Malaise in psychiatric recruitment and its remedy

Aims and method Surveys of career intention among medical students, Membership Examination results and manpower figures are used to examine trends in recruitment to psychiatry over the last 10 years.

Results Problems of recruitment to psychiatry have increased. Consultant expansion contrasts with a fall in the number of medical students. The increase in the number of career senior house officers and specialist registrars is insufficient to fill existing consultant vacancies notwithstanding new and replacement posts. The popularity of general psychiatry and psychotherapy have declined.

Clinical implications Proposals include an increase in the number of medical students, the introduction of psychiatry in the pre-registration year, increased specialisation and closer integration of general adult psychiatry with general medicine.

There are currently problems in recruitment to all grades of medical staff in psychiatry. Re cently, vacancies for specialist registrars in general psychiatry have remained despite re peated advertising; it is not clear how widespread are these trends and whether all specialities of psychiatry are similarly affected.
Two issues require consideration, first, whether there are sufficient recruits to psychia try to fill present and projected consultant vacancies and ensure good quality patient care, and second what variation exists between in dividual psychiatric specialities. Trends over the last decade will be used to explore this problem and offer some solutions.

Medical students
The proportion of medical students choosing psychiatry increased over the last decade (Parkhouse & McLaughlin, 1976;Lambert et al, 1997

Senior house officers
Of the 1217 senior house officers holding posts in 1995, some were pursuing a future career in psychiatry with the majority of the rest training for general practice. Psychiatry also recruits from doctors in placements as part of other rotations, particu larly Vocational Training Schemes for General Practice. However, medical students placing general practice as their first choice fell from 37.6% of those surveyed in 1983 to 25.8% in 199425.8% in (Lambert et al, 1997. This decline in the popularity of general practice will decrease consequent entrants to psychiatry.

Specialist registrars
The number of specialist registrars and senior registrars in psychiatry has increased over the period, from 435 in 1981 to 866 in 1994and 962 in 1996(Hospital Medical Staff, 1981: Annual Census of Psychiatric Staffing, 1994, 1996. The popularity of different specialities within psy chiatry can be quantified by calculating the number of vacancies as a percentage of the available posts in that speciality. We call this the Vacancy factor', the higher the vacancy factor the less popular that speciality, assuming an equal rate of expansion in each speciality. The introduction of Hospital Doctors: Training for the Future (Department of Health, 1993), has seen overall vacancies for specialist registrars in psychiatry increasing from 1.7% in 1993 to 7.5% in 1995. The preferences for different specialities are presented in Table 1.
Psychiatric Bulletin (1999). 23, 227-229 Learning disability and psychotherapy have the highest vacancy factors, child and adolescent psychiatry the lowest. General psychiatry is now less popular than old age or forensic psychiatry despite higher rates of expansion in these latter specialities. This is particularly serious as gen eral adult psychiatry represents approximately 50% of all specialist registrars and consultants in psychiatry. The figures for the number of specialist registrars suggest a maximum of 274 specialist registrars eligible for consultant ap pointments each year if the minimum time required by each speciality, is spent in higher training.

Consultants
The number of posts for consultant psychiatrists in England and Wales has increased by 58.4% over the last 13 years, from 1672 in 1981 to 2650in 1994, and 2941in 1996(Hospital Medical Staff, 1981: Annual Census of Psychiatric Staff ing, 1994, 1996. This represents an annual rate of expansion which varies from 4.5% per year representing 132 posts, to the current 7.2% equivalent to 200 posts each year. Assuming an average career of 30 years as a consultant psychiatrist, approximately 100 appointments need to be made each year simply to replace retirements. In addition it is predicted that approximately 50 early retirements occur each year (Kendall & Pearce, 1997). This suggests that consultant vacancies will increase by 350 posts each year at the present rate of expansion, in addition to the existing 394 consultants vacan cies currently identified in England and Wales.

Recommendations
Recruitment must be improved at all levels. The fall in the number of medical students who qualified over the period provides powerful evidence to support the recommendations of the Campbell Report (1997) that the annual intake of medical students nationally should be increased by 1000 as soon as possible (Depart ment of Health, 1997).
A properly constructed pre-registration house officer year which should include four months spent in psychiatry as part of a planned rotation could provide much needed improvement in communication skills for medical staff, and coincidentally positively assist recruitment into psychiatry.
There should be closer integration of general psychiatry with the rest of hospital medicine. The relatively low popularity for general psychiatry at specialist registrar level is a new phenomenon. It is the largest speciality and normally provides the first clinical experience for medical students. Its problems have been discussed in detail elsewhere (Deahl & Turner, 1997). Consultants describe being exposed to increasing responsi bilities combined with limited resources over which they have little control. The 'inquiry culture' demands a scapegoat and effectively expects the responsible medical officer to accept unlimited responsibility for everything that goes wrong with the management of patients in the community. Sectorisation compounds the pro blem; it often leaves the consultant in general psychiatry in the position of underwriting other specialities and sub-specialities. It discourages specialisation in important areas of psychiatric activity.
Current proposals are displacing general psy chiatry from district general hospitals to stand alone community psychiatric units. This ignores both the likely adverse effect on recruitment at medical student and pre-registration level, and that liaison psychiatry is the most popular subspeciality within general psychiatry.
There should be further development of specialist knowledge within general psychiatry. Specialist services exist, but are confined to certain conditions such as eating disorders or types of service -such as rehabilitation or liaison. Despite compelling research evidence, few psychiatrists implement the recommenda tions for reducing expressed emotion with the families of patients with schizophrenia (Leff & Vaughan, 1981) or use computerised tomogra phy scans to inform treatment and likely prog nosis (Lieberman et al. 1993). Equally, few psychiatrists treating patients with affective disorders have training in cognitive therapy. It is argued that specialist services should be extended to other important areas such as patients with psychoses, affective disorders and behavioural disorders, and sectorisation would remain only for those socio-demographic areas unable to sustain specialist services. Sub-spe cialisation will improve the popularity of general adult psychiatry by offering a more expert service to patients and greater professional satisfaction to practitioners.
These proposals are aimed both at improving recruitment and retaining an enthusiastic and knowledgeable workforce of consultants. This would be of great benefit to future patients.