Response

In their article ‘Meritocracy in psychiatry training: abandoning the common good’, Howarth et al criticise the use of meritocratic selection in psychiatry and suggest a lottery-based admission system as an alternative.^{Reference Howarth, Kennedy and Berelowitz1} In this response, we argue that lotteries are ill-suited for use in applications for training programmes, and there are better solutions we might propose.

Much in our lives is determined by luck: by the ‘social’ and ‘natural’ lotteries of our environment, our biology and the privileges of our birth.^{Reference Rawls2} Howarth et al are right to highlight the risk that distribution based on merit alone can confer an unwarranted sense of entitlement. Lotteries can be used to benefit those who are systematically disadvantaged by the status quo, but there are many dangers to their use and to the elimination of merit from application processes.

First, preparing for a competitive application remains an important driver to engage in career development in teaching, leadership, quality improvement and research. By removing these, we risk discouraging activities that benefit our patients, organisations and, ultimately, trainees themselves.

Second, the use of lotteries strips trainees of agency over their future. If a trainee wants to work in one part of the country, they have little control over this. They cannot choose to work harder to achieve their aims. Leaf et al, writing in the BMJ, survey the ‘powerlessness’, ‘sense of injustice’ and becoming ‘disillusioned’ that the new random allocation the UK Foundation Programme has ushered in.^{Reference Leaf3} Inflexibility of training programme structures and a perceived lack of autonomy have been identified as key factors in the junior doctor workforce retention crisis.^{Reference Lock and Carrieri4} This is perhaps not a glowing endorsement for Howarth et al's proposal.

Third, we challenge the idea that access to high-quality training can be reduced to a problem of distribution. Lotteries do nothing to address the root causes of inequality. As Saunders puts it, lotteries only provide ‘surrogate satisfaction, second-best to getting the good’.^{Reference Saunders5} Our true goal is to provide a high-quality training experience accessible to the widest group of trainees.

High-quality training posts are not a finite and fixed resource. The number and quality of these posts is under our direct control, and we have already seen numbers reduced in London, increasing this scarcity. We agree with Howarth et al that the geographical disparities in psychiatric training require fixing, but we contest that lotteries are an appropriate solution.

Fortunately, Howarth et al offer a more reasonable, alternative proposal: level up by improving under-performing training programmes. We wholeheartedly endorse this approach: instead of harming the opportunities for trainees and training programmes to improve themselves, learn from what the good training programmes do. Encourage sharing resources, lend specialist expertise and make it easier for trainees to undertake specialist jobs in areas outside their training programmes.