Response

The article by Lim and colleagues ^{Reference Lim, Burford, Lloyd, Dave, Alberti and Vance1} published in the British Journal of Psychiatry frames psychiatry’s workforce supply system as a pathway characterised by a positive recruitment pressure (owing to multiple factors as well as intent to train as a psychiatrist), with subsequent attrition driven by misalignment of trainee expectation and experience, motivational erosion and identity strain. Importantly, the article points toward new opportunities for improving selection to the specialty, redesigning the training environment so that resident psychiatrists are equipped to remain within training and realignment of the expectations of both psychiatrists and employers, to generate sustainable consultant roles.

UK psychiatry faces a critical workforce challenge – we are consistently failing to train enough psychiatrists to meet the demand for consultants, leaving a quarter of posts without a substantive and fully trained consultant. ² Regional, speciality and subspeciality variation has led to some areas and complete services lacking any permanent senior medical staff, with obvious implications for service quality and safety, training and support of resident doctors and multidisciplinary team members. With only limited opportunities to increase the capacity of the postgraduate training pipeline, the importance of as many as possible of those within training progressing smoothly and without delay to their Certificate of Completion of Training is therefore obvious. Yet, at present, only about half of those who begin core training move into fourth year specialist training (ST4) posts. ^{Reference Silkens, Sarker and Medisauskaite3} Rather than a problem with recruitment, our current challenge has become the retention of psychiatrists in training, particularly those in early core training years.

Continued use of the Multi-Specialty Recruitment Assessment (MSRA) as the sole criterion for selection to core training has facilitated strategic applications across a variety of specialties without significant applicant investment or intent, and there is no convincing evidence that it selects for the strengths and attitudes that make a good psychiatrist. Indeed, questions specific to psychiatry are not guaranteed to be included within this sole assessment for entry into the speciality. Introduced to manage the challenges of recruitment during the COVID-19 pandemic, the incoming Dean of the Royal College of Psychiatrists (RCPsych), Nandini Chakraborty, expressed their intention to introduce a psychiatry-specific recruitment procedure to replace the MSRA is long overdue and a welcome measure. ⁴

Lim and colleagues suggest that psychiatrists in training experience a collision between their expectations of the specialty and the current realities of clinical practice within the National Health Service (NHS), which exposes them to rota instabilities, professional isolation and emotionally demanding situations. Coupled with increasing clinical demands felt across the NHS, educational opportunities once found in day-to-day practice have been swallowed up by the demands of service provision, with a detrimental effect on well-being and professional satisfaction. Provision of high-quality clinical and educational supervision, feelings of belonging and professional value within rotational placement teams, and fostering of peer support through MRCPsych course attendance, Balint and other psychotherapy supervision groups and informal peer social activities are all important in maintaining motivation and direction. Induction programmes and annual reviews of training progression should focus more on the availability and incorporation of these elements of professional identity formation, which otherwise can remain part of an important but hidden curriculum.

Many psychiatrists in training view some of the consultant posts they observe, particularly in general adult psychiatry, to be professionally unsustainable, and many will complete portions of their training without supervision from substantive consultants. It should not be surprising that they will consequently defer the completion of their training or their applications for substantive senior posts. Increased flexibility within consultant roles and more rigorous and realistic job planning to ensure that filled and advertised consultant posts can be seen as sustainable and attractive will be the only way to change this so that we can move to lower levels of vacancies, even if the numbers of resident doctors completing training can be increased to meet potential demand.

Lim and colleagues should be congratulated for providing a sophisticated analysis of the aetiological components of the current workforce difficulties that psychiatry faces. Their suggestions for ways by which some of the most important difficulties that undermine specialty retention can be tackled have good face validity and – most attractively – should be within scope for action by us as individual members of our profession, our employers and the new Dean of the RCPsych.