Health and Social Care Committee

HSC(4)-01-13 paper 5

Health board reconfiguration plans - Evidence from Wales Deanery

 

 

Written Evidence from the Wales Deanery for the

Health and Social Care Committee

 

 

 

 

1.    What view the Deanery takes on staffing issues currently facing the NHS in Wales:

 

It is perhaps important to put the role of the Wales Deanery (‘the Deanery’) into context before commenting on the questions as outlined in the correspondence with the Health and Social Care Committee.  The purpose of the Deanery is to support, commission and quality assure education and training of trainees, General Practitioners, Dentists and Dental Care Professionals in Wales.  This accounts for approximately 2700 doctors in training and 330 dental trainees in Wales. 

 

The Deanery is accountable to the General Medical Council (GMC) and has to ensure that it meets its obligations for the welfare of its trainees and patients in Wales.  There is now one set of standards for the entire postgraduate medical training pathway from the Foundation Programme up to the award of the Certificate of Completion of Training (CCT).  The Document ‘The Trainee Doctor,’1 published in 2011, incorporates the standards that the GMC will hold postgraduate deaneries accountable for in accordance with the Medical Act 1983.

 

The Deanery provides evidence on a regular basis to the GMC that these standards are complied with, for example Annual Reports and Data Returns.  In addition the GMC undertakes a Quality Assurance Inspection Visit to each deanery in the UK, the most recent in Wales being November 2011.  The GMC also approves curricula and assessment systems, devised by the Specialty Royal Colleges, training programmes and posts.

 

Following the collapse of the Medical Training Application Service (MTAS) in 2007, recruitment to Specialty Training positions continues to evolve.  The process has been streamlined across the UK.  For each specialty, trainees now apply to one entry portal and preference their region of choice.  This process has significantly reduced the number of applications managed by each Deanery; however, this now provides a more realistic reflection of the number of applicants wishing to apply to Wales for a particular specialty or grade.

 

Throughout the UK there are difficulties in recruiting to certain specialties, namely, Paediatrics, Psychiatry and Emergency Medicine.  So Wales is not alone in having difficulties filling rotas within these specialties, however it should be noted that fill rates for Wales are significantly lower than those across England.

 

Specialty

2012 England fill rate

2012 Wales fill rate

2011 Wales fill rate

Paediatrics (end of round 1)

99%

87%

76%

Psychiatry

68%

38%

56%

Core Medical Training

99%

72%

82%

 

 

1.     General Medical Council (2011) The Trainee Doctor, GMC

A further example is that in the last 3 years despite having advertised in excess of 15 posts, Wales has only recruited 4 trainees to Emergency Medicine. 

 

Recruitment gaps impact heavily upon rotas which then puts undue service pressures on the trainees, to the detriment of their educational experience.  It is the Deanery’s recommendation, based upon findings from the Temple Report2, that rotas should have 11 participants to prevent vulnerability from recruitment gaps, less than full time (LTFT) training, sickness absence, out of programme training opportunities and maternity leave. This approach will provide Wales with sustainable training programmes for the future.

 

For most specialties trainees are placed across 15 Units in Wales where rotas consist of less than 11 participants.  This therefore means that our trainees in these specialties are spread too thinly across too many hospitals.

 

In order to comply with the GMC standards in training and the requirements of the individual Specialty Curricula, trainees need to obtain the relevant patient exposure, seeing a breadth and depth of presentations and management of sick patients.  This means that it is not possible to put trainees in every department in every hospital across Wales, as the training opportunities afforded to them during their comparatively short training period are insufficient to meet the curricula requirements. If trainees are unable to meet curriculum requirements they fail to progress to the next year, are more likely to fail Royal College examinations and this in turn leads Wales to have an increasingly poor reputation for training.

 

There is always a tension between service provision and education within the NHS and it is vitally important that we strike the correct balance between our trainees learning in the workplace and making a contribution to service provision, but fundamentally ensuring they get the best possible training. To ensure the future provision of high quality doctors delivering safe patient care in Wales, trainees need protected time for their education to enable them to achieve required Royal College examination success and a smooth progression through their training programme.

 

2.    How staffing difficulties are best explained:

 

It is best to continue to focus on the difficulties we are having in the recruitment of junior doctors, in Wales in the first instance.  The NHS in Wales has had an over-reliance on the presence of junior doctors for service provision, dating back many years.  The European Working Time Directive in 2005 reduced the available hours that doctors could work to 56 per week and the only way that the service could manage this reduction was to increase the number of junior doctors.  Unfortunately, in Wales there was a marked increase in the number of Senior House Officer (now called core training) posts across all Trusts in order to make the rotas compliant.  This had a detrimental knock on effect to recruitment to higher specialty training in Wales as it meant our competition ratios going from core training to higher training were out of sync with the rest of the UK. 

 

2. Temple, J (2010).  Time for Training.  A review of the impact of EWTD on the quality of training

 

 

When deciding upon what specialty and locality to apply to for Specialty training, applicants now have access to information from various sources.  For applicants today opportunities for career progression is an important factor.  The more core posts there are compared to higher posts the less the likelihood that a trainee will progress from core to higher training.  For example, in 2009 the applicant to post ratios for surgical specialties peaked at 58 applicants per post advertised.  This information is known to trainees and can be tracked and is available on the web. 

 

This in itself made Wales an unattractive place to come as it was felt that the competition ratios were too risky to warrant an application.  Successive years with vacancies have resulted in recruitment panels lowering the acceptability threshold resulting in a lower quality of appointees.  These doctors have difficulty passing the Royal College examinations, league tables for which are published and available on the web UK-wide, and again this is a negative factor in applying to a locality with low pass rates.  This is supported by evidence from the annual review of progress reviews of trainees. In 2012 the number of trainees requiring a formal extension to training as a result of failure to progress increased by 35% and the number of trainees withdrawn from training increased by 44%.

 

The immigration rules changed in 2007 which prevented a significant number of international medical graduates from coming into Wales. Wales had previously been well served by a large number of international medical graduates who principally were a great help in service provision and were not in training posts.  In 2008 Wales received applications from 1466 international medical graduates; in 2012 the UK as a whole received applications from 1777.  In turning this traditional source of doctors off, Wales found itself again over reliant on the presence of trainees for service provision.

 

There are other issues that do not make Wales an attractive a place to apply for work and training, one is notably the geography.  Applicants are concerned when they move to Wales they might have to rotate over significant distances, in order to complete their training.  While we, by and large, have no problem filling the hospitals along the M4 corridor, we have increasing difficulties with recruitment to both West and North Wales.  We have sought to address this issue with North Wales by linking in with the Mersey Deanery to have rotations that no longer have to have the trainees travelling to South Wales to gain the necessary experiences to meet the curriculum requirements.   We are therefore looking to maintain rotations across the North of Wales, but this will take some time to bed in.

 

There are other perceptions that trainees and indeed other staff have with regard to coming to Wales. One of which is a misunderstanding of the need to be able to speak Welsh, and indeed it has been reported that some people believe we have a different currency to the rest of the UK.

 

The medical employment pool is evolving.   UK graduate numbers increased by 76% in the 10 years to 2006, of which two thirds were female.  Currently 53% of all trainees in Wales are female.  The demand for LTFT training, for either ill health or disability or as a result of carer responsibilities either for children or dependents, has risen from 87 in 2007 to 173 in 2011.  Currently in 2012 this figure is 203 with another 48 predicted to start by the end of 2012.  This equates to approximately 10% of the trainees in Wales.

 

In 2011, 100 trainees took maternity leave and 50% of these applied for LTFT training following their return to work.  During an average training programme trainees may take maternity leave more than once and may alternate between full and LTFT employment.

 

NHS Wales workforce data shows that the feminization of the workforce has yet to fully impact upon the NHS and more women are yet to arrive in the middle grade years of service and training. 

 

In terms of a marketing strategy, it is highly unlikely that the majority of people applying for jobs would have any real understanding of where Betsi Cadwaladr University Health Board or indeed Hywel Dda Health Board exactly are geographically.  Both have excellent educational opportunities available and are beautiful settings to be located and live in for an excellent work life balance but the benefits of these locations have not been maximised.

 

It is import to highlight that recruitment and retention of General Practice (GP) trainees is an issue in Wales.  This is at a time when GP provision is increasingly key to an integrated modern health service.  Similar patterns exist whereby trainees preferences do not include North or West Wales.

 

 

3.    How staffing difficulties in Wales are best addressed:

 

The most important aspect for attracting and retaining trainee doctors to Wales is to improve the training experience for them when they are in the country.  This means less reliance on their presence for service provision and agreed educational contracts with their employing authorities, as opposed to their current contract which is more predicated on service provision.  Trainees require protected time for education in the working week to attend theatre or outpatient clinics and take study leave. 

 

The role of educational supervisors needs to be professionalised. This can be achieved by the Tripartite agreement that the Deanery has piloted across a number of Health Boards. It sets out an agreement between educational supervisors, Health Boards/Trusts and the Deanery defining roles and responsibilities for the provision of educational supervision.   Inclusion of educational supervision within the appraisal process, with educational supervisors committed to improving their skills through continuous professional development in the role will lead to improved educational experiences for trainees. 

 

The Deanery also believes that training should be undertaken on fewer sites to enable a critical mass of trainees.  This will ensure that trainees get sufficient clinical experience,  that their rotas for out of hours are robust with a minimum of a 1 in 11 out of hours commitment and  that they will get protected time during the working day for education, attendance at out-patient clinic and exposure to theatre time within the craft specialties.  This we believe will improve their experience, improve the examination pass rates and improve patient care.

 

To date the Deanery has introduced a number of initiatives to aid recruitment and retention across Wales.  In some specialties the Deanery has reduced the number of fixed term positions.  These unattractive posts have been converted to long-term sustainable posts offering the security that trainees require. 

 

The Deanery has developed the Wales Clinical Academic Track providing a unique 8 year programme with equal focus on clinical and academic training. This is a much sought after programme attracting and retaining high calibre trainees in Wales.  

 

In certain specialties we have initiated and piloted additional years to provide opportunities for doctors to consolidate their training experience and better equip them for competition into higher training.

 

The Deanery has also undertaken to reduce the number of core training posts in specialties with particularly high competition ratios to bring them more into line with opportunities into higher training.  These posts have been either converted to higher training within that specialty or the funding utilised to develop posts in new emerging specialties such as Pre-Hospital Emergency Medicine, Intensive Care Medicine, Stroke Medicine and the development of the Clinical Leadership Fellow programme which will support career progression and lifelong learning for aspiring medical and dental leaders.   The Deanery believes that investment in these specialties will show Wales in a positive light with regard to the rest of the UK.

 

Other initiatives include the All Wales Foundation Programme iDoc Project which provides trainee doctors with a Smartphone device to enable access to accurate medical information to aid clinical information delivery and just-in-time learning.

 

In 2009 the Deanery launched the Best Educational Supervisor and Trainer (BEST) Awards aimed at ensuring excellence in medical training through the development and support of high quality educational and clinical supervisors throughout Wales. These awards have gone from strength to strength and are a model followed by other deaneries across the UK.

 

The All Wales Health Information and Library Extension Service (AWHILES) which is unique to Wales provides all training grade doctors and dentists with access to high quality postgraduate facilities and educational support so that they can achieve their potential in service provision to the NHS in Wales.

 

The Deanery recognises that the very many positive aspects of training in Wales should be highlighted to potential applicants.  This work started in 2010 with the introduction of the ‘Smart Choice’ marketing campaign with Welsh Government and work continues on this in collaboration with the NHS Confederation.  The Deanery actively promotes ‘Training in Wales’ at various medical careers fairs across the country.  The Deanery recognises, however, more work is needed to emphasize the excellent and highly regarded research facilities, excellent trainers and excellent teaching and training facilities available across Wales. 

 

In 2012 the Professional Support Unit of the Deanery, whose work supports the development of doctors and dentists, were runners up in theHealthcare People Management Association (HPMA) Excellence Awards under the category: Healthcare Performance award for best coaching and personal development strategy.  The Professional support Unit was commended on being the first Deanery submission in the UK for HPMA awards.

The Deanery continues to publicise as best it can the quality of training in Wales and has recently won the Medical Women’s Federation Award for being the most Family Friendly Deanery in the UK.  This is the second year in a row that we have been the outright winner of that award and is a reflection of our commitment to provide not only the best possible training for trainees here in Wales, but also a positive work-life balance in order to promote the retention of doctors who come to Wales. 

 

The Deanery works in close collaboration with Medical and Clinical Schools across Wales. With Cardiff University School of Medicine the Deanery is playing a leading role on the harmonisation of the final year of undergraduate medicine with the first year of Foundation. The aim of this initiative is to  ensure that on graduation newly qualified doctors are fit for purpose for their role in the NHS and are competent and confident clinically.

 

 

4.    To what extent current proposals to service reconfiguration are driven by the need to respond to staffing challenges?

 

The Deanery has worked closely with all the Health Boards with regard to their service reconfiguration plans.  The Deanery’s own training reconfiguration plans started on the 1st March 2010 and pre-dated the service reconfiguration issues thatwe are now facing.  The rationale behind training reconfiguration has already been outlined with regard to fewer sites, sustainable rotas, protected teaching time and less reliance on the trainees for service provision. 

 

Clearly with the number of doctors in training they still do make a substantive contribution to service delivery.  The key for Wales is to get the balance right which is a difficulty throughout the UK.  Although the Deanery has highlighted the need to undertake training on fewer sites, we have never directed any of the Health Boards as to which sites we think training should take place as it is up to the service to decide the exact configuration of service provision for Wales. 

 

The Deanery’s involvement with the Health Boards and the current plans that we have seen (we have on-going dialogue with Betsi Cadwaladr University Health Board and Hywel Dda Health Board, have representation on the South Wales Programme Board and the National Clinical Forum) do suggest that there will be a great benefit to patient care and delivery of care with service reconfiguration.  The Deanery believes this will have a positive effect on training, recruitment and retention of doctors who we hope to retain within Wales as the workforce of the future, delivering the highest possible quality of care for our patients. 

 

While we realise the Health Boards are working to a certain timeframe, we do believe that training reconfiguration in some specialties is likely to occur ahead of the timescale being set for service reconfiguration.  This is particularly pertinent in Paediatrics, Emergency Medicine and Psychiatry, where there are currently insufficient training doctors to either comply with all rotas or indeed ensure they get the best possible training at the best possible sites across Wales. 

 

We are committed to working with the Health Boards, particularly when their service reconfiguration plans are predicated on the presence of trainees, to ensure that the trainees have access to the best possible teaching and training and that we deliver the best possible care for patients.

 

 

 

We are very grateful for the opportunity to present our plans and ideas around the training needs of doctors and dentists in Wales and the positive impact that these can have on the present and future service delivery to ensure the best possible standards of care for our patients.