Appointed czars, elected presidents and windows of opportunity

The coincidence of an elected College President in mid-term and an appointed czar with similar, but not identical, priorities for mental health services in England ¹ is fortuitous - and potentially a powerful influence for the good of patients.

Although democracy can be cumbersome an electoral mandate enables a president to speak out when necessary, create channels of communication with governments and the National Health Service (NHS) Executive and to represent the profession within those contexts. Czars can, nevertheless, have other political opportunities, including the immediate ear of ministers and an apparent ability to anticipate recommendations of a working party before it has commenced its work (Appleby, 2000). Yet I also was tempted to guess the recommendations of a College Working Party on Service Provision for Black and Ethnic Minorities and could indicate that they are likely to include training in cultural competence, establishing an Ethnic Monitoring Committee, and inviting an external review of College structures to determine whether there are elements of discrimination or racism within institutional procedures and service delivery. My aspiration for a Consultant's Charter might include those listed by the National Director, as well as more strident recommendations about recruitment and retention. The need to re-skill staff in the art of managing an acute admission ward has been pertinently stated by Peter Kennedy and Hugh Griffiths in their recent survey of consultant opinion in the Yorkshire Region (Kennedy & Griffiths, 2000). They suggest that there is a need to release the ability of consultants to lead their service in a way consistent with the wishes of their teams without constantly having one eye over their shoulder to managers or the media.

The College should, therefore, be pleased that the National Director shares our vision to keep open the window of opportunity presented by the National Service Framework for England, although now superseded by the more doctrinaire NHS Plan (Department of Health, 2000). But what about Wales with no consultant psychotherapists, and Scotland with unexpected gaps in child and adolescent psychiatry services - and what can we learn from Northern Ireland with a long history of no recruitment problems and combined health and social services departments? How can we maintain our approval of training posts in the Republic of Ireland across an international boundary?

In case readers of these columns assume that only the czar has access to ministers, in the past 6 months senior civil servants and ministers in the Home Office and the Department of Health have been actively seeking out our advice. The College, far from being marginalised, has been able to present its opinions directly to Chief Medical Officers, the Acting Chief Executive of the NHS, the Director of Prison Health Policy, and in various settings with almost all ministers in the Department of Health in London, while in Scotland the Scottish Division provides immediate advice on professional matters to the Scottish Parliament; and Dr Whyte is now Chairman of the Scottish Academy of Medical Colleges.

Why this change of style? The answer lies in several directions, including a specific ‘leaving behind’ for the time being of some anti-medical anti-College rhetoric - a direction signalled by the collaborative intent of the NHS Plan and the implementation process of the National Service Frameworks. Within this context I have promoted the ‘just cause’ of such key issues as addiction psychiatry as a speciality, the need to ‘root out’ discrimination and prejudice and to strengthen, as well as to define, the roles of consultant psychiatrists.

The grass roots of the College are, however, parched at the present time by persisting difficulties with recruitment and retention. Nevertheless, what is new is the extent of recognition of these problems and the active search for short- and long-term solutions.

The increased attendance at recent College meetings (more than 350 at the Child and Adolescent Faculty Residential Meeting, 170 tutors and programme organisers in Lille), a sold-out timely adult psychiatry day-meeting on revalidation, training of external clinical advisory team leaders, the changes in the MRCPsych examination, are all important indicators that the College is both alive and kicking.

As the Lead Postgraduate Dean, Dr Rosemary MacDonald, said in Lille, “ All is changing”. Indeed, it is within this context that College Officers working, when appropriate, with the National Director can provide leadership which could improve the care of patients. The prospect of £ 700 million extra over 3 years, a tone of greater collaboration and respect for the College by Government departments (including recently the Home Office), an important role for the College in revalidation processes, and the input of College members into the National Service Frame-work implementation are grounds for cautious optimism.

We are listened to at the present time, but is that enough? Politicians, like elected presidents, are responsible to their electorates. However, when mental health professionals and user groups are developing a consensus about the way forward, when voluntary groups can begin to share the agenda then the rough seas we have weathered over recent years could be replaced by calmer waters. Our College, one of the largest in the Academy, is a democratic organisation (albeit with powers to co-opt!) so keep your opinions coming in. In that way the channels of communication with governments, which are at present open, can be used maximally.

Hammer also on the doors of your postgraduate deans and regional leads for mental health about establishing more pre-registration house officer posts in psychiatry, increasing the number of senior house officer and specialist registrar posts, and creating imaginative flexible trainee and part-time consultant job descriptions. There is a chance at the present time, an open window of opportunity, not just for influence and clinical leadership, but for clinical ownership of the implementation plans for mental health services.

However, a week is a long time in politics and a month can be a long time in the work of a president. Yet, the College, established 30 years ago, has developed an ability to sharpen its teeth and to maintain a long tradition of corporate endeavour.

UPDATE

A week was a long time in politics and a month a long time in the work of a President; a general election is pending and the College developing its own ‘Manifesto for Change’ and suggesting some key questions to ask politicians. The implementation of the NHS Plan may yet illustrate the warning that all that glisters is not gold, and the grass roots are parched by a drought of consistent policy-making. New community services are not necessarily better - but the ‘window of opportunity’ still remains wide open.