We need to monitor implementation. Commentary on … New Ways of Working

Change of the kind described and advocated by Vize et al is never simple. That it is occurring with some vigour and across a wide front has recently been confirmed by a College survey showing that 66% of psychiatrists across all areas of England reported that the principles of New Ways of Working were being applied in their trusts in changing consultant roles. No data are available for Scotland but corresponding figures for Northern Ireland are 33% and Wales 67%. All other professions in mental health are considering what the programme means for them.

College monitoring

At times like this it is essential to listen carefully and respond constructively to worries and concerns about implementation. The National Steering Group on New Ways of Working, set up at the instigation of immediate past-president Mike Shooter, has included many psychiatrists but they have tended to be the inventors of the initiative or the enthusiastic early adopters of the change. President Sheila Hollins has now established a College group, with representatives of the faculties, to identify and respond to difficulties and conflicts in implementation, to warn on what is not being successful and to promote what is. The director of the National Institute for Mental Health in England national workforce programme (Roslyn Hope) and the director of the National Health Service (NHS) Confederation mental health trust chief executives’ network (Steve Shrubb) have readily agreed to participate and help. Information on problems being encountered is being sought.

Change, however necessary to solve current problems, almost always presents new ones, as Vize et al acknowledge. So now, I think, we need both the enthusiasts and the sceptics to agree what new problems are being encountered and concentrate on helping each other to find the solutions.

Addressing new problems

For example, because there were too many serious incidents attributed to failures in continuity of care (traditionally the consultant's responsibility), distributed responsibility in teams was introduced in the form of the care programme approach in 1994 (long before the New Ways of Working initiative was launched in 2003). However, distributed responsibility has created uncertainty about who leads the multidisciplinary team and what that means. Similarly, specialist functional community teams were introduced with the National Service Framework in 1999 and the NHS Plan in 2000 because generic community teams were failing to deal adequately with crises and patients who disengage. These teams need more specialisation by consultants in order to work well but now we have the problem of managing a more complex whole system with some patients’ journeys crossing more team interfaces, with attendant risks.

I am hopeful because the Psychiatric Trainees’ Committee has identified that specific training in the leadership of multidisciplinary teams is essential to equip them to be consultants of the future. The College has also recognised, in a recent review of strategy, that working with medical directors and chief executives is essential to develop medical management arrangements in trusts so that consultants can engage properly in governance and development of the whole system of care.

New Ways of Working across medical specialties

We are not on our own. There is growing acceptance, in all medical specialties, of the need to adapt working practices to fast-changing service conditions without losing, and indeed in many cases having to regain, the profession's leadership role in health. The best analysis I have seen of why we need to review the profession's values, working practices, and leadership challenges is in the Royal College of Physicians (2005) report Doctors in Society.

Meanwhile, let us value colleagues who cannot make the change. They can provide stability where it is needed. During the decade or so we took in closing mental hospitals, consultants who felt unable to countenance community care, when sensitively deployed, played a vital role in maintaining standards in the institutions while caring for the patients who remained in them. However, it is hardly possible these days to cling on to all the old ways of working with such profound changes in services.