Written evidence submitted by the Royal College of Psychiatrists (RTR0131)

1. The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists and setting and raising standards of psychiatry in the United Kingdom. It works to secure the best outcomes for people with mental health difficulties by promoting excellent mental health services, training psychiatrists, promoting quality and research, setting standards and being the voice of psychiatry.

Summary

2. The Royal College of Psychiatrists has long worked and continues to help resolve one of the greatest challenges faced by the NHS: ensuring the UK has a highly skilled mental health workforce. The COVID-19 pandemic makes this work more challenging, though even more important. From educating to examining, from workforce planning to policy influencing, from campaigning to promoting research, the College plays a major role in ensuring people with mental illness can receive the psychiatric support that they need.

3. Workforce planning has long been a challenge for the NHS. Aside from the difficulties of training, recruitment and retention (set out in discrete sections below), there is a notable absence of data on the number of staff required to meet demand. Current work to consider the impact of changing demographics and disease prevalence, patient and carer expectations, socioeconomic and environmental factors, staff expectations, technological and digital progress, and service models and pandemic recovery is critical. However, it will not solve the ongoing data gap that impedes strategic workforce planning decisions.

4. Key recommendations are listed below, with further recommendations set out in bold within the text.

Key Recommendations

5. Increase the number of medical school places in England to 15,000 by 2028/29 at an estimated cumulative cost of £802m by 2024/25 (on the basis of places reaching 11,000 per annum by then) or around £1.73bn per annum when fully implemented in current prices when including the costs of the foundation programme or £936m per annum in current prices for medical school costs alone.
6. Allocate those places to schools that have a clear plan to encourage more students to choose a shortage specialty, including psychiatry, which would equate to £64m of those cumulative costs to 2024/25 or costs of £138m per annum when fully implemented in current prices if 8% of the total new places are taken by doctors choosing psychiatry.
7. Continue the expansion of core psychiatry posts by making a further 120 additional posts available in 2022 and ensure provision for further expansion in the remaining years of the Spending Review to facilitate long-term sustainability and growth in consultant psychiatrist posts. The additional core training posts made available from August 2021 onwards must be fully funded through the core training pathway, with sufficient provision also made for an expansion in higher training capacity.
8. Lay out plans to publish a comprehensive NHS workforce strategy following publication of Health Education England’s (HEE) strategic framework. This should be accompanied by a multi-year settlement for workforce training and education to allow for the growth in the mental health workforce, including via new roles, necessary to deliver the Long Term Plan, proposed standards from the Clinically-led Review of NHS Standards, and the proposed Mental Health Act reforms. The settlement must take into account that funding for postgraduate medical education and training has been essentially flat in real terms between 2013/14 (£2.111bn) and 2020/21 (£2.080bn).
9. Ensure funding is allocated to deliver the requisite workforce for the Mental Health Act reforms. This includes the additional 333 FTE psychiatrists (including 255 consultants) needed by 2023/24, as identified in the independent research commissioned by the College, as well as the non-medical workforce to be subsequently identified by HEE commissioned research.
10. Provide the necessary investment in workforce to deliver the autism diagnostic pathway and reduce waiting times. Funding is required for both new posts and education and training, while also supporting retention and development among existing staff in these services.
11. Maintain the NHS Staff Support Offer, with £50m funding each year over the three years.
12. Ensure that, from 2022/23 onwards, at least 10% of the 1,000 Physician Associates (PAs) being trained each year work in mental health (including liaison services and GP practices).

Training

13. At present, there is a lack of clarity over whether the system is training enough psychiatrists to meet long-term need. Critically, there is no data source that has taken into consideration training time, training attrition rates, workforce numbers and workforce retirements.

14. Understanding the factors that will have the greatest impact on future workforce demand and supply, such as student expectations, is critical. Important work is already underway as part of Health Education England’s (HEE) refresh of its strategic framework for health and social care workforce planning. It will consider the impact of changing demographics and disease prevalence, patient and carer expectations, socioeconomic and environmental factors, staff expectations, technological and digital progress, and service models and pandemic recovery. This improved understanding will be highly useful as commitments and plans are formulated for the second half of the Long Term Plan, expected to commence in 2023/24, and beyond. However, it will not solve the ongoing data gap on health and care staffing numbers to inform strategic workforce planning decisions.

15. The Health and Care Bill (2021-22) is this Government’s best opportunity to create a better system for workforce planning, but the current duty in Clause 35 for the Secretary of State to publish a report describing the system in place for assessing and meeting workforce needs is inadequate given the scale of the challenge. The duty as currently proposed will not inform us whether the system is training, educating and retaining enough people to deliver health and care services now and in the future. Alongside 90 other organisations[1], the Royal College of Psychiatrists considers that Clause 35 of the Bill should be amended so that every two years the Secretary of State must also publish independently verified assessments of current and future workforce numbers consistent with the Office for Budget Responsibility long-term fiscal projections. 

16. This would increase transparency and accountability on whether we are training enough people to meet demand in the future. Regular, independent and public workforce projection data will provide strong foundations to take strategic long-term decisions about funding, workforce planning, regional shortages and the skill mix required to help the system keep up with rising patient need, based on evolving changes in patient demand and in working patterns among staff, such as a growing proportion of doctors working part-time.

17. Increasing medical school places is an important step to increase the number of home-grown doctors and increase supply over the long-term. The additional 1,500 places per year since 2018 have been welcome, however, they do not go far enough to put long-term workforce planning on a sustainable footing. The unforeseen growth in medical school places due to COVID-19 is a positive development for the future psychiatric workforce. The uplift in medical school places should be retained for 2022/23 and expanded year on year, with 10,000 in 2023/24 and 11,000 in 2024/25, towards reaching 15,000 in 2028/29, as per the Royal College of Physicians recommendation[2]. This should be accompanied by assertive action over the longer term to ensure medical students become trainees in under resourced specialities, including psychiatry. There must also be a secure flow of trainers to train increased numbers of trainees at every level, from foundation through to CCT. This is necessary to deliver a sustainable supply of psychiatrists for the Long Term Plan period and beyond, and is all the more important in light of the extra psychiatrists that will be needed to deliver the planned introduction of mental health access standards and reforms to the Mental Health Act.

18. After foundation training, it takes six years to train to be a psychiatrist and evidence shows that doctors prefer to take longer through training to ensure they have the competencies and confidence they need to manage the complexity and risk of psychiatry. A University College London (UCL) led multi-method research project in 2019 found that psychiatry trainees overwhelmingly did not progress directly through training within six years, with only 14.7% completing training without delays. [3] It found that the average time taken to progress was 11 years, with the largest break in progression occurring between core and specialty training.

19. It also found that trainees desired training arrangements to both support their progression and work-life balance, including allowing time out and Less Than Full-Time (LTFT) hours. These results indicate that trainees want to train more flexibly and that stepping on and off the training ladder will be an increasing feature of the future workforce’s working life. Completing psychiatry training in six years is therefore the exception rather than the norm, and this has important implications for workforce planning.[4] There is also demand for more innovation in training pathways and personalised training, with different models of training now proven to be valued by, and attractive to, applicants. For example, the Children and Adolescent Mental Health Service (CAMHS) run-through pilot which launched in 2018 was an initiative aimed to improve retention of trainees in a hard to fill specialty. It proved popular with candidates from the first pilot, leading to an increased cohort size, and there are now five cohorts going through the pilot. Making training more flexible and personalised would, therefore, support efforts to reduce attrition in training.

Recruitment

20. In the mental health sector, recruiting enough skilled staff to meet the needs of patients was already an urgent and substantial challenge before the pandemic. There have been several plans to try to remedy the workforce challenges surrounding the Five Year Forward View for Mental Health (for the period ending 2020/21)[5] and NHS Long Term Plan, but workforce remains widely recognised as one of the biggest threats to their delivery. This is in part due to the impacts of the pandemic, but also to the slower than needed increases in particular parts of the psychiatric workforce, once headline growth figures amalgamating different staffing groups are broken down, as per original commitments.

21. Workforce planning regularly comes too late in the planning cycle creating difficulties in translating it into action. The Five Year Forward View for Mental Health was followed by a workforce plan – Stepping Forward to 2020/21: The mental health workforce plan for England[6]. To enable the workforce to deliver the Long Term Plan, the NHS published the Interim NHS People Plan covering 2019/20, followed by We are The NHS: People Plan covering 2020/21, both of which were only one-year documents. All three workforce plans were notably unaccompanied by the long-term budgets needed.

22. Stepping Forward to 2020/21 set the intention to add 570 consultant psychiatrists and 8,100 nurses to the mental health workforce. Since March 2017 (the government’s baseline date), the latest data from September 2021 shows only 236 consultants and 2,852 mental health nurses have been added to the workforce[7]. When considering both sets of targets outlined in Stepping Forward and the NHS Long Term Plan, data from September2021 shows that the system is currently almost 400 consultant psychiatrists behind the target for 2020/21, and, therefore, on course to miss the target by 2023/24.[8]

23. The Royal College of Psychiatrists’ 2021 workforce census[9] revealed that 726 consultant posts (9%) were reported vacant or unfilled, an increase compared with 708 in 2019 and 537 in 2017 (a 35.1% increase since 2017). This picture looks significantly worse considering that as of 2021, the locum consultant workforce is at its highest reported level of 1,102 (14%), compared to 915 in 2019 and 685 in 2017 (a 60.9% increase since 2017). The highest consultant vacancy rates were found to be in child and adolescent (13.4%), eating disorders (12.3%), additions (10.8%), and general adult (10.4%).

24. Alongside increased demand for mental health services due to the pandemic, workforce requirements are expected to mount in line with the proposed Mental Health Act (MHA) reforms. The reforms will lead to changes to the timescales for mental health tribunals and the responsibilities of psychiatrists during these tribunals. In turn, this will alter the frequency of tribunals per detention, and the time required for each tribunal and detention. Current workforce constraints indicate that extra work needed to implement these reforms cannot be absorbed by the existing workforce.

25. Independent research commissioned by the Royal College of Psychiatrists estimates the number of psychiatrists needed to deliver the reforms. Using the DHSC’s own estimates on changing numbers of detentions, the research finds that by 2023/24 an additional 333 FTE psychiatrists will be needed, and by 2033/34 a further 161 will be needed.[10] Implementing the MHA reforms will require additional workforce over and above what is needed to achieve the Long Term Plan, and the success of the reforms will be dependent on investment to increase and train the additional workforce needed.

26. Another area contributing to mounting workforce pressures is the cross-government all-age autism strategy for 2021-2026. This contains laudable objectives including improvements to the diagnostic pathway and reducing waiting times. Successful delivery of the strategy will undoubtedly require investment into a substantial number of new posts, including consultant psychiatrists and associated spending on education and training, staff retention and development. Moreover, the planned introduction of mental health access standards must also be matched with appropriate resourcing, including tackling the workforce crisis in mental health. Without this, the standards may fail to drive clinically relevant improvements, while piling further pressure on already stretched staff.

27. The next iteration of the NHS People Plan should recognise these additional pressures and ensure continued commitment to the mental health workforce given high levels of need and record number of referrals to services. Official NHS statistics show significant increases in demand for mental health services, and research estimates there will be 1.8 million new presentations, recurrences or exacerbations of mental ill health expected as a direct or indirect result of the pandemic until 2023.[11] This means that responding to people who need care and support due to the pandemic is already a challenge, and one that will continue to exacerbate workforce pressures. This must be factored into workforce planning.

28. It is well-recognised that recruiting from overseas is crucial for fulfilling workforce commitments required in the NHS Long Term Plan. As of September 2019, there were 8,773 FTE psychiatrists, of which around half had qualified abroad[12]. Indeed, overseas doctors have long had crucial roles in delivering excellent patient care and we need to continue to support international medical graduates more than ever. However, it would be both unsustainable and unethical to over-rely on international recruitment to get the workforce that we need.

29. More doctors must be trained here in the UK. An increase in medical school places should be followed by a similar expansion in the number of training places at Core and Higher levels. The Royal College of Psychiatrists was pleased the Government funded an additional 120 core psychiatry training programmes in 2021/22, however a further expansion of core training posts is required to meet increased demands, as well as overcome geographical and speciality shortages. Trainees are not simply ‘in training’. They are delivering services from day one, so an expansion of core posts has a direct impact on service delivery. Geographically, the South West and Eastern divisions are particularly difficult to recruit to so extra core posts in those regions would support service capacity, as well as potentially helping with consultant applications in the future.  A continuation of the expansion of core psychiatry posts by making a further 120 additional posts available in 2022 is recommended.

30. Integrated Care Systems (ICSs) have an important role in ensuring local health and care organisations attract and retain staff with the right mix of skills. ICSs can identify and seek to address geographical and specialty shortages within their local areas, and invest in new roles, such as Physician Associates PAs), who are an important part of meeting current and future workforce demands. Critically they can enable consultants, specialty doctors and trainees to work to the top of their skill set to improve productivity.

31. It is also recommended that a long-term comprehensive workforce strategy is published. This should be supported by a multi-year settlement for workforce training and education to grow the mental health workforce, including via new roles, necessary to deliver the NHS Long Term Plan, reforms to the Mental Health Act, mental health access standards, and address extra demand due to COVID-19. Any settlement should ensure that the continuing professional (CPD) budget within Health Education England (HEE) is fully restored to 2013/14 levels in real terms. 

Retention

32. There are several factors that impact on retention of both trainees and older consultants that need to be addressed to ensure that new supply can have an impact. Data from 2019/20 showed 1,455 psychiatrists working in hospital and community health services left the NHS, in comparison to the 1,536 that joined the workforce over the same period.[13] Work-related stress is caused by high demand and under-resourced services, including insufficient staffing levels and low recruitment. This leads to an increase in retirements amongst older consultants, as well as disincentivised trainees who desire greater flexibility throughout the training pathway, as a result.

33. Current contractual and employment models are becoming less fit for purpose. While there is much work being undertaken around the country to address this, especially within Trusts that employ transformation officers, there is greater demand for more flexible ways of working.

34. At present, members report high workloads, poor work-life balance and pressures on continuing professional development (CPD). This means that older consultants are more likely to retire early due to work-related stress, which has been exacerbated by the pandemic, and there is a knock-on effect on trainees who can become disincentivised. A lack of flexibility can mean that experienced psychiatrists leave the profession early which impacts on workforce supply. Across the sector, there has been an increase in the number of doctors taking early retirement, with NHS figures showing that the numbers have tripled in the past decade. From 2007/08 to 2018/19, the number of GPs and hospital doctors in England and Wales taking voluntary early retirement or retiring because of ill health rose from 386 to 1186, and the average retirement age fell over this period, from 61 in 2007/08 to 59 in 2018/19.[14] The 2021 Royal College of Psychiatrists’ UK workforce census shows a total of 300 consultants (4.3% of total number) were reported to have retired in 2020 and 2021. This marks a 23.5% increase from 2018/19 (243) and a 64.8% increase from 2016/17 (182).

35. Research also shows gender and specialty differences in retirement ages, and while there is a general societal expectation that people will retire at increasingly older ages, this is not reflected in the medical workforce. A 2018 study of retirement ages of senior UK doctors showed that psychiatrists and GPs retired at a slightly younger age than radiologists, surgeons, and hospital specialists.[15] It also showed that only 15.1% were working full-time in medicine, compared to pathology (17.7%), anaesthesia (19.2%), radiology (25.7%), hospital medicine (28.7%), and surgery (33.3%). This figure was the second lowest after GP (10.1%).

36. An increased focus on retaining retiring doctors is critical to ensuring a sufficient workforce. To increase workforce supply, posts need to be adaptable and able to change as postholders get older and seek to pursue specific interests within job roles, including non-clinical roles (such as medical research and education) which are central to promoting psychiatry. There should also be easier opportunities post-retirement for people to return and offer specialist sessions. Enabling psychiatrists to pursue career development and management opportunities, and access to lifelong learning, can also improve job satisfaction. Credentialling is a good way to support this need through providing an opportunity to offer training and/or upskilling where there is not currently a pathway in place, but also for consultants who are already on the specialist register.

37. Alongside the Mental Health Policy Group[16], the Royal College of Psychiatrists considers there needs to be significant investment in retention and in mental health support for health and care staff, particularly after the strain put on them during the pandemic. This is needed both as a duty of care towards staff, but also to mitigate the impacts of mental health related absence, which has consistently been the most reported reason for sickness absence, accounting for 28% of absences since March 2020.[17] The duration of mental health-related absences was, on average, more than treble that of Covid-related absences between 1st June 2020 and 1st June 2021. The accumulative figure puts lost days to mental health-related absences at 2.5 million working days, compared to 2.1 million working days for Covid-related absences. The loss in productivity over the last twelve months is estimated to have cost the NHS more than £371.2m.[18] The Centre for Mental Health calculated that preventing a 1% increase in the rate of FTE absence rate of NHS staff saves approximately £476,000,000 per annum, based on the £47.6bn staffing cost in 2016/17[19]. This is the equivalent of providing a quarter of a million staff with mental health treatment worth approximately £2,000 per person as a breakeven exercise to reduce staff absence.

38. The Covid-19 Mental Health and Wellbeing Recovery Action Plan[20] committed to £30m of funding for mental health hubs, which is equivalent to approximately £30 per NHS staff member. NHS staff have accessed the health and wellbeing offer 750,000 times, which shows that there is demand for these services. A long-term commitment to funding these mental health hubs is required. Published data on outcomes, number of contacts and the breakdown of protected characteristics of the staff accessing the hubs would enable evaluation of the effectiveness of the hubs, build on success and address gaps or concerns.

39. Another important factor in workforce wellbeing and retention relates to diversity. Data from the NHS Staff Survey Workforce Race Quality Standard condensed on the Royal College of Psychiatrists Mental Health Watch data tool[21] shows that many Black, Asian and Minority Ethnic staff are experiencing workplace-based racism and discrimination. In 2020, of the over 16,000 respondents of Black, Asian and Minority Ethnic background in mental health trusts, 86% had experienced discrimination on the basis of their ethnic background. Against this context, is the important and ongoing work of the Advancing Mental Health Equality Strategy Workforce[22] workstream. No mental health trust staff should experience any discrimination on the basis of their ethnic background, or any other protected characteristics.

40. Finally, capital investment in infrastructure and technology will make the NHS a more attractive place to work, which will make a real difference in increasing staff retention. This is particularly important in regions which struggle to recruit and carry long term vacancies, including the Midlands, South East, East of England, North East and Yorkshire and South West.

Jan 2022