Driving quality implementation in the context of the Francis report

Driving quality
implementation
in the context
of the Francis report
Occasional Paper OP92
December 2013
Royal College of Psychiatrists
London

Professor Sue Bailey, President of the Royal College of Psychiatrists, led this work. The report was drafted
by Lucy Thorpe, Head of Policy, and Greg Smith, Policy Analyst, at the Royal College of Psychiatrists.
© 2013 Royal College of Psychiatrists
The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369).

| | Contents
2 Foreword
4 Introduction and overview
9 Principle one: always put patients first
12 Principle two: prioritise patient safety and well-being
15 Principle three: provide high-quality clinical leadership
17 Principle four: respect regulation, inspection and accountability as
supporting care
20 Principle five: value the importance of outcomes and accurate data
22 References
Contents 1

| | Foreword
Endless changes to the National Health Service (NHS) have been
characterised by a top-down, managerial approach. As David Prior,
Chair of the Care Quality Commission (CQC) observed recently, clinicians
have in part ‘allowed the false dichotomy of clinical leadership
versus “management” to emerge’ and to go unchallenged. They have
become disengaged from a culture characterised by obsession with
financial targets and systems whose purpose has been self-perpetuation
of the organisation (Prior, 2013), while patients have – in some
cases literally – faded away.
Clinicians risk drifting into an insidious mindset of learned helplessness;
when they speak out, their voice has at times been frail and
even inaudible.
As clinicians we need to listen to and learn from each other, and listen
to and learn from our patients and their carers. We need to help the
organisations in which we work to take more seriously what has so
rightly been called the ‘gold dust’ of complaints (The Independent,
2013). We must take complaints more seriously and challenge riskaverse
cultures. Above all, within the Royal College of Psychiatrists we
need to appropriately support whistle-blowers and other members
whose working circumstances and the expectations placed on them
are incompatible with delivering safe practice.
Clinical leadership, transparency and accountability are fundamental to
the future of the NHS and all health and social care. Never before has
there been a stronger need for the family of medical Royal Colleges to
stand together to work on the fundamental commonalities of tackling
unacceptable variability both in practice and in clinical outcomes,
across geographies, 7 days a week.
The Academy of Medical Royal Colleges is 220 000 doctors strong;
our own College is 17 000 strong. Both need a unified voice to tackle
the variation within and across services throughout the UK.
The College response to the Francis report therefore stands alongside
and links with the response of other medical Royal Colleges, allied
health professional bodies, providers, regulators, commissioners
and educationalists. It has evolved from ongoing discussion with
and feedback from College Council, honorary officers, faculties, sections,
divisions, the four UK jurisdictions, members, patients, carers,
special interest groups, College leads and special committees. This
is therefore a dynamic document, which the College will revisit in 6
months’ time. It provides an ethical framework against which we will
align and test College strategy and activities.
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Much work has already been undertaken to mitigate the realities of
the worst care seen in Mid Staffordshire NHS Foundation Trust and
Winterbourne View hospital. Complacency, and seeing challenges as
‘not my business’, have been, and will continue to be, the enemy of
good, safe, whole-person patient care. Continuously reviewing what
works, testing out, revisiting and refining, are essential for providing
values-based, whole-patient care. Most importantly, robust and continuous
review of our own individual clinical and academic practice
in diverse teams, organisations and settings has to be underpinned
by intelligent kindness.
My sincere thanks to the many College members and other colleagues
who have responded with the wise thoughts and practical suggestions
that have contributed to this response to the Francis report.
Professor Sue Bailey, OBE, FRCPsych
President
Foreword 3

| | Introduction and
overview
The Francis report has considered the whole of the medical and
nursing professions, asking difficult questions about the established
practices of health professionals. It holds lessons for every healthcare
professional, including psychiatrists, and also for allied health
and social care professionals. The Royal College of Psychiatrists and
individual psychiatrists have a duty of care to our patients to address
the issues raised.
Although the Francis report focused on the care of patients in the
acute sector, the findings and recommendations are just as important
for mental health patients. The College has carefully examined
the specific recommendations of the report to see how, working
with others, we can provide mental healthcare consistent with the
recommendations and standards set out in the report.
The Francis report highlights the importance of seeing the provision
of care from all perspectives, of involving patients and carers at every
stage, and above all of listening to them. As doctors, we must work
within an ethical framework, and this must govern all the decisions
we make every day in our clinical roles.
The Royal College of Psychiatrists’ formal response to the Francis
report, and the work programme it sets out, are underpinned by five
principles.
1 Always put patients first, engaging openly and transparently
with patients and carers about care and treatment – respecting
their wishes wherever possible.
2 Prioritise patient safety and well-being.
3 Provide high-quality clinical leadership within teams of professionals
and in organisations.
4 Respect regulation, inspection and accountability as supporting
care.
5 Value the importance of outcomes and accurate data in
improving patient care.
Responses to inadequate or abusive practice tend to emphasise the
practical, ethical or moral failings of individuals. These are relevant, but,
alone, statements of the importance of compassion, patient-centred
care and the duty of candour are unlikely to prevent further scandals.
Inadequate and abusive care arises in response to situational forces
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and a variety of behavioural cues. For example, the abusive behaviour
so graphically shown in the BBC’s Winterbourne View television
programme (BBC One Panorama, 2011) arose primarily as a consequence
of placing vulnerable people with challenging behaviours
under the care of ordinary people in a closed environment. The primary
failing at Winterbourne View was not failure to recognise that abuse
was going on (which was a secondary failing) – it was the failure to
recognise that such behaviour was highly likely to arise in that setting
unless active steps were taken to prevent it.
Similarly, the failings in the Mid Staffordshire NHS Foundation Trust
occurred in a culture that prioritised organisational needs over patient
care. Staff were bound to respond to managerial imperatives. If providing
good quality of care and ensuring good patient experience
are not prioritised, they will always suffer when other behaviours are
being rewarded. We need to take on board the lessons of the Milgram
(1974) and Zimbardo (Haney et al, 1973) experiments (research which
was conducted 40 years ago), namely that ordinary, decent people
will behave badly in environments that are not designed to help them
to behave well.
Francis recognises the unhelpful nature of a blame culture. However,
for him systemic factors seem to be administrative rather than about
psychosocial relationships, group and institutional dynamics. What
is missing from his analysis is a psychological perspective.
What is required to prevent poor practice is the setting up of proper
systems of supervision, understanding what pressures staff are experiencing,
taking action when things go a bit wrong rather than waiting
until they are very wrong, and making patient feedback a key indicator
of performance.
Essentially, compassion in care is about training, education and professional
responsibilities for self-care. Ensuring that the workforce feels
healthy, confident and supported, and that professionals are enabled
and encouraged to focus on their own as well as their patients’
well-being, is important for them to be able to function effectively.
At an organisational level, work undertaken by the College in response
to the Francis report will include the following.
1 Emphasising clinical leadership as a core attribute for all psychiatrists,
based on integrity, moral values and intelligent kindness,
and defined as:
◦{
implementing standards of high-quality care
◦{
supporting colleagues and building teams
◦{
speaking out when poor practice is identified and being part
of the solution
◦{
continuing the College’s ongoing commitment to achieving
parity of esteem for mental health.
2 Defining quality standards, which include compassion and
patient-centred care, through the work of the College Centre
Introduction and overview 5

for Quality Improvement (CCQI), and considering the implications
of the Francis report for the accreditation processes run
by the CCQI.
3 Developing mechanisms with providers to support clinicians
raising concerns about services, through:
◦{
creating a culture where the clinical voice is strong and heard
◦{
creating a culture in which clinicians are supported so that
they in turn will support patients
◦{
developing College guidance to psychiatrists on whistleblowing
and/or passing on concerns.
4 Leading the development and implementation of the Quality Mark
for Elder-Friendly Hospital Wards to benefit elderly patients across
the whole range of medical care. This is being developed with key
partners: Age UK, the British Geriatrics Society, the Royal College
of Nursing and the Royal College of Physicians (www.rcpsych.
ac.uk/quality/qualityandaccreditation/elder-friendlyqualitymark.
aspx).
5 Further work on developing outcome indicators to improve
individual and team practice and focus more on patient/carer
experience outcomes, together with clinical outcomes. This will
include developing patient-related outcome measures and composite
outcome data in partnership with patients and carers.
6 Working with the Health Foundation and other medical Royal
Colleges to share good practice to strengthen the role of professionals
in improving service quality.
7 Continuing to publish findings from the National Audits the CCQI
is commissioned to undertake (such as the National Audit of
Schizophrenia), to contribute to collective learning and service
improvement.
8 Publishing a code of ethics for our members.
9 Using any opportunities provided by the Shape of Training Review
(Greenaway, 2013) to look anew at our training programmes to
ensure they are fit for purpose and will produce the psychiatrists
that patients need. We will, with others, review training across
the whole of medicine to increase the psychological mindedness
of all doctors practising in all medical disciplines.
10 Through training and lifelong learning, we will improve our skills
in preventing, identifying and responding to our patients’ physical
healthcare needs.
11 College work on public mental health will focus on improving the
well-being of whole populations. Both professional and lay carers
have to manage their own health and well-being to be effective,
and should be supported by care organisations to operate to the
highest ethical and personal care standards. Professionals must
adhere to agreed standards of professionalised care practices,
which should include compassion and due regard to patients’
concerns and priorities. Courses on public mental health are
being developed, including a shared approach with the UK’s
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Faculty of Public Health, to which self-care and professional
well-being will be central.
12 The College will host a meeting of senior mental health officials
from each of the UK governments at its annual International
Congress to enable exploration of common issues for mental
health for all jurisdictions of the UK.
CCQI Enabling Environments
Award
Through the CCQI the College is in a position to help monitor and raise
standards of care by helping individual clinicians and clinical teams
assess and improve the quality of care they provide. The Enabling
Environments Award (www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/qualityandaccreditation/enablingenvironments.aspx)
recognises that good relationships promote well-being, but that many
organisations and groups fail to address this aspect of people’s lives.
The Award is a quality mark given to those who can demonstrate they
are achieving an outstanding level of best practice in creating and
sustaining a positive and effective social environment. It is specifically
designed to allow services to assess the extent to which they actively
listen and respond to the views of front-line staff and patients.
RCPsych in Wales
In considering both the Francis report (Francis, 2013) and the report
on Winterbourne View (Department of Health, 2013a), the RCPsych
in Wales will focus on several important areas: local health board
plans to fulfil the recommendations of the reviews; plans set by the
Welsh Assembly Government to ensure that outcomes are being
met and their impact on mental health professionals; how services
can be better commissioned; and how to safeguard whistle-blowing.
There will be a conference on ‘the age of anxious practice’, with the
Health Minister for Wales, the Chief Executive of Health Inspectorate
Wales and a Senior Assessment Advisor from the National Clinical
Assessment Service.
RCPsych in Northern Ireland
In Northern Ireland, the College’s current emphasis on the correlation
between good psychiatric leadership and management and safer,
more clinically effective services with improved patient experience
has gained further significance in the light of the Francis report. The
findings have also lent considerable momentum to the ongoing roll
out of the Implementing Recovery through Organisational Change
(ImROC) programme in Northern Ireland. Finally, its long-standing
Introduction and overview 7

prioritisation of listening to the lived experience of patients and carers
has gained ever greater importance.
RCPsych in Scotland
Together with the Academy of Medical Royal Colleges and Faculties
in Scotland, the RCPsych in Scotland is contributing to initiatives that
will support the Francis recommendations. The College is a leading
participant in the Scottish Patient Safety Programme for Mental
Health; this was a major topic at its national academic meeting in
September 2013.
RCPsych Divisions in England
The priority for the College’s Divisions in England is to support the
development of high-quality practice through maintaining and developing
standards. Each Division will:
• z focus on providing high-quality educational events that maintain
and develop mentors’ and trainees’ expertise in the areas of their
continuous professional development (CPD) that cannot be met
easily within their organisation and specialty
z • further develop its recruitment initiatives to help ensure the provision
of a high standard of consultant psychiatrists for future
services.
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| | Principle one: always put
patients first
‘It is a common complaint by patients and their carers that the various services are not “receptive”
to our comments. It is the usual response of disbelief or just not accepting any comments
especially if [they have] the mildest hint of criticism’ (member of the College Carers’ Forum).
‘We must put patients at the heart of everything that we do’ (Professor Sue Bailey, President).
‘Patients, their carers, their families and the public need good psychiatrists. Good psychiatrists
make the care of their patients their first concern: they are competent; keep their knowledge
up to date; are able and willing to use new research evidence to inform practice; establish
and maintain good relationships with patients, carers, families and colleagues; are honest and
trustworthy, and act with integrity. Good psychiatrists have good communication skills, respect
for others and are sensitive to the views of their patients, carers and families. A good psychiatrist
must be able to consider the ethical implications of treatment and clinical management
regimes. The principles of fairness, respect, equality, dignity and autonomy are considered
fundamental to good ethical psychiatric practice’ (Good Psychiatric Practice, Royal College
of Psychiatrists, 2009).
The Francis report highlights the need for
patient-centred care and the consequences of
failing to put patients first in a healthcare setting.
Knowledge and skills are only one aspect of this;
it takes the right attitude, culture and values to
deliver true patient-centered care.
Psychiatrists must be advocates for their patients,
doing things ‘with’ rather than ‘to’ them, considering
their individual circumstances and developing
individual care plans within a framework of consistent
evidence-based practice. Psychiatrists
must work as a team with patients, carers and
colleagues, and do this with compassion, dignity
and respect.
The NHS Constitution (Department of Health,
2013b) commits all NHS staff to:
‘be[ing] open with patients, their families, carers or
representatives, including if anything goes wrong;
welcoming and listening to feedback and addressing
concerns promptly and in a spirit of co-operation’.
This is alongside General Medical Council (GMC)
Good Medical Practice (2013) which sets out the
requirement for all doctors to:
‘listen to patients, take account of their views, and
respond honestly to their questions [and] be open
and honest with patients if things go wrong’.
An important strand of patient-centred care is
continuous and consistent focus, action and monitoring
centred on the minimisation of harm and
risk. In the context of mental health this can include
minimising the risk of a patient harming themselves
or others, and, unlike the rest of medicine, psychiatrists
have an additional role and responsibility
in that they are given the power to detain people
under relevant mental health legislation.
The comprehensive assessment of the patient
must at all times involve the patient as fully as
possible, weighing risk with input from all those
who need to be involved, and putting in place a
plan which respects individual autonomy as much
as possible, with the understanding that therapeutic
risk must be balanced against restrictions
Principle one: always put patients first 9

to individual autonomy. This is even more important
when there are potential risks to others, when
psychiatrists support decision-making processes
across multi-agency teams to decide on the optimum
way forward, protecting both the public and
the patient in a thoughtful, considered and professional
way.
College action
1 The College will continue to support and
develop best practice, and publish educational
materials to support patient-centred
professionalism and care.
2 The College will revise its report Good
Psychiatric Practice to incorporate the necessary
lessons from the Francis report.
3 The College recognises that it is crucial to
recruit doctors with person-centred skills and
values, and we will explore how our recruitment
methods might become more values
based.
4 The College will continue to influence
the development and implementation of
patient-centred mental health policy and
legislation.
5 We will work in partnership with patients and
carers to develop all of the above.
Patient Safety Expert Advisory Group
The Group is currently updating two major College
reports which asserted the need for compassionate
care and collaboration with patients and
carers – Rethinking Risk to Others in Mental Health
Services (Royal College of Psychiatrists, 2008),
due in 2014, with reference to the findings and
recommendations of the Francis report, and Self-
Harm, Suicide and Risk: Helping People who
Self-Harm (Royal College of Psychiatrists, 2010),
which will be reviewed at a later date.
Faculty of the Psychiatry of Old Age
The Francis report is particularly poignant and relevant
for old age psychiatry. Many of the vulnerable
people who formed the basis of the report were
elderly. There is no complacency in old age psychiatry
regarding the issues raised by the report.
Francis states that caring approaches are applicable
to all, but makes particular mention of elderly
people. All staff need to understand life-cycle
changes and dependency issues in old age.
The Faculty has established a working party to
consider the implications of the Francis report for
psychiatric care for the elderly.
Faculty of General Adult Psychiatry
We recognise the profound importance of the
Francis report and its core recommendation that
patients must be at the heart of everything we
do. We must bear in our minds the need to treat
patients not only with technical expertise, but also
understanding and compassion. To this end, the
Faculty has established a ‘compassion in care’
workstream which aims to make sure that the
right values are instilled in psychiatrists from their
training onwards, are maintained in the clinical
workplace, and that psychiatrists model these
values for others.
Compassion and competence are themes of the
Faculty’s residential conference in 2014.
Faculty of Medical Psychotherapy
Consultant psychiatrists in medical psychotherapy
are increasingly active in developing, leading
and delivering flexible integrated services for
people with a diagnosis of severe and complex
personality disorder. These services are delivered
across clinical pathways through primary care,
secondary mental healthcare, local authority and
criminal justice provisions, and specialist treatment
services provided locally within borough/county
and nationally in specially commissioned tier 4
in-patient personality disorder treatment services.
Not uncommonly, this patient group has faced
cumulative adversities and can become fixed in
their response pattern to adversity – a response
that is frequently replicated in the services set up
to manage their extreme difficulties in caring for
themselves safely and in relating to others.
A Faculty member has recently taken on leadership
of a tier 4 in-patient service that was rigid and
fixed in its approach to challenge and change. He,
the multidisciplinary team and the patients have
decided to encourage patients to be present and
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active in all discussions about their care in ward
rounds, in care programme approach meetings
and in mental health tribunal reviews. In addition,
the multidisciplinary team has reintroduced
a monthly carers’ forum. The consultant is involving
all families in meetings with their family member in
treatment to build towards recovery and discovery
of a new way of living safely and with purpose.
Patients and their families, as well as staff, referrers
and commissioners, have responded very
positively to this approach and have welcomed the
opportunities to engage openly and transparently.
Principle one: always put patients first 11

| | Principle two: prioritise
patient safety and
well-being
‘Having recently gone through the process of being in a service in which maltreatment is
tolerated under the guise of keeping the carers and other professionals on board, I blew the
whistle. I acted on GMC guidelines stating that it is a doctor’s duty of care to report any worrying
practice. The result has been that I have been victimised, stigmatised and professionally
penalised. It is of no use whatsoever that there is a duty of candour if there is no protection for
those who actually do put patients first and raise the alarm’ (College member).
Mental health services need to provide high-quality
care which is safe, clinically effective and offers
optimal patient experience. Every psychiatrist must
embed patient safety into daily practice.
Appropriate staffing – both in terms of numbers
and the skill mix being matched to patient need –
is necessary to actually deliver safe services and
to enable professionals to support each other in
their work.
Providing a forum for discussion and understanding
of work-related problems and feelings can
prevent them being acted out. It addresses the
mindlessness and detachment that may characterise
some staff/patient interaction.
Part of the College’s role is to facilitate high-quality
care through:
• z the quality networks run by the CCQI and its
accreditation of services
• z developing new outcome measures
• z supporting appropriate information-sharing
between health and social care
• z fostering and supporting good multidisciplinary
working (via the Interprofessional Mental
Health Senate 1 )
• z working appropriately with government regulators
and inspection systems (see also
Principle four, pp. 17–19).
Providing highquality
services
Rightly, much emphasis is placed on National
Institute for Health and Care Excellence (NICE)
guidelines as providing evidence about clinical
effectiveness and the quality of care. However,
we need to recognise that guidelines make recommendations
based on published research:
the more high-quality studies there are, the more
robust the guideline.
To deliver improved quality of care for patients,
high-quality research and appropriately trained
researchers are needed. Mental illness is the leading
cause of years lived with disability in Western
Europe and a major global public health problem.
We therefore need more funding for mental health
research, equivalent to other medical conditions
such as cancer and heart disease. The College will
continue to press governments for more research
funding for mental health for the express purpose
of achieving better patient outcomes.
1 This is an informal grouping of six professional bodies and
organisations representing the majority of the workforce
(British Association of Social Work, British Psychological
Society, College of Occupational Therapists, College of
Social Workers, Royal College of Nursing, Royal College of
Psychiatrists) that provides care and treatment to people with
mental health problems in the UK. Members have a shared
interest in informing mental health policy and practice and in
ensuring that health reforms and restructuring improve and
enhance services. The Senate meets four times a year.
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College actions
The College is working to:
1 Further develop its own guidance to psychiatrists
on whistle-blowing or passing on
concerns, as transparency and candour are
at the heart of good psychiatric practice.
2 Monitor the implementation of core clinical
guidelines.
3 Support NICE to evolve guidelines for ‘real
world’ care pathways (e.g. requesting that
NICE develop acute care pathways that can
embrace primary and secondary care, mental
health, and accident and emergency).
4 Update the existing College guidelines on risk
to self and others.
5 Work with the College of Mental Health
Pharmacy, the Royal Pharmaceutical Society
and the Royal College of General Practitioners
to reduce medication errors.
6 Support innovative projects in suicide prevention
and other areas of care.
7 Improve safety training in the College membership
examination and CPD.
8 Support and protect members who have been
victimised for whistle-blowing.
Faculty of Medical Psychotherapy
The Faculty of Medical Psychotherapy has long
recognised the importance of developing psychological
mindedness in psychiatrists, alongside all
other members of multidisciplinary teams working
in mental health services. In its strategy for the
education and training of psychiatrists, the Faculty
is seeking to create opportunities to develop the
capacities of psychiatrists to reflect on interactions
between themselves and their patients in a way
that enhances both the emotional development of
psychiatrists and the quality of the care they give to
their patients. A good example of this is the provision
of ‘reflective practice groups’ for psychiatrists
at different stages of their professional life cycles.
These meet regularly and consistently, and have
a focus on learning from the interactions between
doctor and patient. The difficulties and strengths
of patients can be recognised, explored, understood
and worked with as a result of this learning.
Likewise, the difficulties and strengths of psychiatrists
can be recognised, explored, understood and
worked with for the benefit of the wider range of
patients seen throughout the psychiatrist’s career.
Good health organisations recognise the value
of this approach and seek to develop it to ensure
more active therapeutic work with patients.
Faculty of Liaison Psychiatry
The Faculty of Liaison Psychiatry has made explicit
five work streams essential to realising the ambitions
of the Francis report:
• z models of care: all commissioners will understand
what an effective model of liaison
psychiatry service looks like for their hospital
and acute care pathway
• z outcomes: all commissioners will have access
to a balanced scorecard of service outcomes,
including benefit to the patient, the referrer,
the hospital and the system
• z payment and pricing: all commissioners will
know how much an effective model of liaison
psychiatry costs and operate it within
an economy able to return the value to the
system
• z workforce: all services will be able to draw
on a trained and supervised consultant-led
multiprofessional workforce, supported
by accessible education and training
programmes
• z research and development: health services
research will examine models of care, skill
mix, interventions and outcomes to inform
NICE guidance, expert reports and future
commissioning.
Faculty of Academic Psychiatry
A thorough grasp of new research findings and
openness to new ideas is essential for good clinical
leadership, which in turn relies on the symbiosis
between research, teaching and delivery of clinical
care.
Links between university departments and clinical
services should be strengthened. Standards
are raised when research, teaching and clinical
activity (including commissioning) go hand in
Principle two: prioritise patient safety and well-being 13

hand. The Faculty is working with the Academy
of Medical Sciences to help fulfil its recommendations
for strengthening academic training in
psychiatry (Academy of Medical Sciences, 2013).
This includes increasing the exposure of medical
students to psychiatric research, fellowships for
students to perform electives in research at academic
centres, and ensuring an adequate network
of research mentors and supervisors nationally for
medical students and trainee psychiatrists to link
up to perform research.
Faculty of Forensic Psychiatry
The Faculty considers that patient care in forensic
services would benefit from 7-day consultant-led
review across a range of forensic services dealing
with issues such as community crises, prison
transfers, management of risk, seclusion decision
and changes in treatment. Many of these areas
are already addressed in trusts where forensic
consultant psychiatrists share on-call responsibility
with general adult services, but this is not uniform
across trusts. The Faculty is also considering
other developments to address the findings of the
Francis report, such as a prison hotline for urgent
evening assessments, input to police cells and the
probation service.
Perinatal Section
Members of the Section are advising on the revision
of the antenatal and postnatal mental health NICE
guideline. The Section is also producing a joint
consensus statement with the British Association
for Psychopharmacology on prescribing for
pregnant and postnatal women, due for publication
in 2014.
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| | Principle three: provide
high-quality clinical
leadership
‘I believe that psychiatrists chose this career in order to lead, and not simply to advise on
medication’ (College member).
Clinical leadership is essential for high-quality care,
and all doctors are leaders. We need to ensure that
medical leadership is expected and supported by
the culture of NHS trusts, to allow responsibility to
go hand in hand with authority. Psychiatrists must
play a leadership role in their clinical teams and in
their organisations.
Good medical leadership demands an enquiring
and intellectually flexible mind that is grounded in
a thorough understanding of current and future
directions of the science of mental illness and its
treatment. Sometimes leadership demands courage
and, as in science, the ability to communicate
the ‘truth’ demanded by evidence, not political
expediency.
With leadership comes accountability. We must all
strive for improvement and be able to challenge our
colleagues and employers when there is evidence
of poor practice.
Many mental health teams are formally led by the
consultant psychiatrist. In others, psychiatrists have
a de facto leadership role. Junior doctors also have
a significant role to play, and must be encouraged
to speak out, both to challenge bad practice and
to innovate.
All doctors need, and have a duty, to develop personal
leadership skills at all stages of their careers
and to work effectively within multidisciplinary
teams, including with non-clinical managers. The
College will work to facilitate and support these
objectives.
Psychiatrists, whether or not in formal medical
management roles, must:
• z advocate and implement excellent care within
their teams
• z promote a patient-safety-first culture, and
embed this in daily practice
• z support and enable colleagues to deliver
high-quality care
• z promote a culture where colleagues feel safe
and supported in raising concerns.
We need to be aware that too much ‘top-down’
regulation can impede progress and inhibit free
thinking or criticism. Consultants and medical trainees
must be empowered to lead and work with
clinical and non-clinical management colleagues
in the delivery of high-quality care without fear of
retribution.
The Francis report states:
‘A truly caring culture does not stop at the door of the
hospital provider. It should never be acceptable for
patients to be discharged at any time without knowledge
that the patient in need of care will receive it
on arrival at their destination. The emphasis should
be on continuity of care to include a follow-up as to
a patient’s well-being after discharge.’
Continuity of care is particularly important in
psychiatry, whether in hospital or in community
settings, but many services have been reorganised
so that assessment and continued care are separated,
without clear benefits or evidence (Tyrer,
2013). To avoid such changes or untried ‘models
Principle three: provide high-quality clinical leadership 15

of care’ being imposed, clinical leaders need to be
involved in strategy and commissioning.
Psychiatrists need to have a formal communication
structure with senior management, such as a joint
committee with members of a trust’s executive
team, to help ensure that service development
balances clinical need with corporate strategy.
Consultants must set an example to trainees, who
require (and must receive):
• z support
• z supervision
• z encouragement to speak to carers
• z empowerment
• z time for reflective thinking. Also, of course,
consultants should involve trainees in decision-making
early on, to prepare them for their
future roles.
College actions
1 The College will inform national standards
on which any reconfiguration of services
must be based – for example, via the Joint
Commissioning Panel on Mental Health
guidance and guidance on functional splits
in services.
2 The College has established a Leadership and
Management Committee, which has already:
◦{
developed a programme of CPD online
modules
◦{
started discussions with the CCQI about
joint development of networks in leadership
and management to develop skills
and support doctors through peer group
opportunities and examples of good
practice.
Faculty of Addictions Psychiatry
The Executive has co-produced a report with the
Royal College of General Practitioners and Public
Health England on the role of the addiction specialist
in treatment and recovery (in press). The report
focuses on the importance of clinical leadership
in the development and safe running of services.
Faculty of Child and Adolescent
Psychiatry
The Faculty has led in revising the GMC curriculum
for child and adolescent psychiatry, where
medical leadership skills are clearly defined. The
Faculty’s Education Committee is working with
training programme directors across the UK to
ensure its effective implementation.
Section of Eating Disorders
Compassionate services are also high-quality
services, but compassion in eating disorder
treatments is akin to compassion in parenting,
requiring kindness and boundaries. Risk management
of eating disorders is often an unequal
balance between minimising physical risks in the
short term and minimising psychological risks in
the long term. This requires substantial clinical
expertise and leadership.
Section of Neuropsychiatry
The Section has recently approved a plan for
developing future leaders in neuropsychiatric care.
This innovative model of leadership development
will allow promotion of excellent models of care
and development of a regional mentoring system
aligned with College divisional networks and its
national presence in England, Wales, Scotland
and Northern Ireland.
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| | Principle four: respect
regulation, inspection
and accountability as
supporting care
‘When we trained, life beyond being a full-time clinician was tightly defined. You became a
researcher, devoted yourself to teaching or disappeared upstairs into management. Those
three paths describe fewer than 5% of psychiatrists. What about becoming an even better
clinician, facilitating better interventions from other disciplines, and measuring outcomes that
really matter to our patients? We can’t achieve this without working with the best people,
external regulators included, to learn as much about our services as possible. I have learned
more from external evaluation and honest feedback on what we do than from endless internal
reflection. Bring it on’ (College member).
The shape of regulatory and statutory frameworks
for healthcare provision and regulation, new forms
of regulatory control, service innovations and
quality assurance of organisational performance
have the power to change the context in which
healthcare systems work. It will be important, for
example, for the new CQC mental health inspections
to consider the whole patient pathway – that
is, to look at provision of community care as well
as of acute care.
There must be due diligence in gathering patient
and colleague feedback for GMC revalidation,
with information acted on and used to improve
practice with remedial action when appropriate.
Professional responsibility, checked through the
triad of appraiser, appraisee and responsible
officer, is crucial for good practice.
It is appropriate for psychiatrists to have a role in
accreditation and hospital visits to ensure quality
standards are maintained in education, training and
service provision. These visits empower trainees
and provide them with the opportunity to speak
openly and in confidence with assessors.
The Francis report makes clear that education and
training are closely linked with clinical standards.
We need to strengthen the weakened links in some
parts of the UK between strong university departments
and clinical services. Standards are driven
higher when research, teaching and clinical activity
go hand in hand.
College actions
1 The College will continue to issue clear standards
on good psychiatric practice in a range
of specialised areas.
2 As a member of the Academy of Medical Royal
Colleges, the Royal College of Psychiatrists
will lobby for doctors as leaders to be given
sufficient time in their work schedules to be
able to take part in other valuable work that
will lead to improving standards and outcomes
in clinical care. For example, the College will
encourage psychiatrists to become involved
as skilled advisors in the mental health inspections
that will commence in 2014, recognising
Principle four: respect regulation, inspection and accountability as supporting care 17

that when they do so they will go through the
relevant training programme.
3 Prior to 2007, the College was responsible for
accrediting training schemes. Accreditation
teams included a trainee member, who would
spend time with the trainees of the scheme
under inspection with no consultants present.
This produced accurate, valuable and honest
information and was highly successful in picking
up areas of poor practice. The College,
both individually and within the Academy of
Medical Royal Colleges, will push to see this
method of inspection revived within an appropriate
and supportive framework.
4 The CCQI will continue to offer 360-degree multisource
assessment for psychiatrists to enable
their personal development (www.rcpsych.
ac.uk/workinpsychiatry/qualityimprovement/
acp360.aspx). This provides structured feedback
to psychiatrists in relation to one of the
GMC’s core domains – ‘Communication, partnership
and teamwork’, which includes working
with colleagues and relating to patients (General
Medical Council, 2013).
5 The College will continue to develop and
promote gold-standard training and CPD
activities, which are of key importance for
every doctor at every stage of their career.
The College is unique in having adopted a
peer group format for the planning and evaluation
of CPD. This enables a learning context
that is both challenging and supportive, where
each individual has available to them objective
opinion and support against which to test their
development plan and monitor progress in
a setting that permits a positive culture for
learning.
6 The College is exploring more robust ways in
which to support mentoring.
7 The College is currently reviewing how it can
help doctors with remedial needs.
8 The College will push for the identification and
accreditation of clinical areas that are not covered
by any other assessment.
Faculty of Rehabilitation and Social
Psychiatry
The Faculty has worked with the CCQI to develop
the Accreditation for Inpatient Mental Health
Services (AIMS) – Rehabilitation Quality Network
programme to provide a quality benchmark for
in-patient rehabilitation services nationally. These
are also recognised to be of value by the CQC. This
has achieved excellent coverage, despite being the
newest AIMS programme, and staff and patients
have fed back that they have found it an invaluable
process – being rightly proud when they achieve
accreditation.
The Faculty has incorporated the Quality Indicator
for Rehabilitative Care (QuIRC), which was
developed by the Rehabilitation and Effectiveness
for Activities for Life (REAL) study, into AIMS-Rehab
(Cresswell et al, 2012). This standardised quality
tool has enabled national quality data for in-patient
rehabilitation to be gathered and for individual units
to then work to improve quality. It includes seven
domains of quality: living environment, therapeutic
environment, treatments and interventions, selfmanagement
and autonomy, social interface,
human rights, and recovery-based practice. This
comprehensively covers aspects of quality, and
the tool and approach have also been extended
to nine other countries, enabling benchmarking
in the quality of their rehabilitation services. This
kind of standardised, robust and reliable data can
be used to audit quality of care at local, regional,
national and international level to drive up quality.
Faculty of Psychiatry of Intellectual
Disability
The College is a signatory to the Department of
Health (2013c) Concordat: Programme of Action,
agreed to address failures of care of the type seen
at Winterbourne View hospital. The Faculty will lead
within the College on:
• z issuing guidance about the different types of
in-patient services for people with intellectual
disabilities, including some guidance aimed
at commissioners
z • jointly with the Royal Pharmaceutical Society
and other professional leadership organisations,
working with the Association of
Directors of Adult Social Services (ADASS)
and the Association of Directors of Children’s
Services (ADCS) to ensure medicines are used
in a safe, appropriate and proportionate way
18
Occasional Paper OP92

and are optimised in the treatment of children
and adults with intellectual disabilities. This will
include a focus on the safe and appropriate
use of antipsychotics and antidepressants.
The National Audit of Learning Disabilities (NALD)
pilot being undertaken by the Faculty with the
CCQI aims to assess compliance with standards
in general hospitals and mainstream mental health
services in relation to their use by people with intellectual
disability. This is highly relevant to previously
demonstrated poor standards of care.
The College’s Workforce Committee
The College’s Workforce Committee has taken
a lead role in the In-depth Review of Psychiatry
work, jointly commissioned by the Department of
Health and Health Education England, and undertaken
by the Centre for Workforce Intelligence
(CfWI). The Workforce Committee coordinated
stakeholder participation in the horizon scanning,
scenario planning and Delphi exercise and developed
a high-level modelling with CfWI to ensure
that workforce decisions will support the delivery
and organisation of quality innovative services for
the next 30 years.
The Committee is in the process of undertaking a
psychiatry census to update data on numbers of
consultants and specialty doctors across England
and Wales. We will analyse the changes since the
last survey in 2011 by specialty and region.
Supporting members with revalidation
Members will be encouraged to follow advice in
the revalidation guidance document (CR172; Royal
College of Psychiatrists, 2012) to gather supporting
information for revalidation, including:
• z quality improvement activity including casebased
discussion (CbD)
• z feedback from colleagues
• z feedback from patients
• z CPD
• z significant events
• z review of complaints and compliments.
Peer groups endorsed by the College can:
• z share an understanding of the revalidation
process
• z endorse planned CPD and help identify suitable
options
• z participate in CbD
• z assist in reflection on all supporting information,
especially if this is negative
• z engage avoiders
z • identify outcome data required from
organisations.
Principle four: respect regulation, inspection and accountability as supporting care 19

| | Principle five: value the
importance of outcomes
and accurate data
‘The measurement of quality is clearly expected to move beyond ensuring that structures and
processes are in place, to measure the outcomes of care in a way that is of value to both clinicians
and patients […] The Royal College of Psychiatrists is well placed to provide guidance
on the use of outcome measures in mental health based on what is of clinical value to patients
and clinicians and what is feasible in practice. The College strongly supports the implementation
of patient-reported outcome measures in mental health as a way of improving the quality
of care provided’ (Royal College of Psychiatrists, 2011: p. 5).
To improve patient care, we need outcome measures
from well-designed studies that provide
accurate and valid data which relate to the outcomes
we are trying to measure. Both individual
clinicians and providers of services must submit
accurate data to the NHS on patient care. Having
accurate data means services/quality can be monitored
effectively and outcome metrics produced.
The College encourages the use of Community
Mental Health Profiles (www.nepho.org.uk/cmhp/),
which present a range of mental health information
for local authorities in England. These are designed
to give an overview of mental health risks, prevalence
and services at a local, regional and national
level using an iteractive mapping tool. The data
should be used to inform commissioners of health
and social care services in their decision-making,
leading to the improvement of mental health and
mental health services.
The College is involved with the Department of
Health Mental Health Payment by Results (MHPbR)
Quality and Outcomes Group. Its purpose is to
embed quality and outcome measures into payment
by results, to oversee the piloting of a range
of measures, to evaluate them and to inform commissioners
of appropriate quality and outcomes
measures. The key findings from the report of the
group (Department of Health, 2013d) are:
• z seven quality indicators are recommended for
use from a set of indicators analysed
• z the clinician-rated outcome measure (CROM)
based on Health of the Nation Outcome
Scales/Mental Health Clustering Tool
(HoNOS/MHCT) is now recommended for use
• z good progress has been made on the
development of a patient-rated outcome
measure (PROM), with testing of the
Warwick–Edinburgh Mental Well-Being Scale
(WEMWBS) receiving positive feedback from
patients
• z further progress on the development of
patient-rated experience measures (PREMs)
and the recommendation to collect the
‘friends and family’ question
z • completion of the Industry and Mental
Health Service Collaborative (IMHSeC)
website which will provide guidance on the
content of care package for each of the clusters
(www.cppconsortium.nhs.uk/admin/
files/1300792324IMHSeC%20Project%20
Outline.pdf).
20
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College actions
1 The College supports the seven key messages
set out in the Academy of Medical
Royal Colleges report, I-Care: Information,
Communication and Technology in the NHS
(Academy of Medical Royal Colleges, 2013):
◦{
the patient record forms both the cornerstone
of integrated patient care and the
main source of data to inform the service
◦{
patient record systems must be focused
on the individual, not on the disease,
intervention, service or the organisation
in which the patient is seen, in order to
provide an integrated picture of their problems
and the care they receive
◦{
clinical data quality and ease of data
capture are of paramount importance
◦{
the structure and content of records must
be standardised across the NHS
◦{
patients should be given appropriate,
standardised access to their records
◦{
as a learning organisation, the NHS must
use the information it collects in the course
of everyday care to enhance learning
◦{
professionals and patients need access
to reliable information, from both the individual
record and the knowledge base of
healthcare.
2 The College will do further work on metrics
and outcome indicators to:
◦{
incorporate data
◦{
improve feedback to individual and team
practice
◦{
focus more on patient and carer
experience outcomes, together with clinical
outcomes
◦{
support the quality and outcomes work
already undertaken as part of MHPbR
◦{
develop composite outcome data in partnership
with patients and carers.
3 The College supports the central collection
and collation of safety data.
4 The College supports the use of an electronic
patient record and electronic prescribing
within mental health trusts.
The College’s Informatics Committee
The Informatics Committee has had a particular
focus in 2013 on improving quality and safety, and
has co-authored a position statement on informatics
with the Academy of Medical Royal Colleges
(2013) for the Secretary of State for Health.
With regard to zero harm and patient safety, the
Informatics Committee has been an active supporter
of the early delivery of electronic prescribing,
and has significantly contributed to the mental
health discharge summary and the establishment
of chief clinical information officers (CCIOs) within
all mental health trusts.
Faculty of Psychiatry of Intellectual
Disability
The Faculty is undertaking a review of outcome
measures.
Perinatal Section
The Section contributes to the development of
outcome measurement systems in perinatal mental
health.
Principle five: value the importance of outcomes and accurate data 21

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