Robert Howard

I may say something controversial. You can't run mental health services that are overstretched and overwhelmed for years, where clinicians are forced to prioritise high risk, raise the bar for entry and cut anything seen as a "luxury", and then expect junior doctors to develop a high standard of knowledge and skill. What they learn instead is how to manage risk and reject referrals. In a system like this, a lot is treated as a “luxury”: • the therapeutic value of the relationship itself, and of contact with a team (before, it was the status quo. Now patients are not kept open without a clear “intervention”, while the relationship itself can be the intervention) • psychotherapy skills integrated in practice • a psychiatrist seeing a patient when there is no medication need One of the most frustrating phrases I heard in my NHS consultant years was: "I'm not going to prescribe for this patient, so there's no point in seeing them." At first I thought this came from more biologically oriented colleagues. But when resources are this limited, even caring, formulation-focused psychiatrists end up working the same way. Trainees learn that this is normal. Few people have time to add: "It shouldn't be like this. It's because of a lack of resources." So, as generations change, expertise narrows to risk and caseload management. The RCPsych is clearly aware of this, and the push to bring formulation into training is a good step against the current. My worry is that it becomes another tick-box: something to evidence during training, before trainees go back to copying what they see consultants do on a daily basis. Psychotherapy training is often treated the same way: do your two cases, attend Balint, get signed off, move on. For five years I taught psychiatrists in the West Midlands how to integrate psychotherapy and lifestyle skills into everyday practice. The idea is that these skills are not a box to tick, but tools to use in every clinical encounter. Not something to have signed off and forget about. But courses won't change much. What's needed is less pressure on the system, so that the people who care still have the space to pass on what good care looks like. P.S. This isn't about any specific trust. It's about a trend across mental health services.