Billy Boland: Isn’t it time for something radical to sustain our mental health workforce?

The reality of fewer psychiatrists is a problem that is not going to go away

billy_bolandAugust is here, which means that, usually, consultants up and down the country are ready to welcome new trainees into the fold. It’s an exciting time, and it’s always a pleasure to see enthusiastic new recruits who are keen to help patients, to learn, and to get on with the job. Only this year, many can put a hold on getting the bunting out. No one will be coming.

Recruitment into core training is looking pretty dire for a lot of specialties, like mine in psychiatry. I’ve had a look at the figures for national recruitment so far and it is not good. Round one shows that the fill rate for core training in psychiatry for 2017 is a piffling 69%. Compare that to the 82% we had last year and the outlook doesn’t look promising.

As far as I can see there are going to be a lot of rota gaps, a lot of outpatient clinics unmanned, and a lot of wards without their ward doctor. Fill rates have been over 80% fairly consistently since 2009, peaking at 91.3% in 2013, although 2014 then saw a slump to 65%, before recovering to 82% again in 2015.

Yet with rising access to mental health services and a rapidly aging population who are more vulnerable to mental health problems, the reality of fewer psychiatrists is a problem that is not going to go away. So what are we going to do? It’s not like me to not be optimistic, but I’m struggling to see the “green shoots” here. There is no “magic junior doctor tree,” to corrupt a phrase. We may just have to manage without this year. And, with no increase in recruitment numbers in sight, we better brace ourselves for the long term.

Enter Stepping forward to 2020/21: The mental health workforce plan for England, which was published by Health Education England earlier this week, and which sets out the latest strategy to address this. There are some great ideas in here. Proposals include the use of personal assistants to support doctors, physician associates to complement teams, and a major recruitment campaign planned for 2018. The report announces 21 000 new posts in mental health, but do we have any confidence they will be filled?

It’s clear some good people are doing good work to try and sort this out, but I can’t see that it will have real impact in time for recruitment next year. The report recognises the effect of the loss of mental health officer status, which used to see those working in mental health offered earlier retirement, and which I have previously written about. Yet I can’t see a meaningful offer to attract doctors to psychiatry and halt this miserable decline.

The picture is patchy, with places like London and Wessex doing well (at 100%) to fill their places. However, other regions do much worse, like the North East where I’m originally from, which has a fill rate of only 25%. Should we start to offer additional benefits, such as a golden handshake, higher salary, or earlier retirement—particularly in less attractive areas—to encourage doctors to train there and stay? Trainee distribution is radically inequitable across the country, isn’t it time for something radical be done to redress this?

Billy Boland is a consultant psychiatrist and associate medical director for quality and safety at Hertfordshire Partnership University NHS Foundation Trust. You can follow him on Twitter @originalbboland.

Competing interests: I am vice chair of the general adult psychiatry faculty at the Royal College of Psychiatrists.

  • David Levine

    Billy, you mention the possibility of offering ‘additional benefits’ as inducements to recruitment but isn’t it likely that more fundamental aspects of working in Psychiatry, at least in some areas, is what’s putting applicants off? If a career in Psychiatry is as exciting as you and HEE suggest (and as it can still be), there should be no need for additional inducements. Inequitable trainee distribution must indeed be sorted out but what is it about London and Wessex that allows them to fill so many more places?

    In all honesty, HEE’s ‘workforce plan, with all the usual cliches’, says remarkably little in thirty seven pages that might explain the causes of the problem. One hint of possible deeper organisational problems and one mention that polls of trainees’ opinions are to be commissioned. Really…has no one asked them aready?

    Two brief mentions of ‘integration of physical and mental health’ but that’s it. When I trained (as a Physician) in the 1970s there was hugely rewarding joint working and education between departments of Psychiatry and Medicine in two large Teaching Hospitals. Since then I’ve seen increasing separation, professionally and geographically between Psychiatry and the rest of Medicine in many places. Is ‘parity of esteem’ likely to occur when mental health is seen as ‘other’ in these ways.

  • Carol-Anne Wilson

    What about restoring career pathways for mental health workers? In our Commissioning Group they seem to have destroyed mental health occupational therapists career progression and recruitment. With many of them leaving to work in physical medicine only – but OT’s are trained in both physical and mental health with a huge knowledge of skills in behavioural work – dbt, cbt, exposure therapy, emdr just for starters. With extended scope practitioner status and AHP prescribing an option – surely we should make better use of this professional group???