Psychiatry in Scotland is in need of "urgent investment" to address "flatlining" staff numbers and the surge in consultants quitting up permanent posts in the NHS to work as locums, according to new research.

A report by the Royal College of Psychiatrists in Scotland found that stress, work-life balance, and disillusion with the job were the main factors driving psychiatrists to take up locum positions.

Poor organisational culture, heavy workloads, and bullying were also blamed, with one psychiatrist describing how they had had been left feeling "unsafe" as the sole permanent consultant in charge of an entire service after three colleagues left.

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Another said that staffing shortages "meant I was having to cover vacancies to the point of becoming unsafe, only firefighting and [dealing with] emergencies".

The 70 respondents to the survey, who were all current or former locum psychiatrists, also spoke of how they could "earn more than double" working as a locum as well as benefiting from greater flexibility in working patterns.

More than a quarter of consultant psychiatry posts in NHS Scotland is currently vacant or being filled by a locum, with that figure rising to around 40% in Highland and Grampian.

Annual spending by Scotland's 14 health boards on locum psychiatrists reached nearly £35 million last year, up from £20m five years ago.

Dr Jess Sussmann, a policy lead for the College who left her own permanent post as a consultant rehabilitation psychiatrist in NHS Borders in July 2023 after 14 years to work as a locum closer to her home in Edinburgh, said the attention paid to NHS locum spending was misplaced.

She said: "They wouldn't be spending on locum psychiatrists if there wasn't a problem with recruitment and retention.

"The focus is in the wrong place, in my opinion.

"It should be about appropriate workforce planning and funding of mental health services which has been promised, but not achieved."

Stress was the number one reason why consultant psychiatrists had left permanent posts to take up locum roles instead (Image: RCPsych Scotland) Feedback highlighted issues such as safety, pay, and flexibility (Image: RCPsych Scotland) The College's report notes that "despite an unprecedented rise in demand for services in recent years, there has been no corresponding increase in funding or efforts to expand the psychiatry workforce".

According to the NHS Scotland Workforce Census, the number of whole-time equivalent general psychiatrists in March 2024 was exactly the same as the number in post a decade earlier - 804 - even after accounting for locums.

While the Scottish Government has previously committed to allocating 10% of the total NHS budget to mental health, including 1% for Child and Adolescent Mental Health Services (CAMHS), the report says it has "failed to get close to this promise" with current data from Public Health Scotland’s most recent Health Service Costs Summary indicating that the share of funding going towards mental health is actually falling, from 8.66% in 2021/22 to 8.53% in 2022/23.

It also warns that the mental health budget was hit by "disproportionate" 16% cuts of £18.8m in the latest Programme for Government.

It adds: "Without increased funding invested to grow and retain the psychiatric workforce, we cannot expect to create sustainable, practicable roles, address the issues with locums, nor ultimately improve mental health outcomes for Scotland’s citizens.

"Urgent investment is needed to address these workforce challenges and ensure meaningful reform."

Dr Sussmann is currently working as a locum psychiatrist in East Lothian ahead of a planned move with her family in January 2025 to Perth, Australia, where she is due to take up a permanent contract.

Although she stressed that there were "personal, family reasons" for relocating overseas, she conceded that she also recognised the experiences highlighted in the survey.

Dr Sussman will relocate to Australia in the new year. She said she personally recognised the experiences of stress and workload pressure highlighted by the survey (Image: Duncan McGlynn)

She said: "I needed change. On a personal level, I would agree with the work-life balance and the stress and the difficulties with flexibility of work.

"The reduction in staff numbers meant it was difficult to be able to reduce my hours.

"If I said instead of working four days a week I would like to work three days, there was no one to replace me for that extra day."

Dr Sussmann said her workload had "increased significantly" during the 14 years she worked in the Borders, while vacancies for consultants, nurses, and support staff such as occupational therapists rose.

She said: "We had lots of people off sick quite a lot with stress, which contributed to the full team feeling like it was struggling more.

"It was difficult to develop services and to do more than your day to day job under those circumstances."

In addition to extra investment in psychiatry, Dr Sussmann said she would like to see funding ring-fenced "similar to the approach that's been taken in England and Wales" and mandatory reporting by health boards to show that they have met the 10% and 1% spends on mental health and CAMHS respectively. 

"At the moment we've got no demonstration or way of understanding what's been spent that's visible," she said. 

A 'loophole' means that not all locums working as consultant psychiatrists are qualified to the level necessary to be appointed into permanent consultant postsA 'loophole' means that not all locums working as consultant psychiatrists are qualified to the level necessary to be appointed into permanent consultant posts (Image: PA)

Beyond the expense, a major problem for the NHS in being over-reliant on locums to fill consultant posts is that it has knock-on effects when it comes to junior doctor training and service development as these types of functions can only be fulfilled by consultants on permanent contracts.

Dr Sussmann said: "The fact that locums do not fulfil all the roles that a substantive [permanent] consultant would means that the substantive consultants who are left are struggling to do the supervision, the training, the service development, the quality improvement - all of those things that are essential for clinical leadership and for the best quality of care.

"If the locum is only doing the clinical role and not these other roles, then a substantive consultant - who is paid less - is expected to take on even more of these other roles.

"That's causing burnout, stress, and a 'toppling effect' as more and more consultants leave."

In addition, the College is concerned that a "loophole" means that psychiatrists without the qualifications required for appointment into a permanent consultant role are nonetheless being parachuted into consultant psychiatrist positions on a locum basis. 

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In some cases these are doctors who have trained overseas, but others have sat and failed the relevant exams. 

"There's a percentage of people - we estimate about 50 people - who are working in Scotland as consultant psychiatrists who don't have the requisite qualifications and are potentially not on the specialist register for the GMC as trained, specialist psychiatrists," said Dr Sussmann.

"That's a real issue.

"What we want to do is work with these individuals to try to enable them to receive the appropriate training and skills to be able to be called consultants in the future, having qualified as such.

"We want to phase out the practice of appointing doctors into locum roles when they don't have the qualifications."

The Scottish Government said mental health spending by NHS Scotland has doubled in cash terms, £651m in 2006/07 to £1.3bn in 2022/23, and that it is continuing to work with NHS Boards and Integration Joint Boards towards delivery of the 10% commitment on frontline health spending being dedicated to mental health.

Mental Wellbeing Minister Maree Todd said: “Improving retention across the health and social care workforce is a priority for us and we encourage employers to prioritise staff wellbeing at all times.

“We are also working in partnership with key stakeholders, including the Royal College of Psychiatrists, over how we can attract psychiatrists to take up posts in Scotland.

“This has been supplemented by substantial investment in our future consultant workforce and the creation of several additional training places in psychiatry.”