Here - Surrey and Borders Partnership NHS Foundation Trust

Issue 1 

Summer 2010 

Surrey and Borders Partnership 

NHS Foundation Trust 

Journal 

Surrey and Borders Online 

www.sabp.nhs.uk/journal 

in this issue 

• Do you ever wonder why you agree to do things? 

• New Ways of Working – a three year study of the 

practice of a community mental health team 

• How can we improve recruitment into psychiatry? 

• An interview with Fiona Edwards

Contents 

Editorial 

Do you ever wonder why you agree to do things? ...........................................PAGE 3 

Raja Mukherjee 

Let’s do some research.....................................................................................PAGE 4 

Raj Persaud 

Research and Audit 

Bipolar Disorder: how effective is our screening in primary care........................PAGE 9 

Helena Du Toit et el 

Audit of risk assessment documentation in adult inpatients ...........................PAGE 17 

Abigail Crutchlow 

An evolving service – results of a 3 year follow up study of ...........................PAGE 21 

the practice of a community mental health team incorporating 

the principles of “New Ways of Working” 

Jeremy Mudunkotuwe et al 

Commentary and Debate 

How can we look at improving recruitment into psychiatry? ..........................PAGE 24 

Josie Jenkinson 

Book Reviews 

Psychiatry P.R.N. Principles, Reality, Next steps ...............................................PAGE 28 

Josie Jenkinson 

Interviews 

Interview with Fiona Edwards, ......................................................................PAGE 29 

Chief Executive SABP NHS Foundation Trust 

Abigail Crutchlow 

Editorial Board 

Raja Mukherjee: Editor 

Laurence Church 

Philip Hall 

Jeremy Mudunkotuwe 

Abigail Crutchlow: 

Trainee representative 

Peer Review Panel 

All consultant 

psychiatrists unless 

otherwise stated 

Ruth Alloway 

Glen Cornish 

Chandu De Alwis 

Antonio Fiahlo 

Ilenia Pampaloni 

Brian Parsons 

Raj Persaud 

Farida Yousaf 

Next edition December 2010: This will be 

open to the whole Trust and all specialities so 

please submit any articles you may have. 

Editorial guidance and standards as well as 

terms of reference can be obtained from the 

editor via email: 

raja.mukherjee@sabp.nhs.uk. 

Surrey and Borders Online Journal is 

published by Surrey and Borders Partnership 


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Reproduction in whole or part without written 

permission from the publisher is strictly 

prohibited. The views expressed in articles in 

Surrey and Borders Online Journal are those of 

the authors, unless otherwise stated. 

2 Surrey and Borders Online Journal www.sabp.nhs.uk/journal

Do you ever wonder why you agree 

to do things? 

June 2010 By Raja Mukherjee, Editor 

Do you ever wonder why you agree 

to do things? The phrase “just say no” 

comes to mind, but for those of us of a 

certain generation, not in the context it 

was widely used back then! When 

Malcolm Hawthorne, then in his role as 

Medical Director, suggested setting up 

this journal, little did I realise I would be 

the one running with it. OK, naive I hear 

you cry. Maybe even stronger comments 

from some, but unfortunately I tend to 

agree with them. That phrase comes 

back to haunt you from time to time. 

The remit of the journal, to begin with at 

least, is to allow a space for doctors in 

the trust to develop skills at writing to a 

peer reviewed level. When I say that, I 

mean that it will not simply accept badly 

written or poorly thought out pieces. I 

will however, with my editorial board, 

look to develop the talent and skill of 

those in the trust who are interested in 

publishing. They may as yet not have the 

type of data that would interest national 

or international journals, but the piece 

may still be of interest to us locally. 

Primarily, this would initially aim at 

medical trainees but that should not 

exclusively mean it will be restricted to 

this group. 

My own experience of publishing is 

similar to that reported by Dr Persaud in 

his later editorial. It can be brutal out 

there. Like him, I think it is important to 

not give up and keep trying. Not only 

does it make you feel great when your 

name is in print, but even small new 

additions to what is known can be 

important. Perseverance can be 

important as it is not uncommon to get 

initially rejected. There are times I have 

wanted to throttle reviewers who have 

simply not understood what you were 

getting at. Did they actually read what 

you said or was it that you simply did not 

explain it well enough? Limitations on 

what you can present, in terms of word 

counts and restrictions on references 

makes it challenging. In the end though, 

establishing something new is never easy. 

That is unfortunately the reality of how 

things are. As such, better to learn in a 

non threatening environment with peers 

who you might actually know and will 

take your piece seriously. 

With this journal we have several aims. 

Firstly we wanted to allow the 

opportunity for people to present and 

share work they are doing but that would 

not normally be of interest to those 

outside of the trust. Secondly it was an 

opportunity to hone skills. We are using 

the same set of internationally accepting 

standards for publishing that are adopted 

by many journals including the BMJ and 

Lancet. Whilst I suspect we won’t publish 

anything of their calibre, we do hope it 

will be of a good standard. The articles 

will be placed onto the trust internet site 

and thus can be accessed by anyone with 

web access. This means you can be 

quoted in work by others and the 

information you produce will be 

accessible to the wider world. It will also 

count as a peer reviewed publication. 

In this first edition we present some 

audits undertaken by medical teams in 

the trust. There is a book review as well 

as an interview with our Chief Executive 

Fiona Edwards. Ok so it is not expansive 

but you have to start somewhere. We 

hope this will grow and that we can open 

it up to the whole trust and all specialties. 

Eventually we want it to grow into 

something we can all be proud of. We 

hope you enjoy this first edition. It is a 

start and will only succeed with your 

involvement. Thank you for taking the 

time to read and hopefully to contribute 

in the future. 

Editorial 

Surrey and Borders Online Journal www.sabp.nhs.uk/journal 3

Editorial 

Let’s do some research 

June 2010 By Raj Persaud 

I was asked to write this by Dr Raja 

Mukherjee for our Trust’s new 

journal. Here it is… 

If we asked you to predict now whether 

you were going to perform some 

research and publish it, say in the next 

year, what would your answer be? 

Perhaps, from past experience you might 

admit that this is not likely. On the other 

hand, even if wasn’t particularly likely, 

you may also feel that gathering data is 

something that you ought to be doing, 

and given the social pressure and 

management demands (me asking you 

publicly what your research plans are) you 

might impulsively declare, that yes 

research is something you are planning 

and intending. 

Now, here is the interesting research 

question – in merely asking you to 

predict the future – do we change it? 

Let’s say we ran an experiment where we 

divided a sample of the electorate into 

two groups, and for one, we asked them 

to predict whether they were going to 

vote or not, while we did nothing 

pertinent to the second group; they acted 

as a control. Now, if we followed these 

two samples up into the future, to 

examine what they eventually did in the 

privacy of the polling booth; the 

astonishing result is that being asked to 

predict the future...does change it. 

Those who are asked to forecast whether 

they are going to vote, tend to confirm 

they will, and to do so much more than 

would be expected from their past 

behaviour. They are responding to 

external expectation (and internal drivers 

of a similar nature) so they manage the 

impression they want to create of being 

responsible citizens, by predicting a 

behaviour they were in fact much less 

likely to perform in reality. Having 

foretold that they will take part in a 

ballot, they tend to go ahead and actually 

vote. Yet if they weren’t asked to predict 

the future, they were not particularly 

likely to do any casting at all. 

We can demonstrate this experimentally 

by comparing the group asked to predict 

the future with the control group, who 

were not asked to make predictions. This 

second group vote at the lower baseline 

rate of the general population, which is, 

not that much. 

Why does being asked to predict that 

you are going to vote, make it much 

more likely that you will? 

The short answer is that this particular 

psychological phenomenon, like most 

others, inspires many theories that 

attempt to account for it, but no one is 

exactly sure which is the truth. A seminal 

paper on this effect in the Journal of 

Consumer Psychology by Business 

Psychologists Eric Spangenberg of 

Washington State University and Anthony 

Greenwald of the University of 

Washington, pointed out that the trend 

could be used powerfully to manipulate 

large populations into behaviours they 

had previously little intention of 

performing. 

Spangenberg and Greenwald are 

probably the two world authorities on 

this intriguing ‘self-prophecy effect’ and 

their paper entitled ‘Social Influence by 

Requesting Self-Prophecy’ showed how 

asking people to predict their own 

behaviour in the future was associated, 

on follow up, with spectacularly less 

cheating in tests, significantly more 

attendance at health clubs, and more 

voting. 

One theory is that we like to see 

ourselves as consistent creatures, and 

having made a prediction of our 

behaviour in the future, not to confirm 

the prediction by performing the 

behaviour, would force us to confront a 

rather unpalatable truth; we are 

unreliable, inconsistent people who don’t 

know our own minds. 


We are not so aware of the hidden forces 

at work generated by the social 

expectations of being asked about our 

plans in front of another, which push us 

into making a prediction at variance with 

what we would really do in the privacy of 

our own un-observed lives. 

Having made the prediction, we then 

work to fall into line with it. 

Another, related, theory is that this is an 

example of the power of expectation. 

Psychologists have demonstrated for 

almost half a century now, that if 

teachers are manipulated into expecting 

their pupils to be intelligent or stupid, 

they then work to render these 

expectations self-fulfilling prophecies. 

Judges give directions to juries at the 

beginnings of trials that appear to bias 

the outcome in line with the bench’s 

expectation of the future. We also 

directly seem to suffer for this effect – if 

our expectation of ourselves is 

manipulated experimentally, we then 

provide later behavioural confirmation of 

our expectations of ourselves. 

More on Expectations 

One of the most famous experiments in 

Social Psychology which demonstrated 

the power of expectation is a 1977 study 

by a team lead by Mark Snyder, now at 

the University of Minnesota, in which men 

were shown photographs of a woman to 

whom they would be talking by phone. 

The woman in the pictures was 

randomised to being either extremely 

physically attractive or unattractive (as 

rated by other independent observers). 

What the men taking part in the 

experiment didn’t know, was that those 

sneaky psychologists had told a porky pie, 

and the photographs were not only 

randomly assigned to the men, but they 

also did not correspond in any way to the 

actual woman with whom they had the 

phone conversation. 

While it would come as no surprise that 

the men behaved differently to the 

women during the phone conversation 

depending on their (manipulated) beliefs 

on her physical appearance, the really 

surprising finding was that independent 

ratings of the women's segments of the 

conversations revealed that females 

whose conversational partners believed 

them to be less appealing, actually 

behaved and sounded less attractively (eg 

they were rated as sounding less warm 

and interesting). 

The women, just as the men, had also 

been kept completely in the dark by the 

psychologists about the photograph 

manipulation. They were not aware it had 

taken place. This effect, therefore, had to 

have been mediated in some way through 

the men's behavior. One possibility, is that 

the men who were talking to someone 

they believed to be unattractive, were 

themselves less affable than men who 

believed they were talking to an attractive 

woman. This in turn had an impact on the 

way the women responded, and then 

they way they came over to an 

independent observer. 

The ‘Pygmalion Effect’ is a special instance 

of the self-fulfilling prophecy; where 

having an expectation of another, itself 

causes that target to modify their 

performance so it falls into line with the 

expectation of the first party. 

Just in case you are starting to think that 

Self-Fulfilling Prophecies only inhabit the 

obscure world of experimental 

Psychology, remember we are living 

through a banking crisis and suffering its 

long term impact, and banking crises are 

a form of self-fulfilling prophecy. 

Because a rumour starts that a bank may 

fail, this precipitates a run on that bank, 

which in itself inevitably leads to its 

collapse. This is why Chancellors of the 

Exchequer hot foot it to the nearest TV 

studio to ‘steady the markets’ at the 

slightest hint of such runs on major 

financial institutions. Governments, and 

the whole financial system, live in terror 

of the power of the self-fulfilling 

prophecy. 

It’s so powerful and reliable that you can 

literally ‘bank’ on it. 

Editorial 


Editorial 

Expectations and You 

Consider the continuing controversy 

over the benefits or costs of psychiatric 

diagnosis. Is it possible that the 

expectation set up in the patient and 

their social circle, once a diagnosis of 

schizophrenia or depression is made, in 

itself serves to make the implicit 

prophecy entailed in such a diagnosis 

come true? Because of the powerful 

self-fulfilling prophecy effect of a 

psychiatric diagnosis – is it possible that 

users of mental health services would 

benefit more from abandoning the use 

of such labels? 

At the heart of the education system, 

psychologists contend, are ever-present 

self-fulfilling prophecies. We constantly 

stream children and students into better 

classes or universities, then wonder why 

they do better, when the power of 

expectation and self-fulfilling prophecy 

might be the answer, rather than any 

inherent benefit of an elite education. 

Our Trust 

Is it possible, coming back to research in 

our Trust, that the expectation of whether 

or not you are going to do research 

massively influences the outcome? Might 

it be of benefit to the Trust and the 

doctors working within it to transform 

the expectation so that we ‘become 

expected’, by managers, peers and 

ourselves, to generate and publish much 

more research than we currently do? 

And doctors? Why should doctors 

bother to do research? Surely doctors’ 

primary function is to heal the sick, and 

other activities become a distraction? 

Can research by used by some as a 

‘noble’ from the heaving clinic? How do 

eminence and academic honour 

correlate with clinical acumen? Do 

publication lists still appear as a magic 

key in unlocking merit awards? 

There are some serious obstacles that 

will confront any doctor attempting 

research. Firstly, finding the time, 

support, advice and resources to 

conduct the study. On top of a 

burdensome caseload, anyone in an NHS 

contract who is successful in producing 

papers is frequently met with the 

suspicion that they cannot be pulling 

their weight clinically. 

Half way through the study someone 

will usually helpfully point out some 

methodological consideration that 

renders all your meticulous data 

collection redundant, so you are faced 

with the prospect of starting all over 

again. 

Most papers hide the key story of the 

research project, which is in fact how the 

investigators overcame, through adept 

improvisation, often on the hoof, various 

unexpected impediments tripping them 

as they attempted to recruit subjects, or 

measure some variable. 

Once one nightmare study was over and 

the data was presented at various 

conferences, a researcher was asked how 

he would do the study differently if he 

could start all over again. His response 

was that he would not do it at all. 

Once you assemble the data, statistics 

need to be applied. You visit statisticians 

with trepidation, remembering to pack 

your calculator. They take one cursory 

look at the reams of numbers you had 

painstakingly calculated and she bursts 

out laughing because (a) you measured 

the right thing but in the wrong way or 

(b) you measured the right way, but 

chose the wrong thing to measure or (c) 

you didn’t recruit enough subjects or (d) 

the measuring instrument you used isn’t 

compatible with the statistical test you 

hoped to apply…. And so it goes on. 

Some people find that, once you have to 

start using fancy statistics to illuminate 

your hypothesis, the finding isn’t worth 

the candle. This should reassure the 

statistically naïve that genuine 

discoveries are still possible for the 

innumerate. Indeed in the world of 

research, suspicions mount as the 

statistical tests multiply. 

Another wonderful revelation was the 

(geeky nerdy) joy in just inspecting the 

raw data, like graphing it, without 


esorting too soon to complex statistical 

tests. This is a real issue in research in 

psychiatry – how to measure the elusive 

concepts we deal with daily. In the rest of 

medicine measuring blood sugar or bone 

density levels is much more 

straightforward, which is why these 

branches lend themselves so much more 

easily to research. 

So one early tip to the young researcher 

is to think very carefully before you start 

your study about precisely what you are 

evaluating and how you are measuring it. 

Lean heavily towards using an 

instrument, like a questionnaire, that is 

widely accepted in the field. Of course, 

some of the most gloriously innovative 

research in psychiatry involves pioneering 

a new measurement device, because the 

research community has neglected the 

concept you are investigating. 

But the problems don’t end there. Let’s say 

you dodged the statisticians’ scrutiny and 

colleagues’ criticism. Then you may go on 

to long friendships being threatened by 

disputes over how to write it up. And, 

finally who is going to be first author? 

After that jockeying for position come the 

editors’ letters of rejection. This happens 

even to the most published of us. The 

record among people I have known is 10 

rejecting letters from editors for one 

paper and 30 rejections for a book. 

So given all these problems – why do 

research at all? 

I still firmly believe it’s worth it. Much of 

what we do as doctors arises because 

some researcher somewhere bravely 

chose to ask the question – what is the 

evidence for this piece of practice? There 

is nothing more exciting than pushing 

back the frontiers of knowledge and 

discovering something new and – the 

icing on the ‘cake’ - is that it may alter 

clinical practice or improve the outcome 

for patients. 

Having a research interest keeps us 

stimulated and interested in our 

professional lives. It assists in engaging 

with those of similar interests all around 

the world and at a time when doctors 

frequently feel neglected or downtrodden 

by the NHS; it is great for the self-esteem 

and earns the respect of colleagues. 

I have been impressed at the clinical 

acumen and lively minds we are 

privileged to work alongside. I believe 

there would be many benefits, including 

raising clinical morale, for the Trust to 

engage more with a research ethos. 

Another advantage for the future is that 

rapidly climbing the NHS agenda now 

comes the issue of providing, proving and 

improving the quality of care we provide 

our patients. It would be great for us to 

engage in research investigating what the 

determinants of high quality care are, in 

the eyes of patients as well as clinicians 

and scrutinize how to improve this. There 

may well be some surprising answers. It’s 

entirely possible that what doctors 

believe is crucial to treatment outcome is 

much more peripheral. 

Also while we are encouraged to 

constantly keep abreast of the latest 

research, its only by having done some 

yourself, that you are in the best position 

to properly evaluate an academic paper. 

This is because you will now be aware of 

many crucial issues the authors skate 

over, but which you know from hard 

experience, might be influencing the data 

they present. 

Its vital not to get pigeonholed – yes I 

have done brain scanning research, but I 

also got interested in qualitative research 

methods – and used them to sit and 

observe what goes on in waiting rooms. 

These are spaces where our patients 

sometimes spend more time than they do 

actually seeing us! 

Commercial institutions like Banks had 

clearly put a lot of thought into 

considering and influencing the mental 

state of its customers, while they wait to 

see a member of staff. The NHS in 

contrast appeared to view the waiting 

room as some kind of detainment 

compound for undesirables. It was often 

at best an afterthought in planning. 

Yet by the time any doctor sees a patient 

Editorial 


Editorial 

– the outcome of that crucial encounter 

may have already been partly and 

significantly determined by what the 

patient experienced in the waiting room. 

Something the doctor may not just be 

unaware of, but may be usually beyond 

their control. 

Qualitative research has a long and 

respectable history in Anthropology and 

Sociology, though it may be sniffed at by 

medical colleagues; it’s just an example 

that other methodologies are available 

to us as research tools. You don’t need a 

high tech brain scanner to accomplish 

something meaningful. It should not be 

forgotten. 

Here are some possible research 

questions that I would be interested in 

assisting any staff member with 

conducting some kind of project, or 

which I believe others in the Trust may 

want to pick up. 

Why do patients complain and what is 

their experience of the complaints 

process? What leads to higher patient 

satisfaction after a complaint? What is 

the experience of the staff members 

who have been the subject of a 

complaint? What is the impact on them 

psychologically or in terms of the way 

they practice medicine afterwards? 

What is found most helpful by GPs in 

letters from Secondary Care clinics. 

What do they dislike the most in our 

letters to them? What impact do our 

letters have on care? What about a trial 

of different kinds of letters? 

When a patient first hears that a GP is 

thinking of referring them to a 

psychiatric services – what is their initial 

reaction? How does the encounter with 

services alter that? 

When trainees start psychiatry what are 

their expectations? How does doing a 

psychiatry placement alter this? 

Part of the new Trust journal could be 

devoted to throwing out research ideas 

and seeing who wants to collaborate 

over conducting. Part of the week could 

be set aside for doctors in the Trust to 

meet in order to discuss and assist with 

research projects. 

Remember as well that publishing 

doesn’t have to be restricted to 

publishing research – letters to journals 

can often be surprisingly influential. A 

good place to start in your research 

career is by submitting some letters. For 

that you must be aware of the literature 

and eventually dialogues and 

collaborations may develop. before you 

critique it and then eventually dialogues 

and collaborations often develop out of 

such initial correspondence. 

Colleagues could get together and 

submit more letters to journals - drawing 

attention to the implications of various 

research findings on clinical practice 

where we work? 

These are just questions – I don’t 

pretend to have the answers. 

But all great research at least starts with 

a good question. 

This is not as good a paper as I had 

hoped. It was done rather quickly and 

under difficult circumstances. But it 

might stimulate you to think of doing 

research. 

Remember, if you predict you’ll do, you 

are more likely to do it. 


Bipolar Disorder: how effective is our 

screening in primary care 

April 2010 By Helena Du Toit, Raja Mukherjee, Rebecca Farrell and Sudhir Rastogi 

Introduction 

Bipolar Affective Disorder (BPD) is a 

serious, recurrent psychiatric illness 

characterised by periods of mania or 

hypomania, and depression (ICD-10, 

1992). BPD has a global prevalence of 

approximately 1-2%, which is stable over 

all population groups, however, when all 

forms of Bipolar Spectrum Disorder are 

included; the global lifetime prevalence 

rises to approximately 5% (Kessler RC et 

al, 1994; Angst J, 1998). 

It is a leading worldwide cause of disability 

(Hunter R et al, 2004), is associated with a 

high suicide risk (Sachs GS, 2003; Kasper, 

2003) and costs the UK economy about 

£2 billion per annum through active costs 

of managing the disorder as well as 

through loss of productivity (Das Gupta R 

& Guest JF, 2002). 

The condition usually presents in 

adolescence or early adulthood and has a 

recurring, often lifelong course, and 

greatly affects the individual’s functioning 

in several areas and has wide reaching 

implications for close family, friends and 

colleagues (Kasper S, 2003; Weissman 

MM et al, 1988; Stang P et al, 2007). 

In spite of this, it is often several years 

from the first presentation of the illness 

until the diagnosis is finally established, 

sometimes being delayed by as long as 

10 years. The under-recognition of BPD is 

due to several factors. Firstly, the illness 

often first presents with a depressive 

episode, and there may be several 

depressive episodes before the sufferer 

experiences a manic/hypomanic episode. 

These depressive episodes are often very 

difficult to distinguish from unipolar 

depression. Equally, the marked shifts in 

affect characteristic of emotionally 

unstable personality disorder and 

cyclothymia can be mistaken for BPD 

(Corona et al, 2007). Additionally, 

patients often do not present to medical 

services during hypomanic and 

sometimes even manic phases, as they 

find their increased energy levels and 

creativity during these periods quite 

enjoyable and often do not recognize 

them as pathological. Furthermore, 

clinicians often fail to screen for a past 

history of manic/hypomanic symptoms in 

patients presenting with a depressive 

episode (Brickman et al, 2002). Delayed 

diagnosis often leads to inadequate 

management of the illness, with 

associated recurrent illness, diminished 

social and occupational functioning and 

significant distress for both the sufferer 

and his/her family. To make matters 

worse, treating bipolar depression with 

antidepressant monotherapy is not only 

associated with a high rate of treatment 

failure, but also with a switch to rapid 

cycling BPD, increased mood instability 

and greater treatment resistance (Wehr 

TA & Goodwin FK, 1987). 

Conversely, there is good evidence that if 

the condition is diagnosed early and 

managed appropriately, it is associated 

with a significantly improved outcome 

and preserved social and occupational 

functioning (Bauer MS et al, 2006; Perry 

A et al, 1999), as well as a significant 

decrease in the suicide risk. 

The Mood Disorders Questionnaire 

(MDQ) is a short, self administered 

questionnaire that has been validated in 

several countries (including the UK) as 

being an appropriate screening tool for 

use in the community or a primary care 

setting (Hirschfeld RM 2002; de Dois et 

al, 2008). It has both acceptable 

sensitivity and specificity to be used as a 

screening tool, and although some 

studies have suggested that the false 

positive rate is unacceptably high, the 




rate of false negatives is consistently low 

(Twiss J et al, 2008). It is therefore 

recommended that all patients screening 

positive for BPD on the MDQ (using a 

cut off of 9 positive responses as a 

positive test) should be referred for 

diagnostic assessment by a professional 

mental health worker. Additionally a 

large study in a USA health centre with 1 

million adult members identified that by 

administering one off screening for BPD 

to patients presenting with depressive 

symptoms, and following up positive 

screening results with a referral to a 

psychiatrist, reduced 5 year health care 

costs for that health centre by an 

estimated $1.94 million. This reduction 

was mostly due the difference in 

treatment costs between recognized 

versus unrecognized BPD sufferers 

(Menzin J et al, 2009). 

The importance of screening for 

hypomania/mania is that BPD sufferers 

are often misdiagnosed as suffering from 

unipolar depression, frequently leading 

to incorrect treatment. A single episode 

of mania constitutes a diagnosis of BPD, 

whilst an episode of hypomania should 

increase vigilance in looking out for 

future episodes of depression. 

Aims and Objectives of the 

Audit 

The purpose of the audit was to assess 

whether patients presenting to primary 

care practices within our catchment area 

were being screened for BPD. 

Additionally we wanted to establish how 

effective our service was at correctly 

identifying both true BPD sufferers, and 

those suffering from other mental health 

conditions. We intend to examine this 

data and consider whether further 

awareness and screening is required. 

To summarize, our study aimed to 

answer 3 questions: Within the context 

of our service- 

1. Do primary care physicians and 

Mental Health Nurse Practitioners 

(MHNPs), specialist psychiatric nurses 

working in both primary and 

secondary care, screen for BPD? 

2. Does screening for BPD increase the 

likelihood of identifying this 

condition? 

3. Is there a good correlation between 

the diagnosis proposed by GPs and 

MHNPs and the final diagnosis made 

by the psychiatrist? 

Standard 

Currently no gold standard or NICE 

guidelines exist regarding screening for 

BPD in primary care; therefore we did 

not stipulate the use of a specific 

screening tool for our study. There are 

also no globally agreed cut-off points for 

what constitutes an acceptable 

screening test, although most 

researchers would agree that any good 

screening measure should have both a 

low false positive rate and a low false 

negative rate. The actual values that a 

researcher may deem acceptable are 

related to several variables, such as 

prevalence of condition, cost of 

screening and burden associated with 

missing the condition vs. burden 

associated with over diagnosing the 

condition (Simon S, 2007). For the 

purposes of our study, we set 80% 

sensitivity and 80% specificity as the 

standard, based upon levels set in other 

published research (Twiss J et al, 2008). 

Although these are arbitrary cut-off 

values, they are in line with generally 

accepted standards for psychiatric 

screening tests. 

Although we did not require the use of a 

specific screening tool for this study, we 

previously mentioned that a brief and 

acceptable screening tool is available, 

and we may consider using this tool 

routinely in the future. 


Research Method 

The study was conducted in our local 

Primary Mental Health Care Team 

(PCMHT) which is a community 

psychiatric service that operates both in 

GP surgeries and secondary care. A 

retrospective survey was carried out of all 

the patients with affective symptoms that 

were referred to the Tandridge PCMHT 

over a 6 month period between January 

and June 2008. It was felt that this would 

be a sufficiently large sample to accurately 

and validly assess the efficacy of screening 

for BPD in our catchment area. 

Table 1: Proforma used to analyse case records 

These referrals came from local GP 

surgeries, through the Crisis Advisory 

service, the Home Treatment Team and 

following discharge from the inpatient 

psychiatric unit at Epsom General 

Hospital. Some of these referrals also had 

a further triage assessment by a Mental 

Health Nurse Practitioner (MHNP) before 

being referred to the psychiatrist for 

confirmation of their diagnosis. 

We examined all patients’ records using 

an audit proforma that looked at the 

following parameters: 

GP assessment MHNP assessment Psychiatrist 

assessment 

Did the 

patient have 

2/more 

episodes of 

mental 

illness? 

Did the GP 

screen for 

hypomania? 

What 

diagnosis 

did the GP 

propose? 

Did the 

MHNP 

screen for 

hypomania? 

What 

diagnosis 

did the 

MHNP 

propose? 

Final 

Diagnosis 


On completion of the proforma’s the data was analysed using the SPSS statistical 

package. 

The Psychiatrist’s diagnosis was used as the gold standard next to which the other 

proposed diagnoses were measured for accuracy. 

Results 

Between 01/01/2008 – 30/06/2008 there were 58 patients referred to the Tandridge 

PCMHT that presented with affective symptoms. Seven records could not be retrieved, 

subsequently 51 patients were included in the audit. 

The demographics of our study population were as follows: 

Table 2: Demographics of study population 

Gender 

Age 

Male, N = 19 

Range, 19 – 62 years 

Female, N = 32 

Mean = 37.6 

(normal distribution) 

Out of the 38 patients referred by their GPs, 21 (55.3%) had had two or more 

episodes of mental illness whilst for 17 patients (44.7%) it was their first episode of 

mental illness. 13 patients were referred from other sources. In these cases the initial 

referral letter was analyzed in the same way as a GP referral and if they were also seen 

by a MHNP, this data was also included. 



Table 3: Frequency with which GPs and MHNPs screened 

for hypomania 

% 

80 

70 

60 

50 

40 

30 

20 

10 

0 

% Yes 

% No 

GP 

MHNP 

Screened for hypomania (n) Frequency (n) Percent (%) 

GP Yes 8 21.1 

No 30 78.9 

Total 38 100 

MHNP Yes 14 38.9 

No 22 61.1 

Total 36 100 

Table 3 shows the total number (n) of patients that were screened for hypomania by 

the GP and the MHNP respectively as well as their representative frequencies. As 

indicated, only 21.1% of all patients were screened by their GP for symptoms of 

hypomania whilst 38.9% of patients who saw a MHNP were screened for hypomania. 

Table 4: Diagnoses made by GPs and MHNPs vs. screening for 

hypomania 

Combined GP Diagnosis 

Combined MHNP Diagnosis 

100 

100 

80 

80 

60 

Screened 

60 

Screened 

40 

Not Screened 

40 

Not Screened 

20 

20 

0 

BPD 

Total 

0 

BPD 

Total 


Screened for Hypomania 

Yes No Total 

Combined GP Dx BPD 8 1 9 

Other 0 29 29 

Total 8 30 38 

Combined BPD 9 0 9 

MHNP Dx Other 1 13 14 

Total 10 13 23 

Chi-Square Tests 

Value df P value 

Pearson χ² 32.65 1 .000 

Cont.Corr. 27.52 1 .000 

Fisher’s Exact Test .000 

Pearson χ² 19.22 1 .000 

Cont.Corr. 15.63 1 .000 

Fisher’s Exact Test .000 

Key: (df) degrees of freedom, (χ²) Pearson’s chi-square value, (cont.corr.) continuity 

correction – done for 2x2 tables, Fisher’s Exact Test – performed as one or more cells 

and an expected count of


Table 5 shows how the GPs and MHNPs 

combined diagnoses (BPD or another 

condition) performed against the 

psychiatrists final diagnosis, which is used 

as the gold standard in this study. 

Thirty-three patients were seen by both 

the psychiatrist and their GP. Of the 7 

patients diagnosed with BPD by the 

psychiatrist 5 were correctly identified by 

their GP whilst 2 received another 

diagnosis. However in 4 patients where 

the psychiatrist diagnosed another 

condition the GP suggested a diagnosis 

of BPD. The corresponding sensitivity and 

specificity of the GPs diagnoses were 

71.4% and 84.6%. The PPV for the GPs 

diagnoses was 55.6% while the NPV was 

91.7%. However the LR+ and LR- were 

4.75 and 0.34 respectively which are 

outside of the limits of a good diagnostic 

test. (Please refer to Fields A, 2009 for a 

detailed explanation of these terms.) 

Twenty patients were seen by a MHNP 

before seeing the psychiatrist. The MHNP 

correctly picked up BPD in 2 of the 4 

cases diagnosed with BPD by the 

psychiatrist. However in 6 out of 16 cases 

the MHNP diagnosed BPD whilst the 

psychiatrist diagnosed another condition. 

The sensitivity, specificity, PPV and NPV 

for the MHNPs diagnoses were 50%, 

62.5%, 25% and 80% respectively. 

Again the LR+ and LR- which are 1.35 

and 0.8 respectively fall outside of the 

limits of an acceptable diagnostic test. 

Discussion 

There is a growing body of evidence 

showing the importance of correctly 

identifying and treating sufferers of BPD 

to improve their quality of life, preserve 

their social and occupational functioning 

and to lessen the financial burden of 

healthcare costs related to the 

mismanagement of this important 

condition. Equally, the fact that there is 

often a delay of several years before this 

condition is correctly identified, highlights 

the importance of vigilantly screening for 

BPD, especially in the primary care setting. 

Our first aim was to establish the 

frequency with which our primary care 

practitioners screened for BPD. In this 

sample of patients presenting with 

affective symptoms, only 21.1% of those 

referred by their GP showed any evidence 

that they had been screened for BPD. 

Although this figure rose to 38.9% for 

MHNPs, this still represents a rather low 

proportion of screening for patients who 

are within the at risk category. This is 

especially important as tools such as the 

MDQ are available, short, and easy to 

use, and could easily be administered in 

the context of a primary care assessment. 

A potential downfall of this study design 

is that it relied on evidence from the 

referral letter that the clinician had 

screened for BPD and therefore it is 

possible that where a patient screened 

negative, it was not mentioned in the 

referral letter. However, a good referral 

should mention both positive and salient 

negative findings and routine use of the 

MDQ could circumnavigate this issue. 

Secondly, we aimed to establish whether 

screening for BPD increases the likelihood 

of correctly identifying the signs and 

symptoms of this disorder. In our study 

both GPs and MHNPs almost exclusively 

(with the exception of one patient in 

each case) only proposed a diagnosis of 

BPD when there was evidence that they 

had screened for hypomania. These 

highly significant results show that it was 

highly unlikely that clinicians would 

propose a diagnosis of BPD when they 

had not screened for the condition. These 

results emphasize the great importance 

of consistent screening. 

Our third question looks at the accuracy 

with which GPs and MHNPs were able to 

rule in or rule out BPD in their patients. 

As previously mentioned, a good 

screening tool should have both good 

sensitivity (low false negatives) and good 

specificity (low false positives). We also 

looked at PPV and NPV as well as LR+ 

and LR- as these give additional 

information about the quality of a 

screening test. 


In our sample the GPs screening method 

was very effective at ruling out BPD, but 

was less accurate when it came to ruling 

the condition in. 

The MHNPs’ method was also ineffective 

at ruling in BPD and although it was 

slightly better at ruling out this condition, 

only the NPV was above the cut off value. 

However for both groups of practitioners 

the LR+ and LR- of their methods, which 

reflects the value of a positive or negative 

test result, was well below the accepted 

cut off range. This suggests that the 

methods used by the primary care 

practitioners in our study had little value 

in correctly identifying the presence or 

absence of BPD. 

There are, however, some limitations to 

our study. We should note that this study 

encompassed relatively small numbers 

and this makes it difficult to make 

predictions about how these methods 

would perform in a larger population. In 

this study neither the GPs nor the MHNPs 

used a standardized screening tool; 

instead we were examining the validity of 

the methods they are already using. 

Although our results suggest that the GPs 

methods were slightly more effective 

than the MHNPs’ methods, it is also 

possible that the cases seen by the 

MHNPs were more complex and 

displayed a less clear cut presentation. 

Another limitation of the study is that the 

psychiatrist’s diagnosis may not represent 

an accurate gold standard, particularly in 

patients suffering a first episode of 

affective illness. 

In summary, the results of our study show 

that within the primary care setting in our 

catchment area screening for BPD is 

currently unacceptably low. Also it clearly 

shows that screening for BPD greatly 

enhances the chances of recognising this 

condition and that current screening 

methods used by primary care 

practitioners could be improved. 

Recommendations 

1. Increase awareness of BPD and the 

importance of screening within our 

primary care setting. This could be 

achieved by doing a presentation for 

GPs and MHNPs regarding the findings 

of our study. 

2. Role out the use of the MDQ as a 

standard screening tool to be 

administered to all patients in primary 

care presenting with an affective 

episode. 

3. Improve communication between 

primary and secondary care 

practitioners. This could be through 

informal discussions or telephone 

advice. 

4. Re-audit in 12 months to see the 

change in practice. 

References 

• Angst J. The emerging epidemiology 

of hypomania and bipolar II disorder. 

Journal of Affective Disorders, 1998; 50: 

143-51. 

• Bauer MS, McBride L, Williford WO et 

al. Collaborative Care for Bipolar 

Disorder: Part II. Impact on Clinical 

Outcome, Function, and Costs. 

Psychiatric Services, July 2006; 57:937- 

945. 

• Brickman, Andrew L, LoPiccolo et al. 

Screening for bipolar disorder. Psychiatric 

Services, March 2002; 53/3(349): 1075- 

2730. 

• Corona, Rodrigo, Berlanga et al. 

Detection of bipolar disorder with a 

clinical screening questionnaire: The 

Spanish version of the Mood Disorder 

Questionnaire. Salud Mental, March 

2007; 30(2): 50-57. 

• Das Gupta R, Guest JF. Annual cost of 

bipolar disorder to UK society. British 

Journal of Psychiatry, 2002; 180: 227-33. 




• de Dois, Consuelo, Ezquiaga et al. 

Usefulness of the Spanish version of the 

Mood Disorder Questionnaire for 

screening for bipolar disorder in routine 

clinical practice in outpatients with major 

depression. Clinical Practice and 

Epidemiology in Mental Health, May 

2008; 4:1745-0179. 

• Field A. Discovering Statistics using 

SPSS, Sage Publications Limited, 2009. 

• Hirschfeld RM. The Mood Disorder 

Questionnaire: A simple, patient-rated 

screening instrument for bipolar 

disorder. Primary care companion to the 

Journal of Clinical Psychiatry, February 

2002; 4(1):9-11. 

• Hunter R, Fraser K, Martin M, Hudson 

S. Bipolar disorder – aetiology and 

pathophysiology. Hospital Pharmacist, 

2004; 11: 129-32. 

• Kasper S. Issues in the treatment of 

bipolar disorder. European 

Neuropsychopharmacology, 2003; 

13(Suppl 2): S37-42. 

• Kessler RC, McGonagle KA, Zhao S et 

al. Lifetime and 12-month prevalence of 

DSM-III-R psychiatric disorders in the 

United States. Results from the National 

Comorbidity Survey. Archives of General 

Psychiatry, 1994; 51: 8-19. 

• Menzin J, Sussman M, Tafesse E et al. A 

model of the economic impact of a bipolar 

disorder screening program in primary 

care. Journal of Clinical Psychiatry, 

September 2009; 70(9):1230-6. 

• Perry A, Tarrier N, Morriss R et al. 

Randomized controlled trial of efficacy of 

teaching patients with bipolar disorder to 

recognized early symptoms of relapse and 

obtain treatment. BMJ, 16 January 

1999;318:149-153. 

• Sachs GS. Unmet clinical needs in 

bipolar disorder. Journal of Clinical 

Psychopharmacology, 2003; 23: S2-8. 

• Simon S. An introduction to diagnostic 

tests. The Children’s Mercy Hospital 

2007. 

• Stang P, Frank C, Ulcickas Yood M, et 

al. Impact of bipolar disorder: Results 

from a screening study. Primary care 

companion to the Journal of clinical 

psychiatry, 2007; vol/is 9/1(142-47), 

1523-5998. 

• Twiss J, Jones S, Anderson I. Validation 

of the Mood Disorder Questionnaire for 

screening for bipolar disorder in a UK 

sample. Journal of affective disorders, 

September 2008; 110(1-2):180-4. 

• Wehr TA, Goodwin FK. Can 

antidepressants cause mania and worse 

the course of affective illness? American 

Journal of Psychiatry, 1987; 144: 1403-11. 

• Weissman MM, Leaf PJ, Tischler GL et 

al. Affective disorders in five United 

States communities. Psychol Med 1988; 

18: 147-53. 

• World Health Organization. The ICD- 

10 Classification of Mental and 

Behavioural Disorders. Clinical 

Descriptions and Diagnostic Guidelines. 

Geneva: WHO, 1992. 


Audit of risk assessment 

documentation in adult in-patients - 

adherence to Trust guidelines and how 

to improve performance in this area 

By Abigail Crutchlow 

Acknowledgements: Many thanks to Dr L Church for his help in finalising this document 

Background 

Current local policy for SABP NHS 

Foundation Trust states that all adult 

patients admitted to an in-patient unit 

within the Trust should have a 

standardised risk assessment form 

completed on admission and this should 

be updated regularly at every ward round 

or if a significant change in risk occurs. 

The aim of this audit is to provide an 

overview of performance and whether 

these guidelines are being met and, if 

not, to implement methods to improve 

performance. Through re-audit, the 

benefit and impact of such interventions 

and their role in the future will also be 

assessed. Formal ethical approval was not 

required for this audit as all data were 

anonymous and patients were not 

directly approached or involved in the 

audit. The audit was registered and 

approved by the Trust audit department. 

Method 

Initial audit 

The initial audit included all current adult 

in-patients on general adult wards at the 

Abraham Cowley Unit, Chertsey. The 

PICU unit was not included due to 

altered level of risk for these patients. 

Their notes were identified and their risk 

assessment on admission and its 

subsequent updates examined. 

The following questions were asked: 

1. Was a complete risk assessment 

recorded on admission? 

• This included a completed 

comprehensive risk assessment 

within 24h of admission 

2. Has the risk assessment been updated 

regularly /at each ward round? 

• Occasional or irregular updates 

were not considered satisfactory 

• If the patient had been an in-patient 

for a very short time and not yet 

been seen on a ward round 

(meaning regular updates may not 

yet have commenced) then this was 

noted and they were excluded from 

question 2 

3. Is the risk assessment accessible to 

staff? 

• Information needed to be clearly 

visible in the appropriate section of 

the notes 

It was recorded whether all, some or 

none of these three criteria were met for 

each set of notes reviewed. The length of 

stay, regularity with which the patient 

was seen on a consultant ward round 

and the team they were under were also 

recorded, as these were identified as 

possible factors that could influence the 

results. 

In order to meet the standard guidelines, 

all three criteria needed to be met. The 

data was then analysed and results 

identified as below. 




Based on the results of the initial audit, 

strategies to improve performance were 

implemented. An e-mail was circulated to 

all consultants and junior doctors 

involved in risk assessment for adult inpatients 

highlighting the outcomes and 

raising awareness of the need for 

adequate risk assessment. The three 

questions and the need to fulfill these 

were documented in the e-mail along 

with the intent to re-audit in 2 months’ 

time. As the changeover for junior 

doctors occurred shortly after the audit, 

this e-mail was circulated to both those 

doctors completing their post and those 

taking over from them. 

Re-audit 

A re-audit was undertaken in May 2009. 

23 sets of notes were randomly selected 

from all the in-patients currently on ACU 

(split equally across Blake and Clare 

wards). The 23 notes selected were then 

examined using the method and analysis 

outlined in the initial audit. Results were 

obtained for an overall view of the 

different criteria being assessed. There 

was no breakdown of results by 

consultant or regularity of ward round as 

this showed no impact in the initial audit. 

Results were analysed depending on 

length of stay, as this was identified as 

having an impact. These results were then 

compared with those of the initial audit to 

see if the heightened awareness had 

altered the recording of risk assessment 

Based on the results of the first re-audit 

and the possible areas of bias, further 

strategies to improve performance were 

implemented and second re-audit 

conducted in November 2009, which was 

towards the end of the post for the 

cohort of doctors included. The second 

re-audit followed the same method and 

structure as the earlier re-audit in May 

2009. This ensured that there had been 

consistency in the doctors completing the 

documentation over the last four months 

and also a long enough time period to 

ensure no notes had been included in the 

previous audit cycle. Formal teaching on 

risk assessment was delivered to the new 

cohort doctors at the beginning of their 

post in psychiatry at the ACU, Chertsey. 

This included an explanation of the risk 

assessment form and its importance, and 

was conducted by one of the in-patient 

consultants. 

Results 

Fig.1 Initial audit – distribution overall 

100 

90 

80 

70 

60 

% 50 

40 

30 

20 

10 

0 

Criteria 

Initial RA 

Initial complete RA 

Regular updates 

RA accessible to staff 

Meets standard guidelines 


Fig. 2 Re-audit May 2009 – distribution overall 

100 

90 

80 

70 

Initial RA 

60 

% 50 

40 

30 

20 





10 

0 

Criteria 

Fig. 3 Re-audit November 2009 – distribution overall 

100 

90 

80 

70 

Initial RA 

60 

% 50 

40 

30 

20 





10 

0 

Criteria 




Discussion 

When considering the results of the initial 

audit, the numbers in several categories 

are too small to be of value when 

analysing the data by the different factors 

felt to be possible influences on the 

results. Results should be interpreted with 

this in mind. There was no clear variation 

of results by consultant or regularity of 

ward round. There does however appear 

to be a link between increasing length of 

stay and decreasing fulfillment of criteria. 

This may be due to becoming less aware 

of a patient’s risk the longer they stay and 

an assumption that the risk is stable and 

therefore the update is not completed as 

frequently and is more likely to be 

forgotten. The achievement of the 

recommended targets actually 

deteriorated when re-audited. This was 

mainly due to a reduction in completed 

risk assessments on admission and also a 

smaller percentage of risk assessments 

were updated regularly. There was also 

less evidence on re-auditing that length 

of stay impacted on achievement of 

recommended targets. 

Heightened awareness by e mail appears 

to have been ineffective therefore in 

improving standards. However, various 

factors could have impacted upon this. 

As a large number of junior doctors 

changed between the two data collection 

points, this could have affected the 

results as new doctors were less likely to 

have experience and remember to 

complete risk assessment forms than 

those who had been doing the job a few 

months. Also some notes would have 

been included in the data collection on 

both occasions, and this may have also 

altered results. Notes which had not met 

standards initially were unlikely to meet 

standards in the re-audit, which would 

have led to a disproportionately larger 

amount of notes not meeting standards 

in the re-audit compared to the initial 

audit. It was therefore beneficial to 

repeat the audit at a later stage towards 

the end of one group of junior doctors’ 

employment (i.e. November/December 

2009). This allowed a long enough time 

period to ensure that no notes audited in 

earlier cycles are audited for a second 

time, which was a source of bias in the 

initial re-audit. This also allowed for 

consistency in documentation completion 

and had the advantage of identifying if 

time spent working in psychiatry helped 

increase awareness and completion of 

risk assessments and gave a more 

accurate picture of the benefit of any 

interventions that were implemented. 

Formal teaching on risk assessment was 

recommended during induction or in an 

early teaching session for this cohort of 

doctors as this has not been included in 

previous years. An improvement in 

meeting the recommened guidelines was 

evident from the re-audit in all areas, and 

length of stay appeared to have less 

impact than in the previous cycles. 

It appears from the second re-audit that 

structured interventions and formal 

teaching that heighten awareness of the 

importance of risk assessment and how 

to complete the relevant paperwork have 

led to improvements in meeting the 

recommended guidelines. With the 

introduction to the ACU of the new 

computer system, RIO, such interventions 

will become all the more important in 

order to ensure risk continues to be 

documented to the highest standard. The 

overall outcome of this audit suggests 

that formal face to face teaching along 

with time spent working in psychiatry 

and heightened awareness on the ward 

of risk documentation are all necessary to 

optimise meeting the guidelines and such 

interventions should be regularly 

employed by the Trust for doctors, both 

at induction and throughout their 

rotation. 


An evolving service – results of a 3 

year follow up study of the practice of 

a community mental health team 

incorporating the principles of “New 

Ways of Working” 

June 2010 By Jeremy Mudunkotuwe, Farida Yousaf 

Acknowledgements: Helena DuToit, Dipesh Naik 

Introduction 

In 2005 the National Steering Group 

published “New Ways of Working for 

Psychiatrists”1. This document outlined 

the way in which teams could change in 

order to facilitate the time spent by the 

psychiatrist with the team considering 

their training and skill set. The 

requirements for this change necessitated 

a major change in service at the 

community psychiatry level. The changes 

were principally to enhance patients care, 

but were also planning for a perceived 

lack of psychiatrists in the future, due to 

increased retirement and inadequate 

numbers of doctors in training. Services 

around the country made changes in-line 

with the National Service Framework, and 

the authors sort a way to monitor the 

changes within our team with regards to 

psychiatrists’ practice. 

Aim 

To assess over time the nature of 

psychiatrists’ appointments in the Mole 

Valley Primary Care Mental Health Team 

with regard to the changes as outlined in 

the “New Ways of Working” document 

published in 2005. 

Method 

An audit tool listing 15 reasons for 

psychiatric doctor appointments has been 

adapted from an audit tool described in 

the NWW report of 2005 “The Bromley 

and Greenwich Medical Staff Outpatient 

Clinic Audit Tool”1(see table 1). Each year 

from 2005 to 2008, for a 2 month period 

the psychiatrists within the team were 

asked to complete the audit tool for each 

patient they saw, either in their 

outpatients’ clinic, home visit or any 

other planned or emergency 

appointment. After each 2 month data 

collection period the results were collated 

and in 2009 the results for the 3 periods 

of assessment were compared. 

Table 1: The audit tool 

Reasons for assessment 

• DNA 

• New Assessment 

• Carer / family education / support 

• Court report preparation 

• CPA, or planning for CPA 

• Crisis planning / resolution 

• Discharge appointment 

• Medication review / prescribing 

• Mental state exam / diagnostic 

assessment 

• Physical health care check 

• Reassurance & support 

• Risk assessment / monitoring 

• Reports / benefits 

• Session of therapy as part of on-going 

course of therapy 

• Support than only a consultant can 

give due to complexity 




Results 

The results were entered into a database 

and simple comparisons were made 

between the results for each category 

over the 3 periods of data collection. The 

Chart 1 Comparison of results from 2005-2008 

50 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

DNA 

New 

Assessment 

Discharge 

appointment 

psychiatrists were allowed to select, 

none, one, or more than one of the 

fifteen categories for each case that they 

saw. Eight of the categories registered 

any results over the assessment periods. 

The results are shown in Chart 1 below. 

Medication 

review/prescribing 

Mental state 

examination/diagnosic 

assessment 

Reassurance 

and support 

Assessments 2005/2006 

Assessments 2007 

Assessments 2008 

Risk assessment/ 

risk montoring 

Some notable trends were seen in the data collected over the 3 years. 

Crisis planning/ 

crisis resolution 

The percentage of medication review and prescribing increased year on year, from 

27% in 2005/06, to 34% in 2007, and then to 46% in 2008. 

There was a marked increase in mental state examination and diagnostic 

appointments in the 2008 period (43%) compared to the years before, 18% in 2007 

and 20% in 2005/06. 

The percentage of appointments for reassurance and support remained at a similar 

level in each of the assessment periods. 

Risk assessment/monitoring appointments initially decreased in 2007 (1%) from 

the previous period but then markedly increased in the 2008 (14%) period. 

Discussion 

The authors felt that some really 

encouraging results were collected over 

the past 3 years indicating one aspect of 

the NWW movement that had greatly 

altered practice. 

We believe that the increase in the 

proportion of medication review and 

prescribing is a result of the appointments 

with the psychiatrists utilising their skills 

appropriately. Team members have seemly 

felt more able to arrange for the patients 

they care coordinate to attend for this 

specific advice. 

Mental state examination and diagnostic 

should a substantial increase in the last 

period and again the authors believe that 

this is an appropriate use of time for the 

psychiatrist in the team and would 

benefit patient care. Also with increased 

need for coding and monitoring of 

service this allowed accurate accounting 

of illnesses treated within the team. 

Risk assessments have increased markedly 

increased in the past year and is perhaps 

a marker of the increased concern in the 

present climate about serious incidents 

related to mental health. This could be 

seen as a retrograde step towards doctors 


having clinical responsibility for all of the 

patients within the team, instead of this 

being devolved to the respective care 

coordinator. Further research could 

establish what happens with the 

information gathered at this time to 

establish whether risk information adds 

to the care coordinators management 

plan in an appropriate manner. 

Appointments offering reassurance and 

support have remained at a low level 

throughout the assessment period this 

shows that despite changes to the service 

there is an appropriate level of this that 

should be offered by the psychiatrists. 

The authors believe that were this to be 

eliminated from their role then this would 

be to the detriment of patient care and 

job satisfaction. 

A reduction in the DNA rate over the 3 

periods of assessment could be seen to 

be a sign that patients appreciate the 

change in the nature of appointments 

that has occurred over time. The authors 

recognise that this surrogate marker for 

patient satisfaction may not be a true 

reflection of patients’ views. Future audits 

of this nature within the team will include 

more direct measures of patient 

satisfaction. 

Changes within the team that have 

facilitated this evolution are sometimes 

hard to pinpoint. As the population 

covered by the team have not changed 

and neither has the demographics of the 

people living in the area so the change 

has been within the team. The authors 

believe that increased and more effective 

supervision of the MDT has been a major 

factor and resulted in requests for fewer 

outpatient appointments. 

Conclusion 

Debate in the psychiatric literature 

continues about how the NWW 

movement impacts upon the 

psychiatrists’ role, job satisfaction and 

even recruitment 2,3,4,5 This literature has 

undoubtedly uncovered strong feelings 

that the majority feel that this process 

acts to the detriment of the psychiatrists’ 

practice. The authors believe that the 

audit shows that an evolutionary change 

in the service need not be a tremendous 

upheaval if managed well, and could 

improve psychiatrists’ working practices. 

The authors recognise that the process of 

change can only be attempted if others in 

the team are willing to take on new 

responsibilities. We believe that more 

effective and regular supervision from 

medical staff to non medical staff in the 

team has facilitated this change within 

our team. We are aware that our audit 

does not take into respect their view 

points and further work will address this 

as well as more direct measures of 

patient satisfaction. 

References 

1. Department of Health; Final report 

from the National Steering Group. New 

ways of working for psychiatrists: 

Enhancing effective, person-centred 

services through new ways of working in 

multidisciplinary and multiagency 

contexts. Department of Health; 

31 October 2005 67. 

2. Craddock N, Antebi D, Attenburrow 

M-J, et al. Wake-up call for British 

psychiatry. The British Journal of 

Psychiatry 2008 July 1, 2008;193(1):6-9. 

3. Dale J, Milner G. New Ways not 

working? Psychiatrists' attitudes. 

Psychiatr Bull 2009 June 1, 

2009;33(6):204-7. 

4. St John-Smith P, McQueen D, Michael 

A, et al. The trouble with NHS psychiatry 

in England. Psychiatr Bull 2009 June 1, 

2009;33(6):219-25. 

5. Vize C, Humphries S, Brandling J, et al. 

New Ways of Working: time to get off 

the fence. Psychiatr Bull 2008 February 1, 

2008;32(2):44-5. 




How can we look at improving 

recruitment into psychiatry? 

January 2009 

By Josie Jenkinson 

If recent figures are to be believed, fewer 

UK graduates are entering higher 

specialist training in psychiatry than ever 

before. Just 6% of candidates sitting 

Paper 1 of the MRCPsych in diet one of 

2008 were UK graduates (Oxtoby, 2008), 

and this is likely to be a national indicator 

of recruitment trends (Brown et al, 2009). 

This has lead to widespread attention 

being focused on potential ways of 

improving recruitment into psychiatry, 

and the Royal College of Psychiatrists 

having taken specific steps to address the 

issue (Royal College of Psychiatrists, 

2009). 

The current recruitment crisis is by no 

means a new problem. In fact, concerns 

regarding poor recruitment into 

psychiatry have been discussed since the 

1970’s and there have been similar issues 

in other countries, most notably in the 

USA (Brockington, 2002). As a result, 

there has been a substantial amount 

written on the subject of recruitment into 

psychiatry. Much of the literature has 

been concerned with identifying the 

factors influencing the choice of 

psychiatry as a career as well as 

suggesting strategies that might be 

adopted to improve recruitment based on 

these factors. However, in the light of 

ongoing change within the NHS and 

medical education, as well as a current 

climate of doubt and uncertainty as to 

the future role of the psychiatrist this is a 

very real and current issue facing the 

profession. Increasing reliance on 

international medical graduates to 

support and maintain delivery of 

psychiatric care increases the pressure to 

improve the current situation even 

further, given the possible impact of 

Home Office immigration policy changes 

(Brown et al, 2009). 

Any strategy aimed at improving 

recruitment into psychiatry would need 

to take into account the possible reasons 

why people choose psychiatry as a career, 

as well as what might deter them. This 

may be difficult as processes which 

influence doctors in their choice of career 

have been described as “subtle and 

complex” (Eagles 2007), however I shall 

outline some of the possibilities below. 

Prior to entering medical school, many 

specialties including psychiatry are rated 

as a very attractive option (Maidment et 

al, 2003). However, this attitude is not 

maintained throughout the years of 

undergraduate training, with medical 

students tending to develop more 

negative attitudes about the specialty 

(Brockington, 2002). This may in part be 

due to the negative attitudes towards the 

profession from non-psychiatrists and 

even psychiatrists themselves, for 

example describing psychiatrists as ‘not 

proper doctors’ (Craddock, 2008 p70). 

This is confounded by the sadly ever 

present stigma surrounding those with 

mental health problems and those who 

treat them, which medical students are 

exposed to both inside and outside of 

their training (Brockington, 2002). Four 

broad categories of negative opinions 

surrounding psychiatry as a specialty have 

been identified amongst medical 

students. These are related to the 

assumption that psychiatry lacks 

objectivity and is unscientific, that 

treatments are ineffective, that 

psychiatrists are ‘emotionally unstable’ 

and ‘second rate’ doctors, and a dislike of 

the patient population treated by 

psychiatrists (Scott, 1986 p99). 

However, undergraduate exposure to 

psychiatry seems to be particularly 

important as a potentially positive 

influence, with consultants in psychiatry 

citing a lasting influence of medical 


school exposure to psychiatry as an 

influence on their ultimate choice of 

specialty, even if their career choice was 

made after leaving medical school (Dein 

et al, 2007). Several studies have found 

that intentions of students to pursue 

psychiatry as a career were increased 

following exposure to a psychiatric 

attachment during their years at medical 

school. Specific factors are likely to be 

associated with a greater intention to 

pursue psychiatry as a career following a 

psychiatric attachment; namely receiving 

encouragement from consultants, seeing 

patients respond to treatment and having 

direct involvement in patient care 

(McParland, 2003). 

Positive elements of career in psychiatry 

which have been identified as appealing 

to prospective trainees are empathy for 

patients with a mental disorder, better 

working conditions, and the interface of 

psychiatry with neuroscience and the 

social sciences (Dein et al, 2007). Other 

factors identified as being important 

when choosing psychiatry as a specialty 

are enthusiasm and commitment for the 

specialty, and self appraisal of one’s own 

skills and aptitudes (Goldacre, 2005). 

In the light of the above, it would seem 

that focusing on the undergraduate 

experience of psychiatry as a target for 

increasing recruitment is paramount. 

Historically, this has been the reaction to 

the recruitment problem, and as a result 

pre-clinical teaching in psychology, social 

science and behavioural science now has 

a much greater emphasis. Inclusion of a 

psychiatry placement is now universal, 

however unfortunately it would seem 

that in recent years with the ever 

expanding demands placed on the 

curriculum, placements have decreased in 

length (Brown et al 2009). As such it is 

increasingly important that the best use is 

made of these placements, with students 

being actively involved in clinical care, 

being taught enthusiastically with an 

emphasis on evidence based medicine 

and patient recovery. Psychiatric trainees 

may be ideally placed to provide 

additional teaching and support to 

medical students, and should be 

encouraged to do so by their supervising 

consultants. Liaison psychiatry 

placements have been identified as being 

of particular appeal to medical students 

and may have special value in aiding 

recruitment in the future (Brockington, 

2002). Medical students who show an 

interest in pursuing psychiatry as a career 

should be encouraged and given ongoing 

support and careers advice (Eagles et al, 

2007). 

Another potential target for recruitment 

are those who have not yet entered 

medical school. It has been found that 

the type of person likely to pursue 

psychiatry as a career tends to have an 

interest in more psychological, 

sociological and artistic subjects, with 

many tending to have one A-level in a 

non-science subject (Brockington, 2002). 

They are also more likely to be from a 

lower social class, come from cities and 

be politically liberal (Eagle and Marcos, 

1980). It may be that development of 

widening participation schemes and 

graduate entry programmes may result in 

a greater number of students with these 

interests and attributes entering medical 

school and hence moving into psychiatry, 

although the effect of these 

developments has yet to be evaluated. 

Greater public awareness of mental 

health issues and the ongoing challenge 

of tackling stigma, possibly by 

improvement in public education and 

covering of mental health issues as part 

of the primary and secondary school 

curriculum may in time raise the profile of 

psychiatry and lead to greater 

understanding and appeal of the 

specialty, however this is unlikely to yield 

results in the short term. 

Several surveys have identified that the 

majority of people choose psychiatry as a 

career after graduation rather than 

during the undergraduate years 

(Brockington, 2002). With this in mind, 

increasing positive exposure to psychiatry 

during the foundation years may well 

have a positive effect on recruitment. By 

the end of their first year of work post 




qualification, doctors surveyed reported 

work experience as being a more 

important determinant of career choice 

when choosing psychiatry than with 

other specialties (Goldacre 2005). This 

would indicate that foundation posts in 

psychiatry may have a positive effect on 

recruitment, and this has been borne out 

to some extent (Boyle et al, 2009). Even 

where a doctor is unable to work in a 

foundation post, tasters in psychiatry can 

be organized as part of the foundation 

programme in order to give the 

foundation some additional experience 

of psychiatry. 

Unfortunately, doctors’ experiences of 

psychiatry if they are not doing a 

foundation post may be limited to 

occasional acute presentations, which if 

they do not have access to a psychiatric 

liaison service may be very difficult and 

frustrating to manage. Liaison psychiatry 

services, where they exist, may present 

valuable opportunities for psychiatrists to 

demonstrate the relevance of the specialty 

across all branches of medicine, to portray 

a positive image of psychiatry to our nonpsychiatric 

colleagues as well as to 

educate and motivate those doctors who 

are as yet undecided in their career choice 

towards considering psychiatry as a career. 

In summary, the major possible targets for 

recruitment into psychiatry would appear 

to be improving undergraduate experience 

in a variety of ways, maximising positive 

exposure to psychiatry during the 

foundation years, and supporting those 

who show an interest in psychiatry early 

on. Ideally any strategy should be coupled 

with an overarching aim to increase the 

profile and awareness of the importance 

and validity of psychiatry as a profession 

amongst the lay population as well as the 

medical community. 

So what has been done to address the 

problem? The Royal College of 

Psychiatrists has taken urgent steps by 

means of a Scoping Group on 

Undergraduate Education in Psychiatry, 

which has helped to develop a core 

curriculum for undergraduate psychiatry. 

Work is also being done with the 

Academic Faculty and the Association of 

University Teachers of Psychiatry to address 

issues within the undergraduate 

experience that adversely affect the image 

of psychiatry (Brown et al, 2009). 

The Royal College has also prioritised a 

process of engaging more closely with 

medical students. A student associate 

grade has been introduced, whereby 

interested students can sign up to the 

Royal College for free and gain access to 

various resources, such as electronic 

versions of the Royal College’s 

publications, a dedicated section of the 

Royal College website, reduced prices for 

college events and a variety of other 

benefits. An annual summer school has 

been organised in collaboration with the 

Institute of Psychiatry and South London 

and the Maudsley NHS Foundation Trust. 

A lot of this work has been done with the 

help of the Psychiatric Trainees 

Committee, who have also embarked on a 

project of developing student psychiatry 

societies in each medical school across the 

UK. These societies, with the support of 

local consultants, academic departments 

and trainees, aim to foster interest and 

raise the profile of psychiatry within 

medical schools by means of talks, careers 

events and educational meetings (Royal 

College of Psychiatrists, 2008). 

There is an additional aim to expand the 

numbers of foundation posts available 

within psychiatry, however this will require 

extensive negotiation and planning with 

the Foundation Schools and is an ongoing 

project. The Psychiatric Trainees 

Committee is also developing an e- 

learning project to enable foundation 

doctors to develop psychiatry 

competencies, which will be mapped to 

the new foundation curriculum, and with 

an emphasis on the overlap of psychiatric 

problems and physical health problems. 

This project endeavours to increase the 

resources available for foundation doctors 

to further their understanding of the 

relevance of psychiatry to the medical 

profession as a whole. 


The measures outlined above will 

hopefully go some way to addressing the 

current issues surrounding recruitment 

into psychiatry, however it seems clear 

these measures will require the support 

of the profession as a whole. Portraying a 

positive image of psychiatry, by means of 

emphasis on academia, use of evidence 

based treatments, enthusiastic and active 

involvement in teaching of medical 

students and foundation doctors requires 

the help of all psychiatrists (of any grade) 

who may encounter them. Medical 

students and foundation doctors are our 

potential colleagues of the future, and 

we owe it to our patients to try to recruit 

the very best. 

References 

Boyle A.M. et al (2009) ‘Recruitment 

from Foundation year 2 posts into 

specialty training: a potential success 

story?’ Psychiatric Bulletin 33: 306-308 

Brockington I., Mumford D. (2002) 

‘Recruitment into Psychiatry’ Br J 

Psychiatry 180: 307-12 

Brown N., Vassilas C. A., Oakley, C. 

(2009) ‘Recruiting Psychiatrists – A 

Sisyphean task?’ Psychiatric Bulletin 33: 

390 - 392 

Craddock N. et al (2008) ‘Wake-up call 

for British Psychiatry’ Br J Psychiatry 193: 

6-9 

Eagles J. M., Wilson S., Murdoch J. M., 

Brown T. (2007) ‘What impact do 

undergraduate experiences have upon 

recruitment into psychiatry?’ Psychiatric 

Bulletin 31: 70-2 

Maidment R., Livingston G., Katona M., 

et al (2004) ‘Changes in attitudes to 

psychiatry and intention to pursue 

psychiatry as a career in newly qualified 

doctors: a follow up of two cohorts of 

medical students’ Medical Teacher 26: 

565 - 569 

McParland M., Noble L. M., Livingston G., 

&McManus, C. (2003) ‘The effect of a 

psychiatric attachment on students’ 

attitudes to and intention to pursue 

psychiatry as a career’ Medical Education 

37 (5): 447-454 

Oxtoby K. (2008) ‘Psychiatry in Crisis’ 

British Medical Journal classified 

supplement 27/8 

Royal College of Psychiatrists (2008) 

Tackling psychiatry’s recruitment crisis 

head on RCPSych News 2010 Jan 

(http//www.rcpsych.ac.uk/member/rcpsyc 

hnews/november2008) 

Royal College of Psychiatrists (2009) 

Dean’s newsletter Royal College of 

Psychiatrists website 2010 Jan 

(http://www.rcpsych.ac.uk/specialtytrainin 

g.aspx) 

Scott, J. (1986) ‘What puts medical 

students off psychiatry?’ Bulletin of the 

Royal College of Psychiatrists 10 



Book Reviews 

Psychiatry P.R.N. 

Principles, Reality, Next steps 

June 2010 

By Jose Jenkinson 

Edited by Sarah Stringer, Laurence 

Church, Susan Davison, Maurice 

Lipsedge 

Publisher Oxford University Press 

ISBN 978-0-19-956198-8 

Price £24.99 

Psychiatry PRN is a new textbook 

primarily aimed at medical students, 

which introduces the specialty in a very 

practical and unique way. It offers a 

different approach to the majority of 

psychiatry texts by means of focussing on 

the key aspects of psychiatry from a 

clinical point of view rather than a purely 

academic one, whilst covering most of 

the subject matter needed by 

undergraduates to get the most out of 

their placements and to equip them for 

the OSCEs. 

Part one of the book gives an overview of 

psychiatry, including classification, 

interviewing skills, safety, mental health 

law and the basics of assessment. Part 

two consists of 20 chapters which cover 

the major areas of psychiatry including 

mood disorders, schizophrenia, 

personality disorder, addictions and old 

age psychiatry. Topics are covered in 3 

stages, as per the title. Each chapter 

starts with outlining the ‘principles’ of the 

subject in question, followed by taking 

the reader through the ‘reality’ of how 

such patients present, by means of case 

histories, and practice OSCE stations. 

‘Next steps’ then focuses on 

management and specific issues relevant 

to the subject, eg capacity issues in 

relation to dementia. This pattern is 

followed throughout the chapters and 

the format makes it a very easy book to 

dip in and out of as the need arises. 

The book is beautifully illustrated, with 

many of the pictures serving as an aide 

memoire for major conditions. Use of film 

and book quotes to illustrate topics and 

lists of books and films alongside books 

and papers for further reading bring the 

subject alive and further increase the 

accessibility and subjective relevance of 

psychiatry in the eyes of the reader. 

Additional online resources are also 

included, with video clips of assessments, 

downloadable OSCE mark sheets, an 

MMSE outline as well as all the artwork 

in the book which can be downloaded 

for use in teaching sessions. 

Overall: This book is very much focussed 

on practical ins and outs of assessing 

psychiatric patients, and the importance 

of communication and empathy, rather 

than purely focussing on diagnostic 

categorisation, psychotropics and exam 

questions. As a result this is an extremely 

useful aide for students, and very 

different from other undergraduate 

textbooks available. Read in conjunction 

with one of the other weightier texts this 

should provide students with sound 

knowledge and practical ability, as well as 

being useful for any doctor starting their 

first psychiatry post or wanting to refresh 

their basic knowledge of the subject. It 

will also be highly relevant for anyone 

who teaches medical students as a basis 

for structuring teaching sessions, running 

practice osces and providing useful 

handouts. It is fairly lightweight (and very 

portable) and offers good value for 

money given the amount of materials 

included in the price. 

Highly recommended 


Interview with Fiona Edwards, Chief 

Executive SABP NHS Foundation Trust 

June 2010 By Abigail Crutchlow (supervised by Raja Mukherjee) 

Fiona Edwards is the Chief Executive of 

Surrey and Borders Partnership NHS 

Foundation Trust and I met with her 

recently to interview her about some of 

the current issues and her views and 

opinions on her role and how the Trust 

can progress: 

Q. Many people working in the Trust 

may not know that much about you. 

Can you tell me a bit about your 

background and interests? 

“My background is human resources 

professional, originally in industry, before 

working for the NHS. I achieved seniority 

fairly early on in my career, and initially I 

was very focussed on that, and then 

thought “what’s next? What does my 

career look like?” I was interested in 

exposure to an industry that I thought 

would be more people based. I became 

HR director in a Community Mental 

Health and Learning Disability Trust in 

Berkshire and after about six years 

became very focused in wanting to move 

into general management and a Chief 

Executive role, largely because I felt my 

professional background and the nature 

of the services and the work would match 

well in terms of what I consider needed to 

be sorted in the Health Service, which is 

people management. In my spare time I 

do a lot of running; physical exercise is 

important to me, it is my personal and 

switching off time. I am competing in the 

London ASICS 10k race”. 

Q. We have now been a Foundation 

Trust for about two years. What do 

you feel has gone well so far? 

“I am pleased to have achieved 

foundation trust status in a struggling 

health and social care economy. Surrey 

has never had a good reputation from a 

financial management point of view, and 

given that one of the main issues for a 

foundation trust is competence in 

running the organisation and being 

focussed, that has been a big 

achievement. Key factors in this include a 

strong executive and board team working 

ethos. We have invested a lot of time at a 

senior level concentrating on how we 

work as a multidisciplinary team. The 

other bit is optimism - rather than 

spending all our time focussing on what 

is going wrong and what is worrying us. 

One example would be when we were 

thrown by a negative visit by the Health 

Commission where it did expose some 

genuine criticisms. You could then go 

into immediate disaster scenario, 

thinking: “Is this what all our Services are 

like?” which is what we did. But what we 

then did, to get ourselves into a positive 

frame of mind, was to then systematically 

look at all the issues, but also why we, as 

a board and executive team, were not on 

the alert to this. It meant we had a much 

more comprehensive view of things, 

which some people might think is quite 

bureaucratic and audit based, but has 

helped me and the board to really focus 

on the importance of local team 

leadership”. 

Q. What are your visions for the 

future and can you outline any 

particular challenges faced, 

particularly running a geographically 

large Trust? 

“Over the last year we have put a huge 

amount of effort into our Staff Survey, 

getting a high level of response, and 

involving all of our staff. This is to 

demonstrate to staff that we really want 

to understand where they are at, and 

through managing that process via local 

managers and leaders it will help me to 

understand and manage individuals 

better as well as the organisation. With 

Interview 


Interview 

regard to challenges I don’t see the 

geography as such a problem as the 

clinicians on the ground, because I have 

worked in a multinational organisation 

with places in different countries and 

actually this Trust is not that big in the 

terms of geographical spread, although 

admittedly it is not like a hospital in that 

we are not all on one site. For the 

clinicians on the ground I think it is about 

really working at our IT infrastructure 

better and realising that we do not all 

have to be in one place. If you can get 

the IT infrastructure connected then the 

organisation will feel more connected in 

a different way, rather than in the 

traditional way of all being in one 

hospital. The IT strategy includes a 

Blackberry pilot which is now beginning 

to take off and one very basic, simple 

thing that Mandy Stevens, Director of 

Quality Performance, has (she comes 

from the Priory, which has sites across the 

country) is doing telephone 

conferencing”. 

Q. I suppose the other issue is having 

sufficient funding and resources there 

for rolling out the Blackberries, and 

other more financially draining 

aspects of communications? 

“They are actually reasonably easy to 

deliver; we just need to make sure we are 

managing it at a decent pace, because 

we do have a lot of people (not least 

myself) who are not over confident with 

technology!” 

Q. That leads on to discussing money 

and other opportunities. If money 

was no object, as a hypothetical 

question, what other services would 

you like to bring in? 

“Well I would object to that question 

because that is not the real world. I think 

as an organisation we have to help 

people understand that limited resources 

and service development go hand in 

hand. My particular interest is around 

having a much greater focus on 

wellbeing. I am very interested in the 

nature of the Surrey population and why 

Surrey has such a high usage of general 

hospitals acute care, when it is technically 

supposed to be one of the healthiest, 

wealthiest counties in the nation. I think 

we have some fantastic opportunities as 

a Mental Health and Learning Disability 

Trust to move away from looking at 

individual specialties and to try to use the 

expertise we have in our clinicians to start 

answering those questions for a bigger 

population. I think that getting people to 

understand and think of the connection 

between mental and physical health, in 

the way Services are commissioned, is a 

real challenge”. 

Q. There have been some difficult 

decisions recently that have had to be 

made across the Trust regarding bed 

closures and reconfiguration. Do you 

think there are any particular lessons 

that came out of that? 

“I think one of the lessons is that there 

has been no reduction in the number of 

people that are being seen and the 

reason we have been able to close beds is 

because the system in the community is 

up and running well. Admittedly there 

has been some discontent around it, but 

not as much as there may have been 

elsewhere. The readiness of people to 

work with it and try it out is a 

phenomenal testimony to the sound 

clinical practice and teamwork in those 

systems. The best way to manage such 

issues is to have a strong multidisciplinary 

team locally, with strong confident 

clinicians, who are able to work 

collaboratively. My job is to make sure we 

have the right people in the senior 

leadership positions and the competence, 

confidence and climate so that people 

have the challenge and discussion before, 

rather than after, the event”. 


Q. Very topical to that is the 

appointment of a new Medical 

Director of the Trust. How do you 

view the role of medical director? I 

understand that there has been some 

discussion of the role changing in 

some respects. How do you envisage 

that role and how will you ensure you 

seek out and engage the right 

person? 

“I view the Medical Director as being the 

clinical leader of the organisation. What I 

really want to see is someone who brings 

a vision for the clinical tasks of the Trust 

overall and pulling the whole thing 

together. This is someone who can talk to 

all clinicians, not just doctors, who can 

understand where everyone is at and 

someone who is excited by the thought 

of taking the leadership, rather than 

doing it out of evil necessity”. 

Q. How do view the role of medics 

and clinicians within the Trust? How 

do you feel they should be working 

with management to get a 

collaborative approach? 

“I think they should be part of the 

management team, not see themselves 

as separate from it. They should be 

confident leaders. I would like to see a 

little bit more pressure from the clinicians 

in the organisation, a bit more testing 

and more questioning and confidence in 

admitting what they don’t know, and 

what they need in help in understanding 

about how a foundation trust and the 

finances work. I do see some really good 

examples where clinicians are very clear 

on their ambition for theirs services, for 

example a liaison service in one part of 

the Trust got up and running from the 

vision of the medical lead”. 

Q. Do you have any final comments 

that you would like to make? 

“The other area that I am really interested 

in for this organisation, going back to 

your question about what I get excited 

about, is research and education. I think 

we have more opportunities emerging in 

the sense of research for patient benefit. 

It is something we could build our 

reputation around in partnership with the 

service user community and also with the 

universities”. 

Q. That was one of the areas that the 

Care Quality Commission mentioned 

as lacking on their recent visit to the 

Trust so it is an important area. So 

again that is something quite 

important. 

“I wasn’t aware of that specific issue so 

much, but it doesn’t surprise me. What 

we are doing with the role of the Medical 

Director and the fact that we want to 

elevate the research and development 

directorate function, to have it more 

closely overseen by the Board, dovetails 

with seeking to address that concern. I 

am very clear as Chief Executive that we 

need to get it right, for the kind of 

organisation we are, but also pay much 

more strategic attention to it”. 

Interview 


Surrey and Borders Partnership 


Surrey and Borders Partnership NHS Foundation Trust 

Trust Headquarters, 18 Mole Business Park 

Leatherhead, Surrey KT22 7AD 

Tel: 01883 383838 www.sabp.nhs.uk

Here - Surrey and Borders Partnership NHS Foundation Trust

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