Current training landscape

Medical undergraduates’ exposure to old age psychiatry remains variable. A 2015 survey reported wide disparities in teaching time, from a single lecture to several weeks of clinical attachment (Bennett Reference Bennett, Ilderton and O’Brien2017). Although the RCPsych introduced a core undergraduate psychiatry curriculum in response to such findings, its adoption and impact remain unclear and is a gap that invites future research. At foundation level, the Broadening the Foundation Programme recommendations mean that one-third of doctors now undertake psychiatry posts, although not specifically in old age psychiatry (Health Education England 2014). Core trainees all rotate through old age psychiatry, yet questions remain about whether this equips them for future practice, especially as dementia care in particular becomes more complex. Specialty and specialist (SAS) doctors also require structured opportunities, but provision is inconsistent.

Higher specialty training in old age psychiatry has modernised through the 2022 curriculum (RCPsych 2022). However, this raises the question: what have we gained and what have we lost?

Curriculum changes: gains and losses

Gains include explicit emphasis and space for reflection on physical health, health promotion, intersectionality and palliative care in dementia, areas previously underrepresented. These changes encourage holistic, person-centred care and challenge entrenched dualistic thinking. Despite significant regional variation, cross-specialty collaboration is now more visible, with opportunities to link with neurology and geriatric medicine, particularly seen at the dementia and frailty interface. This is timely, given the priorities for integrated care and workforce flexibility to face future NHS challenges set out in NHS England’s (2025a) Medical Training Review diagnostic report. NHS mental health trusts are beginning to collaborate with their local acute and community trusts, bringing innovation such as mental health and physical frailty wards.

The 2022 curriculum newly highlights applying the principles of ‘experts by experience’ in clinical practice as a key capability, an approach that brings authenticity and depth to training, with opportunity for embedding co-production (RCPsych 2022).

Losses, however, are notable. The pre-2022 curriculum included ambitious outcomes such as demonstrating knowledge of applying for research and development funding, skills that foster academic leadership. Their absence risks narrowing trainee aspirations and reducing engagement with innovation. This tension reflects a broader dilemma: should curricula prioritise breadth and inclusivity or maintain high-end academic expectations? Trainers must ask whether removing these aspirational goals inadvertently signals that research and leadership are optional rather than integral to clinical and academic excellence.

Recruitment and workforce challenges

Recruitment into old age psychiatry remains a concern, regional variation being the main contributor. Overall fill rates (NHS England 2025b) for higher specialty training improved in 2025 (87%, up from 71% in 2024), yet a vicious cycle persists in old age psychiatry: lack of supervisors limits training posts, which in turn limits workforce supply.

Although Specialty Trainee Year 4 (ST4) fill rates for old age psychiatry in England sat at 71.4% in 2024, there was significant regional variation, with rates as low as 25% in the East Midlands and 33.3% in the South West, compared with 100% in London. This raises the question of bespoke regional innovations to increase trainer and trainee numbers in these regions.

Interestingly, dual training in old age and general adult psychiatry shows better fill rates (98% in 2024), but many dual trainees anecdotally later move into subspecialties such as liaison psychiatry, rather than remaining in old age psychiatry.

Addressing these patterns requires creative solutions, including varied and flexible consultant job plans with enhanced mentorship. Without tackling these structural issues, curriculum reform alone cannot secure the future workforce of old age psychiatrists.

International perspectives: learning, not leading

Global and UK ageing trends demand adaptable and culturally sensitive training models. The RCPsych International Diploma in Older Adults’ Mental Health (www.rcpsych.ac.uk/international/international-diploma), which serves as a knowledge enhancement programme designed for doctors outside the UK, could be perceived as a unilateral export of British values; however, it is co-produced with practising clinician contributors from a range of diverse cultures and countries. This collaborative model counters concerns of curriculum colonisation.

On reflection, there is much that UK practice can learn from international models. For instance, community-based dementia care in parts of Scandinavia and Asia emphasise social inclusion and family engagement, approaches that could enrich UK practice and training. Rather than assuming leadership, we should embrace mutual learning and adapt global insights to our local contexts, particularly given national pressures on social care providers and the UK’s more hospital-centric model.

Future outlook: realistic and evidence based

Demographic projections indicate rising prevalence of dementia and frailty, a trend that will intensify demand for skilled clinicians. Disease-modifying treatments, although promising, have also brought disappointment, highlighting the need for trainees to navigate uncertainty and communicate realistic expectations of availability and effectiveness. This is not just a clinical challenge but an ethical one: how do we balance hope with honesty in conversations with patients and families?

Digital technology and artificial intelligence (AI) are often cited as transformative, but their current role is modest. Practical examples include:

• AI predictive prognostic models: predicting with high sensitivity and specificity the likelihood that mild cognitive impairment will progress to Alzheimer’s disease (Lee Reference Lee, Vaghari and Burkhart2024);

• risk stratification: predicting which individuals with dementia are most likely to require in-patient care or enhanced community support, enabling early targeted interventions (London Reference London, Chen and Sidhom2024).

These developments illustrate that AI is already beginning to shape research and service planning. Training must prepare psychiatrists to integrate, interpret and apply these cutting-edge tools responsibly, while recognising AI’s limitations and ensuring that they learn and develop time-tested core and clinical skills.

Cross-specialty collaboration: an opportunity

The Medical Training Review report identifies key priorities for future medical training in the NHS, including workforce flexibility (NHS England 2025a). Old age psychiatry is well placed to lead cross-specialty initiatives with neurology and geriatric medicine, particularly in dementia care. Current collaboration between the RCPsych’s Faculty of Old Age Psychiatry and the British Geriatrics Society on dementia diagnosis in acute hospitals exemplifies this approach. Expanding such partnerships could help trainees develop the skills needed for complex, multi-morbidity care, a reality for most older patients.

The emergence of biomarkers and disease-modifying treatments in dementia care is accelerating interdisciplinary working, requiring trainees to understand not only the clinical application of biomarkers, but also the nuances of diagnosing preclinical or prodromal dementia. Training will shift from a primarily symptom-focused model to one encompassing precision diagnostics and early intervention.