There have been suggestions that there are significant problems in the recruitment and retention of psychiatrists (Reference StorerStorer, 1996; Reference SimsSims, 1997; Reference Jenkins and ScottJenkins & Scott, 1998). A survey of psychiatrists who retired prematurely revealed significant dissatisfaction with current practice of psychiatry in the UK (Reference Kendell and PearceKendell & Pearce, 1997). Trainee morale has anecdotally been reported as low (Reference MiltonMilton, 1998; Reference ThompsonThompson, 1998), particularly in general psychiatry (Reference Deahl and TurnerDeahl & Turner, 1997), although for a significant number of trainees this is still a career choice (Reference Davies and SchlichDavies & Schlich, 1999). To provide objective information about trainees' views on training and service conditions the Collegiate Trainees' Committee (CTC) surveyed trainees in three regions representative of the UK in 1998. Such data have been lacking in the literature to date (Reference MiltonMilton, 1998).
The study
Members of the CTC, an elected committee of the Royal College of Psychiatrists representing trainees (Reference SullivanSullivan, 1997), devised a questionnaire for all grades of trainee. Information was gathered on demographic details, career choices and local working conditions, including items related to stress at work. Trainees were specifically asked to respond to the statement, “The following factors are active problems or issues in psychiatry, with a major impact on quality and/or safety of the practice of psychiatry”. Ten specific issues felt by the CTC to be important areas in UK psychiatry were then listed:
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(a) bureaucracy;
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(b) excessive on-call;
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(c) excessive clinical workload;
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(d) general understaffing;
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(e) inadequate resourcing;
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(f) in-patient bed numbers;
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(g) patient expectations;
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(h) professional isolation;
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(i) public expectations;
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(j) violence to staff.
A five-point Likert scale, from ‘strongly agree’ to ‘strongly disagree’, was used to rate responses. Responses to the question, “What one thing should be changed to improve the situation in psychiatry?” were also sought.
Three regions were chosen: (a) the West Midlands, which is one of the largest training regions; (b) South Wales, which is semi-rural and has been noted to have recruitment problems (Reference StorerStorer, 1996); (c) North-West Thames, covering London and representative of the problems of inner-city psychiatry (Reference Deahl and TurnerDeahl & Turner, 1997).
Questionnaires were personally distributed by CTC representatives between May and December 1998 at a variety of settings including postgraduate educational meetings and regional CTC training days.
Findings
A total of 235 questionnaires were collected, evenly balanced between the regions. Of those completing questionnaires 35% were higher trainees and 65% juniors; 52% of respondents were male, and the majority of trainees (82%) were in full-time employment. Census data from 1996 (Royal College of Psychiatrists, 1996) report a total of 647 trainees in posts within the three regions of this survey. Overall 36% of trainees responded to the survey, with a 42% rate for specialist registrars and 33% rate for juniors.
Three to five per cent of answers relating to the 10 specific issues were unusable as they were blank or contradictory. The results are summarised in Table 1. The majority of respondents agreed or strongly agreed that there is inadequate resourcing of psychiatry (92.1%), understaffing (86.4%) and excess bureaucracy (81.5%). Seventy-eight per cent felt workloads were excessive, but only just over one-third (37.2%) felt they had excessive on-call commitments, with 45% feeling this was not an issue. Public expectation of psychiatrists' capabilities (91.6%) was more frequently rated as problematic than individual patient expectations (76%).
Table 1. Trainee views. Total of 235 questionnaires, n, total questions answered (% of questions answered)
| Issue | Strongly agree/agree | No opinion | Disagree/strongly disagree | n |
|---|---|---|---|---|
| Inadequate resourcing | 210 (92.1) | 17 (7.5) | 1 (0.4) | 228 |
| Public expectations | 208 (91.6) | 10 (4.4) | 9 (4) | 227 |
| General understaffing | 196 (86.4) | 23 (10.1) | 8 (3.5) | 227 |
| Bureaucracy | 185 (81.5) | 34 (15) | 8 (3.5) | 227 |
| In-patient bed numbers | 182 (80.9) | 26 (11.6) | 17 (7.5) | 225 |
| Excessive workload | 175 (78) | 19 (8.5) | 30 (13.5) | 224 |
| Violence to staff | 172 (77) | 29 (13) | 22 (10) | 223 |
| Patient expectations | 171 (76) | 18 (8) | 36 (16) | 225 |
| Professional isolation | 133 (58.8) | 42 (18.6) | 51 (22.6) | 226 |
| Excessive on-call | 83 (37.2) | 39 (17.5) | 101 (45.3) | 223 |
Fifteen per cent of trainees reported taking stress-related time off work. Professional isolation was felt to be a problem by 58.8%. Lack of in-patient beds (80.9%) and violence towards staff (77%) were seen as more active problems. Written comments to specific questions were received from 186 trainees (79%) flagging up a total of 327 issues. These could broadly be broken down into 12 categories which trainees felt should be addressed to improve UK psychiatry (Table 2).
Table 2. Issues identified in written comments by 186 trainees as things that could be changed to improve UK psychiatry, n=327 (%)
| Categories of issues | Number (%) |
|---|---|
| Resources | 157 (48) |
| (Breakdown of resource issues) | |
| Staffing levels | 46 (14) |
| Organisation of resources | 45 (13.8) |
| In-patient beds | 16 (4.9) |
| Specific resources (e.g. forensic) | 11 (3.4) |
| Training/supervision | 43 (13) |
| Society's expectations (public and government) | 26 (8) |
| Communication (within and without psychiatry) | 21 (6.4) |
| Personal/local issues (e.g. accommodation) | 15 (4.6) |
| Bureaucracy | 11 (3.4) |
| Clinical/workloads | 11 (3.4) |
| Safety/security | 9 (2.8) |
| Changes to Mental Health Act | 9 (2.8) |
| Recruitment into psychiatry | 7 (2.1) |
| Professional isolation/peer support | 4 (1.2) |
| Miscellaneous | 14 (4.3) |
| Total | 327 (100.0) |
Discussion
A number of potential biases were introduced into the survey. The initial choice of regions may have emphasised local rather than national problems. Distribution methods may have excluded more disillusioned trainees and part-time workers (6% of respondents), who may be less likely to attend meetings. Despite these systematic biases the advantage of this methodology may have been to yield higher response rates than previously experienced by CTC postal surveys (Reference MulhollandMulholland, 1996). Of those responding there was an even spread between geographical areas and a representative proportion of senior and junior trainees.
The 10 items surveyed may have been biased towards certain topics, but these were chosen by a representative trainee body and so were likely to reflect the concerns of trainees themselves. Despite these methodological flaws we believe this survey provides some useful objective information on the current concerns of trainee psychiatrists within the UK.
Availability of resources and public expectation appear to be of greatest concern to trainees, and this must be addressed at a national level. The White Papers on the NHS, The New NHS: Modern, Dependable (Department of Health, 1997) and the implementation of clinical governance may ensure that scarce funds are maximised. The latest campaign of the Royal College of Psychiatrists against stigma (Reference Cowan and HartCowan & Hart, 1998) may help to educate the public and create more realistic expectations of psychiatric services.
Improving the quality of training was the second greatest concern within the written comments (13%). In particular, issues of supervision, professional respect and more pastoral care were raised. The Royal College of Psychiatrists and individual educational supervisors have a responsibility to ensure the quality of teaching experiences for all trainees. Log books (Reference CoxCox, 1997), accreditation visits, guidance for educational supervisors (Reference Robertson and DeanRobertson & Dean, 1997) and improving the quality of teaching/supervision are recent developments aimed to achieve higher standards of training.
Issues of safety and quality of accommodation rated highly on the improvement wish list for trainees. These issues are frequently debated and subject to a number of reviews and reports (Reference Cormac, Crean and MotrejaCormac et al, 1999). Local trusts should be informed, encouraged and monitored to ensure high standards are achieved in these areas, to retain the confidence of all staff.
Recruitment remains an important problem. A number of key issues are being addressed both at national and local levels, which correlate with the concerns raised by the training body in this survey. By working together we hope the College tutors and trainees can continue to improve training experiences and so positively shape the future of UK psychiatry.
Acknowledgements
We would like to acknowledge the help of Dr Cormac and other members of the CTC. We would also like to thank all the trainees who participated in this survey.
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