Psychiatry Recruitment and Retention Working Group: final report

Phase 1: Psychiatry Training and Trainee Recruitment Issues

This section explores the Group’s considerations of trainee and trainee recruitment issues. The Group’s recommendations relating to these issues can be found in Annex A.

Introduction

Based on initial exploratory work from a training perspective, the Group set out to explore in Phase 1, the key issues of improving fill rates for recruitment into psychiatry training programmes at Higher Specialty Training (HST) level and addressing the high attrition rates currently being recorded at various stages of the training pathway.

As the work of the group progressed, related topics were explored, and further interconnected issues were uncovered and considered including gathering stakeholder data and reviewing publications like the State of the Nation Report.

The key topics and issues explored include:

• Specialty Training related issues
  • attrition between Core and Higher Specialty Training
  • regional recruitment challenges
  • delays in completing Specialty Training
  • impacts of increases to Less Than Full Time (LTFT) working
• Supervision capacity

The other topics and issues considered:

• Attraction-related considerations including exposure to psychiatry, trainee experience and stigma, particularly at early stages of training
• Workforce planning to link between training places and consultant vacancies
• The availability and quality of data

The typical training pathway for psychiatry is illustrated below. It shows the journey through foundation years, core medical training, speciality training, Certificate of Completion of Training (CCT) and appointment to consultant.

Some stigma against psychiatry has been identified through surveys and studies^[1],[2].

The ‘State of the Nation’ Report noted that a majority of medical undergraduates had encountered negative attitudes to psychiatry and were less likely to choose to pursue psychiatry as they progress through their studies. The report went on to highlight that early exposure to psychiatry during medical school and Foundation Training, including through positive placement experiences, may help with trainee attraction.

Foundation Trainees can undertake placements in Psychiatry in Foundation Year 1 (FY1) or Foundation Year 2 (FY2).

*Data current as at February 2024

There are difficulties in fully involving FY1 trainees in psychiatry-related work due to their lack of clinical experience and their utilisation is limited by their pre-registration status which limits their ability to perform certain duties (for example the granting of an emergency detention certificate under the Mental Health Act) and to perform without supervision. These limitations can also cause concern among some FY1s about being able to meet programme competencies. Liaison posts, which are popular among FY1s (as noted by the Working group), are a useful way of offering some level of exposure for FY1s but their use varies by region.

Regarding FY2s, many working in psychiatry during the day are often excluded from psychiatry out-of-hours rotas and are instead placed on medical rotas. The Working Group also highlighted the challenges around increasing FY2 exposure to psychiatry in regions outside the Central Belt (due to the availability of training opportunities and educational supervisors) and given the recent expansions to Foundation and Core Training.

The Foundation Priority Programmes (FPPs), which are offered in North of Scotland, also focus primarily on increasing and enhancing exposure to psychiatry. Recruitment into FPPs takes place prior to that for the standard Foundation training programme and the Scottish Foundation School is considering whether this can be replicated in other NHS regions. All trainees who secure a place on this FPP in the North will:

• Rotate through a psychiatry placement in the second year of Foundation training (FY2)
• Be allocated a Psychiatry mentor / Educational Supervisor
• Receive enhanced Psychiatry supervision
• Have access to the Scottish Royal College of Psychiatrists conference

Core and Higher Specialty Training: Attraction and Flow-through

Recruitment at entry level into specialty training programmes in Scotland is largely competitive and sees consistently high fill rates on an annual basis (Table 2). Core psychiatry – a pre-requisite for Higher Specialty Training – has been filling at 100% for a number of years. This is similar to patterns elsewhere in the UK.

**2024 data accurate as of 14^th October (when fill rates were published by NES) and do not necessarily reflect the end-year position. 2024 figures will remain subject to change until end-year data (which includes recruitment during the third and final recruitment round of the year) is published.

Attrition between Core Training and Higher Specialty Training:

However, there is a clear and obvious breakpoint between the final year of core training (CT3) and the first year of higher specialty training (ST4). This is evidenced through recruitment data which shows vacancies at ST4 level in various psychiatric subspecialties (Table 3).

*Data shown is mid-year fill rates and is accurate as of 14^th October 2024

There are several possible reasons for this attrition between Core Trainees (CT) and Higher Speciality Training (HST), as identified through the Working Group and RCPsychiS research as set out in the ‘State of the Nation’ report:

• Trainees feeling they need more experience in their chosen field
• Trainees feeling undecided about HST or unprepared for the greater responsibilities of HST
• Stress around availability of and access to higher training opportunities including around application criteria
• Inadequate time to complete professional exams and competencies and an inflexible assessment system
• Experiential demotivators including training challenges and risk of burnout
• Trainees opting for Clinical Development Fellowship (CDF) posts
• Having settled in a region during CT and not wanting to uproot for HST as well as a lack of understanding about options, opportunities and prospects in other regions

Regional challenges with recruitment to Higher Specialty Training:

Data considered by the Working Group showed that recruitment challenges to HST are more prevalent in some regions than others. For example, ST4 psychiatry programmes in the Central Belt appeared to fill at a higher rate than those in the North and East.

When considering Scotland overall, the average number of ST4 posts advertised each year (57 from 2020-2023) is higher than the average number of trainees completing CT each year (43 from 2020-2023) but there were regional differences. The identified gap between core trainee output and the number of higher training posts available (Table 4) is biggest in the East and North and there were not enough higher training posts to accommodate core trainee output in the South East. This is because the regional distribution of training posts is based on future workforce requirements rather than trainee preference.

Delays in completing or failure to complete Specialty Training:

The limited supply of CT3 completers into higher specialty training jeopardises trained doctor output. This in turn limits the number of individuals who can apply for consultant posts – something that is reflected through the strong reliance on locums which is described elsewhere in this report.

Another key issue which is limiting/staggering the output of trained Consultant Psychiatrists through the training pathway is the delay in completing or failure to complete Specialty Training.

The ‘State of the Nation’ report, on average, 27% of trainees complete Core and HST within the minimum 6-year timeframe.

There are several possible reasons for trainees not to complete the ST within the minimum six years. This could be a result of trainees working Less Than Full Time (LTFT), taking career breaks (as noted previously), opting for educational/developmental posts out with training and/or failing to achieve the competencies needed to progress satisfactorily through training. Another reason could be due to the challenges involving College exams, particularly for International Medical Graduates (IMGs).

LTFT working is becoming more popular over time especially across specialty training.

While LTFT working may improve trainee health and wellbeing by offering a healthier work/life balance, its impacts on particular geographical areas, supervision requirements and service delivery rotas require careful consideration and planning. Supervision requirements remain the same whether a trainee works full time or LTFT. Fragile rotas and a lack of support can be off-putting for trainees and could potentially jeopardise/delay their ability to progress through training.

Failure to achieve necessary competencies or successfully complete assessments can also delay the completion of Specialty Training. For example, as the State of the Nation Report highlighted, some core trainees may need longer to demonstrate psychotherapy competencies due to service and other demands. The Group noted that some trainees may delay Royal College examinations in order to have more time to prepare for them (to reduce chances of failing and having to re-sit at considerable cost) and that there are generally poorer pass rates for written exams than the CASC exam.

There are also differences in exam pass rates for different demographic groups (e.g. UK graduates with different ethnic backgrounds) and exam pass rates are generally lower for IMGs than for those who received their Primary Medical Qualification (PMQ) from a UK university. A tool on the General Medical Council’s (GMC) website, taken from the annual National Training Survey in 2024, can calculate roughly how many IMG’s across the UK are training at core and higher level in Psychiatry. This is one of several challenges experienced by IMGs more generally; others include visa-related concerns and issues settling in and adapting to a new country.

Some trainees may choose to become specialty doctors in order to avoid the expense of sitting College exams, as trainees do not need to complete HST in order to practice as specialty doctors. While some do return to training at some stage, however, some could be tempted into consultant locum posts which are lucrative from a financial perspective and avoid the need to complete HST.

Supervision of Trainees

Supervision quality and capacity are crucial for the effective delivery of training and positive trainee experience and therefore ultimately the successful and timely completion of training and post-Certification of Completion of Training (CCT) retention in the workforce.

Several concerns and considerations related to supervision have been identified through discussions of the Group, including:

• Limited supervision capacity due to high consultant vacancy rates and compounded by recent expansions in medical school places (and therefore Foundation training) and Specialty Training places, plus the need to consider this in planning any future expansions to the pipeline
• Limited consultant availability for providing clinical and teaching support to medical students (and the need to review how Additional Cost of Teaching [ACT] funding could more effectively support undergraduate teaching in psychiatry)
• Risks of Higher Specialty Trainees not receiving the consultant time prescribed by the Royal College of Psychiatrists
• The need to ensure that educational supervisors have adequate time for supervision and teaching, including through consideration of factors such as job plans and 9:1 contract (discussed in more detail elsewhere in the report)
• The need and opportunity to increase supervision capacity through alternative models of clinical supervision.