Imagine a cancer ward where one in three consultant posts over the last 3 years is either empty or filled by a temporary doctor who will be gone in 3 weeks or 3 months. Imagine the outrage.
The author has been into Psychiatric services* where there are strings of 5 or more locums in succession over 5 to 7 years; in one Trust (up north) I was locum consultant number 15 in the last 3 years of an unbroken chain of locums. These are services who all are committed to delivering 'the highest quality care' - relative to rock bottom perhaps. But wait for it - the reasons given for this 'beyond ridiculous' nonsense? They range from "We don't know why.." to "It's happening all over the country".
Now enter the RCPsych Workforce Census 2025. How does this grab you - 669 locums psychiatrists and 748 posts totally vacant! That didn't happen all on one day! It was a systemic, structural and long term accumulation. Stop rubbing your eyes and look at the table below from the report. Then rub your eyes some more!
Be informed by me: the College's document is fifty-eight pages long. Not to worry; you're not missing much if you don't click that link. The narrative text—the actual prose—runs to three and a half pages. The rest is tables. Page after page of tabulated workforce data was presented with lack-lustre interpretation. The numbers are all in there. The story is not. But I can expect a majority of psychiatrists to like the report because it is concise and readable, though very few will actually study what the whole trove of data really means. This article tells it.
This article examines what the census reveals. It is not a commentary on individual clinicians. It is an examination of the structural conditions in which they are being asked to work, and in which patients are being asked to place their trust. The census does not assign blame but I can. It provides numbers. Those numbers tell a story that has consequences far beyond the walls of any single hospital.
If you or someone you love might ever need a psychiatrist, the next ten minutes matter.
Quick facts:
By specialty (from the report's specialty tables):
- Eating Disorders Psychiatry: 24 vacant posts (20.4% vacancy rate). Highest proportionally.
- General Adult Psychiatry: 179 vacant posts (16.7% vacancy rate). Largest absolute number.
- Child & Adolescent Psychiatry: Vacancy rate of 16% (absolute number not explicitly totalled in a single table but derivable from regional breakdowns).
- Old Age Psychiatry: 104 vacant posts (13.8% vacancy rate).
- Forensic Psychiatry: 45 vacant posts (11.2% vacancy rate).
- Rehabilitation Psychiatry: 20 vacant posts (12.9% vacancy rate).
- Medical Psychotherapy: 3 vacant posts (5% vacancy rate).
- Academic Psychiatry: 0 vacant posts.
On 31 March 2025, the Royal College of Psychiatrists took a snapshot of England's mental health workforce. Forty of forty-eight NHS mental health trusts responded. What they reported should stop anyone who reads it. Over a quarter of consultant psychiatrist posts in England have no permanent doctor. In the North West, it is one in three. In eating disorders psychiatry—the speciality treating the highest-mortality patient group in mental health—it approaches two in five.
This is not a dry HR spreadsheet. It is a diagnostic scan of a system that has normalised its own depletion. The numbers describe a profession held together by locums, vacancies, and the dwindling goodwill of those who remain. They describe a statutory framework—the Mental Health Act—that presumes a stable consultant workforce that no longer exists across large swathes of the country. They describe a postcode lottery in which the quality of psychiatric care available to ordinary people depends on whether you live in Manchester or Cambridge.
I have no allegiance to any trust, any professional body, or any political narrative. My only commitment is to the evidence as it appears on the page.
Over the sections that follow, I will walk through the key findings:
- The central metric—the "true vacancy" rate—that defines the scale of the crisis
- The geography of depletion, showing which regions are in freefall
- The specialties we are systemically abandoning through understaffing
- The overlooked SAS doctor workforce that holds services together
- The shifting gender composition of the profession
- And finally, what all of this means for the patients and communities who depend on psychiatric care.
The Number That Defines the Crisis
On 31 March 2025, there were 5,193 consultant psychiatrist posts across the NHS mental health trusts in England that responded to the census.
Of these, 3,776 were filled by substantive consultants—permanent employees with ongoing responsibility for their patients and services. A further 669 were filled by locums—temporary doctors engaged on short-term contracts to plug gaps. And 748 posts were simply vacant. No one in them. (Page 4, upper third; Page 7, data table.)
The headline vacancy rate—the figure most commonly cited in press releases and policy discussions—is 14.4%. This is the proportion of consultant posts that are entirely unfilled. It is a troubling number. It means one in seven consultant psychiatrist posts in England has no doctor in it at all.
The census introduces a second, more honest metric: the "true vacancy" rate. This figure accounts not only for empty posts but also for posts filled by locums. Why does this matter? Because a locum consultant is not a permanent consultant. They do not carry the same caseload continuity. They do not attend the same multi-agency safeguarding meetings. They do not hold the same long-term clinical risk. They are—by design and by necessity—temporary.
When locums are counted alongside vacancies, the proportion of consultant posts not filled by substantive, permanent psychiatrists rises to 27.3%. (Page 4, lower third; Page 7, data table.)
Over one in four.
This is the number that defines the crisis. It is not a marginal shortfall. It is not a seasonal fluctuation. It is a structural feature of psychiatric staffing in England. For every four consultant posts that exist on paper, one is either empty or occupied by a doctor who will not be there in six months.
The trend is not improving. The true vacancy rate has climbed from 21% in 2019 to 24% in 2021, to 29% in 2023. The 2025 figure of 27.3% represents a slight decline from the previous census, but it remains substantially higher than pre-pandemic levels. (Page 4, lower third; Page 56, Appendix E.)
What does 27.3% mean in practice?
It means that in more than a quarter of cases, the clinical anchor—the consultant psychiatrist who holds the long view of a patient's illness, who knows their history without opening a file, who dares to reduce a complex medication regime or authorise a trial leave from a secure ward—is not permanently present. The role is either unfilled or performed by a succession of temporary doctors who cannot provide continuity of care.
This is not a criticism of locum psychiatrists. Many are highly skilled clinicians doing essential work under difficult circumstances. The issue is structural. A system dependent on locums to fill more than one in eight consultant posts is a system that has normalised discontinuity. And discontinuity, in psychiatry, is not an inconvenience. It is a clinical risk factor in its own right.
The remainder of this article will examine where this crisis is most acute, which specialties are being hollowed out fastest, and what the data reveals about the workforce that remains. But every finding that follows must be understood against this central, irreducible fact: over a quarter of consultant psychiatrist posts in England are not filled by permanent doctors.
The system is running on temporary stitches. And the seams are straining.
The Geography of Depletion
A national average is a blunt instrument. The 27.3% true vacancy rate for consultant psychiatrists in England is alarming enough, but it describes a crisis that is not evenly distributed. Some regions are managing—barely—to hold the line. Others are in freefall.
The census divides England into eight divisions. The variation between them is not marginal. It is the difference between a stretched service and a service that has lost the capacity to function as intended. (Page 58, Appendix G.)
The Regions Under Greatest Strain
The North West is ground zero. The true vacancy rate for consultants—vacant posts plus locums—stands at 33%. One in three consultant psychiatrist posts in the region is either empty or filled by a temporary doctor. (Page 5, upper third; Page 58, Appendix G.)
The situation among Specialty and Specialist (SAS) doctors in the North West is even worse. The non-substantive rate for SAS doctors—again, vacancies plus locums—is 35%, more than double the England average of 17%. (Page 26, data table; Page 58, Appendix G.) More than a third of these essential middle-grade posts lack a permanent doctor. The SAS workforce is the backbone of service delivery in community teams, inpatient wards, and crisis services. In the North West, that backbone is fractured.
The West Midlands follows closely. Consultant true vacancy stands at 31%. SAS non-substantive posts are at 15%, slightly below the national average but still indicative of significant locum dependence. (Page 5, upper third; Page 58, Appendix G.)
London and the South West both record consultant true vacancy rates of 30%. (Page 5, upper third; Page 58, Appendix G.) In the capital, the situation is compounded by a crisis among Locally Employed Doctors (LEDs), where the non-substantive rate is 26%—the highest in England and nearly three times the national average of 9%. (Page 44, data table.) London's mental health trusts are haemorrhaging junior and middle-grade doctors to locum agencies and overseas opportunities, creating a two-tier workforce of exhausted permanent staff and a rotating cast of temporary replacements.
The North East and Yorkshire presents a more complex picture. The headline consultant vacancy rate is the highest in England at 20%—one in five posts entirely empty. Yet the true vacancy rate, at 27%, sits precisely on the national average. (Page 5, upper third; Page 7, data table; Page 58, Appendix G.) This suggests the region is filling proportionately fewer gaps with locums than other areas—whether by choice or by necessity is not discernible from the data.
The Outliers: Where the System Is Holding
Two regions diverge significantly from the national pattern.
The East of England records a consultant true vacancy rate of 22%—five percentage points below the England average and eleven points below the North West. The headline vacancy rate is just 8%, the lowest in the country. SAS non-substantive posts are at 10%. LED non-substantive posts are at zero. (Page 5, upper third; Page 26, data table; Page 44, data table; Page 58, Appendix G.)
The East Midlands (labelled "Trent" in the census tables) shows a consultant true vacancy rate of 23%. The SAS non-substantive rate is 9%, half the national average. (Page 58, Appendix G.)
The census does not explain why these regions are faring better. It invites the question but does not answer it. Are the differences attributable to more effective workforce planning, more attractive living and working conditions, lower historical burnout, or simply chance? The data does not say. But the pattern is unmistakable: some parts of England are managing to maintain a predominantly permanent psychiatric workforce. Others are not.
What Geography Tells Us
The regional disparities documented in the census are not abstract. They mean that the quality and continuity of psychiatric care available to a patient in Manchester or Liverpool is materially different from the care available to a patient in Cambridge or Norwich. The postcode lottery is real, measurable, and has consequences.
For the regions in freefall, the vicious cycle is well understood. Permanent staff burn out covering vacancies. They leave. The trust becomes more dependent on expensive locums. The financial drain of agency fees diverts resources from recruitment, retention, and service improvement. The working environment deteriorates further. More permanent staff leave. The cycle accelerates.
The North West did not arrive at a 35% SAS non-substantive rate overnight. This is the accumulated consequence of years of strain. The question the census poses but cannot answer is whether the East of England and East Midlands represent a sustainable model or merely a temporary reprieve before the same forces overtake them.
The geography of depletion is a map of risk. And on that map, large swathes of England are coloured deep red.
The Specialties We Are Losing
The census breaks down the consultant workforce across thirteen psychiatric specialties. The variation between them is stark. Some are functioning with near-full permanent staffing. Others have been hollowed out to the point where the majority of posts are either vacant or filled by locums.
Eating Disorders Psychiatry
The worst figures in the entire census belong to eating disorders psychiatry.
On 31 March 2025, there were 94 eating disorders consultant posts across the responding trusts in England. The headline vacancy rate stood at 20.4%—one in five posts entirely empty. But the true vacancy rate, accounting for locums as well as vacancies, reached 37.4%. (Page 15, data table.)
Over a third of consultant posts in this specialty are non-substantive.
Eating disorders have the highest mortality rate of any psychiatric illness. The conditions are complex, often chronic, and require sustained, specialist intervention. Continuity of care is not optional. Yet the workforce data shows a specialty that has been systematically deprived of permanent medical leadership.
The regional breakdown on page 15 reveals the problem is concentrated but widespread. The North West reports a 33% vacancy rate. The "national organisation" category—likely referring to specialist commissioned services—reports an 80% vacancy rate, though the absolute numbers are small. London records 19% vacancy. Even the South West, a region with comparatively low overall consultant vacancy, reports a 0% vacancy rate for eating disorders—but the table shows this is because the posts are filled by locums rather than substantive consultants. The true vacancy rate in the South West for eating disorders is not zero. It is 100% locum coverage.
General Adult Psychiatry
General adult psychiatry is the workhorse of the mental health system. It covers the broadest patient population, from first-episode psychosis to severe depression and anxiety disorders. It is the frontline that sees everything.
There were 1,634 general adult consultant posts in the responding trusts. The headline vacancy rate was 16.7%. The true vacancy rate was 34.2%. (Page 17, data table.)
One in three general adult consultant posts is non-substantive.
The regional data on page 17 shows the North East and Yorkshire with a 24.2% headline vacancy rate—the highest for this specialty. The West Midlands reports 26.6%. The North West reports 12.5% headline vacancy but, as established in the previous section, the region's overall locum dependence means the true figure is considerably higher.
Child and Adolescent Psychiatry
Child and adolescent psychiatry recorded a headline vacancy rate of 16%. The true vacancy rate—though not tabulated in a single summary cell—can be calculated from the specialty breakdowns and aligns with the 29% figure cited in the report's narrative. (Page 4, lower third.)
The SAS doctor data for child and adolescent psychiatry reinforces the picture of strain. Of 177 SAS posts in this specialty, 19.2% are non-substantive. The South West reports 23.5% non-substantive SAS posts. London reports 20.6%. (Page 32, data table.)
The Curious Case of Academic Psychiatry
At the opposite end of the spectrum sits academic psychiatry.
There were 29 academic psychiatry consultant posts across the responding trusts. The vacancy rate was 0%. The true vacancy rate was 0%. (Page 11, data table.)
The SAS doctor data for academic psychiatry tells the same story. Only four substantive SAS posts were recorded, and the non-substantive rate was 0%. (Page 30, data table.)
This is not an accident. Academic posts are typically joint appointments with universities, offering protected research time, teaching opportunities, and a different professional rhythm from purely clinical NHS roles. They are attractive. They retain staff. The zero vacancy rate in academic psychiatry is the exception that proves the rule: where working conditions are more sustainable, workforce depletion does not occur.
Other Specialties of Note
Several other specialties merit attention:
- Medical Psychotherapy: Headline vacancy of 5%, true vacancy of 9%. One of the lowest non-substantive rates in the census. (Page 20, data table; Page 57, Appendix F.)
- Forensic Psychiatry: Headline vacancy 11%, true vacancy 16%. Forensic services, which manage high-risk patients in secure settings, appear to be retaining permanent staff more effectively than general adult services. (Page 16, data table; Page 57, Appendix F.)
- Rehabilitation Psychiatry: Headline vacancy 13%, true vacancy 25%. SAS non-substantive rate is 29%, one of the highest across all specialties. (Page 24, data table; Page 42, data table; Page 57, Appendix F.)
- Liaison Psychiatry: Headline vacancy 11%, true vacancy 20%. The SAS non-substantive rate is 30%, the highest of any specialty. (Page 19, data table; Page 37, data table; Page 57, Appendix F.)
What the Specialties Tell Us
The pattern is clear. The specialties under greatest strain are those with the highest clinical intensity, the least protected time, and the greatest exposure to unrelenting demand. Eating disorders psychiatry, general adult psychiatry, and child and adolescent psychiatry share these features. They are the frontlines. They have been hollowed out.
Academic psychiatry, by contrast, offers a different model. It is not immune to the wider pressures on the NHS, but it has retained its permanent workforce. The zero vacancy rate is not a statistical fluke. It is evidence that working conditions determine retention.
The census does not tell us why medical psychotherapy and forensic psychiatry are holding up better than general adult psychiatry. It offers no commentary on the relative attractiveness of these specialties. But the data invites the inference: some parts of psychiatry are survivable careers. Others have become unsustainable.
When a specialty like eating disorders psychiatry reaches a 37% true vacancy rate, the question is no longer about recruitment. It is about whether the specialty, as a functioning clinical service, continues to exist in any meaningful sense across large parts of England.
The Second Pillar: SAS Doctors
Consultants hold the risk. SAS doctors hold the continuity.
Specialty and Specialist doctors—SAS for short—are the middle-grade psychiatrists who work alongside consultants in community teams, inpatient wards, and specialist services. They are not trainees rotating through six-month placements. They are experienced clinicians in permanent roles, often with years of accumulated knowledge about their patients and local services. When a consultant post is vacant or filled by a rotating locum, the SAS doctor is frequently the only clinician who knows the patient's history in full.
The census counted 1,863 SAS psychiatrist posts across the responding trusts in England. Of these, 1,544 were filled by substantive doctors. The remaining 319 were either vacant or filled by non-substantive locums. (Page 25, upper third; Page 26, data table.)
That is a non-substantive rate of 17.1%.
One in six SAS posts lacks a permanent doctor.
The Regional Picture
The geography of SAS depletion mirrors the consultant crisis but with even sharper peaks.
The North West again records the worst figures. The non-substantive SAS rate is 34.9%—more than double the England average. (Page 26, data table; Page 58, Appendix G.) More than a third of SAS posts in the region are vacant or locum-filled. This is the same North West that carries a 33% consultant true vacancy rate. The two workforces are crumbling in parallel.
London follows at 26.8%. The North East and Yorkshire at 17.5%, fractionally above the national average. (Page 26, data table.)
At the other end, the East Midlands reports 9%. The South West reports 9.1%. The East of England reports 9.7%. (Page 26, data table; Page 58, Appendix G.) These figures remain concerning—nearly one in ten SAS posts non-substantive—but they represent a materially different operating environment from the North West.
The Specialties at Risk
The census breaks down SAS posts by specialty. The variation is instructive.
Liaison Psychiatry has the highest non-substantive SAS rate of any specialty: 30.3%. (Page 37, data table.) Liaison psychiatry is the frontline of the general hospital. Its doctors assess patients in emergency departments and medical wards who present with self-harm, psychosis, or acute psychological distress. When 30% of these posts lack a permanent doctor, the bottleneck in A&E departments—patients waiting hours or days for a mental health assessment—is not a mystery. It is arithmetic.
Rehabilitation Psychiatry follows at 28.6% non-substantive. (Page 42, data table.) Rehabilitation services care for patients with severe and enduring mental illness, often over years or decades. Continuity is the active ingredient. When more than a quarter of SAS posts are temporary, that continuity is broken.
Eating Disorders Psychiatry records 26.5% non-substantive SAS posts. (Page 33, data table.) Combined with the 37% consultant true vacancy rate, this specialty is being hollowed out from both ends.
Child and Adolescent Psychiatry stands at 19.2% non-substantive. (Page 32, data table.)
General Adult Psychiatry—the largest SAS workforce—reports 16.7% non-substantive. (Page 35, data table.)
At the lower end, Forensic Psychiatry records 11.7% non-substantive SAS posts. Intellectual Disability Psychiatry reports 10.2%. Perinatal Psychiatry stands at 12%. Academic Psychiatry records zero non-substantive SAS posts. (Page 34, 36, 41, and 30, data tables.)
The Gender Dimension
Over half of substantive SAS doctors in England are female: 54% women, 46% men. (Page 25, upper third.)
The gender split has fluctuated over successive censuses but has consistently shown a female majority. In 2019, the split was 53% female to 47% male. In 2021 and 2023, it was 55% female to 45% male. (Page 25, upper third.)
The SAS workforce is disproportionately female. This matters because women in medicine continue to carry disproportionate caring responsibilities outside work and are more likely to work part-time. The census bears this out: female SAS doctors significantly outnumber male SAS doctors in part-time substantive posts. (Page 26, data table.)
The point is not that women are less committed to full-time work. It is that the SAS workforce depends heavily on a demographic that has historically been underserved by inflexible working arrangements. When those arrangements fail, the workforce contracts.
What SAS Doctors Tell Us
The SAS workforce is the second pillar of psychiatric staffing. It is less visible than the consultant workforce. It attracts less policy attention. But when it fractures, the consequences are immediate.
A vacant consultant post can be papered over with a locum. A vacant SAS post is harder to fill. The pool of locum SAS doctors is smaller. The work is less well remunerated than consultant locum shifts. The result is that SAS vacancies often translate directly into unfilled sessions, cancelled clinics, and longer waiting lists.
The North West's 35% non-substantive SAS rate is a warning that the second pillar is crumbling in the region that can least afford it. London's 27% rate, combined with its 26% non-substantive LED rate, suggests a capital dependent on temporary doctors across all grades.
The specialties with the highest SAS non-substantive rates—liaison, rehabilitation, eating disorders—are the same specialties showing the highest consultant true vacancy rates. The two workforces are not independent. They are under simultaneous, compounding strain.
A system that loses its SAS doctors loses its memory.
The Gender Composition of the Workforce
The psychiatric workforce in England is not uniform in its gender composition. The picture varies significantly depending on which tier of the profession is examined.
Consultants: Approaching Parity
In 2025, 48% of substantive consultant psychiatrists in England were female, while 52% were male. (Page 4, upper third.)
The gap has narrowed steadily over successive censuses. In 2019, the split was 55% male to 45% female. In 2021, it was 53% male to 47% female. In 2023 and 2025, it has held at 52% male to 48% female. (Page 4, upper third.)
The consultant workforce is not yet female-majority. It is approaching parity. At the current rate of change, the 50% threshold may be crossed within the next census cycle or two, but it has not been crossed yet. Caution: nobody is 'saying' this is a bad thing. But helloooo - in case it is news to some, women tend to get pregnant on occasions. That's fine - totally - but what's the impact for continuity of care delivery. None? Does the NHS have sufficient capacity to cater for increasing maternity and particular biologically-related leave requirements? If you believe the answer is in the affirmative, you would sleep well tonight. If you're not so sure, read on.
The distribution of part-time working tells a more detailed story. Among substantive consultants, women are significantly more likely to work part-time than men. The census records 806 female part-time substantive consultants compared to 487 male part-time substantive consultants. (Page 7, data table.) Women constitute 62% of the part-time consultant workforce.
This pattern holds across every English division. In the North East and Yorkshire, there are 76 female part-time substantive consultants and 18 male. In the South East, 115 female to 48 male. In London, 146 female to 74 male. (Page 7, data table.) The disparity is not regional. It is structural.
SAS Doctors: A Female Majority
The Specialty and Specialist doctor workforce is already female-majority. Women hold 54% of substantive SAS posts, men 46%. (Page 25, upper third.)
This is not a new development. The female majority among SAS doctors has been consistent across recent censuses. In 2019, the split was 53% female to 47% male. In 2021 and 2023, it was 55% female to 45% male. (Page 25, upper third.)
The part-time disparity is even more pronounced than in the consultant workforce. There are 333 female part-time substantive SAS doctors compared to 84 male. (Page 26, data table.) Women constitute 80% of the part-time SAS workforce.
The pattern is consistent across regions. The South East records 48 female part-time substantive SAS doctors to 12 male. The North East and Yorkshire records 54 female to 18 male. London records 46 female to 14 male. The North West records 9 female to 3 male—the smallest absolute numbers but the same proportional skew. (Page 26, data table.)
Locally Employed Doctors: The Strongest Female Majority
The LED workforce shows the most pronounced female majority. Women hold 63% of substantive LED posts, men 37%. (Page 43, upper third.)
The census does not provide a detailed part-time breakdown by gender for LEDs in the same tabular format as for consultants and SAS doctors. The overall pattern, however, is clear: the most junior and least securely employed tier of the psychiatric workforce is overwhelmingly female.
Locum Consultants: A More Balanced Picture
The locum consultant workforce shows a different pattern. Among full-time locum consultants, there are 145 female and 133 male. Among part-time locum consultants, 106 female and 104 male. (Page 7, data table.) The locum workforce is more gender-balanced than the substantive workforce, and the female skew in part-time working, while still present, is far less pronounced.
What the Data Shows
The census establishes three distinct patterns:
- SAS doctors and LEDs are female-majority workforces. This is an established fact, consistent across multiple census cycles.
- The consultant workforce is approaching gender parity but has not yet reached it. The 52%/48% split in 2025 represents a significant narrowing from 55%/45% in 2019, but it does not constitute a female majority.
- Part-time working is heavily gendered across all tiers. In the substantive consultant workforce, 62% of part-time workers are female. In the SAS workforce, 80% are female. The pattern is unambiguous and universal across English regions.
What the Data Does Not Show
The census does not explain why these patterns exist. It does not examine the reasons women are more likely to work part-time, nor does it assess whether working conditions are adapting to the changing composition of the workforce. Those questions fall outside the census methodology.
What the data does make clear is that any workforce strategy for psychiatry in England must account for a profession in which:
- The SAS and LED tiers are predominantly female
- The consultant tier is approaching an even gender split
- Part-time working is a central feature of the workforce, and it is overwhelmingly women who work reduced hours
These are not marginal considerations. They describe the shape of the workforce as it actually exists.
What This Means
The census is a document of measurement, not commentary. It provides numbers. Those numbers describe a system under structural strain that has become normalised.
The Normalisation of Discontinuity
The central finding is the 27.3% true vacancy rate for consultant psychiatrists. Over one in four consultant posts is either empty or filled by a locum. (Page 4, lower third; Page 7, data table.)
This figure has remained above 20% since 2019. It peaked at 29% in 2023 and has fallen only marginally to 27.3% in 2025. (Page 56, Appendix E.) The system has not recovered. It has stabilised at a level of locum dependence that would have been considered a crisis a decade ago.
Continuity of care is not a luxury in psychiatry. It is the mechanism by which risk is understood, monitored, and managed over time. A locum consultant, however skilled, cannot provide continuity. They do not know the patient's history in the way a permanent consultant does. They do not attend the multi-agency meetings. They are not present for the tribunal six months later.
When 27% of consultant posts lack a permanent doctor, the system is operating without continuity in more than a quarter of cases. This is not a temporary shortfall. It is a structural feature of psychiatric staffing in England.
The SAS Workforce: The Second Pillar Under Strain
The SAS doctor workforce is less visible than the consultant tier, but its depletion is equally concerning. A non-substantive rate of 17.1% means one in six SAS posts lacks a permanent doctor. (Page 26, data table.)
In the North West, the figure is 35%. (Page 26, data table.) More than a third of SAS posts in the region are vacant or locum-filled. This is the same region carrying a 33% consultant true vacancy rate. The two pillars of the psychiatric workforce are eroding simultaneously.
The specialties with the highest SAS non-substantive rates are those where continuity matters most. Liaison psychiatry, at 30.3% non-substantive, is the frontline of emergency mental health care. (Page 37, data table.) Rehabilitation psychiatry, at 28.6%, cares for patients over years and decades. (Page 42, data table.) Eating disorders psychiatry, at 26.5%, treats a patient group with the highest mortality rate of any psychiatric illness. (Page 33, data table.)
When the SAS workforce fractures in these specialties, the clinical memory of the service is lost. Patients see a succession of temporary doctors. The long view disappears.
The Regional Divide
The census reveals a postcode lottery in psychiatric staffing.
The North West is the most depleted region in England. Consultant true vacancy at 33%. SAS non-substantive at 35%. (Page 58, Appendix G.) The West Midlands follows at 31% consultant true vacancy. London and the South West both at 30%. (Page 58, Appendix G.)
The East of England and East Midlands show comparatively lower rates. Consultant true vacancy at 22% and 23% respectively. SAS non-substantive at 10% and 9%. (Page 58, Appendix G.)
The gap between the North West and the East of England is not marginal. It is the difference between a system that is barely holding together and one that, while stretched, retains a predominantly permanent workforce.
The census does not explain the regional variation. It invites the question: what are the East of England and East Midlands doing differently? Are their working conditions more sustainable? Are their recruitment pipelines more effective? Is their locum expenditure lower, freeing resources for permanent posts? The data does not answer. It only maps the disparity.
The Specialties We Are Systematically Depleting
The specialties with the highest true vacancy rates share common features. They are clinically intense. They offer little protected time for non-clinical work. They face unrelenting demand.
Eating disorders psychiatry is the worst affected, with a 37.4% true vacancy rate. (Page 15, data table.) General adult psychiatry follows at 34.2%. (Page 17, data table.) Child and adolescent psychiatry at 29%. (Page 4, lower third.)
Academic psychiatry, by contrast, has a 0% vacancy rate. (Page 11, data table.) Medical psychotherapy has a 9% true vacancy rate. (Page 57, Appendix F.) These specialties offer different working conditions. They are not immune to wider pressures, but they have retained their permanent workforces.
The inference is unavoidable: where working conditions are more sustainable, vacancies do not accumulate. Where they are not, the workforce haemorrhages.
The Statutory Safeguard That Is Compromised
The Mental Health Act 1983 places specific duties on the Responsible Clinician. In psychiatry, this role is almost always held by a consultant. The Responsible Clinician is accountable for detention decisions, treatment without consent, and discharge planning. They must know the patient. They must be present for tribunals and managers' hearings.
A locum consultant cannot adequately discharge these functions. They do not have the longitudinal knowledge of the patient. They are not the clinician who will be accountable in six months. They are temporary.
When 27% of consultant posts are non-substantive, the statutory safeguard of Responsible Clinician oversight is structurally compromised in more than a quarter of cases. This is not a criticism of locum psychiatrists. It is a statement about the design of the Mental Health Act and the reality of the workforce available to implement it.
The law presumes a stable, permanent consultant workforce. That presumption is no longer valid across large parts of England.
The Cost of Locum Dependence
The census does not provide financial data. It does not calculate the cost of locum expenditure. But the scale of locum dependence documented in the census has financial consequences that are well understood elsewhere.
Locum consultants are more expensive than substantive consultants. Agency fees, premium rates, and the transactional nature of locum work divert resources from permanent recruitment, service development, and retention initiatives.
The trusts with the highest locum dependence are paying a premium simply to stand still. Money that could fund additional substantive posts is instead consumed by the higher cost of temporary cover. The financial drain reinforces the staffing crisis. It is a vicious cycle.
The Unanswered Questions
The census answers many questions. It leaves others unasked.
It does not tell us why psychiatrists are leaving substantive posts. It does not measure burnout, moral injury, or the cumulative effect of working in understaffed services. It does not capture the reasons locum work is more attractive to some clinicians than permanent employment. It does not assess the quality of care provided by services with high locum dependence compared to those with stable workforces.
These are not failures of the census. They are beyond its remit. The census measures posts. It does not measure the human experience of filling them, or leaving them, or depending on them for care.
What the census does provide is a reliable, quantified account of the structural condition of psychiatric services in England. That condition is one of normalised discontinuity, regional disparity, and the systematic depletion of the specialties that face the highest clinical demand.
The numbers are clear. The implications are for policymakers, trust leaders, and the profession to determine.
Section 8: Conclusion
The RCPsych Workforce Census 2025 is not a prediction. It is a measurement of present reality, and that reality should alarm anyone who depends on mental health services in England—anyone who might one day need them, or love someone who does. Over a quarter of consultant psychiatrist posts lack a permanent doctor. In the North West, that figure rises to one in three. In eating disorders psychiatry, the specialty treating the patient group with the highest mortality rate in mental health, it approaches two in five. These are not temporary pressures. The true vacancy rate has remained above twenty per cent for six years. The system has not recovered. It has stabilised at a level of locum dependence that constitutes a new, degraded normal.
If nothing changes and fast, the trajectory documented in this census will continue. The regional divide will widen, with some parts of the country drifting into a state of permanent workforce crisis where substantive posts go unfilled for years and services are delivered almost entirely by rotating locums. Certain specialties—eating disorders, general adult psychiatry, child and adolescent psychiatry—will cease to function as coherent national services. Patients will wait longer, deteriorate while waiting, and some will die. The statutory framework of the Mental Health Act, which presumes the existence of a Responsible Clinician who knows the patient and holds long-term accountability, will become increasingly unworkable. Detention decisions and discharge planning will fall to clinicians who do not know the patient and will not be present to manage the consequences. The law will say one thing; the workforce will be able to deliver another.
None of this is inevitable. The East of England and East Midlands demonstrate that lower vacancy rates are achievable within the same national system. Academic psychiatry's zero vacancy rate demonstrates that sustainable conditions retain staff. The evidence exists. Filling the 748 vacant consultant posts and converting the 669 locum posts to permanent appointments would require a sustained expansion of training numbers and a serious effort to make substantive employment more attractive than agency work. It would mean addressing workload, support systems (like proper secretaries for starters), autonomy, and the erosion of professional satisfaction that drives clinicians out of permanent posts. It would take years. However, due to the current economic climate and political unsettledness at home and abroad, it could take decades.
There is a comparison we refuse to make. If twenty-seven per cent of oncologist posts were vacant or filled by locums, cancer waiting times would dominate every news bulletin. Psychiatry is treated differently. The workforce depletion documented in this census has been allowed to accumulate over years without the emergency response it would trigger in any other branch of medicine. The reasons are complex and include stigma, the relative invisibility of psychiatric illness, and the fact that the consequences of depleted psychiatric services often manifest outside the healthcare system—in prisons, on the streets, in suicide rates reported as individual tragedies rather than system failures. Whatever the reasons, the result is the same. We have normalised a level of psychiatric understaffing that would be considered scandalous elsewhere. The census quantifies that normalisation. The question it leaves unanswered is whether we are prepared to accept it. But maybe we will be forced to accept it. Or maybe how we ended up in such a mess, is the end point of 'force' dressed up as incompetence.