The International Fellowship Scheme: from Silicon Valley to the Potteries and back

I was one of the initial applicants to the NHS International Fellowship Scheme and joined the North Staffs Combined Healthcare NHS Trust in November 2003 as a consultant at the Greenfield Centre, Stoke on Trent. It had always been my dream to work in the UK as a consultant. I always wondered how similar it was to the consultant/faculty position I held at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Here I describe my experiences.

Clinical work

It did not take me long to settle down to the clinical work. I was unused to managing patients alone, as at NIMHANS my role was to give an expert opinion, supervise patient care and postgraduate training. At the Greenfield Centre, I had to do an assessment on my own, prescribe, counsel and advise. I was impressed by policies for monitoring patient confidentiality, particularly when patients did not want information to be shared with their relatives (even parents or children) or partners. I was used to sharing information and colluding with relatives back home in India.

Prescribing was a challenge. I had to frequently consult the British National Formulary and the pharmacy. I had to be careful to use a drug only for conditions it had been approved and at the appropriate dose. I also had to pay close attention to the described drug interactions. In India I could use medications based on information from textbooks and journals, experience or even common sense. There was more freedom to use drugs for conditions other than those for which they had been approved and at doses above those recommended; most times this worked without problems. Patients at the Greenfield Centre were often well informed about their conditions and medications having accessed other sources of information.

I found in-patient care to be of an admirable standard, with involvement of social workers, nurses, community psychiatric nurses, occupational therapists, patient advocates and probation officers. The ward rounds were well organised with time allocated for each patient; relatives were given a prior appointment. I had no previous knowledge or experience of the care programme approach or involvement of community care assistants.

I ran a clinic at a community centre at Biddulph Moor once a week. The centre provides depot injections and runs a carers’ and users’ support group periodically. Multidisciplinary community rounds were new to me and were impressive, being conducted by community psychiatric nurses or occupational therapy colleagues. Community mental health as practised in the UK is totally different from the rural clinics treating epilepsy and mental retardation in India.

I had no prior experience of special services such as those for assertive outreach, crisis intervention and early intervention or of user groups and carer groups. The Greenfield Centre itself had numerous facilities, including day care, occupational therapy, aromatherapy, Indian head massage and many other complementary therapies. There were groups for anxiety management, anger management, self-esteem and weight management, among others. The occupational therapy section was very active and popular among users and carers; the last group to start while I was there was the laughter therapy group.

Academic programmes

The academic department of psychiatry had a busy programme. Every week there was a study day with a case conference followed by a seminar. It was possible to meet all the other consultants and trainees working in the trust on this day. The case conferences were challenging and usually had multidisciplinary involvement. Guest speakers from different parts of the country presented the seminars. The MRCPsych training programme continued during the afternoon. The journal club was a lunchtime activity with specific learning objectives. My own publication on schizophrenia was reviewed at the journal club with a lot of polite criticism.

The certificate and degree courses on addiction started while I was employed by the trust and I was involved in the administration and had 2 days’ teaching on epidemiology and assessments.

While in the UK I attended many teaching programmes at the University of Keele School of Postgraduate Medicine which helped to build up my teaching skills. I attended workshops on the objective structured clinical examination, assessment, appraisal, small group teaching and medical teaching. Like many consultants, I attended a number of pharmaceutical meetings, which were organised quite differently to those in India. I had numerous opportunities to deliver lectures to general practitioners, psychiatrists and community mental health teams.

Research

While in the UK I planned to undertake a study on the quality of life of my psychiatric patients. First, I had to write the proposal and seek approval from the local trust, which was granted rather promptly. I applied for a competitive research grant but was not successful. The proposal was sent for both internal and external peer review after which I had to make some modifications. I then submitted the project for ethical approval and was called to the ethics committee meeting where I was asked incisive questions on statistics, methodological issues and consent-related matters. I was advised to make some changes and seek approval again. The process took about 9-10 months but was in vain.

Audits are very popular in the UK and in addition to attending a few sessions on doing audits and attending presentations of some well-done audits, I did a brief audit exercise. It was also informative to observe audit actually being done on my patients.

Conducting systematic reviews is another preoccupation among professionals in the UK, in search of evidence-based practice. I, with the help of a trainee, conducted systematic reviews of published literature on the postgraduate education system and the postgraduate examination system in the UK. I sent an article to the Psychiatric Bulletin but it was not accepted; the editors of the British Journal of Psychiatry said that they were aware of the results of our systematic reviews. I sent the article to a European and an American journal only to be told that I should send it to the British journals! I found this frustrating but I did have a letter published in Acta Psychiatrica Scandinavica and three in the British Journal of Psychiatry, besides writing some invited reviews for journals.

The aftermath

On return to NIMHANS, Bangalore, I am attempting to change my style of practice, teaching and research. Communication with patients and their relatives has improved and I am better equipped to handle difficult questions. My style of teaching has become more systematic and allows greater student participation. Many systems in clinical and academic practice which have remained unchanged for decades are being reviewed to determine whether any positive modifications are possible. My employment in the UK provided me with a much-needed break from routine and postponed (or prevented) eventual burnout.

Benefits of the scheme

For me the scheme has had many benefits. It has provided me with an opportunity to work in a different very pleasant environment, with a different system of high quality healthcare. In the UK there are few constraints to practice resulting from lack of services. I realise my actual worth, in terms of money. I received payment for different types of reports (including court reports), domiciliary visits, applications to the Driver and Vehicle Licensing Agency (DVLA), for the lectures I gave, telephone interviews for surveys and even for meetings I attended. I also enjoyed the autonomy of my work.

Some of the most memorable events were the farewell meetings with the carers’ group, the trainees and my own patients. I have never experienced such events in my 25 years of psychiatry. No wonder some or many consultants wish to stay in the UK. However, that should be left to the individual.

Conclusions

I derived many benefits from the International Fellowship Scheme and I hope that the scheme continues to offer opportunities for psychiatrists from overseas to work in the UK. Consultant psychiatrists in India have limited options, there is no locum system, no job hopping and no movement to better jobs - consultants are stuck until they retire or resign.

Trainees, specialist registrars and consultants from the UK would benefit from a similar opportunity to work in low- and middle-income countries such as India. One MRCPsych trainee from Stoke has already spent a few weeks observing Indian psychiatric practice at NIMHANS, a psychiatric nurse wants to spent a few days at the centre and a clinical psychologist a few months!

The winds of change are blowing!

Declaration of interest

S.K.C. was a consultant at North Staffordshire Combined Healthcare NHS Trust under the International Fellowship Scheme from November 2003 to November 2004.