Q&A with Presidential candidates

There is a wide disparity in the availability of a broad range of talking therapies across the UK and unacceptably long waits for treatments such as psychodynamic psychotherapy and psychological treatment for complex trauma. How would you address and prioritise this?

Dr Lade Smith CBE

Psychiatric care is incomplete without psychotherapeutic interventions. Patients need them as part of their individualised, biopsychosocial therapeutic care. There should be a range of modalities readily available across the country. 

IAPTs improved access to talking therapies but is limited in the type of therapy offered and the expertise of those offering it. Other modalities are essential to meet the broad range of conditions encountered in mental healthcare, including people with SMI and complex conditions, trauma and co-morbid substance use. We need skilled and competent therapists who can take on complex cases and contain risk. 

For this to become reality, we must train more psychotherapists, ensure every psychiatrist has meaningful psychotherapy training, and provide special interest sessions for more in-depth learning. 

As President:

• I will work with the Psychotherapy faculty to expand training and care pathways for psychotherapeutic interventions for complex issues to every part of the country. 
• I will support building the evidence-base for psychotherapy so that we can be clear what works for whom and support Commissioners to understand the importance of psychotherapy to managing and improving outcomes in complex trauma. 
• I will support development and maintenance of psychotherapy proficiencies, provide standards and ensure supervision. 

Psychotherapy enriches the profession.   

Dr Kate Lovett

For three decades, access to CBT in NHS services was limited despite its evidence base. Now, IAPT services in England provide evidence-based therapies to over a million people a year. 

Despite this, provision of talking therapies within secondary mental health care has not kept pace. Waiting lists are long and it has become difficult to access anything other than short-term eclectic therapy. People with the most severe relational disturbance are unable to access the specialist, longer-term intensive therapies they need.

This results in significant costs:

• out of area admissions
• health care
• criminal justice system
• social care  
• personal suffering 
• intergenerational transmission of trauma

It was economic argument laid out by Lord Layard, not arguments about quality of care, that kickstarted IAPTs development. In order to improve access to relational and trauma-focused therapies for the most severe, we will need to make the economic case. As President I will work alongside the national talking therapies task force, the psychotherapy faculty, and mental health policy group to influence national strategy to meet the psychotherapeutic needs of people with most complexity, using evidence from the Health Economics and Relational Disorder study when it reports in early 2023.

Professor Russell Razzaque

The fact that patients sometimes have to wait years for psychotherapy and psychological treatment is a genuine scandal. Patient surveys regularly show that this is something that patients want the most and I, like many colleagues I am sure, feel embarrassed to tell patients that they are likely to have to wait over a year to get this. 

The first thing we need to do is invest more, specially in psychotherapy services. Medical psychotherapy was a much more prominent aspect of standard mental health services when I was a trainee than it is now. I have long believed that the media coverage the College has won us now needs to hone more on particular areas of underinvestment within our services and this is one of them.

In addition, I believe that many more clinicians should be trained in psychological approaches. It should not be just the preserve of a specialised few – important though their leadership will always be – the ability of all disciplines to engage therapeutically, utilising techniques they have learnt, even running groups where possible, will go a long way to widening the options for talk based treatment and I believe this will be an important priority going forward.

Setting standards in psychiatry is a core function of the College. What would you do to ensure our MRCPsych Exam is as fair as possible for all potential candidates?

Professor Russell Razzaque

I think fairness is fundamental to the MRCPsych Exam. Making sure the papers and especially the practical/clinical aspects are free from any subjective bias when scoring is a key part of this. This isn’t always easy, specially as an important part of the exam is assessing empathy and the ability to forge relationships with patients. Maintaining consistency across candidates and papers will therefore be essential, as will closely monitoring validity and reliability as the exam evolves.

Fairness also needs to be about the opportunities that candidates have to attend the highest quality training and preparation. The move to online learning should help us better ensure this, so that the best teaching can be delivered to candidates from anywhere in the world. Additional support with preparation will be key to fairness too. I know colleagues who needed to retake the clinical parts numerous times, ultimately benefited from being able to video their performance and review it afterwards. Opportunities and technologies like this should be available to all. On the whole I do believe the exam is conducted with fairness but it will be important to make sure this continues and is always perfected, year on year.

Dr Lade Smith CBE

Our exam is one of the best in the world and increasingly sought after internationally. This has been possible through high standards in training and examination. However, despite recognition, differential attainment has not been addressed. Several groups are disadvantaged, including IMGs, ethnic minority doctors, doctors with disability and neurodivergence. 

As RCPsych Lead for Advanced Learning and Conferences, I developed a quality assurance framework ensuring consistently high standards of accessible training to support psychiatrists to excel in examinations and maintain high quality CPD. 

As your President, 

• I will work closely with the current Dean and Chief Examiner, to engage all Heads of School, TPDs and DMEs to actively address fairness in training and examinations in a way that promotes excellence, whilst preparing psychiatrists to become highly skilled clinicians ready for real-world practice. 
• I will use RCPsych’s Equality Action Plan, which I co-developed, to employ a data-driven approach to identify and address existing disparities, to ensure fairer systems for examinations and training. 
• I am co-leading a disability working group developing recommendations which will support reasonable adjustments, including for examinations.  
• I will ensure equity in training opportunities, experience and WBPA assessments so that fairness is achieved in exam outcome. 

I will ensure fairness. 

Dr Kate Lovett

Patient safety is fundamental to the MRCPsych exam which sets standards for clinical practice. The MRCPsych is internationally respected and a key college function. High stakes exams impact on life and career opportunities. It is therefore essential that MRCPsych exams are:

• Reliable
• Valid
• Minimise risk of cheating
• Supported by statistical expertise
• Quality assured
• Make adjustments for access
• Use best practice in assessment
• Analyse demographic data
  

Like many professional examinations, MRCPsych pass rates vary between groups including by country of primary medical qualification and race. An external review in 2015 did not find exam bias. However, several factors have been identified indicating the educational playing field is not equal e.g., poorer relationships with trainers and fewer learning opportunities, amongst others.

As Dean, I worked with UK Heads of Schools and equivalents to support equity:

• Promoting local performance dashboards and initiatives e.g., coaching and mentoring
• Accessing funding from HEE to run CASC masterclasses for borderline candidates to improve pass rates.
  

As President I will ensure fairness, by giving my total support to the Dean and Chief Examiner to deliver initiatives promoting equity and ensuring the exam and its governance remains fully resourced.

We know, especially following the independent review of the Mental Health Act, that significant disparities still exist in mental health care for those of Black, Asian, and ethnic minority groups. How will you help to ensure equity in mental health care is achieved for these groups?

Dr Kate Lovett

Racism throughout UK society results in differential opportunities and allocation of resources for people from Black, Asian, and ethnic minority backgrounds. Institutional racism, cultural racism (causing stereotype threat and internalised racism), as well as individual exposure to racial trauma, take a huge toll on people’s mental and physical health. People present later, are more likely to find themselves under compulsion due to lack of trust and poor experiences, and have poorer outcomes. 

There are no straightforward answers to what are complex societal problems. However, the college has a responsibility to strive to improve health outcomes for the most deprived, marginalized and discriminated against.

As President I will:

• ensure that the college continues to take an anti-racist position
• lobby for the necessary resources and workforce to implement the proposed reforms of the Mental Health Act in England and Wales
• review the college’s equality strategy in 2023, focusing on patients, communities, and social determinants of health 
• expand the number of services accessing the Advancing Mental Health Equality Collaborative
• support CPD and training in population health, working with communities, coproduction, and racial trauma
• help services to become culturally more responsive through the College’s Centre for Quality Improvement

Professor Russell Razzaque

The disparities both in terms of access to services and also over-representation on in-patient wards and among sectioned patients is stark for many Black, Asian and ethnic minority groups. Improving access requires partnership with local communities, 3rd sector organisations and faith groups. When this happens it makes a major difference but it takes committed outreach and a consistent effort.

In terms of in-patient services, I have been engaged in some enlightening  research involving training staff around the experience of Black, Asian and ethnic minority patients – hearing from them first hand and understanding their culture, backgrounds and personal experience of service usage. Interventions like this have a real impact on the way a service responds to diverse population groups.

Finally, strong patient participation in Trusts can really help to orientate services in positive ways. Co-production of services and protocols in a consistent way is also key to forming a strong feedback loop that then enables continuous learning and improvement on an ongoing basis. 

Dr Lade Smith CBE

Addressing ethnic disparities in mental healthcare is a priority, for ethical, moral, legal and financial reasons. 

I worked on the independent MHA review with Simon Wessely. I developed recommendations aimed at reducing ethnic disparities in mental healthcare, including the Patient and Carer Race Equality Framework, now adopted by government and being piloted across the country.  As President, I will continue to embed systems to improve mental health equity.

I am Joint RCPsych Presidential Lead for Equality and Clinical Director of the National Collaborating Centre Mental Health and developed the Advancing Mental Health Equality (AHME) resource, an equality system which underpins the AMHE strategy for NHS-England. This informs the Core20PLUS5 programme, which is influencing equity across physical and mental healthcare. 

The RCPsych Equality Plan we developed led to the AMHE collaborative, helping organisations achieve competence in tackling health disparities, including race inequity. I am also co-leading the RCPsych team developing guidance to tackle racism in psychiatry. 

As your President, along with designing, developing and implementing systems that tackle inequality, I will continue to encourage education and training of clinicians, researchers, organizations and regulators in understanding and addressing health inequality, nationally and internationally. 

All the above measures are already making a difference.    

Many psychiatrists experience trauma, blame, isolation and consider leaving the profession following a serious incident, magnified by media hounding. How will you improve this situation at an individual, team, organisational and wider system level? 

Dr Lade Smith CBE

As President, I will support the creation of better systems and expertise in managing serious incidents for individual clinicians, wider teams and organisations. This will improve safety and help retain our workforce. Specifically:

• We must move away from the “blame culture”. Cases like Bawa-Garba show how systemic factors contribute to incidents yet are too frequently overlooked. I will encourage organisations to adopt Appreciative Inquiry which uses a strength-based approach to establish a learning culture where the emphasis is on the whole system and not on blaming individuals. Teams particularly benefit from this approach.
  
• We must not underestimate the importance of immediate practical support when incidents happen. The College should develop guidance for organisations on how to provide individualised support. 
• Facilitated peer groups have been shown to help psychiatrists dealing with serious incidents. As President I will re-establish a network of senior psychiatrists and colleagues to support clinicians to navigate serious incidents.
• I will enhance access to the Psychiatrists’ Support Service and signposting to the Practitioner Health Programme.  

As President, supporting and protecting psychiatrists when they are dealing with the consequences of system failures is one of my top priorities. No one should go through something like this alone.  

Dr Kate Lovett

Risk and complexity are integral to our work as psychiatrists but mitigating risk is often dependent on variables outside our influence. Society can be quick to blame, and services slow to support when things go wrong.

I have written previously about how I think we can better prepare psychiatrists throughout their careers by:

1. improving preparation for professional loss and trauma for trainees and early career psychiatrists via training and the Startwell programme
2. developing a Thrivewell programme for mid-career psychiatrists which addresses strategies for surviving difficult professional experiences

I will support psychiatrists impacted by serious incidents and trauma by:

1. maintaining and developing college resources which currently include webcasts and written information 
2. developing regional, facilitated peer support groups 
3. peer support via the PSS (psychiatric support service)  

Nationally, I will work to reduce risk by:

• relentlessly focusing on workforce to achieve safe staffing
• ensuring promised funding reaches the frontline
• promoting early intervention and rehabilitation and recovery
• setting standards.

In addition, I will strongly represent you through the Academy of Medical Royal colleges, to influence fairer treatment of doctors involved in serious incidents referred to the regulator.

Professor Russell Razzaque

The experience of colleagues after a serious incident can be harrowing. While there has been a lot of good media attention around mental health in recent years – a lot of it driven by the College - there hasn’t been coverage on the actual role of the psychiatrist and how decisions made are often finely balanced. Our ability to predict the future is far more limited than people realise and it’s very possible to do a good job by a patient and still have a poor outcome. These are the kind of nuances we need more public airing around so we can slowly start to move away from a reflexive blame culture in our systems and wider media.

In terms of individual and local level, I believe reflective practice is crucial. We should all have spaces in which we can share our subjective experience with others and become more in touch with our own reactions. This kind of space is by no means the norm and I believe that making this more available, as well as building a more sympathetic narrative around the role of mental health professionals, will be a much needed focus for the College going forward. 

It is widely agreed that continuity of care alongside holistic, patient-led treatment should be fundamental to a good mental health service. How will you ensure that this becomes a reality for all those in need of mental health services?

Professor Russell Razzaque

Making care more person-centred, holistic, with better continuity will be a priority for me if elected President. The documentaries that have emerged about poor care in various units needs an active response and we can use this as an opportunity to turn the tide. I propose establishing a Commission for Compassionate Care alongside other professional bodies and, through it, we can highlight the following 

1. The damage a lack of continuity does to patient care and the ability to forge lasting and meaningful relationships. There are ways of doing things that put the relationship and continuity at the heart of the way we work again.
2. We also need to highlight the impact of the over-bureaucratization of mental health care, where clinicians are required to fill out forms and check boxes as much or more than seeing patients.
3. We need to highlight the lack of emotional support and reflective practice for clinicians who face unique levels of stress at work.

This all can then create a strong case for substantial policy change; reducing bureaucracy, improving emotional support and returning to more holistic and relational ways of working, enabling us to ultimately develop new priorities and systems for our services.

Dr Lade Smith CBE

Continuity of therapeutic care is core to psychiatry. For this to become the norm, we need adequate staffing and managed workloads, so we can complete comprehensive assessments with formulation incorporating biopsychosocial determinants of health. 

As President I will work with commissioners, regulators (CQC, Mental Welfare Commission), MH CCIOs, clinical leaders and the Dean to embed therapeutic care in law and practice. This must include:-

• Streamlining documentation; digitizing processes and improving administrative support.
• Training and maintaining skills in person-centred holistic care which will be embedded in the curriculum
• Focusing on meaningful outcomes, such as employment, housing, supportive social relationships – integrating these into the CCQI peer network review standards
• Supporting implementation of the Community MH transformation in England, which I helped develop. This recommends comprehensive biopsychosocial assessment and treatment plans completed by senior clinicians, delivered by whole teams. 
• Following the MHA Review recommendations, developed by myself and others. These suggest making patient-centred therapeutically-beneficial care a statutory requirement. 

For continuity of care to become reality, systems need re-organising to reduce the burden of bureaucracy and provide time-to-care. I have developed systems that promote continuity of patient-centred care and enhance job satisfaction. This is crucial for retention and fundamental for good mental health services.

Dr Kate Lovett

Good mental health care depends on developing therapeutic relationships with properly trained staff to enable access in a timely manner to evidence-based social, psychological and biological treatments which are tailored to the person’s individual needs.

But the reality is that many of us are working in services which are short-staffed, under-funded and under pressure. Waiting lists are at an all-time high with over 1.4 million people currently waiting for mental health care.

So far, much of the planned reform by UK governments has been very welcome. However, to translate this into reality we need to work with governments to influence

1. a relentless focus on workforce with fully funded long-term NHS workforce plans that address recruitment, retention, and professional development
2. training for all staff (including unqualified) to understand basic psychological principles e.g., attachment theory/defence mechanisms etc.
3. strong leadership that understands the importance of therapeutic relationships, psychological containment through continuity and of involving people with lived experience in designing services
4. promised funding for reform reaching the frontline
5. prevention at a population level, alongside investment in rehabilitation and recovery, and early intervention
6. setting standards and calling these out when they fall short

What would you do to ensure the College provides the general public with a balanced account of the benefits and risks of psychotropic drug treatment?

Dr Kate Lovett

The college has a key role in communicating evidence on treatments for mental illness, including drug treatment, through:

• our members  
• media including 
  • webpages
  • social media
  • print, radio and TV 

Last year the College’s website was visited 6.8 million times with 10 million pages viewed. The patient information area was one of the most visited areas. The public engagement editorial board, which includes people with lived experience, produces high quality downloadable leaflets.

I will support the board to continue: 

• develop materials in collaboration with the psychopharmacology committee and patients and carers
• make the information available in multiple languages

To maintain credibility of the information I will ensure that:

• income to the college from the pharmaceutical industry remains restricted 

In addition to a strong social media presence, last year the College achieved a media reach of 712.5 million. We are therefore in a powerful position to deliver key messages to the public. 

We must:

• maintain scientific equipoise in reviewing the evidence for drug treatments 
• continually update guidance in light of new evidence
• develop national and regional communications plans which widen our pool of spokespeople to respond authoritatively to media medication stories.

Professor Russell Razzaque

I think this is an important role of the College and some good work already goes on in this area. There is some well laid out information on different classes of drugs on the College website – making it easier and more accessible for the public to understand – and the evidence base and NICE guidance is clearly outlined in addition. There has been more work recently on outlining the risks too, eg. withdrawal effects, and this is a positive development as well.

As the evidence base evolves and new medication and information comes to light, it will be important for our messaging to change with it, and as social media platforms evolve over time too, it will be important to adjust our methods of delivery as well as content. I think it will be equally important for us to disseminate pertinent information about other modalities of treatment too and how the psychiatrist's role can involve a variety of these. How we arrive at a decision around medication – in collaboration and partnership with the patient – is crucial too. This relational aspect of care is central and therefore should be an important additional part of our messaging around drug treatment going forward too.

Dr Lade Smith CBE

The College must be at the forefront of promoting evidence-based mental health and addressing misinformation in a timely way. 

As President, I will re-energise RCPsych’s Public Education arm led by psychiatrists and Experts By Experience (EbE) and supported by our Communications department. This group was previously set up to provide evidence-based accessible information about mental health treatment. This can pro-actively counter misinformation about psychiatric care. 

I will promote a dynamic strategy:

• develop a compendium of accessible evidence-based resources to tackle the different types and sources of misinformation – e.g. leaflets and briefing documents (including lived experience accounts); 
• disseminate this information using a wide range of communications methods ensuring digitally excluded people are also reached; 
• develop a media-trained team of individuals at different levels of seniority from different specialties, EbEs and College staff. They will be able to launch an agile response, as required, to inform and educate using different types of media, from broadcast to social media;
• work with the current Dean to support public education training and CPD for psychiatrists;
• work with universities training MH professionals, other professional bodies and mental health charities to ensure evidence-based messaging.

We can no longer leave things unsaid, this is a patient safety issue.

What are your plans to support psychiatrists who have been impacted by patient suicide and patient homicide?

Dr Lade Smith CBE

There is a 1 in 3 chance of a consultant psychiatrist losing a patient as a result of suicide. It is devastating for many of us. It was for me. This is all the more so with homicide.

As President, I will scale up and disseminate the work done by Rachel Gibbons and colleagues. I will 

• Support the development of a regional network of facilitated peer support groups based in Trusts. The groups provide a sense of fellowship felt to be critical to allowing psychiatrists to grieve and then grow after experiencing a death by suicide or homicide and remove the burden of being the “superhero”.
• Strengthen links between the College’s Psychiatrists’ Support Service and Practitioners’ Health Programme such that there is an active support approach for psychiatrists to help address the stigma and the sense of blame felt, using a restorative just culture framework.
• Make the booklet “If a Patient Dies by Suicide” recommended reading for all psychiatrists and MH professionals. 
• Make coping with a patient’s death by suicide or homicide part of the curriculum.

As President, my main priority is supporting and nurturing psychiatrists – it is fundamental that the College supports psychiatrists at their time of greatest need.

Dr Kate Lovett

Psychiatrists are human and need to process complex emotions if we are to remain well and effective in our work with others. Losing patients through suicide is not uncommon, with on average 1/3 of us experiencing a patient suicide each year. Our response to professional loss can often be complicated by feelings of responsibility and guilt but as senior leaders we frequently prioritise looking after other staff and families. 

There is little research on what support is effective, but there are some published examples of what psychiatrists can find helpful such as facilitated peer support groups. The College has a dedicated webpage of resources including webcasts and a booklet produced via the College’s working group on patient suicide and homicide. 

As President I would plan to actively support and build on this work

1. improving preparation for professional loss and trauma for trainees 
2. incorporating coverage of professional loss and trauma into the Startwell programme for early career psychiatrists
3. developing a Thrivewell programme for mid-career psychiatrists
4. promoting regional facilitated peer support groups
5. supporting the PSS (psychiatric support service) to identify peer supporters for psychiatrists affected by the rarer and yet devastating experience of patient homicide

Professor Russell Razzaque

I think the whole area of emotional support for psychiatrists is one where we have a long way to go. For example, psychotherapists usually have their own regular therapy, but even though most front-line colleagues see far more acuity and severity in our roles, our support is minimal in comparison. Making personal development a core part of professional development is therefore key for me. The College has a crisis support line but very few people know about it, according to surveys. We need to build this up through a system of ongoing support through peer networks and beyond.

In terms of the specific reactions to homicide or suicide, this can be genuinely traumatising for psychiatrists and yet the support received in response can be hit and miss. There was an excellent paper published in recent days by Tamworth et al. about specifically dedicated and facilitated consultant peer support groups and it showed very promising results in terms of helping participants process the grief involved.  This is very much the kind of model I would like to see becoming routine practice for any colleagues who want it, as well as a more general prioritisation of emotional wellbeing for psychiatrists.

The recent BBC and Channel 4 documentaries highlighting barbaric practice within mental health services have clearly shown how far we have to go in ensuring safe and humane care is a reality for all. How should the College be leading the way in ensuring that patient-centred, compassionate care is a reality for all in need?

Professor Russell Razzaque

We were all shocked by the Panorama documentary, but then this was followed up by a further documentary on Channel 4 and then more footage on Sky News after that. Now it is clear that this is a problem that goes beyond a single unit. 

I believe we need to come together with all of the other professional bodies – RCN, BPS, BASW etc. – to form a Commission on Compassionate Care. I actually have been calling for this since the start of my campaign. Together the clinical leadership at national level can then scrutinise what the impediments are to true person-centered, compassionate care. Clearly some of the solutions will be about resource, but it should also be about training, culture and the prioritisation of the relational dimension of care once again. Too often our services are designed with this as an afterthought – seeing clinicians roles as purely technical; prescribing medication, administering depots etc. We need to put the relationship front and centre again and we need to evaluate services – especially regulators – based on the extent to which patients feel heard, listened to and respected. This can be done with sufficient national focus and, if elected President this would be my priority.

Dr Lade Smith CBE

Mental health services are vulnerable to developing closed cultures and abusive practices. We need to understand why some services descend into the bullying abusive culture depicted, whilst others consistently provide compassionate, patient-centred care. Addressing this problem is part of promoting excellent care. 

I’m Clinical Director of the National Collaborating Centre for Mental Health. Our work in Reducing Restrictive Practice, Sexual Safety and Coproduction shows that both organizational and individual factors play a part. 

As RCPsych President, I would:

• Appoint a Presidential Lead for Patient Safety and Compassionate Care
• Work with inspectorates in all UK nations to improve detection, reduce bureaucracy and clearly delineate between abusive cultures and caring but overstretched services
• Strengthen the College Centre for Quality Improvement peer accreditation networks’ and NCCMH’s role in maintaining positive professional communities across the UK
• Establish a UK-wide observatory to collate recommendations and best practice
• Commission a College Report into the leadership role of psychiatrists in protection and safeguarding
• Embed these recommendations in postgraduate training curricula
• Work with national Freedom to Speak Up Guardians to enhance whistleblower support

As President I will ensure appropriately trained, skilled and nurtured staff who can identify abuse when it happens, prevent it and call it out.

Dr Kate Lovett

The recent documentaries are the latest in a long line of scandals involving the care of the most vulnerable and traumatised in society. There is no room for complacency that these were “other” places. Every unit up and down the country is potentially at risk from neglectful and abusive practice.

Influencing entrenched, institutionalised care is almost impossible on an individual basis. We must learn from repeated inquiries highlighting common themes of poor leadership and training. We must act together by working nationally with 

1. patients and families whose concerns were not heard
2. nursing leaders to influence culture, selection, leadership, CPD, supervision structures, training, and reflective practice
3. regulators to understand why inspections have failed to identify issues
4. governments and NHS bodies
   • to rethink reliance on untrained staff in inpatient units
   • calling for a statutory inquiry
   • re-opening debate on lack of professional regulation for support workers and non-clinical managers
   • reviewing inadequate access to beds and community alternatives
   • lobbying for fully funded long-term workforce planning

The college can also support us develop personal strategies for speaking out when standards of care fall short through training, CPD and tailored, individual advice via PSS (psychiatric support service).

Addiction services have seen a vast depletion of highly trained staff over the last decade. Dame Black's report is a good start but how will you as our President ensure that addiction psychiatry is seen as a core psychiatric skill and how will you lobby for this to be an essential part of all addiction services?

Dr Kate Lovett

Dame Black’s report was a damming indictment of how precarious addiction services have become as the result of commissioning changes in England.

Consultant numbers dropped by 40% between 2007 and 2017 paralleled by a 59% reduction in higher training posts. The result was that 40% of English Deaneries became unable to offer a single higher training post in addictions.

As RCPsych Dean:

• I led our review into addictions training - “Training in addiction psychiatry: current status and future prospects”
• I established a network of addictions tutors throughout UK
• I introduced the concept of workplace-based assessments in addictions into the curriculum.

I was also the first Head of School to establish addiction training posts outside the NHS.

However, curriculum reform is simply not enough. We need to influence government to ensure that the recommendations of both the college’s and Dame Black’s report become a reality. We must lobby for

• centrally, fully funded addiction training posts
• strategy to properly design and fund training for all staff
• services clinically led by addiction psychiatrists

I will be tenacious in highlighting the consequences of not acting. If we don’t, we are condemning people to impoverished care, impaired life chances and shortened lives. 

Professor Russell Razzaque

I was an addiction consultant for several years in the early 2000s and it was a job I loved. However, the commissioning back and forth made it very hard for the team and eventually the contract went to the third sector. This process was a really informative one for me, seeing not only how under resourced the services were but also how persistent instability around commissioning made matters a lot worse and genuinely impacted patient care. 

I too welcomed Dame Black’s report and am very glad to see the emphasis on changing commissioning systems and improving accountability as well as capacity. It also talks about improving competence and expertise and I think this is where the College can make a strong case. To really maintain the high level of expertise and competence, psychiatry needs to return to the heart of addiction service provision and vice versa. The College can play an active role in advocating and advancing this and, over time, more services should mean more opportunities for trainees. It will doubtless take time to turn this ship around but the College has an important role to play here and it’s a role I’d be very keen to take on.

Dr Lade Smith CBE

We cannot afford to lose Addiction psychiatry. Sixty percent of mental health patients have co-morbid substance use and ~80% in Addictions services have mental health problems, yet having dual diagnosis often precludes access to both types of service.

The reduction in Addiction specialists has coincided with increased patient mortality. We have lost training places and psychiatrists in specialties such as general adult and forensic do not get exposure to Addictions and thus become de-skilled. 

All substance use services, whether statutory or non-statutory, must have input from a senior psychiatrist. This requires an increase in Addictions specialists, which would help ensure there are more training opportunities which would in turn provide greater exposure to Addictions work for all types of psychiatrists and other professionals, reducing the likelihood of patients with dual diagnosis not receiving the care they require. 

I support the creation of a Centre for Addictions Medicine. As President, I would advocate for this to be hosted by the RCPsych and would strongly lobby DHSC, HEE and national equivalents and all UK governments for enhanced Addictions services, education and training. I did this recently with the Joint Committee for the MHA Bill. 

Addictions must return as a core psychiatric skill.

What is your plan to engage and support the growing number of psychiatrists currently working in non-NHS organisations?

Dr Lade Smith CBE

Psychiatrists working for independent health providers treating NHS patients; wholly private providers; universities; not for profit voluntary and community sector organisations and those working in portfolio roles across different types of organisations are still subject to the same standards and expectations of the quality of their work, as psychiatrists working in NHS organisations.

The College is at the forefront of setting these standards and should support the working conditions and professional development of all psychiatrists, wherever they work, so that they can deliver the best quality care and achieve their potential.

My main priority is supporting psychiatrists, so that psychiatrists can support patients. To do this properly the College must truly understand the needs of all psychiatrists. I will conduct a survey, consultation and focus groups aimed at understanding the different needs of and how best to support psychiatrists working in non-NHS and NHS organisations and those with portfolio careers. I will run regular update meetings, giving psychiatrists the opportunity to discuss their work and concerns and to hear feedback about the College’s progress.

All psychiatrists must have the basic equipment and infrastructure to do their role; adequate caseload sizes; administrative and professional support, and access to good CPD. 

Dr Kate Lovett

The college represents Psychiatrists deployed in the military, in medico-legal practice, in the voluntary, community and social enterprise sector, in independent private practice and those who work for large independent providers as well as the NHS. 9/10 patients in private beds are NHS patients. Issues of quality unite us all.

I am determined that all Psychiatrists feel a sense of being valued and belonging within the college, regardless of where in the world they work, their grade or who they work for.

There is much more we can do to support colleagues working in non-NHS organisations through

1. Encouraging uptake of College quality improvement programmes to champion standards
2. Better workforce data collection from outside the NHS via the college census
3. Developing training opportunities outside the NHS
4. Supporting colleagues in the private sector working towards CESR
5. Influencing uptake of college job approvals process by non-NHS organisations
6. Tailoring specific support for non-NHS psychiatrists via Psychiatric Support Service
7. Encouraging the private sector to support psychiatrists to undertake college work.

Psychiatrists can make a positive difference to people’s lives in a rich variety of important roles. We must keep highlighting this in all our work on recruitment.

Professor Russell Razzaque

It is clear that increasing numbers of colleagues are either choosing to work outside the NHS or combining their working lives to include aspects of both. I wouldn’t presume to make judgements on any colleague for the choices they make in their working lives and indeed, wherever we work, we have some very strong common ground. We all want the best for our patients, we all want to grow mental health service provision to fulfil the demands upon it and we all want to create an environment of excellence and continuous learning wherever we work.

On this basis the College should be there for everyone equally. The support we provide should be consistent, irrespective of where anyone works, whether that be NHS, private or the voluntary sector. Indeed our commitment to doing so should also enable us to serve as a meeting point where ideas and innovations can be shared across all sectors so that the best care ultimately flows to all. The role of the College should therefore be one of uniting, sharing and collaborating, with all members welcome and as many as possible engaged. 

Should a trainee psychiatrist learn to treat patients according to what the NHS expect of them or to what they think is ethical?

Professor Russell Razzaque

On a national level the role of College President should be to make sure these things don’t conflict. We want the NHS expectation to align with the highest ethical standards. It is, however, true that services are so stretched today that we are often left unable to deliver the full holistic care we would like. A way services deal with this is often to raise their thresholds for accepting people or lower the thresholds for discharge. And even when people are in services there are increasingly waiting lists within the service itself - to see a psychiatrist, to see a psychologist or to be allocated a care coordinator.

The role of the individual clinician in such circumstances should always be to do what is ethical to the best of our abilities. These are decisions that thousands are making daily. The College’s role needs to be to support that by calling out the problems and shortages unapologetically and unreservedly. We should back our members up by highlighting the context that throws such dilemmas up for clinicians every day. I believe this will be a crucial role for the College going forward, specially if further cuts to public services become a reality. 

Dr Lade Smith CBE

A trainee psychiatrist should learn to treat patients according to their needs and what is ethical.

I hope that what the NHS expects of them aligns very closely with that. If it does not then there is a problem with that NHS service and the goals of the service are clearly being distorted as they should match the needs of the patient and should always be ethical.

Our training expects this of us; we have regulators who expect this of us; and as individual practitioners and as individual citizens, we should expect and demand this of ourselves.  

Should you be concerned that you are being pressured to work in an unethical fashion, then that should be reported. Systems exist to report unethical practice or pressure to follow unsafe clinical care. The National Caldicott Guardian; professional indemnity organisations; peer groups; supervisors and even unions can all support us in ethical practice. 

Dr Kate Lovett

Given that the NHS constitution calls for the highest ideals of practice, NHS values and ethical practice should be in theory be aligned. However, I suspect that what lies behind the question is a very real worry about the quality of mental health care provided in many services, and perceptions about management priorities in under-resourced services, under pressure.

Ethics forms the bedrock of medical practice. The four ethical pillars of principlism; justice, autonomy, beneficence, and non-maleficence are familiar to medical students and trainees throughout the world. Our regulator and the College expects us to adhere to ethical guidelines via Good Medical Practice and Good Psychiatric Practice.

The College must continue to play a key role in supporting all psychiatrists to:

1. Use different concepts to grapple with complex problems including basic ethical principles.
2. Develop reflective practice and strong relationships with colleagues to help navigate through the daily challenges of the work we do as psychiatrists working across complex systems.
3. Wholeheartedly participate in high quality psychiatric supervision, mentoring and leadership training.
4. Develop personal strategies for raising concerns when standards fall short.

Covid has changed the world and all our lives. It is becoming increasingly clear the concerns are here to stay with us for a long time. In this scenario, what would be your vision in shaping the services and ways of working of psychiatrists? How would you plan to take that vision forward among the existing challenges of recruitment and retention?

Dr Kate Lovett

Covid brutally demonstrated that life is unpredictable and things we take for granted can change in an instant. My hope is that we will retain the flexibility that we demonstrated during the national emergency, to repeatedly reassess priorities and find new and better ways to deliver care.

Covid also powerfully demonstrated the falsehood of the brain/body divide and gave us a welcome opportunity to rethink how we design care. There are many excellent examples of psychiatrists working alongside colleagues in other parts of medicine, to deliver holistic care to people with physical and mental health complexity. As we move away from this pandemic, we must continue to capitalize on this.

Severe inflationary pressures on health budgets, likely significant public funding cuts and the impact of economic recession will increase current pressures. The challenges are immense with workforce in a perilous state in many services. In this context, maximizing our efficiency and support for each other will be critical. Making full use of digital resources, working collaboratively across health and care systems and cutting across clunky internal interfaces of care will be important to get through this. This will require us all to step up and help lead.

Professor Russell Razzaque

Some of the most significant long term pressures on the NHS due to COVID-19  will be on mental health services. We experienced our own surge as the lock down ended and infection rates subsided. Now referral rates to mental health services are at their highest ever and waiting lists have never been longer. The first role of the College must therefore be to communicate this loudly to government and articulate the dire need for increased investment clearly.

One of the gains of COVID has been an increasing familiarity with virtual consultations. Indeed, I wrote a guidance document for a study I am currently helping lead, about how to maintain therapeutic relationships through virtual meetings. New possibilities of working systemically have also emerged as a result.

In terms of recruitment and retention, remote working enables a wider field of people to apply for a job, when we are no longer required to travel to work each day. It can also allow clinicians to forge a better work life balance. As these changes take shape, therefore, it is essential that we make some of it work to our advantage and that of our patients. 

Dr Lade Smith CBE

Covid has resulted in less money being available relatively to mental health

services, whilst at the same time increasing need and demand. This is on top of chronic underfunding of mental health services. It has resulted in unprecedented challenges, but also shown us that the system can be flexible and adaptable.

We must hold on to that flexibility and innovative way of working. Crucially, we know that good therapeutic relationships and continuity of care are key to better experience and outcomes as well as being vital for quality and patient safety, and are more rewarding for clinicians.

This is an opportunity to re-work the system. Many have left in the wake of the pandemic, and as they look back they see outdated tech and systemic inefficiencies. We must shift the focus from length of stay and bed management, to actual clinical improvement and recovery-based metrics. These are more likely to be associated with better outcomes for patients. This will require collaboration across all health and social services, as well as meaningful, clinically-informed and patient-centric changes to our digital systems. This will help retain existing psychiatrists and encourage recruitment, as younger doctors will see that we are a dynamic, responsive sector.

Why should I vote for you instead of the other two nominees? What attribute makes you stand out?

Dr Lade Smith CBE

I have developed and implemented ideas that informed national policy and improved clinical practice, you are likely to have used these in your work – CMH Transformation; MHA reform; NHSE MH equality strategy; Patient and Carer Race Equality Strategy.

I have advised NHSE, DHSC, CQC, NHS Race & Health Observatory and 10 DS regarding mental health inequality and physical health in SMI. I’ve lobbied parliament for resources and policy change, requiring detailed preparation, collaborative working and development of good working relationships with politicians and their advisers.

I have strong links with other stakeholders in mental health - Mind, Rethink and the Centre for Mental Health.

I have extensive academic and clinical experience. My role as Clinical and Strategic Director of the NCCMH is about implementing research evidence and quality improvement.

I organise the International Congress, one of the most successful psychiatric conferences in the world.

In 2019, I was awarded Psychiatrist of the Year and a CBE for services to psychiatry.

Despite 30 years in psychiatry, I remain warm and compassionate, people delight me, especially my patients. I am someone to whom you can always come and share your concerns with, assured of a listening ear and solution-focused approach. 

Dr Kate Lovett

My biggest strength is having served psychiatry for 5 years as College Dean. As a result, I have a clear understanding of what the job of president is (and importantly is not). We are a professional body, different from other membership organisations, and we are not a trade union.

As Dean, I worked closely with three presidents as part of the senior management team. I also served on the Trustee Board. I therefore understand the complex governance structures of the college and am experienced in considering difficult decisions about finance, risk, policy, human resources and our legal responsibilities. Education is at the heart what the College is about. I have a unique wealth of experience and expertise in educational governance and delivery.

My manifesto is realistic. I am not promising anything that cannot be delivered from current resources, or that is not within our gift to deliver. The leadership of the college will set the direction for psychiatry for the next 3 years and arguably longer. My advice is to use your vote wisely. I have the necessary college senior leadership experience which means I will hit the ground running on taking up office.

Professor Russell Razzaque

The fundamental theme of my campaign is to put relationships back into the heart of care. This is what I have been passionate about my whole career; practicing it, teaching it, researching it, publishing papers in peer-reviewed journals as well as books on it. I’ve worked as a clinician, a manager and an academic and I have seen close up the obstacles that prevent us from providing the best care we can, as well as the models and innovations that hold the most promise..

Alongside this I have studied self care and wellbeing for colleagues too, specially for reducing burnout as well as perfecting the therapeutic relationships we have with our patients.

I have brought this work into the College, across a range of Executives - General Adult Faculty, Academic Faculty and London Region, as well as College Council - and I have delivered real change on the ground; launching pilot teams across a number of NHS Trusts as well as leading the Community Mental Health Transformation in my own. 

Given the widespread resource crunch within the NHS, Digital Transformation assumes great significance. How would you champion the cause for more digital transformation in mental health?

Professor Russell Razzaque

I very much agree that digital transformation will play an increasingly important role in the future of mental healthcare. Patients should be able to hold, access and keep their own notes through specialised apps, meetings should be recorded on specifically designed devices so that notes are transcribed and fields completed automatically. All of this actually happens in some countries and I have started engaging in research around them myself in the UK. They are just a couple of examples that have the ability to significantly save clinician time, enabling us to spend more time with patients.

Precision in diagnosis and specificity around treatments will be vastly improved by the use of AI too and none of this will take away from the vital human dimension that clinicians bring, particularly the relational work we do in psychiatry. VR also offers vast new possibilities for therapeutic engagement, enabling people to connect with their childhoods and aspects of their inner world like never before. I have been exploring studies in this area with academic colleagues myself too. I truly believe that we are at the beginning of a new era for mental healthcare in terms of the promise that digital technology brings

Dr Lade Smith CBE

Digital is here to stay.

Virtual consultations provide flexibility and convenience; reduce travel and transport, are environmentally-friendly; are cost effective; free up time and increase productivity.

Electronic patient records offer more reliable storage; accessible, rapid sharing of patient information; are more secure. With structured records and automatic referral form-filling, they could be much more intuitive, ease workflow, and reduce paperwork.

E-prescribing significantly reduces medication errors; allows for readily accessible prescriptions and facilitates medication review.

Digital monitoring systems help record and monitor physical observations, reducing the need to disturb patients whilst they sleep and freeing up nurses to do other work. 

Clinical informatics using population-based data allows better understanding of local need and for services to be tailored accordingly. Digitised patient and clinician related outcome measures can be more easily collated and analysed allowing ready evaluation of quality, safety and effectiveness.

Educational meetings are made more accessible by digital.

BUT we must get the basic infrastructure right – working devices, software and connections and we must make provision for the digitally excluded. Digital must not be “instead of”, but “as well as” – another tool in the toolbox, which when used wisely and well, should help to enhance the working lives of psychiatrists. 

Dr Kate Lovett

Patients must be at the heart of all our thinking around the adoption of digital technologies. To date we have been plagued by poorly designed electronic records systems that have not been designed alongside patients or frontline clinicians. That must change if we are to develop systems that work.

Computers need to be able to make us more, not less effective. Every piece of data inputted must be relevant to delivering and improving care. That means everyone must be able to see the results and the impact of the data they have contributed. Without this, data input will remain patchy and we will continue to hit targets under duress, whilst often missing the point.

The use of computer technology through telemedicine, smartphone apps, diagnostic wearables, monitoring, genomics, virtual reality, automated image interpretation, artificial intelligence and robotics has huge potential to improve the mental and physical health of our patients over the next 2 decades. The main challenge for the profession will be ensuring that psychiatry does not get further left behind in both clinical and research investment when it comes to digital. We must keep strongly advocating for parity of digital esteem with government, funding bodies and commissioners.

As per the ACEs studies, should the psychiatric profession and the RCPsych take a more active role in campaigning on social issues such as war, poverty, social exclusion, and domestic and sexual violence which are the largest contributory factors to the mental health issues of our patients? If so, how would you do this?

Dr Kate Lovett

The evidence for the contribution of social determinants to mental illness is stark. As the professional body representing psychiatrists, we have a responsibility to provide an authoritative voice on research evidence to governments, the public and our members. We already do this in a variety of ways via:

1. our academic journals
2. the curriculum
3. CPD and conferences
4. media
5. influencing policy.

The college has an important role to play in promoting prevention:

1. at a population level – highlighting the links between social determinants and mental illness
2. by intervening early with evidence-based strategies which we know work– e.g., recognition and intervention for domestic violence
3. through recovery e.g., access to psychological therapies where this is known to be effective.
4. through research

Much of our policy influencing is done away from the spotlight and this should continue in collaboration with our strategic alliances with other organisations e.g., the mental health policy group.

Health is a deeply political matter. However, translating aetiological evidence into effective political policy is not always simple. We must ensure that the policy advice of the college is always underpinned by clear scientific evidence and not driven by ideology.

Professor Russell Razzaque

Yes, I believe the College should absolutely be proactive in highlighting these issues and we have a very valid professional reason for doing this.  So long as we couch our statements in the language of patient care, we can talk explicitly about our concerns for the impact each of these issues likely has on mental health. Just as other branches of medicine inform the public about the health risks of various actions and situations, so we should be able to do the same when it comes to the areas that lead to harm in mental health.

In terms of how we go about this, I think it requires ongoing monitoring of the news agenda and when related stories come up, we need to make statements, field colleagues in the media and place stories about the concern we have about the harm that can be caused. In other words locating landmark moments that can then enable us to state our position, voice our concerns and educate the public. As our work on public mental health grows too, I believe this will be an increasingly important aspect of the College’s work in future. 

Dr Lade Smith CBE

Yes. The College has a key role in helping the public to understand mental illness.

The RCPsych and the psychiatric profession should collaborate with other system stakeholders and leaders and take a more pro-active approach, using the evidence to advise and shape the policy of our different governments, commissioners and policymakers, supporting them to tackle longitudinal drivers of poor mental health. This is the right thing to do clinically, morally, ethically and financially. 

The role of the College’s Public Mental Health Implementation Centre (PHMIC) hosted by the NCCMH, of which I am the Clinical and Strategic Director, should be enhanced.  

The College should build on the work it is doing already around sexual and other violence (Forensic Faculty and the WIMHSIG) and with asylum seekers and this work should be scaled up and disseminated further.

Myself and Raj Mohan have supported the new curriculum developments. It now includes social and wider determinants of health. Training and CPD must equip psychiatrists with the competence and skills to assess and integrate these factors and arrive at individual & personalised formulations to inform more compassionate, therapeutic, context-understanding care.

Michael Marmot said – “social determinants are not the footnote to health…they are the main issue”.