Brief Feedback from Delegations on Professional, Training Or Service Matters

PS9 Apr2014

Brief feedback from Delegations on Professional, Training or Service Matters.

April 2013

Denmark

The government published a rather comprehensive report about the future of psychiatry. There was main emphasis on the following themes:

• Closer involvement of relatives and network
• More influence on own treatment by patients
• Right to admit themselves
• Reduction of enforcement and restraint

The uneven distribution of money between “medical specialities” and psychiatry have been pointed out of both patients, relatives ,the medical doctor association and the scientific society. Money is allocated to projects rather than to institutions.

Towards the end of the year a high profiled colleague from the Cochrane Institute wrote in one of the main newspapers that there was almost no evidence for antipsychotic and antidepressive medicine. Patients should in principle avoid psychiatric medicine. If given, then only in short periods and only in acute situations. Psychiatrists in Denmark protested loudly!

There is constantly examples of psychiatric treatments that are insufficient, but also reports on violent patients resulting in health injuries on psychiatric staff.

There is a lack of psychiatric specialists in particularly in the outskirts of the country. It is partly due to a mismatch between the number of trained specialist and many more available positions in psychiatry. And higher demands of psychiatric services. In addition many senior psychiatrists retire with pension or leave the public field for private practice.

Jørgen Nystrup

Torsten Bjørn Jacobsen

Greece

Economic crisis in Greece and the impacts onmentalhealth

Economic crisis in Greece has caused major concerns in the eurozone and the international economic community. Reports from Greece are particularly relevant because on the basis of them one may predict what is likely to happen in other countries. Managing the psychological consequences of financial crises is a complex undertaking, which may include political intervention.

The financial crisis in Greece has adversely affected the physical and mental health of the population.

Unemployment, poverty and debt have been associated with psychiatric morbidity and suicidal potential, and therefore measures to counter them may reduce harm.

Since the economic crisis hit several years ago, the government’s health spending has been slashed and hundreds of thousands of people have been left without health insurance. Restrictions have been made on prescribing medicines, with no access to all medicines. Cuts have been made to public health prevention programs (e.g. HIV), to drug users programs of harm reduction or substitution etc.

People with mental health problems are more likely to be pushed into poverty through increased health costs, loss of employment, reduced work hours, and stigma. In this frame, several risk factors for suicidal behaviour have been identified and have been classified as primary (such as the presence of psychiatric and medical disorders, severe somatic illness, previous suicide attempts), secondary (adverse life situations and psychosocial risk factors), and tertiary (demographic factors such as male sex and old age). The risk of suicide seems to be highest when primary risk factors are present. So far there are no data to support a causal link between the economic crisis in Greece and suicide, and reports in the mass media and journals are premature over interpretations. There will be no conclusive data for perhaps another 5 years, and an impressive increase in figures might be necessary, in view of the fluctuations seen over past decades.

As well, it would take years to measure the long-term consequences of people being without regular access to health care, particularly those with chronic conditions.

Many believe thatthis sudden and vertical cut in public health care services can be a violation of human rights.

Analyses show that the main causes of the Greek predicament lie in the serious structural weaknesses in public administration, economic activity and societal configuration resulting to bureaucracy, corruption, and low cost-effectiveness in services. Although the total expenses for health were increased (5,3 % of the Gross Domestic Product in 1991 to 9,7 % in 2008) the efficacy of the Greek health system was diminished. Greece faces the greatest economic crisis of its modern history.

The structure and organization of most Greek public institutions are bureaucratic and characterized by the lack of suitable systems for validation, evaluation, control and regulation. Politics adhere mainly to political gains, the pressure of public opinion, professional and economic vested interests and less to a rational system of predetermined priorities and strategical decision making. The Greek primary care is highly fragmented due to the absence of a system of coordination and control of the various different public and private health professionals who are involved in it, and the quality of healthcare services is expected to decline further in the face of the economic crisis. The considerable stability of Greek health rates is mainly due to the good climate, the relatively high life quality and the rather healthy diet.

Health care personnel need to be alert and respond to the changes in the health care landscape so as to contribute and influence for most cost effective reform processes. Special attention should be paid to strengthening areas such as primary health care, public health and health promotion in the direction of minimizing the demand of hospital services.

Health care personnel shortages will make health professionals scarce and tasks more strenuous. Burnout and job dissatisfaction are more likely to be revealed. According to the WHO Report, incomes are the most important motivation for health workers’ migration followed by job dissatisfaction, career opportunities and political instability. There is also a negative impact of the economic crisis on health professional’s education.

Welfare provision can limit psychiatric morbidity during periods of economic crisis, and active labour market programs and family support programs have been found to be effective and cost-effective.

Psychiatry can respond to the challenges posed by economic crises through its holistic, biopsychosocial and person-centred ethos. Furthermore, mental healthprofessionals can help those suffering from economic crises. Mental illness prevention and mental health promotion should be integral parts of clinical management and service planning. Mental health professionals should highlight the cost-effectiveness of mental health investments.

Psychiatric education / training

Much improvement had been observed over the last decade in psychiatric training in Greece. The educational needs of the Greek psychiatric trainees seem multidimensional and refer to the biological, psychological and social aspects of psychiatry, integrated in the new environment of modern technology and informatics. However, there is still inadequate compliance to some of the recommendations developed by the European Board of Psychiatry.

A big problem is that there is lack of recent data regarding Greek psychiatric training.

The overwhelming majority of Greek psychiatric trainees do not have individualized training programs (88%) and logbooks (99%). There is no auditing experience (90%) and no exposure to internal (90%) or external (93%) evaluation. On the other hand, structured theoretical training is available to the majority of trainees (94%) although psychotherapeutic supervision is offered to only 25% of trainees.

In order to promote the harmonization of training in psychiatry and facilitate mobility of psychiatrists across Europe, the 2 psychiatric associations in Greece regularly organize educational seminars and meetings. Significant improvement in variety and quality of psychiatric education was achieved, with the main problem focused on the differentiation of training by region and hospital.

Unfortunately the economic crisis did not allow further improvement of training conditions. In contrast there was a reduction of these training opportunities. A lot of the educational seminars and meetings were based in grants of pharmaceutical companies. Other educational events were based on the 2 psychiatric associations, which no longer have the financial capacity to continue these activities.

A positive thing is that Greek residents, who received the last years a much better education, are now young professional psychiatrists. It seems that these young psychiatrists are sensitive to demand more from the academic community and from politicians, who seems to be not worthy of the positions they hold.

Bibliography

1. WHO summary 2013: Health, health systems and economic crisis in Europe. Impact and policy implications
2. Oikonomou N, Tountas Y. Greek economic crisis: a primary health-care perspective. Lancet 2011; 377: 28-29
3. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457-1458
4. Fountoulakis KN, Grammatikopoulos IA, Koupidis SA, Siamouli M, Theodorakis PN.Health and the financial crisis in Greece. Lancet 2012; 379: 1001
5. Konstantinos Efthimiou, Eftychia Argalia, Evgenia Kaskaba, Athanasia Makri. Economic crisis & mental health. What do we know about the current situation in Greece? ENCEPHALOS 50, 22-30, 2013
6. NG. Christodoulou, GN. Christodoulou. Financial Crises: Impact on Mental Health & Suggested Responses. Psychother Psychosom 2013;82:279–284
7. Venetia Notara, Konstantinos Koulouridis, Aristidis Violatzis, Elissabet Vagka.Economic crisis and health. The role of health care professionals. Health Science Journal.2013;7 (2)
8. N. Kokras, G. Samiotakis, E. Gerasi, D. Oikonomou, A. Ntoumanis, R. Psarras. A survey on psychiatric training in Greece from trainees’ perspective. European Psychiatry - EUR PSYCHIAT 01/2011; 26:1730-1730.

* This report is somehow general, but in Greece these years we face a crisis not only financial, but also social and of values. Thisforced us to reconsider many things and to miss targets that in other countries may seem obvious.

Anastasios K. Papakonstantinou

EFPT

EFPT continued its work through the working groups via online means (the group meets face-to-face once a year). The working groups are: Exchange; Research; CAP; Psychotherapy; Promoting Positive Image of Psychiatry; Cultural Diversity; Establishing National Trainee Associations and Physician’s Health.

Ongoing projects:

-Study on psychiatric competencies in training programmes in collaboration with UEMS –study proposal completed

-Brain drain – preliminary results presented at EPA

-Exchange Programme –next application period will open in May

-ECNP Research Internship – to be launched in June

-Study on preferences for online CME in collaboration with EPA – focus groups

-Psychotherapy survey – ongoing

-Chapter 6 CAP in collaboration with UEMS CAP – to be endorsed by UEMS council

-Video to promote image of psychiatrist – ongoing

Future developments:

-Increase EFPT visibility – newsletter to be launched; twitter feed @EFPTraineestwitter.com/EFPTraineesand LinkedIn group

-Fundraising remains an issue – promote donations through website Donors (individuals or organisations) are acknowledged

And last but not least, our Annual Forum will take place in London from the 21st to 25th of June and UEMS is invited for a session.

The Forum will focus on “Making links”. For the past 22 years EFPT has been stimulating connections between psychiatric trainees, who have worked together to improve training and consequently mental healthcare across Europe.

This year, we want to expand the links to students, patients, carers, academics and healthcare leaders.

There are many examples of good practice and exciting initiatives across Europe and we want to highlight those during the e-poster session and excellence awards.

The scientific day will be combined with the International Congress of the Royal College of Psychiatrists and there will be plenty of networking opportunities.

Marisa Casanova Dias, president

Mariana Pinto da Costa, president-elect

Hungary

1. HungarianFederation of PsychiatricTrainees

The Hungarian EFPT wasestablishedinMarch 2014, joinedtoHungarianPsychiatricAssociation.The proceduretoapplyfor EFPT membership is ongoing.

2. National Institute of Psychiatry and Addictons, Budapest

In June, 2013 the National Institute of Psychiatry and AddictonswasestablishedinNyiro GyulaGeneral Hospital, wichotherwisewasone ofthebiggestpsychiatryinstitutein Hungary.

Main field of theinsitute:

- outpatientcareinpsychatricspecialities (OCD, eatingdisorders, psycho-oncology, sexualpsychiatry, substance-induceddisorders)

- acute psychiatriccare unit

- education- focusedonpsychiatrictraining

- research–cognitiveneuropsychiatry

3. Braindrainand problem of the human sourceinthehungarianhealthsystem

15-20 % of psychiatrists (trainees) aremissingIncomesupportforthetrainnesbythegoverment

- thegovernmentprovidesbiggerpaymentforthetraineesselectingthescarcejobs

- specialscholarshipfortrainees, whoareworkingin Hungary

Zoltan Makkos

Ireland

Negatives:

• Manpower is the biggest issue - recruitment is a major problem.

• Still battling stigma/under funding.

• Tensions between primary care/general hospitals/community services when funding is short and people “stretched”.

• Publication of a list of “never” events – “Patients attending mental health services must never die by suicide.”

Positives:

• Irish College just held very successful spring meeting.

• New structured Basic and Specialist Training schemes beginning to take shape.

• Irish clinical exam allowing progress to Higher Training in Ireland will commence later this year.

• More conversation about mental health issues in media.

• Increased involvement of patients and carers in service development (ARI Project).

Rachael Cullivan

Norway

There are as far as I can see no major News in the Field of psychiatry and psychiatric training in Norway since Our last Meeting. We are now implementing the New national specialist training program and requirements described earlier, and this is developing according to schedule. We will at a later Meeting be better able to describe the Challenges and benefits from this implementation.

Edvard Hauff

Forensic psychiatry: The practice in Norway have until now been the biological principle: if you have a psychosis and commits a severe crime you can not be sentenced to prison. But you can be sentenced to psychiatric care. The Norwegian Psychiatric Association has for years been promoting the psychological principle: even if you are psychotic, you should be held responsible for your actions. Unless your actions are motivated by psychotic beliefs. Then you should be sentenced to treatment rather than prison.

The Norwegian Medical Association has asked the Psychiatric Association to come up with a statement on this matter and the report has just been released. It recommends a practice more according to the psychological principle. The lawmakers are also looking into the matter and we are hoping for a change in our laws where the psychological principle will be more emphasized.

Training: Our new checklist and UEMS inspired training program is being implemented and generally well received. The main problem being an intermediate solution for those training under the new system but who will be recognized under the old training program.

Service delivery: Strong political signals for more community based mental health care, less psychiatric hospitals, more empowerment of the users, more focus on human rights and the UN convention on the rights of people with disabilities (Norway signed CRPD June 2013).

On a more personal note: I have recently left the Board of the Norwegian Psychiatric Association, as the longest serving member, and will be replaced at UEMS. Thus, the Madrid meeting will be the last meeting I attend. In the future , hopefully,I will be able to attend the Bergen City Marathon instead of the spring meetings of the UEMs....

Andreas Landsnes

Slovakia

Problems with the accreditation of continuing medical education –Since 1.1.2014 is Slovak Medical Chamber (professional registration body) is not accepting credit points awarded by Slovak Accreditation Council for Continuing Medical Education. At the same time, there are two organizations awarding credit points to medical education activities – Slovak Medical Chamber with its own credit system and Slovak Accreditation Council for Continuing Medical Education – internationally accepted collaborative organization of EACCME. Ministry of Health is now trying to deal with this confusing situation.

Jozef Dragašek

UK

Shape of Training Review:

This is a major review of the structure of postgraduate medical education in the UK. The final report was released at the end of October 2013 and its implementation is currently being considered by the Departments of Health of the four administrations in the UK.

The review was established to examine postgraduate medical education to ensure that the training of doctors met the needs now and in the future of patients, society and the health services. The review was to take into account the changing environment of healthcare with significant medical, technological and scientific advances, coupled with changing demands on healthcare services with higher patient expectations, a growing and ageing population and increasingly complex medical conditions.

The major proposals in the review are: -

• To broaden specialty training and thereby reduce the total number of specialties
• To introduce sub-specialty training after qualification as a specialist in response to local patient and workforce needs
• Increase flexibility of medical careers, so that doctors can change roles and specialties throughout their careers
• Full registration with the national regulator (General Medical Council) at the point of graduation, provided graduates can meet GMC standards at the end of medical school.

Broad-based Training Programme:

This is an innovative two year post-Foundation, training programme that consists of training experience in four specialties: general (internal) medicine, general practice, paediatrics and psychiatry. Doctors who complete the BBT programme may enter the second year of one of the parent specialty programme. BBT was established to address similar issues to those behind ‘Shape of Training’ and was also intended to support recruitment into the four constituent programmes. BBT has just recruited into the second of the pilot. So far, indications are that there is strong competition for places in BBT and that entrants are of above average attainment. There is one more year to go before the pilot evaluation can be published.

Andrew Brittlebank

Amit Malik

Delegate Summaries as at 23.4.14

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