Psychiatry under siege

The formulation that psychiatry is under siege is not new. For decades, concerns about the dilution of the ‘role’ of psychiatrists – fears of being subsumed by either neurology or psychology, challenges to diagnostic validity and stigma against mental health – have contributed to mistrust in psychiatry and self-doubt among psychiatrists. Indeed, some have doubted its very survival.

The good news is that interest and recruitment in psychiatry are thriving – spurred on by strategies such as the Royal College of Psychiatrists’ Choose Psychiatry campaign. ¹ Workforce numbers and investment in mental health too seem to be rising: for example, in England the respective numbers have increased from 114 000 mental health workers and £12 billion of funding in 2018 to 157 000 and £18 billion in 2024.

However, the increase in workforce numbers (22%) is dwarfed by the increase in demand (44%), with a lower increase for doctors (9%), ² impacting access to professional expertise. Patients are eight times more likely to have to wait for a mental health appointment than for a physical health appointment. The mortality gap of nearly two decades for patients with severe mental illness is unchanged. In a stretched system, focus on managing ‘flow’ and multiple interfaces in the patient pathway adversely affects both patient experience and outcome. Senior-level vacancy rates of 15–20%, accompanied by rising complexity in patient presentation and reduced investment in the skill mix, lead to an underresourced and often poorer quality of care.

Existential angst and trust gap

Psychiatrists feel embattled. Staff turnover, stress and burnout have increased, with a doubling of mental illness-related staff shortages. ² Attempts to relieve clinical pressure through the utilisation of alternative professionals, such as physician assistants or multi-professional approved clinicians, have not been without controversy. The supervision capacity of psychiatrists has been stretched, raising fears about the substitution of professional experts with less skilled staff, diluting the quality and safety of care. An inadequately resourced pipeline of academic psychiatry has impacted on advances in diagnostics and treatment, crucially impeding access to evidence-based treatments. ^{Reference Critchley, Tracy, Malhi, Alexander, Baldwin and Cavanagh3}

Pressures from the outside have not helped. Unregulated digital media and tools for self-diagnosis have led to misinformation and disinformation, fuelling negative perceptions about psychiatrists. ^{Reference Battle, Álvarez-Mon, Lara-Abelenda, Perez-Araluce and Pinto da Costa4} Calls to name individual psychiatrists involved in critical incidents have caused apprehension about institutionalising a blame culture.

Demoralised, devalued and disillusioned with their working conditions, some leave the profession while others express existential discontent. ^{Reference Tweed, Holmes and Pinto da Costa5}

What is the role of psychiatry and psychiatrists? How can psychiatry alone solve the impact of psychosocial determinants of mental illness such as poverty, rising trauma, poor housing and homelessness – that feel largely out of the control of ordinary clinicians?

Strengths of psychiatry

Simply put, on our own we cannot reverse the impact of worsening health inequities. ^{Reference Marmot6} However, what the bleak landscape fails to acknowledge are the natural strengths of psychiatry. Neuroscience expertise, deep understanding of psychosocial determinants, systemic thinking, relational care rooted in science, a culture of compassionate curiosity, person-centred precision medicine and prevention-focused public health are hallmarks of psychiatry. These attributes are critical to the three shifts (hospital to community, treatment to prevention and analogue to digital) highlighted in the NHS 10 Year Health Plan for England, but are also relevant to healthcare globally. ⁷

The way forward

First and foremost, psychiatrists are medical doctors – wanting to improve outcomes for their patients. Policies and initiatives that empower psychiatrists as clinicians to influence individual and population-level patient outcomes will help. As a medical Royal College, the Royal College of Psychiatrists has an important role to play in shaping professional identity, in locating psychiatry at the heart of wider healthcare policy and reform and in ensuring a clear and explicit synergy between policy and science supporting professionals to deliver high-quality patient outcomes.

Professional identity: from doctor–patient to doctor–community

Modern medicine is a systemic enterprise yet medical education is largely pathology-focused, preparing doctors to treat individual patients. Disease processes are complex and are caused by multiple factors, from genes to climate change, loneliness and exposure to toxic substances in the food chain. As experts in the biopsychosocial formulation, psychiatrists are the natural leaders in precision personalised medicine.

This paradigm shift, from a doctor–patient to a doctor–community model, building in effective prevention at different levels of care, is critical to changing the script for our potential patients. It encourages us to adopt a life course approach, requiring a recognition that most psychiatric disorders are neurodevelopmental in origin and that a focus on early life and women’s health yields significant returns on quality of life, functional and economic outcomes. ⁸

Pioneering initiatives from the Royal College of Psychiatrists provide a foundation – through the new curricula with the twin lenses of formulation-driven, person-centred care and public mental health.

New initiatives include new stations in the Clinical Assessment of Skills and Competencies evaluating personalisation of assessment and management, return of the long clinical case to assess workplace-based formulation skills, a public mental health (PMH) leadership course, a new appraisal tool, promoting peer group learning in population health and a community of practice led by the PMH Implementation Centre.

Addressing eroded medical identity, however, will need more than curricular and assessment change. Medical leadership needs strengthening and support. The College can help amplify the voice of medical leadership by building on current networks of medical directors and directors of medical education. A network of chief executive officers of mental healthcare providers should help translate College policy and guidance to action through board-level influence, shoring up the medical voice at this senior level. Formal guidance from the College on the structure and resourcing of medical leadership and management should also help define the professional identity of psychiatrists, from mere prescribers to biopsychosocial experts who can effect systemic change at the population level.

An important element of psychiatrists reclaiming medical leadership will be to move closer to our primary identity as medical practitioners. In the UK we remain figuratively – and often literally, as in the case of many a mental health unit in the country – at the margins of medical establishments. In the two decades during which the UK has had postgraduate deaneries, not a single psychiatrist has become a postgraduate dean. Similarly, a negligible proportion of psychiatrists have been appointed to generic healthcare leadership positions. Such marginalisation is to the detriment of both psychiatry and wider healthcare.

Many of the problems described – burnout and mental illness in staff, rising patient demand and fears of overmedicalising, as well as the impact of poverty and social determinants of health – are the problems of medicine too. Psychiatrists can, and should, play a greater role in improving the health of the nation.

Psychiatric workforce: numbers, skill mix and well-being

For psychiatry to fulfil its promise, it needs a workforce delivering highly skilled care, while remaining invested in the training of future professionals, with the welcome increase in numbers of trainees and medical students. Protecting supervision time in job plans advantages education and supports patient care. Certain principles will help inform the ongoing reform of postgraduate medical training in the UK.

First, establishing the correct numbers within the workforce: regional accountability frameworks should address employer reluctance in funding training place expansions. The College has lobbied for an urgent review of national recruitment policy to address rising competition ratios, to ensure that UK foundation trainees have a clear progression path to core training and that international medical graduates wishing to train in the UK have fair and transparent, but also realistic, expectations. Optimising the role of the large group of specialist and locally employed doctors in clinical, educational and leadership roles will also help.

Second, achieving the appropriate skill mix: this has been a significant hotspot with disproportionate lack of capacity – for example, in addictions, eating disorders and neurodevelopmental and academic psychiatry. RCPsych Learn credentials can upskill psychiatrists in these areas of clinical need ⁹ – relatively rapidly and cost-effectively. Incentivising and engaging with regional research networks, particularly for early-career psychiatrists, can help reinstate an academic culture in routine psychiatric practice.

Third, the well-being of the workforce is critical: reducing professional autonomy destroys joy at work. Employing solutions such as ambient voice technology to improve clinician efficiency frees up time for relational care, improving patient satisfaction and productivity. Building good occupational mental health capacity can create mutual benefit for both employer and employee.

Finally, regulatory and legislative reform is needed to make fitness-for-practice processes swifter, less adversarial and more compassionate. The College’s Retention charter, Disability Action Plan and Act Against Racism framework provide actionable ideas to improve working conditions. We must now focus on implementing these ideas.

Patient outcomes

Building trust with sceptical policy makers and the public requires us to demonstrate our relentless focus on patient welfare.

While it is true that our patients face wide treatment gaps due to inadequate mental health funding, reflection on current practices is necessary. For example, our patients also face unacceptable delays in access to evidence-based and previously funded treatments, such as clozapine or electroconvulsive therapy for refractory severe mental illnesses. Systems must prioritise design processes to address these delays. Digital innovations may offer solutions. Initiatives such as Locating Clinically Useful Information, a pilot clinical dashboard that monitors at-risk patient groups, can help the move from reactive to proactive coordinated care, improving patient outcomes and saving costs. However, digital innovations require digital literacy, and the College has a head start with its Digital Literacy Framework, ⁹ alongside digital and data literacy training courses delivered through College Divisions.

From smoking cessation programmes to the Lester tool, the key lesson arising from the relatively unsuccessful attempts at addressing the mortality gap for our patients with severe mental illness is that the translation of innovations into action needs the backing of robust implementation science. Developing policies and guidance centrally is hard enough, but implementing them locally and regionally takes further coordinated and co-produced effort involving patients, carers, psychiatrists and multidisciplinary team professionals. Learning from devolved nations, College Divisions need to be empowered to facilitate the implementation of good practice regionally.

Finally, and crucially, measurable outcomes can help patients, clinicians and commissioners of care. As clinicians, we must exercise leadership in informing and influencing outcome frameworks that will both demonstrate clinical effectiveness and attract new funding streams. Equity as an underpinning principle will ensure that innovations and implementation do not exclude sections of the population.

As a trainee, I saw psychiatry at the cutting edge of science, an opportunity to explore and practise in an intriguing web ranging from individual thoughts and feelings to social and neural networks. As Dean of the College I have found that this remains true today – in a world of machine learning and artificial intelligence, psychiatry stands tall in its daily endeavour to understand the human condition, humanely, within its complexity.

Over the years I have been variously labelled a molecular psychiatrist or a social psychiatrist. We must resist such pigeon-holing. Being united as experts in biopsychosocial medical practice, irrespective of our subspeciality, is not just about the persona of psychiatrists but more fundamentally about good patient care – for both individuals and the wider population.