This booklet is the first edition of what is hoped will be the key document setting out agreed standards for practice in psychiatry. The introduction welcomes comments and suggestions for improvement, as it is ‘anticipated’ that it will aid in ‘appraisal and revalidation of medical practitioners’. It is thus a first stab at outlining requirements, and should be carefully read by all of us.
The format is clear and quite formal, aligning excerpts from the GMC Good Medical Practice (1998) publication with key points from the College relative to that area on the opposite page. Topics covered include core attributes, good clinical care, confidentiality, working as a member of a team and clinical governance. There are also sections on teaching and training, research and consent, and two appendices. Appendix 1 comprises the basic knowledge and skills (competencies) and Appendix 2 goes through good practice within each separate speciality.
There is, not surprisingly, nothing very surprising in all this, in that the majority of statements are straightforward, uncontroversial and what anyone would expect of a good doctor. Thus, examples of unacceptable practice include ‘communicating poorly with others’ and ‘acting against the best interests of the patient’. Good practice by contrast involves such things as ‘being open to peer review’ and ‘only signing documents when assured as far as possible that the information is correct’. The College's responses, in fact, are divided into good and unacceptable practice, by and large, and it would be surprising if any College Member really did not know these core principles. The sceptic might consider that there is an element of spoon-feeding here, but there are one or two more controversial statements.
For example, among the examples of unacceptable practice, under the section entitled the trusting relationship, is apparently the ‘abuse of power relationships within the team and in the therapeutic alliance’. This seems somewhat subjective in its understanding, and one might ask why not simply use the term ‘bullying’, as is used in employment tribunals? Under the consent to treatment section it is suggested that unacceptable practice includes an ‘unwillingness to recognise the importance of seeking advice when children are at risk’. But one might ask why not also seek advice when adults, the elderly or other individuals with specific disabilities are at risk? Others might ask what the phrase ‘formative assessment’ means in the context of teaching and training, and question what is meant by an ‘overcritical attitude’ towards trainees. Again, is this not somewhat subjective, in that because a trainee feels criticised is that going to be sufficient evidence for the trainer being deemed ‘overcritical’?
This lack of specificity is also seen in Appendix 2. Thus there is a large difference in the range of items required for general adult psychiatry (10 bullet points) as compared to the psychiatry of learning disability (17 bullet points). The speciality of substance misuse requires skill in risk assessment and ‘knowledge of the spectrum of effective pharmacological treatments’, but the term risk assessment is not included in the general adult psychiatry section. By contrast, general adult psychiatrists are asked to develop good practice in understanding, prescribing and monitoring the side-effects of a range of pharmacological therapies. What is clear, in fact, is that a lot more work needs to be done on boiling down these specialist roles, since there is both a lot of overlap, a lot of bland generalisation and a lot of the somewhat obvious. For example, under the forensic section there is required ‘an understanding and awareness of issues relating to ethnicity, culture, gender and sexual orientation’, which is fine, but not specifically forensic. Psychotherapists are enjoined to undertake ‘regular supervision of own work’ (and why not for everyone?), while liaison psychiatrists must have ‘knowledge of specific interventions’. This whole section needs radical review.
Overall, of course, this kind of booklet does need to be published, since at its core is a sensible summation of good practice. It would benefit from a coordinating and purifying editorial hand, and from trying to avoid the unnecessarily obvious (e.g. ‘listen to members of the team’) and the tendency towards being something of a wish-list (‘ability to be decisive’). It is clearly the task of every thoughtful psychiatrist to read it, report his or her concerns, positive and negative, to the relevant division or faculty and for the College to refine it further for the future.
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