schools
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1 What is the name of your deanery?
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2 How many higher training posts are there in your deanery?
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• Child and adolescent
-
• Forensic
-
• General
-
• Learning disability
-
• Old age
-
• Psychotherapy
-
-
3 How many core training posts (CT1, 2 and 3) are there in your deanery?
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4 How many FY1 posts are there in your deanery?
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5 How many FY2 posts are there in your deanery?
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6 How many of these posts are in psychiatry?
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• FY1
-
• FY2
-
-
7 In the past 2 years how many of your foundation trainees have had psychiatry special interest ‘taster’ opportunities?
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8 Comments.
CT, core trainee; FY, foundation year training.
All 13 heads of schools of psychiatry in England returned their questionnaires. We found 1498 core training posts and 1378 higher training posts. As both core and higher training programmes are 3 years long, we estimated that the training capacity for schools of psychiatry in England is about 500 doctors per year for core training and 460 doctors per year for higher training. This represents a ratio of 1 core post to 0.92 higher posts (Table 2).
TABLE 2 Higher and core training posts in schools of psychiatry in 2008/2009
| School of psychiatry | Higher training posts, n |
Core training posts, n |
|---|---|---|
| East England | 128 | 129 |
| Mersey | 60 | 60 |
| Northern | 74 | 87 |
| North Western | 110 | 123 |
| Kent, Surrey, Sussex | 43 | 54 |
| London | 492 | 462 |
| Yorkshire and the Humber | 80 | 116 |
| East Midlands | 47 | 90 |
| Oxford | 100 | 62 |
| South West Peninsula | 27 | 36 |
| West Midlands | 102 | 163 |
| Severn | 61 | 63 |
| Wessex | 54 | 54 |
| Total | 1378 | 1498 |
The percentages of higher training posts in the six subspecialties were: child and adolescent 16%, forensic 9%, general psychiatry 48%, learning disability 6%, old age 17%, and psychotherapy 4% (more data available from the authors on request).
Our freedom of information request to the GMC was made in March 2009. There are a number of specialist registers for psychiatry and some doctors are on more than one, for example old age and general psychiatry registers. It was reported that 8433 doctors were registered as psychiatrists, out of a total of 119 868 doctors on all specialist registers. Approximately, a further 120 000 doctors are registered with the GMC but not as specialists.
There were 577 171 specialist general practitioners (GPs). Psychiatrists therefore comprised 7.0% of all registered specialists including GPs and 13.6% of all non-GP specialists (Table 3).
TABLE 3 Doctors on specialist General Medical Council registers as of March 2009
| n | |
|---|---|
| All specialties | 119 868 |
| General practice (GP) | 577 171 |
| All non-GP specialties (including psychiatry) | 62 151 |
| Psychiatry | 8 433 |
Discussion
Using our measure of success, namely the number of posts in psychiatry in the foundation programme, we found that our standard was substantially not met, which means that only a minority of foundation doctors (20%) could expect to receive programmed training in psychiatry. Approximately 400 out of 12 000 posts in the foundation schools in England are designated for psychiatric training. Assuming each post is of 4 months’ duration (a conservative estimate as some posts are of 6 months’ duration) there would need to be about 2000 posts in psychiatry (12 000 divided by 6) to meet the standard (since each post can train three doctors per year and foundation training lasts 2 years). The index of success for psychiatry in the foundation schools in England therefore currently stands at 400/2000 or 0.20, that is, low. We would conclude therefore that the recently reformed postgraduate educational structures of the UK are not meeting the mental health training needs of newly qualified doctors.
However, this conclusion and the study on which it is based could be criticised on a number of levels. It might be argued that our data are unreliable or inaccurate. We would point to the high return rate (21 out of 22 schools) obtained directly from source. Furthermore, there is consistency with Department of Health workforce data gathered via trusts and strategic health authorities in England for a similar time frame, which found 290 foundation posts in psychiatry as of September 2009. 7 At this time, aggregate information about the number of posts in particular specialties was not gathered by the UK foundation programme itself.
Second, it might be said that our measure of success, namely the number of posts in psychiatry in the foundation schools, is invalid in some way, partial or too crude. It could be argued, for instance, that most foundation doctors actually receive their foundation training in psychiatry and achieve mental health competences in a variety of ways outside of specialist posts via, for example, foundation ‘tasters’. However, a clear negative finding of our survey was a lack of information about tasters. Although the new foundation programme reference guide recommends enhancing the role of ‘tasters’ to inform career choices, and a number of foundation programmes are looking towards Balint-type groups for their trainees, we know of no national initiative to provide training in psychiatry to foundation doctors by any means other than via training posts. Furthermore, to recommend that training in any specialty be delivered ‘informally’ or ‘collaterally’ to foundation doctors would be contrary to the founding principles of the foundation programme itself.
It might also be said that we set the standard too high, that psychiatry as a medical specialty is not of sufficient importance to society – or is simply not ‘medical’ enough – to warrant a substantial place in a medical foundation programme, that is, at least one training post in psychiatry for each and every foundation doctor. This perspective is not supported by the levels of psychiatric morbidity and mortality that are regularly found among medical populations, 8 including notably general practice and hospital patients. Psychiatry is not a small specialty as shown by our data on the numbers and proportions of UK specialist doctors registered with the GMC as psychiatrists – 13.6% of non-GP specialists, the same as anaesthetists. Furthermore, the foundation programme curriculum itself highlights mental health as an important domain of competency acquisition for all doctors.
Finally, it could be said that our sample is unrepresentative of the foundation programme as a whole since the programme is a UK-wide institution and we had access to only an English sample. Anecdotally, it appears that there may be proportionately more foundation posts in psychiatry in Northern Ireland and Scotland than England and possibly Wales. Historically, Northern Ireland and Scotland pursued a more active policy of converting core specialty posts into foundation training posts. It would be interesting to have more data on this, including the extent to which foundation doctors ‘migrate’ across national borders when they graduate to specialist training. However, although Northern Ireland and Scotland may constitute important exemplars that England would do well to note, it seems unlikely, due to their relatively small size, that they would substantially influence the overall UK picture.
All in all, therefore, we find our conclusion, that thus far psychiatry is substantially underrepresented in the foundation schools of the UK, to be sustained. The potential impact of what is in effect a 2-year psychiatry-free introduction to being a doctor is not the subject of further study or discussion here but is clearly of great concern. Recruitment to psychiatry, the professional standing of the specialty, the psychiatric knowledge and skills of all doctors, and the mental and physical well-being of patients as a whole are unlikely to be improved by this situation.
The data reported in the paper constituted part of the Royal College of Psychiatrists’ presentation to Professor John Collins and his Expert Advisory Panel charged with reviewing the foundation programme. Reference Collins9 Their recommendations were extensive but included that the foundation programme curriculum should give greater emphasis to the total patient, longer-term conditions and community care. They also advised that increased flexibility in foundation posts should reflect trainee career choices, workforce needs, and increased community placements. There should be provision of careers information and advice and access to ‘tasters’ should be maximised. If widely implemented, these recommendations, and many others, should improve the position of psychiatry in the foundation programme.
Appendix – Definitions of terms
Foundation programme – the 2-year training programme for newly qualified doctors, completion of which is essential for progression to specialist training, as specified by Modernising Medical Careers. Reference Herzberg, Forrest and Heard3
Foundation years 1 or 2 (FY1, FY2) – the first and second training years of a foundation programme.
Foundation trainee – an FY1 or FY2 trainee.
The Foundation Programme Office – central administrative body which oversees the delivery of the national foundation programme through the local foundation schools.
Core trainee – a doctor training on a core specialty programme, in this case psychiatry.
Higher trainee – a doctor undertaking a further 3 years of post-membership specialty training resulting in gaining their Certificate of Completion of Training (CCT).
Post – a training post, usually 4 months for foundation trainees, 6 months for core trainees, and 12 months for higher trainees (these durations were assumed in this study). The number of posts need not equal the number of trainees, and each post can train three, two or one trainee per year.
Foundation school – administrative unit organising recruitment and training of a number of local foundation programmes.
Training programme (core or higher) – an administrative unit, usually linked to an academic department, and one of several programmes in a school. (In some schools each trainee has a programme which consists of the posts they will do in their training; we have not used programme in that way in this paper.)
Tasters – up to 1 week of elective specialist experience available in the second foundation year designed to inform career choice. They would normally be taken in the first or possibly early in the second FY2 post, assuming 4-month duration of post.
Acknowledgements
We would like to thank Stuart Carney, Deputy Director of the Foundation Programme UK; Clare Oakley, Joanna Carroll and Robert Howard at the Royal College of Psychiatrists, the directors and administrators of the foundation schools and the heads of psychiatry schools and their administrators in England for their kind assistance and support.
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