Recommendation 1: Reform postgraduate medical education and training as a matter of urgency

Reform could begin by recognising psychiatry of intellectual disability as a core domain of modern psychiatric competence. Despite advances in genomics, psychopharmacology and personalised interventions, psychiatrists working with people with intellectual disabilities often work in isolation from mainstream clinical, academic and training structures. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3} A comprehensive reform agenda should embed psychiatry of intellectual disability teaching across the psychiatric curriculum, ensuring that every trainee psychiatrist gains exposure to neurodevelopmental and intellectual disability psychiatry, in line with equality duties and population need.

The Royal College of Psychiatrists’ (RCPsych) Broadening the Foundation Programme Strategy (2016–2021) means 45% of doctors in foundation training now gain experience in general psychiatry placements. ⁵ However, very few of these placements are in psychiatry of intellectual disability. ⁶ Previous experience within the specialty has been cited as a critical reason for pursuing specialist training in psychiatry of intellectual disability. ^{Reference Walton, Williams, Bonell and Barrett7} Even those who pursue other medical specialties report enhanced skills in supporting people with intellectual disabilities, an outcome that benefits the wider NHS workforce (a case study is provided in the Supplementary material, available at https://doi.org/10.1192/bjb.2026.10221). National reform should make such placements systematic rather than exceptional, with clear funding, supervision and evaluation frameworks.

A novel realignment, for example a split Foundation Year (FY1–FY5) or Core Trainee Year (CT1–CT3) post combining acute psychiatric care with community intellectual disability services could deliver improved educational and service benefits for future general practitioners, psychiatrists or specialists in other medical fields (Supplementary material).

Recommendation 2: Address bottlenecks across training and workforce development

The intellectual disability psychiatry workforce exemplifies systemic bottlenecks. The RCPsych found that 14.1% of consultant posts in intellectual disability were vacant at the time of its 2023 census. ⁸ Anecdotal feedback suggests that applicants are deterred by heavy caseloads, under-resourced services and large geographical areas. These pressures coexist with trainees’ concerns about limited post-CCT (certificate of completion of training) opportunities near where they have settled, creating regional mismatches between workforce need and personal circumstance.

In our view, national workforce planning must address these maldistributions by expanding training numbers and aligning consultant posts with realistic service models. Closer coordination among stakeholders is essential to develop the future workforce. Expanding supervisor capacity, improving consultant job planning, flexible deployment models and targeted incentives for practice in underserved areas all need consideration.

The Review highlights the need to achieve the right balance between local and international medical graduates. ¹ International medical graduates historically have lacked structured mentorship or research opportunities. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3} The Review offers an opportunity to address these inequities, promote integrated career development for all trainees and strengthen diversity within the specialty.

Recommendation 3: Make training more flexible

Psychiatry has a strong tradition of flexibility in training, a strength that should be further developed. Psychiatry of intellectual disability requires breadth spanning lifespan psychiatry, neurology, forensic psychiatry and general practice and depth in developmental neuroscience, genetics and behavioural medicine. Expanding dual training options, as demonstrated with child/adolescent and forensic psychiatry, to include neurodevelopmental psychiatry, neuropsychiatry and older adult specialties would better reflect real-world practice and enhance recruitment.

Flexible pathways should accommodate locally employed and specialty doctors, allowing recognition of prior experience. The research and teaching capacity of non-training clinicians remains under-used. ^{Reference Lagunes-Cordoba, Maitra, Dave, Matheiken, Oyebode and O’Hara9} Embedding flexibility and academic opportunity at all levels is essential to revitalising the specialty.

Recommendation 4: Support all doctors to progress, and reduce rigidity between ‘training’ and ‘service’ roles

Intellectual disability services rely on psychiatrists in non-training roles who deliver complex care yet face restricted progression. The current rigid separation between ‘training’ and ‘service’ undermines morale and continuity.

Structured mentorship, funded continuing professional development (CPD) and protected time for teaching and research should be extended to all in the field. Service-level doctors can drive national quality improvement. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3} Formalising progression pathways based on competence and leadership rather than contractual status would retain talent and strengthen service sustainability. Increasing transparency and implementing clear processes to accelerate training progression once competencies have been attained need consideration.

Recommendation 5: Integrate the review of rotational structures into wider reform

Training rotations must reflect the full journey of patient illness, needs and experiences, across in-patient, community and primary care interfaces. Currently, many trainees experience fragmented exposure, limiting their understanding of the complex ecosystems within which psychiatrists operate.

A teaching model developed by the London Foundation School demonstrates how rotational innovation can deliver breadth and continuity simultaneously, combining experiences in acute and community services. ^{Reference Lewis, Hall and Polledri10} Wider adoption of such integrated posts would enhance learning and strengthen collaboration across multidisciplinary settings. The aim is to standardise psychiatry training for all foundation doctors, to improve knowledge and skills in general.

In the General Medical Council’s (GMC) 2025 National Training Survey, psychiatry of intellectual disability scored the lowest of all psychiatric subspecialties for regional teaching (51.39/100). ¹¹ This could be due to regional training events remaining underfunded. Teams report growing difficulty obtaining funding for training days. This underinvestment in educational infrastructure undermines reform ambitions. A transparent and protected budget for regional training linked to outcomes and participation should accompany any restructuring of rotational models.

Recommendation 6: Ensure equitable workforce distribution across the UK

Equity must be geographical and demographic. Historically, training posts in intellectual disability psychiatry remain concentrated in certain geographical areas, yet the greatest unmet need exists in rural and socioeconomically deprived regions. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3}

Redistribution of training places could follow epidemiological data and deprivation indices from legacy institutions. However, it can be argued that legacy institutions provide better training opportunities. Decentralised academic–clinical partnerships working alongside legacy institutions can enable recruitment and innovation. ^{Reference Shankar, Sawhney, Tromans, Jaydeokar, Oodiyor and Sheehan4}

Addressing workforce gaps must also involve allied health and social care professions. Declining recruitment into intellectual disability (‘learning disability’) nursing and social care threatens service viability and, by extension, psychiatric training. Universities have ceased offering intellectual disability nursing owing to limited interest. The Royal College of Psychiatrists should collaborate with the Royal College of Nursing and professional bodies to develop a joint recruitment and retention strategy, recognising that psychiatry cannot flourish in isolation from its multidisciplinary partners.

Recommendation 7: Develop and support educators with transparent funding

Training reform will succeed only if educators are resourced and valued (GMC Good Medical Practice). ¹² Psychiatry of intellectual disability scored the highest of all psychiatric subspecialties in the 2025 GMC National Training Survey for both educational supervision (95.83/100) and supportive environment (95/100). ¹¹ However, educational responsibilities in the subspecialty often fall on a small cadre of consultants with minimal protected time. Transparent funding mechanisms, parity of esteem for teaching, and reduced bureaucratic burden are essential to support trainers. Educators should be supported to employ co-production and digital pedagogy, recognising the increasing role of online and simulation-based learning.

A closer look at psychiatry curricula, particularly those for intellectual disability, in medical schools across the UK is warranted. A 2023 scoping review highlighted wide variation in the content and delivery of teaching on intellectual disability in UK medical schools. ^{Reference Towson, Daley and Banerjee13} Although some medical schools provide robust exposure to intellectual disability psychiatry, others offer little or none. A national ‘levelling up’ strategy for undergraduate and postgraduate intellectual disability psychiatry curricula, with clear standards and accountability, is overdue. Such standardisation would ensure equity in training access and prevent future regional disparities.

Recommendation 8: Provide time for developing procedural skills and ensure independent-sector engagement

Psychiatry of intellectual disability is rich in certain areas, such as mental capacity assessments, positive behaviour support planning and multidisciplinary crisis management. Reform should mandate structured training that provides opportunities for experiential learning in a community of practice.

Given that the independent sector provides many in-patient intellectual disability placements, it must contribute actively to training delivery. Commissioning contracts should require the independent sector to provide equitable access to supervision, teaching and research. Without this, training capacity across a range of clinical encounters will remain fragmented and inequitable.

Recommendation 9: Collaborate across UK nations to modernise curricula and maintain generalist and digital competencies

The future psychiatrist must be both a clinician and a scientist. Psychiatry of intellectual disability sits at the frontier of genomic medicine, artificial intelligence (AI)-assisted diagnosis and precision medicine. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3} UK-wide collaboration on curriculum reform therefore should embed digital literacy, data science, ethics and genomics as core competencies.

Modernisation also requires embedding rights-based care and reasonable adjustments within all curricula. The omission of intellectual disability from the 10 Year Health Plan for the NHS in England underscores the need for proactive leadership from training bodies to ensure that policy neglect does not translate into educational neglect. ^{Reference Shankar, Sawhney, Tromans, Jaydeokar, Oodiyor and Sheehan4}

Recommendation 10: Reform recruitment to support flexibility, fairness and excellence

Recruitment into psychiatry of intellectual disability has long been challenging. Stigma, uneven teaching quality and lack of academic visibility deter potential applicants. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3} A qualitative study showed the importance of positive role models and mentors in influencing many of the trainees who choose psychiatry. ^{Reference Appleton, Singh, Eady and Buszewicz14}

Reform must begin at medical school but continue across Foundation and Core Trainee years. Nationally, there remains a marked discrepancy in intellectual disability psychiatry teaching across institutions. Introducing a core curriculum with recommended exposure, outcome evaluation and lived-experience teaching involving patients/carers would help address this. High-quality undergraduate placements like the split Foundation Year posts described in the Supplementary material are potential gateways into psychiatry. International exchange programmes like the Medical Training Initiative can be promoted to widen participation in specialties such as intellectual disability.

Recruitment processes should assess not only academic metrics but also empathy, reflective capacity and commitment to inclusion. Incorporating patient and carer voices into selection panels would align recruitment with the co-production ethos central to psychiatry of intellectual disability.

Recommendation 11: Strengthen clinical academic medicine across the NHS

The vitality of psychiatry of intellectual disability depends on its academic underpinnings. Yet British academic psychiatry has contracted dramatically, with a one-third decline in full-time academic psychiatrists since 2004. ^{Reference Shankar, Bowater, Laugharne, Tracy, Critchley and Young15} Clinical academic posts in psychiatry of intellectual disability are even rarer, leading to reduced capacity to generate the evidence base, attract trainees and influence national policy. ^{Reference Shankar, Tromans, Laugharne, Courtenay, Sawhney and Roy3}

Restoring academic leadership requires sustained investment in clinical lectureships, academic fellowships and university–NHS joint appointments. Funding should cover regional training events, protected time for research, and mentorship programmes for early-career psychiatrists.

Networks have shown how co-produced, translational research can drive policy change and workforce morale. ^{Reference Shankar, Sawhney, Tromans, Jaydeokar, Oodiyor and Sheehan4} Such models, combining community-based research, academic mentorship and digital innovation, should become integral to the future training ecosystem. Making academic psychiatry visible, accessible and sustainable within psychiatry of intellectual disability will ensure that scientific progress and compassionate care advance together.