President's Report

Introduction

The President reported that it had been a challenge to know how to focus his President's Report at the Annual General Meeting (AGM) of the College, particularly in a year that had included the thirtieth anniversary of the College; the celebration of a new millennium; ‘2001: A Mind Odyssey — Journey into New Therapeutic Space’; and a year in which the pace of change within the medical profession and in the renegotiation of the boundaries with governments and the public had been breathtaking. All was changing and all had changed. Yet the College, which had had to look inwards and outwards had, the President believed, renewed its core commitment to its core tasks — standard setting, training and education, research and public education.

Professor Cox's report would therefore sample those activities that he wished to communicate at this point to College members, and which should be placed within the full account of College activities contained in its ‘new look’ Annual Review, now published in December.

Politics

This had been the year of the National Service Frameworks in England for Adults of Working Age, Older People and, thanks to effective and shrewd College lobbying, for Children. It had also been the year when we had begun to face up to the issues of devolution and the new roles of the Welsh, Scottish and Irish Divisions as well as the future responsibilities of College officers within these new political contexts. As Professor Cox wrote in ‘Corridors of Power?’ (2001), much of his time was rightly devoted to the public education of governments and to lobbying on behalf of psychiatrists and other mental health professionals — and fundamentally on behalf of our patients and carers. Never before in his experience had mental health services achieved such a priority within the public policy and financial commitment of governments, and within a specific context of restoring and rescuing the NHS.

He believed these ‘corridors of power’ had indeed been traversed by himself and other officers to good effect; such diplomacy and advocacy was undoubtedly an art that, like a musical performance, required rehearsal, good timing, risk taking and a healthy recognition that it was, at the end of the day, only the art of the possible.

It was, however, a totally new and welcome situation for Government to appoint a National Director of Mental Health who was a psychiatrist, but could have been a nurse or psychologist. This individual needed the College to fulfil the public goals of implementing the Government's policies in England, and must therefore work with an elected President of a Medical Royal College. Informal contacts with Senior Civil Servants and indeed with Ministers had been numerous, and would continue, Professor Cox hoped, with the new-look Government.

Formal links were also crucially important. The College had now established a twice yearly Committee with the Department of Health, the Home Office and the Prison Health Service Chaired alternately by the President and Professor Louis Appleby — and most Faculties had observers from the Department of Health on their Executive Committees. Professor Cox was himself a Member of the Mental Health Taskforce and the Workforce Action Team.

Democracy may be cumbersome but once opinion became clarified, then Government plans for new mental health legislation, for example, could be delayed, modified and conceivably ‘binned’. Vindication indeed for the College's strategy endorsed by Council, led by the Registrar Dr Mike Shooter, and sustained by the opinions from members as expressed through Divisions and Faculties. The College had therefore now established good formal and informal links with the Department of Health in London, which had characterised for some time this political interface in Scotland. What was certainly lacking at the present time was a similar advisory structure for the Government in the Republic of Ireland.

The President concurred with the view that these years were providing a ‘last chance’ for the values of the NHS. The re-election of a government that, having encouraged the ‘bashing’ of doctors, was now signing up to a new concordat and recognising perhaps that, unless recruitment and retention of doctors in general and psychiatrists in particular improved, delivering the NHS mental health policies (and being re-elected) became less likely outcomes.

The College was therefore urging the UK Government and the NHS to maintain mental health as a core priority and had welcomed the additional resources. So far, most new monies had gone to the Government's preoccupation with safety and public risk, and sadly into changing our secure hospitals into institutions more like category B prisons — razor wire on the walls of Broadmoor included. Other monies had not been ring-fenced and so never arrived at a local target.

The College had offered to help the Government to track these lost monies, and to develop systems to ring-fence monies so that they impacted locally. Members of the College working in local implementation teams, and those Divisions that were intrusive in their links to regional offices could undoubtedly exert considerable influence in this regard. Similar structures would need to be in place for primary care trusts and the new strategic health authorities.

General issues

Against this political backdrop, the President in the remaining sections of his Report focused on those aspects of the year that had particularly preoccupied him as he endeavoured to fulfil the full-time responsibilities of his office. He reported this as being a job that was mostly enjoyable, was appropriately hard work and yet thoroughly backed up by a most able team of officers whose skills and styles complemented each other, as well as by over 100 College staff (led by Vanessa Cameron) who remained deeply committed to providing management and administrative support — without which there would be no time to think, write or travel.

Adult psychiatry

In the past year the agenda set by the College and by the Government had been close to Professor Cox's own work as an adult psychiatrist with a special interest in transcultural and perinatal psychiatry. As the first Chairman of the then Section of General Psychiatry, he was pleased that this Section had now become an Adult Psychiatry Faculty. Council Reports on community psychiatry Chaired by Professors Burns (Royal College of Psychiatrists, 2001a ) and Thornicroft, together with the Faculty's Report Roles and Responsibilities of a Consultant in Adult Psychiatry (Royal College of Psychiatrists, 2001b ) had at long last begun to re-establish this once pristine speciality and this development was for the good for all other specialities — boundary disputes included!

Learning disability

Consultants in learning disability and their Faculty Executive had described in their survey that they appeared to have discovered the secret of how to maintain morale even when there were staff and resource shortages. Other Faculties may have something to learn in this regard. The President was hopeful that the new Consultant's Charter would capture some of the core components of what being a consultant psychiatrist really was, how to delegate and to recreate team work that could enhance motivation, interest and altruism.

Working parties

During the year, two major working parties established by Council had reported with far-reaching recommendations. The first, on the international responsibilities of the College, Chaired by Professor Cox's predecessor Dr Kendell, made powerful recommendations, including establishing a revived International Committee, urging the College to become better Europeans, to strengthen the overseas groups, and also to recognise the College's historic and wider international responsibilities. The College was indeed an international organisation and Professor Cox believed we had now left behind our more isolated offshore islands image, as we engaged, perhaps at some cost, with colleagues and other mental health professionals working across the world in developed and developing countries. During the year the President had attended, for example, meetings of the Pakistan, Brazilian, Turkish and American Psychiatric Associations, several of these being Joint Meetings with the WPA. The President was glad to announce that Professor Hamid Ghodse, a Vice-President of the College, had been appointed as the new Director of the Board for International Affairs.

The second report was by a Working Party that the President Chaired on training and service delivery issues for Black and ethnic minorities (Royal College of Psychiatrists, 2001c ). This Working Party made 10 striking recommendations, all of which had been endorsed by Council. They were far reaching and the commitment of the College was persistent. They related to training in cultural competence, rooting out individual discrimination and racism, and inviting an external body to review our procedures and structures to determine the extent to which institutional discrimination was present. The new Ethnic Issues Committee would be Chaired by a Sub-Dean, Dr Parimala Moodley and was currently advertising in the Psychiatric Bulletin for committee members. This could be seen as a key example of the College setting its own agenda.

The President reported that other notable reports during the year had included an authoritative report on research with human subjects from a working party Chaired by Professor Sir Michael Rutter (Royal College of Psychiatrists Working Party, 2001), and that of Dr Margaret Oates (2000), on Provision of Perinatal Mental Health Services. Council was reviewing the roles of the Research Committee, and the Joint Report by the College, College of Physicians and British Medical Association (BMA) Mental Illness: Stigmatisation and Discrimination within the Medical Profession (Royal College of Psychiatrists et al, 2001) was likely to ignite the Changing Minds Campaign.

In the Autumn, the College would publish a consultation paper reviewing the Faculties, Sections and Special Interest Group structures that had developed some organisational anomalies which, when resolved, could unlock yet more creativity within these structures. There was also a constitutional review being undertaken by College officers.

Addiction psychiatry and the need for an addiction psychiatrists' paper landed on Ministers' desks, and the debate unlocked a review of the number and range of Specialist Certificates and how to train a sufficient number of consultants in that speciality.

The College Research Unit, thanks to Professor Sir David Goldberg and Dr Tim Kendall, had maintained its place as a highly respected research unit promoting multi-professional research and yet being able also to influence more directly the College agenda.

Court of Electors

The Court of Electors — the senior Education Committee of the College — Chaired by Professor Cox, had been equally hardworking and bold in its innovations. It had agreed to proceed with a Diploma in General Psychiatry based on the Part I MRCPsych examination; agreed a new MRCPsych curriculum and changes to the examination based fairly and squarely on sound educational principles. Within the context of the high-speed senior house officer (SHO) Modernisation Task Force, the College's examination fortunately continued to assess the learning taking place at the end of SHO training. The Dean, Chief Examiner and their teams had worked well within the new Committee structures set up some years ago, and Professor Cox acknowledged fully the extent and importance of that work with its implicit standard-setting and innovation. The Dean, having established peer review as a core component of continuing professional development (CPD) had now stood down as Director of CPD, and was replaced by Dr Joe Bouch. The President felt that the Dean deserved our thanks for steering this particular ship — in addition to directing other educational matters.

A Revalidation and Performance Committee was established during the year under the Chairmanship of the Senior Vice-President, Dr Sheila Mann. Vice-Presidents were now no longer unclear as to their responsibilities — both now Chaired key committees! Dr Mann brought to bear her authority both as a member of the General Medical Council (GMC) and former Chief Examiner, and Professor Cox acknowledged fully her support to himself and, as important, her coordination of the crucial standard setting, audit, revalidation and appraisal mechanisms. She, together with the Dean and others, produced the much-respected publication Good Psychiatric Practice (Royal College of Psychiatrists, 2000). That the College had now been asked by the GMC to do yet more work on unacceptable practice, to produce guidelines for revalidation and to consider being involved with the revalidation process for unusual groups of doctors (e.g. those taking career breaks, non-clinicians, doctors working in non-managed institutions and Presidents of Royal Colleges), was a measure of the new concordat between the GMC and the Colleges. The College would remain as an examining and a standard setting body and, with a delegated authority from the Specialist Training Authority and the new Medical Education Standards Board, a certification body.

So far, the President had reported on selected aspects of College activities, many of which were the fruits of earlier productive Presidential reviews and officers' away-days that had characterised the past decade. These activities, when considered alongside a membership that now exceeded 10 000, the largest number of MRCPsych Part II candidates ever (429) and a financial situation steered by Dr Fiona Subotsky that had allowed risks to be taken (for example the refurbished high-tech Warren Suite, the Mind Odyssey, and this joint meeting with the WPA) would all suggest that the College was very much alive — and kicking — and forward-looking.

Recruitment and retention

Yet there was, of course, a down side. The President noted that we continued to face major problems of recruitment and retention that, in a climate of opinion only slowly changing from a blame to a learning culture, continued to sap the morale of mental health professionals to the extent that his overall optimism over a 5- to 10-year period had to be tempered because of this specific issue. Indeed, Professor Cox had never before heard, in the 15 years since he first worked in Belgrave Square, the issue of recruitment and retention achieving such a priority and prominence in College committees. He had Chaired a Department of Health committee on this subject, which made strident recommendations contained within the Workforce Action Team Report — now with Ministers. College officers had themselves reviewed recruitment and retention options, supported by Dr Sally Pidd. These had ranged from roadshows for medical students and combating stigma in medical schools to tracing the so-called ‘lost SHOs’. Sixteen per cent of flexible trainees who got onto the Specialist Register did not immediately take up consultant posts — another exit poll had therefore to be undertaken.

The Joint Workforce Committee with the Department of Health was a good example of collaboration at its best, the end result being more influential workforce projections to the Workforce Numbers Board; 12% of consultant posts in England and Wales remained unfilled, yet 120 more consultants were now in post. The 95 new national training numbers (NTNs) in general adult psychiatry and a further 85 NTNs in old age psychiatry were much to be welcomed — and the budgets would now be held by Postgraduate Deans.

The College was also arguing stridently for an increase in SHO posts by at least 25% and, as a member of the SHO Modernisation Board, Professor Cox recognised that this review could be good news for the mental health training of all doctors. Never before had the President seen physicians and surgeons being almost proactive in their inclusion of mental health and mental disorder in their basic curricula. The workforce capping on SHO numbers in other specialities facilitated recruitment of young psychiatrists and of general practitioners.

Medical regulation

The President wished to conclude his Report by reviewing some of the persisting and specific challenges that we also faced at the present time within the field of medical regulation. Undoubtedly there were opportunities as well as threats. Yet, if we remained true to our core purposes of standard setting, education and training, public education and research then, he believed, because of the good standing of the College and the strength derived from almost all psychiatrists being members of the College, that the present was also a rich opportunity.

Any threats to the power and influence of Colleges was also an opportunity. One could construe the new Medical Education Standards Board, the workforce confederations, the National Clinical Assessment Authority, powers of Commission for Health Improvement and National Institute for Clinical Excellence (NICE) as threats. They were only threats if we ceased to maintain our core tasks, or brought ourselves regularly into disrepute. The College would remain a body independent of governments, yet able to collaborate and constructively debate when it was for the good of our patients. In the President's judgement, the more external bodies, the more lay involvement, the more Department of Health officials who wished to scrutinise our work, the better. We had nothing to hide and everything to be proud about; the front door of the College must remain wide open.

There was, however, a risk that the Academy of Medical Royal Colleges would become weakened, and that the lack of concordat with Government and the public would mean that if other older Colleges sunk, then we would sink with them. Politicians were sensitive to votes and voters — and the media — and in 4 years' time would be even more so.

However, the structures presently in place — including new governance of the GMC, annual appraisal underpinning revalidation, the Academy led by a full-time Chairman more influential than ever, College CPD high up the agenda, a Government that was prepared to listen and work with the College and our increased credibility with the public and patients — should all enable the storms that would blow following the Bristol Inquiry not to become a destructive hurricane.

Users and carers groups

During the year, the President had Chaired a Black/White User Committee. Initially they had met in a somewhat clandestine manner in the basement of the College; however, 2 weeks ago, the work of this group had achieved such prominence that we were on the search for more leaders of Black User Groups and this Working Group would, in future, be accountable to the new Ethnic Issues Committee. This development was potentially of the utmost importance as patients from Black and ethnic minorities were disadvantaged by a perceived gulf between their needs and the mental health services that were available. The Patients and Carers Committee, now a Special Committee of Council, would therefore become increasingly influential; why should they not contribute to the Court of Electors and to the Education and Examination Committees of the College?

Certainly, the boundaries between the Government and the medical professional were being redefined. Colleges who had jealously guarded their independence now had to accept much greater accountability to Parliament and the public. The President noted that, as psychiatrists, we knew that seeming opposites were the energy for creative endeavour, and that threats were spurs to action for wider links with other professionals, governments and user groups.

Professor Cox said that we had known, or should have known, from Maxwell Jones et al all about user involvement, multi-professional training and comprehensive care planning — but we had not had the resources and the back-up to deliver what we knew to be better management. The roles of consultant psychiatrists, including those with psychotherapy training, within multi-disciplinary teams needed to be clarified. Medical psychotherapists were central to the culture of our profession.

Conclusion

The President said that his Report reflected his own opinions and his hopeful belief that those who worked in the mental health field in 5 years' time — and perhaps sooner — would see substantial improvements in recruitment and retention and in working conditions, including the appalling state of the acute in-patient wards. We might then gradually see a return to much greater job satisfaction than was at present the norm. CPD, the intellectual excitement of discovering new things, including why things went wrong, having responsibility with power and the ability to own and influence a budget could restore the self-confidence of well-trained consultant psychiatrists.

As he entered his third and final year as President, Professor Cox concluded by thanking members for their support and thanking Keele University and Combined Healthcare NHS Trust for ‘seconding’ him to the post.

He also expressed his thanks to his wife, Karin, and to his three daughters, who had seen them through some unexpected severe health problems, which had placed them on the receiving end of the NHS, and their resultant recognition of the benefits of skilled tertiary, secondary and primary care services. The learning curve was steep; the suffering real and yet the care and cure miraculous.

Professor Cox suspected that by the end of the AGM on Friday, and certainly by Saturday, the College staff would need and deserve a holiday, and that the College as well as the WPA would by then have changed a little for the benefit of our patients and for the good of all.

The Winged Cross, the Egyptian Ankh, as a symbol of Hope on the College crest was surely an imaginative act of heraldry. When 30 years ago the Royal Medico-Psychological Association became the Royal College of Psychiatrists, wisely the motto Let Wisdom Guide was chosen, wisdom being defined as an “ability to think and act utilising knowledge, experience and understanding, common-sense and insight”.

Such wisdom was therefore both a science and an art: it was a mind odyssey.

Professor Cox hoped his report had shown that wisdom in its fullest sense nurtured by his predecessors was still present in the here and now, and would, he was sure, follow us into the next College year — and beyond.