Foundation pic

Foundation Psychiatry Placements

Good Practice Guide

Updated November 2015


Doing a psychiatry post in the Foundation years
Key personnel
The Foundation Curriculum
Assessment during foundation training
The syllabus
Recommendations for training in a psychiatry foundation post
Report authors


  1. Foundation Posts in Psychiatry: Severn PGME August 2016
  2. Example of detailed syllabus; Relationship and communication with patients
  3. Summary of background literature relating to Psychiatry Foundation posts.
  4. Foundation posts and recruitment to psychiatry


If you are considering a psychiatry foundation post or are looking at how to plan your Foundation training, we hope this guidance will encourage you to apply for one of our posts and welcome you to this lively group of trainers and doctors in training.

This guidance has been compiled by reviewing national guidance and literature in this field, by using data from the local GMC survey, by liaison with foundation doctors, trainers and others associated with the Foundation psychiatry training posts in Severn PGME. If you have any queries, please contact any of the staff below, who will try to help.

We have included information for potential new foundation doctors to help them to make their decision about training in psychiatry, and to show them some of the opportunities available. It is also for trainers (including potential new trainers and existing) to make clear their requirements and what they need to offer. We have included up to date information about the curriculum. We also hope the guidance will be useful for foundation doctors in post, to help them to understand the range of training opportunities we would like them to have. In this way the guidance may help over time to influence standards of training and foundation doctor experience. The document could be used in induction and also to help us to look at future post development.

The Foundation Programme was established in the UK in 2005 as part of Modernising Medical Careers. It is a national 2-year generic training programme, consisting of three different placements in each of the first (F1) and second (F2) years, which forms the bridge between medical school and specialist/general practice training.

The 2012 Foundation Programme Reference Guide has been updated in 2014 and is available through the Severn PGME Foundation School website

This document provides guidance to deaneries and foundation schools about the structures and systems required to support the delivery of the 2012 Foundation Programme Curriculum – updated 2014 (the Curriculum). The Reference Guide applies across the UK and sets out what is required to deliver the Curriculum and provides guidance for deanery/foundation school quality management. Where appropriate, it is aligned to the Reference Guide for Postgraduate Specialty Training in the UK (Gold Guide).

Doing a psychiatry post in the Foundation years

There are many positive reasons for considering a psychiatry post in the Foundation training years, summarised below:

Reasons to consider a foundation psychiatry post

  • Psychiatric practice is holistic and provides an opportunity to develop real understanding of psychological problems.
  • Many people find the problems of psychiatry to be interesting and thought provoking.
  • Psychiatric problems are very common and every doctor will face these in their professional lives.
  • The reason for medical problems being difficult to treat is often only understood through an understanding of complicating personality or mental health factors.
  • Psychiatry is largely a community based specialty and provides opportunities to work in many varied settings.
  • There is a growing evidence base demonstrating the links between physical and mental health, and thus having an understanding of the psychological basis of illness will be relevant to other specialties.

Foundation doctors often like working in psychiatry because they have time to fully assess a patient’s difficulties and get an understanding of social and psychological aspects of the presentation.

There are many opportunities for teaching, research, audit and service development in psychiatry and foundation doctors are actively encouraged to get involved in many other activities such as psychotherapy if they show an interest.  Some of the posts have more time to complete audits and publications than acute medical/surgical posts

Psychiatric foundation doctors have weekly protected, one hour supervision with their consultant and this provides particular opportunities for support and broadening the doctor's understanding of the field.

Psychiatric foundation doctors receive fortnightly whole-day teaching as a year group. This is protected time, and a good opportunity to consolidate knowledge base, pick up tips for exams, and meet with the peer group.

For people considering a career in General Practice, some experience of Psychiatry will be enormously useful, as mental health difficulties are some of the most common presentations to primary care.

There will be many opportunities in psychiatry posts to hone your history taking style and communication skills. If you work on these skills at the start of your career it will aid the rest of your work in medicine, whatever you choose to do. Better communication is linked to better patient experience and improved general healthcare outcomes.

It is important to understand how mental health services work so that you can signpost patients effectively to various sources of help.

Key personnel

Dr Clare van Hamel, Foundation School Director, Severn PGME: Main responsibility is to oversee the education and training of all Foundation trainees in the Severn region, ensuring that all programmes provide trainees with appropriate experience to fulfil the curriculum.

Dr Steve Arnott, Director of Medical Education AWP Mental Health Trust
Dr Amjad Uppall, Foundation lead and Director of Medical Education, 2Gether Trust
Dr Amanda Hoare, Foundation lead and Director of Medical Education, Sompart Trust
Dr Rob Macpherson, Head of School of Psychiatry
Dr Linda Heaney, Training Programme Director, Severn PGME

Please feel free to contact any of the above individuals through the appropriate Trust or Severn PGME website.

Psychiatry Posts in Severn Foundation School

Placement descriptions for each post can be found under the Trust pages.

The Foundation Curriculum

The Foundation curriculum in psychiatry has been revised in 2014.

The Curriculum is based on the General Medical Council (GMC) documents Good Medical Practice (2006) and the Trainee Doctor (2011). All foundation doctors and trainers are expected to be familiar with GMP and TTD and to follow the guidance contained therein on the principles and standards of clinical care, competence and conduct.

Satisfactory completion of foundation year 1 (F1) will satisfy the needs of the GMC, making the foundation doctor eligible to apply for full registration. Satisfactory performance in foundation year 2 (F2) will lead to the award of a Foundation Achievement of Competence Document (FACD) which will indicate that the foundation doctor is ready to enter a core, specialty or general practice training programme.

The purpose of foundation training is clearly stated and is underpinned by two central concepts:

Patient safety

Patient safety must be put at the centre of healthcare and depends both on individual practice and also effective multidisciplinary team working.

Personal development

Throughout their careers, doctors should strive to improve their performance to demonstrate progression from competent, through proficient to expert, with the aspiration always to provide the highest possible quality of healthcare.
Learning is best achieved when there is frequent observation of practice in the workplace with immediate feedback on performance from a senior clinician. Every clinical experience is a learning opportunity whether it occurs during ward rounds, in clinics, in primary care settings, on call, during procedures etc. Interaction between the foundation doctor and trainer during supervised learning events (SLEs) should lead to reflection and further targets for development. Foundation doctors and trainers should work to maximise the opportunities for SLEs both as unscheduled, opportunistic events and also arranged in advance with a specific focus. The feedback should be recorded contemporaneously in the foundation doctor’s e-portfolio.

Assessment during foundation training

The syllabus in this curriculum is outcome based rather than competency based.

Formal assessment of progress will be made at the end of each placement and at the end of F1 and F2. The clinical and/or educational supervisor’s end of placement assessments will be based on multiple sources of evidence including feedback from colleagues who have observed practice in the workplace (Placement Supervision Group). Other important evidence will be provided through the e-portfolio including team assessments of behaviour (TAB), engagement with SLEs, reflective practice throughout the placement and satisfactory demonstration of the core procedural skills required by the GMC.

Recommended minimum number of SLEs per 4 month placement

Direct observation of doctor/patient interaction:

  • Mini-CEX: 3 or more
  • DOPS: Optional to supplement mini-CEX
  • Case-based discussion (CBD): 2 or more
  • Developing the clinical teacher: 1 or more

Frequency of assessments per 4 month placement

E-portfolio: Contemporaneous
Core procedures: Throughout F1
Team assessment of behaviour (TAB): Once in first placement in both F1 and F2, with optional repetition.
Clinical supervisor end of placement report: Once per placement
Educational supervisor end of placement report: Once per placement
Educational Supervisor’s End of Year Report: Once per year

The e-portfolio is a record of a foundation doctor’s progress and development through the foundation years. Successful completion of the Curriculum requires the achievement of competence in a variety of domains based on Good Medical Practice. Evidence of achievement of outcomes and increasingly sophisticated performance will be recorded in the e-portfolio. The Syllabus lists competences into subsections. Each subsection is headed by outcome descriptors indicating the levels of performance that foundation doctors must achieve in foundation year 1 (F1) and how they should be developing their ability to work with increasing independence in foundation year2 (F2).

At the first session with the educational supervisor, the foundation doctor may wish to discuss aspects of the Curriculum, which might include:

  • how to build on strengths from undergraduate training
  • particular areas of interest to explore
  • any potential targets for development which may need to be addressed
  • how to record achievements in the e-portfolio.

The foundation doctor and educational supervisor should also agree a timeline for this undertaking and recording of achievements, and they should agree the time and dates for subsequent meetings.

Supervised learning events (SLEs)

These are opportunities to receive feedback from consultants and other senior colleagues. They should prompt foundation doctors to reflect on what they have learnt and help them recognise both strengths and target areas for further development. To be most effective, SLEs should cover a range of situations and challenges of varying complexity. SLEs should start early in each placement to give foundation doctors time to gain the most from feedback. Foundation doctors should also read the feedback and comments from Team Assessment of Behaviour and discuss any areas of concern with the educational supervisor.

SLEs should start early in each placement to give foundation doctors time to gain the most from feedback. Foundation doctors should also read the feedback and comments from Team Assessment of Behaviour and discuss any areas of concern with the educational supervisor.

The syllabus

The syllabus is broken into 12 sections:

  1. The foundation doctor as a professional and a scholar
  2. Relationship and communication with patients
  3. Safety and clinical governance
  4. Ethical and legal issues
  5. Teaching and training
  6. Maintaining good medical practice
  7. Good clinical care
  8. Recognition and management of the acutely ill patient
  9. Resuscitation and end of life care
  10. Patients with long-term conditions
  11. Investigations
  12. Procedures

Each section of the syllabus is broken down further into subsections, with guidance about key areas to cover in the F1 and F2 years. An example of the section on Relationships and communication with patients is given in Appendix 1

Recommendations for training in a psychiatry foundation post

These recommendations recognise the contractual differences resulting from the F1 being a pre-registration training year and the differences in clinical experience in foundation doctors undertaking the F1 and F2 years.

Taster day posts

Guidance for trainers in planning and running taster posts can be found in the recent paper by Dr Tom Brown prepared for the Royal College of Psychiatrists which can be found on the Deanery School of Psychiatry web site.

If you are a foundation Year 1 or Year 2 doctor who is interested in applying for psychiatry, we would like to encourage you to spend 1-2 days following a junior psychiatrist and their team to learn about what the job and training entails.
In the School of Psychiatry we have established a series of taster days which are led by core trainers and trainees in psychiatry. We are aiming to cover as much of the geographical area of the Severn PGME as we can, with opportunities for foundation doctors to shadow the core trainee, consultant and team for 1-2 days. Foundation doctors have a number of days available to take as taster days in medical fields of interest for further training. These may be of particular use if it is not possible to do a post in this specialty as part of foundation training or if the placement would occur after the application process. Taster days are arranged to help to understand what work you can expect to do as a psychiatrist, understand more about the training available and discuss sub-specialties within psychiatry and career development.

We aim to tailor taster days depending on individual interests, to include a selection of the following:

  • Ward rounds and ward work and 1:1 time with a core trainee
  • Time with the multidisciplinary team to include senior psychiatrists and community psychiatric nurses
  • Outpatients work and community visits
  • Experience of specialties within psychiatry, for example Child and Adolescent Psychiatry, Eating Disorders, Liaison Psychiatry, Learning Disabilities, Forensics, Old Age Psychiatry.

Please view the Severn School of Psychiatry webpage if you would like to arrange a taster day or for more information or contact the School of Psychiatry.

In addition to the taster days, there is also a programme of Deanery teaching days, regional events where all the foundation year 2 trainees can attend a day of teaching in psychiatry. For psychiatry, Royal United Hospital Bath is the host and Dr Geoff Van Der Linden organises the program. The programme runs in the autumn & details are available on the Foundation School website.

Structure of full time posts

All posts are of 4 months duration.

It is strongly recommended that groups of foundation training posts should be developed in certain locations, to promote peer support, enable joint learning and cover arrangements and to reduce isolation. Posts should provide breadth of experience, including in-patients and out-patients work, as well as ward/clinic/community experience. All posts need to allow full access to trust information technology systems and bleeps or an appropriate alternative. Also, secretarial support for administrative work, such as writing discharge summaries.


All trainees should have specific induction to provide details of the type of psychiatry placement before allocation. This should include an overview of the key roles of the foundation trainees, their responsibilities and working relationships.

It is essential that in clinical settings where foundation trainees are regularly placed, nurses and other staff members are aware of F1 and F2 roles and responsibilities and what can be expected of them (such as prescribing and the responsibilities for use of Mental Health Act).


All foundation doctors must be appropriately supervised at all times and should initially be directly supervised by a more senior colleague when seeing patients, until they gain confidence and can feed back to a consultant. Trainees must have regular, timetabled 1 hour supervision time with the consultant trainer (e.g. meeting the consultant weekly or with an advanced trainee alternating weekly) to bring a topic or cases for discussion and for completion of assessments and to provide clinical and educational support and for career guidance.

It is strongly recommended that where possible foundation trainees are paired with core trainees or advance trainees in the form of mentoring relationships, with encouragement from the educational and clinical supervisor to meet regularly for additional support and to discuss any clinical or other concern.

Independent practice

F1 psychiatry trainees should not assess patients independently and they should always work jointly in the community, with senior and fully trained team members, rather than alone. Patients seen by foundation doctors in clinic should also be seen by the consultant after the trainee has made their assessment so that the assessment can be verified and there are further opportunities for the trainee to learn from how the consultant interacts with the patient.

Both F1 and F2 trainees should be supported carefully to develop skills in carrying out and documenting risk assessment. Clinical risk assessment may be carried out under supervision by a trainer, a more senior trainee or an experienced team member. Risk assessment should be viewed as another specific responsibility with potential legal consequences, for which training and competency assessment should be provided and formally confirmed before trainees carry out these duties independently.

Responsibilities for work carried out under the Mental Health Act

Year 1 foundation doctors are not fully registered and can not therefore undertake the role of the deputy for the Responsible Clinician and can not assess patients under the mental health act for Section 5(2) or 4.

The F2 doctors are often part of psychiatry duty doctor rotas, together with core psychiatry trainees. The duty doctor customarily has particular responsibility to assess voluntary in-patients for detention under the Mental Health Act, by signing Section 5(2). As an action under the law this requires knowledge of the Mental Health Act and guidance to develop the skills and competence required to undertake such assessments. This is an appropriate activity for F2 doctors to undertake provided that they are adequately trained, which will include supervised practice until they are assessed as competent. (Specific arrangements need to be tied to duty rota documentation, designating the nominated deputy legally.) F2 doctors should only sign Section 5(2) forms (or carry out any other Mental Health Act responsibility) or carry out risk assessment once shown to be competent (e.g. by evidence in the portfolio of supervisors confirming specific supervised experience and discussion in personal supervision) and therefore not during a specified initial period of the attachment.

On call

F1 doctors should not be doing psychiatry on call, but ideally should continue to do medical on call in their acute hospital even when in a psychiatry placement. This will help to maintain links with peers and to build on medical skills being developed.

F2 trainees will generally be on call on the standard core training rota, but require close supervision from the on call consultant when making any assessment or clinical decisions. This supervision gradually reduces as the trainee feels more confident in the psychiatry post.

Assessment of Medically Ill Patients:

The following guidance is given routinely to Foundation doctors starting in psychiatry.

A Foundation doctor may be called upon to assess patients who are medically unfit either in the psychiatry in-patient units or possibly in the community.

It is important to be aware that psychiatric hospitals do not have facilities to support patients with serious physical health problems and the foundation doctor is not in a position working in these settings to facilitate urgent investigation, or initiate immediate and complex treatment such as IV support, or catheterisation.

In many respects the support available may even be less than in a standard community setting as there is a lack of access to GP level medical advice.

Most patients are not acutely physically ill. Some patients will have general medical needs, as in any other community setting. In this regard, psychiatric hospitals are like other community hospitals, residential and nursing homes, and crisis houses. None of these sites, in common with many psychiatric hospitals, have resident doctors of any grade.

In the event that a patient needs more immediate and complex physical assessment, it is expected that the foundation doctor should discuss with a senior psychiatry colleague and it is generally necessary to have these individuals seen in the nearest A&E department. It would of course be helpful if a patient was referred, to discuss the case with the casualty team, while the transfer is being organised. This would normally require an ambulance, which the in-patient team would generally organise.

As a Foundation doctor working in psychiatry, you would not normally be expected to initiate complex physical treatments. If you are uncertain about appropriate physical care of an individual, you should always discuss this issue with a senior psychiatry colleague, who may be the local core/advanced trainee in your unit or your consultant or the consultant on-call.

It may be useful to contact the specialist team in the general hospital for advice, but where a complex decision is being made this should always be shared with senior colleagues in the psychiatric team, who will be responsible for the treatment while the patient is in a psychiatric hospital.

Note that discussion of the physical problems with a more senior psychiatric colleague is not generally to get expert medical advice (bearing in mind that as the psychiatric specialists become more senior their physical medicine skills tend to become out of date), but to bring the concerns to their attention so they can advise on the need to contact local acute medical/surgical services and how best to do this.

Some Foundation doctors have expressed reluctance to contact the consultant on call. It should be stressed that reluctance plays no part in this decision. It is a duty of any doctor to seek advice when feeling out of depth or uncomfortable with clinical decision making, and this is expected as part of good medical practice (GMC).

Linkage with other foundation trainees

All foundation trainees should be able to attend teaching sessions and social events at the acute Trust; such teaching there should include psychiatry topics and be given by psychiatric trainers/teachers.

Other approaches should be made to ensure that foundation trainees can maintain links with their peer group in the acute hospital. It is noted that problems of isolation will also be reduced if, in line with the Psychiatry Taskforce recommendations, more training posts are developed within community settings such as psychiatry.


Handover arrangements in psychiatry posts are often rather different in mental health trusts, as compared with acute Trusts. The typical medical model of handover may not be suited to services which include multiple community and in-patient mental health teams and where members of the crisis team often hold and carry forward key risk information, but it is important to note that as they enter the culture of mental health services, foundation trainees bring knowledge and skills associated with other medical cultures with them and these ways of working may operate equally well in mental health services. It is vital that key information is handed over effectively from and to teams working out of standard 9-5 working hours.

Specialty posts

Many foundation trainees will want as part of their placement to learn about the different psychiatry specialties and how these work together across the system as a whole. Some foundation trainees may specifically seek to work in an old age psychiatry post to help to maintain their medical skills, whereas others may be more interested in general adult psychiatry in order to develop their experience of psychopathology, assessment and treatments and to test whether psychiatry may be the right career choice for them. Where possible there should be flexibility in the foundation trainee timetable to allow them to experience at least one alternative form of specialty during their placement, for one or two taster days.


All foundation trainees need to have protected time for their formal teaching programme (usually at the main acute site). They should also be able to attend the local Trust provided medical education programme (usually 2 hours per week). Posts should also include where possible opportunities for simulation training, time set aside to share cases and experiences with colleagues and time for teaching others (for example medical students).

Audit and Quality Improvement

Foundation, core and advanced trainees working in psychiatry are all encouraged to participate in audit, either in ongoing projects or creating new audits, and to participate in quality improvement projects. There is a Royal College of Psychiatry guide which provides methodologies for audits to be taken ‘off the shelf’ (Royal College of Psychiatrists, 2010).

Clinical learning experiences

Foundation doctors and their trainers should recognise the importance of maximising the wide variety of learning opportunities in the clinical workplace and undertake SLEs to capture this:

  • Work as a medical professional, including clinical practice, meetings and documentation
  • Accounts by patients, service users and carers of their experiences
  • Analysis of care scenarios supported by literature reviews
  • Quality improvement and audit projects
  • Audio/video recording of personal practice or a colleague’s practice
  • Computer-controlled simulator
  • Discussion of one’s own or another’s practice
  • E-learning: e-LfH, BMJ Learning, FP Curriculum 2012 Resource
  • Group discussion of typical cases

Responsibilities of trainers

All foundation year 1 (F1) and foundation year 2 (F2) doctors must have a named educational supervisor.

The named educational supervisor will be responsible for:

  • ensuring that the programme is appropriate for foundation doctors’ needs
  • meeting with the foundation doctor at the beginning of each placement to discuss what is expected in the placement, learning opportunities available, the foundation doctor’s learning needs and the foundation doctor’s introduction to the Placement Supervision Group
  • helping foundation doctors by reviewing their learning needs in the light of achieved goals

Every foundation doctor will have a named clinical supervisor for each placement.

The named clinical supervisor is responsible for:

  • guaranteeing suitable induction to the ward/department/practice
  • meeting with the foundation doctor at the beginning of each placement to discuss what is expected in the placement and learning opportunities available. The foundation doctor’s learning needs will also be discussed and the Placement Supervision Group be made known to the foundation doctor
  • ensuring that the clinical experience available to the foundation doctor is appropriate and properly supervised.
  • undertaking and facilitating SLEs
  • monitoring, supporting and assessing the foundation doctor’s day-to-day clinical and professional work
  • providing regular feedback on the foundation doctor’s performance. Ensuring that all training opportunities meet the requirements of equality and diversity legislation
  • allowing the foundation doctor to give feedback on the experience, quality of training and supervision provided
  • discussing serious concerns with the educational supervisor about a foundation doctor’s performance, health or conduct
  • seeking formal feedback from the Placement Supervision Group regarding the foundation doctor’s progress
  • completing the clinical supervisor’s end of placement report (which can include recording achievements of outcomes and competences) at the end of the placement.

Some training schemes appoint an educational supervisor for each placement. The roles of clinical and educational supervisor may then be merged.

Study leave during foundation training

Please refer to the Study Leave page.

Report Authors

Rob Macpherson, Head of School of Psychiatry, Severn PGME
Linda Heaney, core Training programme Director, Severn PGME School of Psychiatry
Hayley Richards, Director of Medical Education, AWP
Guy Undrill, Regional Advisor in psychiatry
Geoff Vanderlinden, Lead foundation trainer, AWP
Liz Ewins, Advanced trainee, Severn PGME
Ami Kothari, Advanced trainee, Severn PGME


Boyle AM, Chaloner DA, Millward T, Rao V, Messer C. Recruitment from
foundation year 2 posts into specialty training: a potential success
story? Psychiatric Bulletin. 2009; 33: 306-8.

Brown T, Addie K, Eagles J. Recruitment into psychiatry: views of consultants in Scotland. The Psychiatrist, 2007; 31:411–413.

Collins J. Foundation for Excellence. An Evaluation of the Foundation
Programme. Medical Education England, 2010.

Herzberg, J., Forrest, A. & Heard, S. (2004). Modernising medical careers:
An opportunity for psychiatry? Psychiatric Bulletin, 28, 233-234.

Royal College of Psychiatrists (2011). 101 Recipes for Audit in Psychiatry
Eds: C Oakley, F Coccia, N Masson, I McKinnon and M Simmons. Gaskell.

Welch, J, Bridge, C, Firth D et al (2010)Improving psychiatry training in the Foundation Programme. The Psychiatrist, 35, 389-393.

Appendix 1: Example of detailed syllabus; Relationship and communication with patients

Treats the patient as the centre of care within a consultation

F1 outcomes

• Prioritises the needs of patients above personal convenience without compromising personal safety or safety of others
• Works in partnership with patients in an open and transparent manner, treats patients as individuals and respects their perspective/views on their own treatment

F2 outcomes (in addition to F1)

• Works with patients and colleagues to develop sustainable individual care plans to manage patients’ acute and long-term conditions

  • Considers the patient as a whole, respecting their individual needs, dignity and right to privacy, autonomy and confidentiality
  • Discusses management options with patients
  • Recognises patients’ expertise about their care
  • Respects patients’ views and encourages patients with knowledge of their condition to make appropriately informed decisions about their care
  • Demonstrates understanding to the whole clinical team that respect of patients views and wishes is central to the provision of high quality care
  • Considers care pathways and the process of care from patients’ perspectives
  • Respects patients’ right to refuse treatment or take part in research
  • Recognises and responds to patients’ ideas, concerns and expectations
  • Deals appropriately with angry or dissatisfied patients.

Communication with patients

F1 outcomes

• Communicates effectively and with understanding and empathy in straightforward consultations

F2 outcomes (in addition to F1)

  • Demonstrates increasing ability and effectiveness in communicating more complicated information in increasingly challenging circumstances e.g. time limited consultations (outpatients and GP clinics) and as outlined (2.3 - 2.5)
  • Deals increasingly independently with queries from patients and relatives
  • Ensures sufficient time and appropriate environment for communication
  • Listens actively and enables patients to express concerns and preferences, ask questions and make personal choices
  • Recognises that patients may have unspoken concerns and communicates in an empathic manner to elicit and address these
  • Responds to patients’ queries or concerns
  • Seeks advice promptly when unable to answer patients’ queries or concerns
  • Explains options clearly and checks patients’ understanding
  • Provides or recommends relevant written/on-line information appropriate for individual patient’s needs
  • Documents communications with patients in their records
  • Teaches communication skills to students and colleagues.

Communication in difficult circumstances

F1 outcomes

  • Breaks bad news to patients or carer/relative effectively and compassionately, and provides support, where appropriate

F2 outcomes (in addition to F1)

  • Recognises where patient’s capacity is impaired and takes appropriate action
  • Demonstrates involvement with others in the team when breaking bad news
  • Considers any acute or chronic mental or physical condition that may have an impact on communication understanding
  • Considers patients’ personal factors including relevant home and work circumstances
  • Ensures sufficient time and a suitable environment for discussions
  • Deals appropriately with distressed patients/carers and seeks assistance as appropriate
  • Demonstrates the ability to communicate when English is not a patient’s first language, including the appropriate use of an interpreter
  • Manages three-way consultations e.g. with an interpreter or with a child patient and their family/carers
  • Understands how the communication might vary when the patient or carer has learning or communication difficulties themselves e.g. deafness
  • Deals appropriately with angry or dissatisfied patients, trying to calm the situation and seeking assistance as appropriate.


F1 and F2 outcomes

  • Recognises situations which might lead to complaint or dissatisfaction
  • Apologises for errors and takes steps to prevent/minimise impact
  • If involved in a complaint, deals with it under guidance including:
    • Ensuring appropriate arrangements for patient care
    • Communicating with other staff and patients where appropriate
    • Demonstrating appropriate learning from episode
    • Obtaining appropriate mentoring advice and counselling
  • Identifies or describes a potential complaint and the role of the multidisciplinary team in methods of resolution
  • Understands and addresses common reactions of patients, family and clinical staff when a treatment has been unsuccessful or when there has been a clinical error
  • Seeks to remedy patients’ or relatives’ concerns with help from senior colleagues and/or other members of the multidisciplinary team
  • Understands that complaints do not necessarily imply blame and is open to discussion of the issues concerned
  • Demonstrates understanding of the local complaints process and its value in learning for both the individual and the organisation
  • Consults with other members of the team on factual information/explanations of error to ensure that the patient is given a single clear picture of causation of fault rather than suggestions or probabilities
  • Follows an untoward incident or complaint through the trust/LEP process.


F1 outcomes

  • Obtains consent as appropriate in accordance with Consent: patients and doctors making decisions together (2008) including for core procedures

F2 outcomes (in addition to F1)

  • Increases the breadth of procedures for which consent is taken in accordance with GMC guidance
  • Practises in accordance with Consent: patients and doctors making decisions together (GMC, 2008) and does not take consent when contrary to GMC guidance
  • Describes the principles of valid consent and obtains valid consent after appropriate training
  • Gives each patient the information they ‘want’ or ‘need’ in a way they can understand in order to obtain valid consent
  • Provides or recommends relevant written/on-line information appropriate for patients’ needs
  • Listens to patient concerns and answers their questions regarding treatment
  • Considers any acute or chronic mental or physical condition that may have an impact on the consent process both in terms of understanding and influence on outcomes of the procedure
  • Understands how to undertake a capacity assessment and does so where appropriate
  • In patients who lack capacity understands and applies the principle of ‘best interests’
  • Ensures that the patient with capacity understands and retains information long enough to make a decision
  • Considers any acute or chronic mental or physical condition that may have an impact on the consent process both in terms of understanding and influence on outcomes of the procedure

Appendix 2: Summary of background literature relating to Psychiatry Foundation posts.

Brown and Bhugra (2005) set out the aims, objectives and intended leaning outcomes of the psychiatry foundation programme at the time of the programme’s inception:

Aims: To produce doctors with knowledge and competency to treat common psychiatric conditions

Objectives: To identify mechanisms underlying an exemplar condition, e.g. depression. To develop skills in history-taking and mental state examination for an exemplar condition, e.g. depression

Intended learning outcomes: Attain and utilise knowledge and skills required to treat common psychiatric conditions

Identify and summarise mechanisms underlying an exemplar condition, e.g. depression

Acquire and demonstrate skills in history-taking and mental state examination for an exemplar condition, e.g. depression

The authors pointed out that in addition to full 4 month placements short-duration release (week, fortnight or day release) for attachments in psychiatry is another way of introducing trainees to psychiatry. During the attachment trainees should obtain an appreciation of the way that psychiatry contributes to individual patient management in a range of settings and in different patient groups, including prevention, assessment, diagnosis, treatment and follow-up, and the contribution to protection of vulnerable individuals and children. They should learn about the use of physical, social and psychological investigations for common psychiatric disorders, general principles underlying diagnosis and treatment choice, commonly used pharmacological and psychological treatments and the career opportunities in psychiatry. The authors noted the potential value of working with enthusiastic, knowledgeable teachers and contact with patients and recommended ongoing linkage with other foundation components, especially the general practice posts.

Review of psychiatry foundation training by Welch et al (2010).

This review triangulated national and local (South Thames Foundation School) feedback from various sources:

  1. Feedback from local faculty groups and academic Boards revealed largely negative evaluations of psychiatry posts, including overall unpopularity (and trainee avoidance) or judgements (by both F1 doctors and consultant psychiatrists) that posts provided little useful training. There were criticisms of clinical and educational supervision, inappropriate responsibility and the duration and relevance of induction.
  2. The Postgraduate Medical Training Board (PMETB) Survey 2009 results were reviewed. The survey showed:
  3. Scores above average for overall satisfaction for F1 psychiatry and below average for F2, and similar results for clinical supervision; scores above average for workload and European Working Time Regulations compliance; hours of education (i.e. teaching time) scored highly for both F1 and F2, although F2 psychiatry had a lower than average adequate experience score; induction and educational supervision had an average score at F1 and F2.
  4. Three focus groups were carried out among 47 Foundation trainees. Group A covered placement structure and facilities, group B induction, handover, legal aspects and team interaction, and group C teaching, curriculum and support. Results were mixed: variable general quality of posts (applying to any training post) including the availability and quality of clinical and educational supervision, internet access and timely and relevant induction; isolation of mental health trusts from ‘acute’ trusts, at which were sited foundation peers, induction, generic training as part of delivery of the Foundation Programme, and acute medical experience; professional position of junior psychiatrists (typically in multi-professional teams with few doctors, with traditional handover and other practices, often working across multiple sites); responsibilities and processes of the Mental Health Act and risk assessment.

It was emphasised that with particular reference to community based work, Foundation trainees may undertake psychiatry at an early stage of their training, with particular concern when a psychiatry placement was the first part of an F1 rotation. The newly qualified doctor would sometimes be located several miles away from the main site and their peers, in an unfamiliar environment without immediate opportunities to reinforce many skills learned at medical school and acquire acute medical competences. They would sometimes be the only newly qualified doctor, working within a multi-professional team of staff whose roles may not be immediately obvious, as they have overlapping skills and responsibilities and seldom wear uniforms. Operational and educational arrangements commonly differ from those in acute trusts, for example some clinical supervision being provided by clinical psychologists or community psychiatric nurses rather than more senior doctors. The multi-professional team may have considerable experience but little understanding of the Foundation trainee’s needs and the situation could be made more difficult by the absence of appropriate induction and regular, timetabled supervision.

HESW Severn data relating to foundation psychiatry posts

It is known that future career choice is influenced by a foundation doctors’ current training post and of concern, the number of foundation trainees who know where to look to find information to help them plan their career has fallen from 41% (2010) to 25% (2011). The experience in foundation training is likely to have a profound effect on decisions about the future career.

A quality panel report in autumn 2014 looking at all foundation posts in psychiatry across Severn concluded: Overall, psychiatry Foundation years 1 and 2 posts appear to be working well across the Deanery. Generally good supervision, educational experience, ongoing links with Foundation group, a variety of good practice examples. 

Appendix 3: Foundation posts and recruitment to psychiatry

From an early stage in the planning of the Foundation programme, there was a hope that a positive involvement of psychiatry would lead to improved recruitment to the profession (Herzberg et al, 2004). Despite early hopes (Boyle et al, 2006) this has not yet occurred.

The question of why postgraduates do not choose to train in psychiatry has been addressed by a number of authors and it was noted by Maidment et al (2003) that sixth form students have positive views of the specialty, suggesting as have other authors (Brown et al, 2007) that poor information and prejudice in medical schools may deter trainees from entering the specialty. In a large survey of Foundation trainees, Shah et al (2009) found that overall, foundation trainees trainees become more keen on the specialty during the first two postgraduate years and those who were exposed to the specialty through doing a post became much keener to pursue it as a career. Three groups of influencing factors were identified: early medical student experience (including interest in psychiatric patients, aptitude); influence of seniors; aspects of the working envirnment (patient contact, pace of the specialty, team working). In keeping with other research (McParland et al, Eagles et al (2007), these findings suggested that experience of undergraduate psychiatric clerkships improves attitudes to psychiatry and likelihood of recruitment. Singh et al (2003) found that during psychiatry placements medical students found patient contact rewarding, become more accepting of community care, and had greater appreciation of the therapeutic potential of psychiatric interventions. Attitudes to mental health and psychiatry improved, again suggesting the importance of exposure to practice, to challenge stigmatised and ill educated beliefs.

The issue of balance of specialties in the Foundation programme was addressed in the review of the Foundation programme by Collins (2010). In recommendation 15, it was argued that the ‘curriculum should be revised to give greater emphasis to the total patient, long-term conditions and the increasing role of community care. It should also reflect the changing ways of working, in particular the need for team-working skills within a multi-professional environment’. In a section on ‘maldistribution of placements by specialty’, recommendation 16 stated that the ‘successful completion of the Foundation Programme should normally require trainees to complete a rotation in a community placement, e.g. community paediatrics, general practice or psychiatry. It was noted that ‘specialties with recruitment problems such as paediatrics and psychiatry are under-represented in terms of opportunities to experience these specialties at foundation level’. This report has resulted in the establishment of a Psychiatry Taskforce which has recommended clear targets for increased numbers of Foundation year 1 and 2 posts in 2013 and 2014.


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Brown T, Addie K, Eagles J. Recruitment into psychiatry: views of consultants in Scotland. The Psychiatrist, 2007; 31:411–413.

Eagles, JM, Wilson, s, Murdoch, JM et al (2007). What impact do undergraduate experiences have on recruitment to psychiatry? Psychiatric Bulletin, 31, 70-72.

Herzberg, J., Forrest, A. & Heard, S. (2004). Modernising medical careers:
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Maidment, R, Livingstone, G, Katona, M, et al (2003). Carry on shrinking: career intentions and attitudes to psychiatry of prospective medical students. Psychiatric Bulletin, 27, 30-32.

McParland M, Noble LM, Livingston G, McManus C. The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career. Med Educ2003; 37:447–454.

Shah P, Brown T, Eagles J. Choosing psychiatry: factors influencing career choice among foundation doctors in Scotland. Teaching psychiatry to undergraduates. London: RCPsych Publications, 2011:255–263.

Singh, SP, Baxter, H, Penny Standen, P et al (1998). Changing the attitudes of 'tomorrow's doctors' towards mental illness and psychiatry: a comparison of two teaching methods Medical Education, 33, 115–120.