When is a consultant psychiatrist not a consultant psychiatrist?

Answer: When they are a sticking plaster made out of gold.  

Readers of the Daily Record and the Guardian have seen the comments of our Policy Lead, Jim Crabb, who said ‘Using agency locums to patch up the gaping wounds in NHS is like using a sticking plaster made out of gold. It’s a massively expensive patch-up job that doesn’t fix the problem.’  The media haven’t got it wrong, but they’ve only highlighted the tip of an iceberg, which has larger and more ominous depths.    

We do not wish to demean the status of Locum Consultants, whether employed by agencies or directly by Health Boards.  Indeed, we feel that their status will be better respected if the public can have confidence that all those accorded the title of Consultant do have the appropriate qualifications for the role.  The millions of pounds spent on agency locums could be better spent – although for many years it’s proved impossible to divert that money wisely.  In times of panic without the luxury of thought, we throw money at problems. 

In fact, a Consultant Psychiatrist – like any senior doctor – is always an expensive ‘commodity’.  The tragedy is that we are not getting the quality of service that is paid for, and that the College works so hard to describe and hallmark.  We were dismayed to learn that in 2023, around 50 locum consultant posts across Scotland were held by individuals not on the Specialist Register and sometimes without MRCPsych.  

Most of us will be, or will care for, mental health patients at some point.  It’s wrong to inflict lower standards on the public, and dishonest to lie to them.  This is lying to save face, and it damages the reputation of psychiatry if its highest levels are represented by transient postholders of untested competency.   The term ‘consultant psychiatrist’, locum or otherwise, surely must guarantee that the doctor has earned a place on the GMC’s specialist register, whether by the rigorous MRCPsych and CCT route, over many demanding years of training, or by the equally arduous and rigorous CESR route.  

As a College we don’t exist to dictate how budgets are spent, although we campaign for equity.  Our raison d’etre, is to maintain standards so that the public can count on the best possible care, delivered compassionately, professionally and in accordance with evidence and good practice.  College Report 207 ‘Safe patients and high-quality services: a guide to job descriptions and job plans for consultant psychiatrists (CR207 Nov 2017)’ is explicit on the following:

Ensure that any assessments or interventions are delivered by staff who have the appropriate skills, training, capability and capacity to fulfil their roles.

Millions of pounds and the sweat of many brows are spent to design and deliver trainings, examinations and appraisals to reach, test and monitor our high standards.  The GMC curates registers not only of qualified doctors, but of those who possess the qualifications to be on the Specialist Register.   We should not condone a loophole that allows a doctor hired on a locum basis through an Agency to be described as a consultant if they are not in possession of a CCT or CESR.  The loophole that tolerates such appointments is meant to be only a temporary measure in emergency situations.  It’s time to work our way diligently out of the state of chronic emergency, and meanwhile acknowledge the necessity of employing under-qualified staff rather than effectively falsifying their qualifications.

It happens all too often that mental health management simply cannot find senior cover when there are no acute beds available in the whole of the country and outpatient services cannot tolerate the risks involved.  The acute risks involved in closing wards – with the fear that they may never open again – dwarf the longer term risks of someone noticing that the ‘consultant’ in charge was not trained to take the responsibilities involved.  Our ‘rescue culture’ means colleagues will bust a gut to somehow keep going, crisis is averted for another day, and any legal cases (though dreadful for morale) seem less of a risk than closing down services.

We’re sympathetic to managers who must cover psychiatric responsibilities at all costs, but it is time to stop misrepresenting the level of competence of some of those employed to do so.  We’re sympathetic too, to the doctors concerned.  Some Agency doctors have told us they are afraid of the burden of consultant-level responsibility and the inevitable lack of appropriate supervision. They are often resented by colleagues from secretaries and nurses to pharmacists and fellow psychiatrists. Maree Todd, Minister for Social Care, Mental Wellbeing and Sport, has spoken feelingly of the serious dangers of working as the pharmacist colleague of an unskilled locum consultant Psychiatrist.  

We are sympathetic to our hard-working trainees and CESR fellows - the future of the profession - who ask themselves why jump the hurdles of specialist training only to end up with less pay and more responsibility.  We sympathise with our loyal and diligent SAS psychiatrists, who respect their own expertise, without misrepresenting the level of responsibilities they should take on.  We sympathise whole-heartedly with fellow substantive consultants who are desperate for peers with whom to share their clinical, teaching and other duties as true equals, but find themselves with another liability to be managed.

In this climate, some substantive consultants have resigned their hard-won NHS Consultant posts to work in the private sector.  The issue is not money, but the protection of boundaries an agency can set, and the recovery of lost work-life balance. In addition, the common, and unpopular, 9:1 job plan inhibits time for anything beyond direct patient care; and this is a real frustration for the substantive workforce. Without change our entire workforce could turn to agencies and private employers to ensure that the demands on their expertise don’t spiral out of control.  That said, job plan changes are possible: we are aware that some boards have introduced at 8:2 plan, and we applaud this important step in the right direction.

In England, the NHS already purchases a substantial proportion of mental health services from private providers and is less able to insist on quality standards in a sellers’ market.  This may partly explain why the English NHS spends a higher proportion of its NHS budget on mental health without offering a strikingly better service.  

Indeed, though we continue to campaign to hold the Scottish Government to its promise to increase the proportion of NHS frontline budget, it is ironic to see that on the whole the Boards with the highest spends are those with the most heavily criticised services, where agency fees are highest.

We are not seeking to make the designation of unqualified post holders as ‘consultants’ illegal.  We hope management will understand the benefits of gradually putting alternatives in place.  We don’t demand an immediate prohibition of underqualified Agency Locum Consultants, rather a transition period of two to three years over which new appointments of people without the necessary expertise is ended.  Employment Law may allow those already in post to remain.  These will automatically accrue longer local experience and offer greater continuity than generally seen in the present transient Agency Locum climate, and we hope they will be encouraged to undertake portfolio training towards CESR qualification.  

Our College has raised alarms, and we offer our expertise and experience in outlining and supporting solutions.  We would rather do that than raise a media furore, unless public indignation is the only way to drive change.  Members of the public have told us they were appalled to discover that a ‘locum consultant’ may not have higher qualifications.  Some raised the issue of whether this might open Boards to legal action.  

We realise that the situation cannot change at a stroke.  After all we regularly understand how our patients cling on to destructive habits that may have served them well in the past or perhaps were the only available response to trauma or illness.  We patiently use bio-psycho-social interventions to gradually bring about change.  There is a parallel with the whole system of mental health services.  The situation in which we find ourselves just now may seem insane.  It will take time for our campaigns to bring about the changes we seek.  Luckily, perhaps, I have more time than most Chairs to witness progress.  In fact, my term of Office still hasn’t officially begun.  Perhaps until June, I should sign off as ‘Locum Chair’.  

Dr Jane Morris, Chair, RCPsych in Scotland