Psychiatry Recruitment and Retention Working Group: final report

Phase 2: Recruitment and Retention Issues

The Group agreed that improving staff retention in Psychiatry within NHS Scotland is critical in ensuring confidence in longer-term mental health workforce planning and in meeting the needs of patients.

This section explores the Group’s considerations of recruitment and retention issues as well as outlining the current position of Scottish Government. The Group’s recommendations relating to recruitment and retention can be found in Annex A.

Given the complexities and significance of retention, the Group held an additional sub-group meeting (November 2024) which highlighted:

• The importance of realistic job plans as well as ensuring that there is realistic job planning guidance to support this process, which is specific to mental health. For example, considering the wider areas of responsibility and oversight of caseloads.
• The importance of retire and return policies and the need to understand some of the policy limitations. As well as a need to have early and collaborative discussions on planned partial or retirement with staff. Ensuring that this is factored into workforce planning. Understanding the effect of employer’s contributions and discretionary points which can be lost at point of retirement and can increase the incentive to move into agency.
• Encouraging the use of sabbaticals, career breaks, unpaid leave and secondments as ways to support the workforce and improve retention and wellbeing. Understanding the barriers and processes and how workforce planning can support their uptake.
• Support wellbeing in workplaces by enabling time for honest conversations about how people are finding their jobs, how workloads are, how teams are managed and how any of these aspects can be improved at a personal and organisational level.
• The importance of clinical expertise being at the heart of decision making.

Job Plans

There have been and continue to be calls for the structure of job plans in psychiatry to be improved and standardised to a more favourable ratio across NHS Scotland Health Boards. These calls have also requested that consideration is taken into account of the ratios in place in England and Wales. Evidence and rationale behind the request for change are available in publications such as the ‘State of the Nation’ report.

This report, states that, ‘Key challenges for consultants include: 9:1 job plans that do not allow time for training, teaching, supervision, service development and research’.

It further states that, ‘Consultants on 9:1 contracts are left feeling dissatisfied, disenfranchised and disengaged with their peers and the wider service. This provides poor role modelling for trainees. There are clear benefits to involving clinicians in service development, yet this does not seem to happen consistently and is a lost opportunity. Clinicians are well placed to share knowledge and real-world experience with managers to help develop and sustain services’.

Job plans were raised multiple times by Group members and in particular, the negative effect the reported 9:1 ratio was having on both attracting and retaining psychiatrists to posts in NHS Scotland. There were some differences in viewpoint within the Group on the importance of a defined ratio with the RCPsychiS strongly advocating that all new consultant posts in psychiatry are advertised as 7.5: 2.5 job plans. Whilst others expressing that flexibility is required for Boards on workforce planning and did not want to specify on the ratio on that basis. There was agreement from the Group that the ratio needed to reflect the need for allocated learning, development, training and supervision. As well as time to participate in the leadership and governance of services.

In these considerations, the Group also referred to the ‘NHS Hospital Medical and Dental staff and doctors in Public Health and the Community Health Service (Scotland), Consultant grade, Terms and Conditions of Service’. It states at section 4.2.2 of this document:

‘Unless otherwise agreed, a full-time consultant will devote 7.5 programmed activities per week to direct clinical care, and 2.5 programmed activities to supporting professional activities.’

Current Scottish Government Position:

Scottish Government Ministers do not have a role in influencing the employer (NHS Scotland Health Boards) and employee relationship as the make-up of the job plan is between the employer and employee. The current contracts allow for various job plan splits (9:1, 8:2, 7:3 etc.) depending on the agreement of local job plans between the employee and employer. Through the existing job planning review process, any Consultant employee has the right to ask for changes to their job patterns and any changes should be mutually agreed between employer and employee.

As part of the 2024/25 pay agreement with Consultants, the Scottish Government has agreed to enter “Discussions on the balance of different elements of the job plan for consultants to facilitate attractive employment opportunities within NHS Scotland and to enable retention of the existing workforce”. These discussions are being taken forward via a subgroup of the established tripartite Joint Negotiation Committee with BMA, NHS Employers and the Scottish Government.

Realistic workloads

Related to job plans, the Group stressed the need for realistic workloads in psychiatry to ensure job planning can be effectively put in place. The Group noted guidance available from RCPsych:

• Safe patients and high-quality services- a guide to job descriptions and job plans for consultant psychiatrists (CR207 Nov 2017)
• Job planning for a community consultant psychiatrist in England (CR236) (rcpsych.ac.uk)

The Group supports the development of updated and explicit guidance on what a reasonable workload looks like in psychiatry alongside developing a Target Operating Model/Service Specification for general adult and older adult services as a matter of urgency. This should help in defining the role, scope and remit of services and help in understanding the required workforce to meet demand.

Use of Locums

Representatives from the Group attended the Scottish Government’s Medical Locum Engagement Task and Finish Group in October 2024 and presented on the challenges around locum use in psychiatry. The presentation prepared by RCPsychiS highlighted:

• Loss of workforce. Highlighting a reduction in general psychiatrists (826 in December 2016 to 786 in June 2023)
• The increased use of locum psychiatrists highlights long standing workforce issues in psychiatry and are systematic of wider challenges such as unprecedented demand and pressure on workforce and gaps in workforce planning
• Showed that 1 in 4 positions are vacant or filled by locums across health boards
• There are between 50 and 60 non-CCT (non-qualified) locums Whole Time Equivalent (WTE) in post
• Highlighted that remote and rural areas have a higher number of posts filled by locums
• Issues raised by substantive staff on the use of locums included:
  • Diverting essential resources away to pay for locums.
  • Reported high levels of stress/burnout caused by having to take on extra responsibilities not covered by locums whilst being paid less.
  • Loopholes in legislation that allows appointment of locum consultant psychiatrists who do not have appropriate qualifications for the role.
  • The importance of continuity of care and the effect this has on patients.
  • Concerns on how it can affect quality assurance, patient care and patient outcomes.

The presentation also highlighted a survey undertaken by RCPSYCHIS of locums in Scotland, which showed that:

• 31% of respondents were highly experienced and qualified staff (had held a substantive post for more than 30 years) are leaving posts to take up locum positions. It also highlighted that 13% of newly qualified psychiatrists had chosen to become locums instead of taking up substantive posts.
• People who left substantive posts left their positions due to stress (31%) work-life balance (27%) and disillusion (24%).
• When asked about perceived positives of becoming a locum over two thirds (67%) said that they had more flexibility, freedom, control, work-life balance or felt less stressed, and
• Proposed a dual approach as a solution. This approach would address issues in workforce as outlined above, and whilst seeking to move away from appointment of under-qualified locum psychiatrists, support those in locum posts to move into substantive posts.

The Group recognised the need for use of Locums in Psychiatry to ensure service provision and cover periods of absence. However, the Group had particular concerns about an increased reliance on the use of under-qualified locums (those not on the Specialist Register) using the term ‘Consultant Psychiatrist.’ An issue that was also picked up in the VoX report.

The Group therefore recommends that the term ‘Consultant Psychiatrist’ is reserved for those who are on the Specialist Register to increase transparency on qualifications held, maintain quality and protects the professional title of Consultant. The Group also noted that those Consultants returning to post after retirement should be offered the title of Emeritus Consultant to recognise their experience and expertise.

Current Scottish Government Position:

The use of temporary staff in an organisation as large and complex as NHS Scotland will always be required to ensure vital service provision during times of unplanned absence, sickness and increased unforeseen activity.

The deployment of medical agency staff, including locum Psychiatrists, is a matter for individual NHS Scotland Health Boards. Boards should always be seeking to secure best value whenever they enter into arrangements regarding use of locums in order to maximise the outcome that investment has on the quality and availability of patient care.

At a national level, the Scottish Government established a Medical Locum Engagement Task and Finish Group, co-chaired by the NHS Fife Chief Executive and Scottish Government’s Deputy Director of Health Workforce, which aimed to ensure appropriate locum usage across NHS Scotland. The Task and Finish Group has developed best practice guidance designed to strengthen Board governance surrounding the approval of agency medical locum engagements. It has also led exploratory discussions regarding the potential for collaboration across NHS Scotland Boards on the development and operation of medical staff banks, with that work now being taken forward by NHS Scotland HR Directors. Whilst the Group’s work is now drawing to a close, a number of further actions have been identified which will be progressed through other routes, be that alternative working groups or as part of the core business of Government.

While the Medical Locum Engagement Task and Finish Group didn’t have a direct role in addressing the underlying supply challenges facing particular medical specialities such as psychiatry, the group recognised that these supply challenges are significant drivers of locum usage across NHS Scotland. The Task and Finish Group therefore endorsed the exploration of opportunities to address these workforce challenges and were supportive of any potential steps that could be taken to increase capacity within the psychiatry speciality, noting that it is an area with high locum usage across the country.

Leadership and Governance

The Group highlighted that there is considerable variance across boards in how psychiatrists are involved in decision making as highlighted in the NHS reform wishlist as published by RCPSYCHIS (2024). They advocate for Health Boards to use the expertise of Psychiatrists to inform decision making on delivery of mental health services.

While Medical Managers in Psychiatry were well represented in the membership of this Group, it was apparent from their feedback and that of other stakeholders that there is ongoing concern that decision making and governance arrangements for mental health services do not consistently involve psychiatrists. It is suggested this results in a sense of disempowerment and contributes to retention challenges. The Senior Medical Managers in Psychiatry Group (SMMPG) recommended that a Director/ Deputy Medical Director of Psychiatry for each Health Board area to give a clear line of medical psychiatric responsibility and accountability for psychiatrists in mainland Health Board areas. This should be supported with protected non-clinical time to ensure effectiveness.

Current Scottish Government Position:

NHS Boards undertake a comprehensive range of planning at various levels dependent on the services to be delivered. The Scottish Government looks to Boards to undertake overarching planning and prioritisation which sets out, at a Board-wide level, the planning for the vital services the Board will deliver. Further to that, the Scottish Government expects Boards to ensure this is suitably informed by appropriate quality, financial and workforce planning. As well as setting the context for more detailed planning for the delivery of specific services and the effective running of the organisation, such as digital, governance, and other corporate functions.

Decisions taken and who participates in those discussions are ultimately developed, approved and implemented by the Health Board itself and as such, should reflect the Boards own individual strategic context, priorities and membership. It is however essential that decisions are aligned to the national priorities of the Scottish Government and NHS Scotland as a whole.

Psychiatrists are currently represented on the Scottish Government Mental Health and Wellbeing Leadership Board through the membership of the Academy of Medical Royal Colleges and Faculties in Scotland. The Board is responsible for overseeing the implementation of the Mental Health and Wellbeing Strategy (2023) as well as the associated Delivery Plan and Workforce Action Plan.

The SMMPG is a management group formed in early 2023 when there was recognition that psychiatry leads for Scotland needed a forum that was not part of the RCPSYCHIS. Ensuring there was space for operational management concerns/interests and allowing a direct relationship with Scottish Government on those matters.

Adult Secondary Care Services

The Group heard from RCPSYCHIS that a target operating model/ service specification should, in their view, be developed to help define the role and remit of adult secondary care mental health services. This could prevent the loss of workforce by defining and valuing the role of these services. Noting that this could be of particular benefit to those working in general adult and older adult psychiatry.

Current Scottish Government Position:

The Scottish Government is considering what work is needed to ensure nationally consistent healthcare delivery and to define the future state of mental health services. As part of a wider programme of reform, it is considering the development of service specifications, or a target operating model for mental health services.

The Scottish Government will continue to work with services, including community mental health teams, to ensure they provide person-centred multi-disciplinary treatment and care.

Neurodevelopmental conditions

In recent years, there has been a significant increase in adult referrals for neurodevelopmental condition assessment and support in Scotland. These referrals are placing an increased pressure on mental health services and in particular general psychiatry staff. The National Autism Implementation Team (NAIT) Adult Neurodevelopmental Pathways report (2023) recognised there was a need to improve experiences and outcomes for autistic adults, adults with Attention Deficit Hyperactivity Disorder (ADHD) and those with co-occurring neurodevelopmental conditions in Scotland and made a series of recommendations that the Scottish Government accepted.

In January 2025, whilst the working group was underway, the RCPsychiS submitted a letter and proposal to the Minister for Social Care, Mental Wellbeing and Sport outlining a proposal which outlined a neurodevelopmental conditions tiered service. Scottish Government officials are engaging with the RCPSYCHIS on their proposal.

Targeted incentives for recruitment

The Group discussed whether incentives should be in place to attract psychiatrists to take up posts in rural locations. It is well documented that in some rural areas there are significant challenges in recruiting and retaining psychiatrists and there was a need to consider the incentives that are offered to attract high quality staff to those areas.

During the development of this paper some Group members requested a separate recommendation for recruitment incentives for hard to recruit areas such as areas of severe urban deprivation.

Current Scottish Government Position:

The Scottish Government has incentives in place, amongst which is the Scottish Distant Island Allowance (SDIA), an addition to salary which supports staff with the costs of travelling to and from the mainland for those working in island communities. NHS staff who work in the majority of Scotland’s islands are eligible to receive SDIA.

Culture, Wellbeing and Working Environment

There is a wealth of evidence that highlights addressing workplace culture and staff wellbeing is critical to retention. Psychiatrists have highlighted specific issues to their profession which includes office space and working conditions that are critical to working with the particular needs of patients under care. Other reported issues include staff burnout and a lack of capacity to engage with activities that support wellbeing at work such as personal development, research, support and supervision.

The SMMPG has suggested that consideration should be given to exploring the use of technological innovations to better support working practices and learning from other medical specialities such as General Practice where they have already been used. This could help in reducing administrative time for doctors and aid with productivity.

Current Scottish Government Position:

The Scottish Government identifies that health, social care and social work services have been, and continue to be, under substantial pressure. In order to provide long-term, sustainable support at both a national and local level, there is a need to ensure that they are aligned to existing and emerging needs.

The Scottish Government is continuing to work with leaders across health, social care and social work, as well as hearing directly from staff, to understand where the current pressures are, and what further actions can be taken to mitigate their effect on staff.

It is agreed that staff wellbeing is paramount, and it is critical that staff are able to take rest breaks and leave to which they are entitled, as well as being given time to access wellbeing support, to help avoid burnout. The Scottish Government has committed national funding of over £2.5 million per annum to support the wellbeing of health and care staff from 2024/25.

It is also recognised that employers have a responsibility to support the health and wellbeing of all employees. This includes ensuring the availability and uptake of clinical supervision and reflective practice to support staff. This should be monitored and reported through clinical and staff governance structures.

Flexible Working and Retention in Careers

The State of the Nation report highlights a growing trend for doctors to work less than full-time and a lack of forward planning to take into account the demographics of the workforce. This has led to requests in how workforce numbers are published and used in workforce planning. Discussions by the Group also highlighted how addressing the reasons why psychiatrists are choosing to reduce their hours or leave the profession are closely interwoven with issues around the increase usage of locums.

In addition to improved collaboration between employers and employees about flexible working options the case was made for considering how to better support consultants in their special areas of interest. Supporting doctors to take career breaks or sabbaticals or undertaking more educational roles if desired by the individual.

The discussion extended to how to support staff in the latter stages of their careers including use of late career breaks, sensitive and flexible career planning and ceasing on-call requirements in pre-retirement years. Using the knowledge and expertise of individuals beyond clinical roles.

It was noted during discussions that the RCPsychiS intend to produce a retention charter which should be considered by NHS Scotland Health Boards.

Current Scottish Government Position:

Once for Scotland workforce policies have been developed to be used consistently throughout the NHS in Scotland. These policies have been designed to ‘promote NHS Scotland as a modern exemplar employer; showcasing core values and promoting consistent employment policy and practice that supports the implementation of the Staff Governance Standard and effective recruitment and retention.'

Policies include flexible working patterns, career breaks and retirement. Areas not addressed by the Once for Scotland policies continue to be covered by the current workforce policies of each NHS employer.

NHS Scotland Retirement Policy

The NHS Scotland Retirement Policy provides a framework to support employees transitioning from work to retirement or returning to employment after they retire. This includes information on how to access a phased retirement as well as the processes for retire and return and how to access partial retirement.

Phased retirement is an entitlement of NHS Scotland employment and supports employees in adjusting from employment to retirement or retirement and return. This offers employees a gradual reduction in working days during a phased period.

The retire and return process supports retention issues as well as being beneficial to the employee and ensuring specialist knowledge and skills are retained. This policy requires the employee to resign from their original NHS contract of employment and a new contract will be offered for agreement. Through the application process the employee can state how they would like to retire and return. This includes indicating whether they would like to return to the same post, return to another post in the same or different job family or undertake shifts on the staff bank. Under this policy an employee can choose to work part-time or full-time. Current pension payments won’t be stopped, and employees can re-join the 2015 scheme (as long as they are under 75 years of age).

Partial retirement could be considered as an alternative to retire and return. This allows members of the NHS pension scheme to claim some or all their pension without leaving their job or having a break in service. To qualify, the employee will need to reduce their pay by 10% for the first 12 months. This could have consequences for service provision that would need to be considered. This is agreed through the flexible working request.

Employees accessing their pension need to make sure they understand the implications of accessing either of these policies. Employees are advised to contact Scottish Public Pensions Agency for advice.

Conclusion

The recruitment and retention issues outlined in this section of the report provides a summary of the discussions and evidence considered by the Group on these issues. This resulted in agreement to provide the recommendations in Annex A.