MR 06

Ymchwiliad i recriwtio meddygol

Inquiry into medical recruitment

Ymateb gan: Deoniaeth Cymru

Response from: Wales Deanery

 

The Wales Deanery Response to the Health & Social Care Medical Recruitment Inquiry

 

Background

 

The Wales Deanery delivers the highest quality training and innovative postgraduate medical and dental education for Wales.  It provides nearly 3,000 training grade doctors and dentists across Wales with access to high quality postgraduate facilities and educational support so that they can achieve their career aspirations, whilst ensuring high quality care and patient safety in Wales.  The Wales Deanery provides a wide range of activities underpinned by the General Medical Council (GMC) approved quality management framework.

 

1. The capacity of the medical workforce to meet future population need in the context of changes to the delivery of services and the development of new models of care

1.1     It is acknowledged that the NHS is facing challenges in recruitment and retention of trainee doctors in certain specialities.  These shortages are not unique to Wales and reflect a complex and fluid system.  There are a significant number of vacancies in a range of specialties across NHS Wales including Core Medical Training, General Practice, Psychiatry, Acute Medicine, Higher Emergency Medicine and Higher Paediatrics.  These shortages produce gaps in rotas that can and do impact negatively on trainees and compromise the quality and sustainability of their experience and training.  As a consequence there has been a lowering of morale in this group.  In addition pressure to recruit to training posts has often led to a reduction of appointability thresholds leading to the appointment of trainees who require additional training time and input from trainers as they are unable to progress through the programmes at the expected rate.

 

1.2     In General Practice (GP) the demand for services has increased substantially in the past decade but the target intake to the GP training programme for Wales has remained at 136 for the past decade whilst in England, the target number has risen from 2,400 to 3,250.  Large increases in recruitment targets in percentage terms have also been applied in Scotland (target increased to 400 entrants per annum) and Northern Ireland.  It is true that all these countries are failing to appoint to full capacity.  Also, despite having the proportionately lower and static target intake, in Wales too, the fill rate for these posts has not been met in recent years.  However, to demonstrate positive ambition for GP training recruitment in Wales, we believe that the Inquiry should strongly consider the case for setting targets (relative to population) which begin to look at least close to those already set in the other three devolved nations.

 

1.3     Other innovative models of care are needed to ensure patients have a safe, sustainable and appropriate service.  Service models should be developed and rigorously tested without relying solely on trainee doctors to deliver service.  Each trainee is working to a Royal College defined curriculum approved by the GMC with specific learning objectives for each year of training.  When service pressures come into play trainees will prioritise the clinical need often at the expense of their training requirements.  In turn the quality of training metrics such as the Royal College exam pass rates for certain specialty in certain hospitals are therefore poor and these are available on the web sites of each Deanery.  This in turn leads to a situation whereby certain hospitals/units are perceived as unattractive by trainees.

 

1.4     There is an imperative to move to, wherever possible, non-doctor focused or reliant service models.  These need to be articulated within the new 10 year strategic workforce plan.  In General Practice there will be opportunities for skill mix change and new attractive models of care whereby skilled NHS workers (i.e. nurse specialists, pharmacists, physician’s assistants) undertake at least some of GP’s traditional roles.

 

1.5     There are two medical schools in Wales; Swansea University’s Graduate Entry Programme and Cardiff University’s mainly school leaver programme with a total output per year of 376 medical graduates.  In Wales the Foundation training intake is not aligned to this medical school output, 339 Foundation year 1 (F1) matched with 339 F2 posts are currently funded.  Wales has generally retained two thirds of its medical school output (above the UK average).  An option to consider, as has been recently announced in England, is to increase the intake into the medical schools, so even if the retention rate remained at two thirds the number of graduates staying in Wales would increase.  However, as a medical degree takes a minimum of five years to complete it will be at least five years before the impact of such extra places is felt and of course there is nothing to guarantee that a Welsh graduate will continue to train in Wales.  This would appear to be an expensive strategy at the point of investment but it would reap rewards in the longer term because it is important to recognise that the rota gaps caused by poor recruitment and retention are filled by locums that are expensive and, on occasions, of questionable quality.  There is a need to undertake a cost/benefit analysis to look to the changes that are needed to increase the number of welsh students entering welsh medical schools.  The actual direct cost of gaps in rotas will also need to be identified.

 

1.6     The Wales Deanery continues to look to develop innovative solutions to the recruitment challenges.  We are currently looking to develop a post-Certificate of Completion of Training (CCT) fellowship programme for newly qualified GPs to work in some areas where recruitment is a problem.  In order to support the rural agenda we have also advertised a two year Broad Based Training programme (which includes core medicine and general practice) with placements in Hywel Dda and Betsi Cadwaladr University Health Boards.

 

2. The implications of Brexit for the medical workforce

2.1     The implications of Brexit on European Union (EU) doctors is currently uncertain and will inevitably present Wales with some significant challenges.

 

2.2     There is general concern that it will become more difficult to recruit doctors trained abroad in the future.  We are aware that already there are large numbers of EU doctors at consultant, GP and Staff grade and Associate Specialist (SAS) grades working in NHS Wales who are due to retire and a number who are leaving the NHS to work in overseas.

 

2.3     The UK Government has pledged that the NHS in England will be self-sufficient in doctors after Britain leaves the EU having set out a series of measures aimed at reducing its reliance on foreign trained doctors.  However this initiative will not stop the NHS from needing to recruit overseas staff.  This rise in training places will cost £100m from 2018 to 2020, but in the long-term the Government hopes to recoup money by charging foreign students more than it does now.  Medical students will also be expected to work for the NHS for at least four years or face penalties.  The Wales Deanery does not however think that this is an achievable aim.  This will equate to 1,500 new medical students per year in England and is likely to have a detrimental effect on Wales in terms of the level of funding for foundation training in Wales.  The DH also plans to offset part of the cost of some £100m by requiring foreign medical students to pay for their own clinical placements and that will undoubtedly increase fees for medical schools for students from overseas.

 

2.4     It is hoped that the Home Office will relax immigration rules for doctors such that EU nationals would be able to work in the UK or at least allow EU nationals who are already here to be able to stay post-Brexit.

 

2.5     If we cannot recruit and retain EU doctors in Wales we will need to look to other parts of the world or train more Welsh domiciled students and encourage them to undertake their postgraduate training here in Wales with comprehensive incentive packages (financial and  non-financial) to continue to work in Wales for a defined period of time.

 

2.6     In regard to the wider medical workforce demographic the Wales Deanery has limited information on the proportion of EU doctors working in Wales but we do know that currently 3% of the training grade doctors in Wales initially qualified from Medical Schools in the EU and as such we are confident that the impact of Brexit in Wales in this group is likely to be small.

 

3. The factors that influence the recruitment and retention of doctors, including particular issues in certain specialties and geographic areas

3.1     There are a number of factors that influence the recruitment and retention of doctors across NHS Wales.  Fill rates for specialties vary across Wales and the reasons are varied; ranging from an increase in less than full time training, increased proportion of female medical students, increased pressures on rotas and workload, changes to the immigration regulations and increased numbers of Foundation trainees not choosing to apply for specialty training.  It is important to note that these challenges are not unique to Wales.

 

3.2     The educational experience and how trainee doctors are treated and valued has a major impact on career decision making for trainee doctors.  Evidence shows us that where trainees have had a positive postgraduate training experience this generally improves long term retention.  However, where their experience has been influenced negatively as a result of poor training or because of issues, trainees will use social media to communicate with their peers leading to a negative perception of Wales.

 

3.3     At the heart of the Wales Deanery’s recruitment and retention strategy is the provision of the best possible training environment and the evidence from the GMC National Training Survey shows that this year the overall satisfaction in Wales is the highest of all the four UK Countries despite proportionately fewer trainees.  The overall satisfaction score also reflects an on-going trend in the level of trainee satisfaction in Wales with an increase being reported for the fifth consecutive year (appendix 1).

 

3.4     Although the overall satisfaction rate is high the Wales Deanery Quality Unit continues to work with Health Boards and Trusts to address challenges that were reported in specific areas.  The 2016 results clearly highlight significant improvements in many of these areas.  Of particular note is the progress in Emergency Medicine training across Wales that, uniquely in the UK, has no major concerns but does have three examples of excellence for local teaching, regional teaching and access to educational resources.  The Wales Deanery has worked very hard despite severe recruitment challenges, to ensure the results for Core Medical Training programmes demonstrates a marked improvement in training satisfaction in many parts of Wales.  Our success is in part because of the comprehensive Quality Management Framework that we use to identify concerns and initiate early and proactive action planning in collaboration with local education providers.

 

3.5     In addition a number of education initiatives have been introduced to support trainees and enhance their training experience.  One example is the Boot Camp for Core surgical trainees providing trainees in Wales with comprehensive skills, clinical and non-clinical to ensure safe services for patients.

 

3.6     Geography is an important factor to trainees, who in general prefer to live and work near cities rather than in rural areas.  Another factor is the remoteness of a large proportion of the Welsh population and a generation of doctors who want to focus on living an urban lifestyle.  A potential solution could be to increase the number of trainees working within a 60 mile radius of those urban areas in Wales e.g. Wrexham with a view to them then drifting out into more rural areas.

 

3.7     Low levels of competition together with an increasing preference for city or large town life-styles, means that remote areas are less popular and more difficult to fill.  The situation is particularly difficult in the rural parts of Wales.  In General Practice, the popularity of the twelve schemes in Wales diminishes as the distance from a major urban centre increases.  We are currently operating within a buyer’s market and due to less applicants than posts trainees are able to select and preference where they wish to work and live.  We are also seeing a cohort of trainees who are prepared to resign from training programmes rather than be placed in a location not of their preference.

 

3.8     In order to meet training requirements as detailed in the GMC approved specialty training curricula, trainees, particularly at the higher level, are often required to rotate into tertiary or specialist centres to obtain specialist or sub-specialty experience and competences.  Such Tertiary level experience can often only be gained in specialist centres or teaching hospitals.  Across Wales this presents a challenge as trainees have been required to rotate from South Wales to North Wales and vice versa to obtain such experience.  This has impacted upon recruitment and retention to some specialties and the Wales Deanery has proactively worked with colleagues in other Deaneries in the UK to address some of these issues.  For example the Wales Deanery now places trainees in Arrowe Park Hospital to obtain Level 3 Neonatal experience and to Alderhey to obtain sub-specialty paediatric training.

 

3.9     There are risks attached to any such training programmes that rely on a rotation /consortium arrangement with England as Health Education England (HEE) strategy is to become self-sufficient and devolution has seen a wider gap emerge between the two countries in terms of readiness for collaboration.

 

3.10   There is a need to increase in Wales domiciled medical undergraduates and this could be achieved if Welsh Government ceased funding welsh medical students to study in England via taught programme tuition fees.  We also know that the number of Welsh students applying to study medicine has fallen by 15% in the last five years because of entry requirements, the quality of education in schools and narrowed aspirations in some communities.  It is clear that, in some schools, aspiring to attend medical school is not seen as achievable.  There is a need to reverse this trend.  There is some work underway with medical schools and local communities but this work would benefit from a Welsh Government policy position and further resources to ensure that access to medical school is open to all who have the ability irrespective of their background.

 

3.11   Consideration has been given to the introduction of both financial and non-financial incentives bonded to a formal agreement for the trainee to remain in a particular area for a specified period of time.  Any bonding would need to be handled sensitively and is only likely to be successful if this approach was taken across the UK whereby trainees were permitted to flow from Wales to other parts of the UK and vice versa.

 

3.12   The Wales Deanery supports all Wales medical workforce planning, considering and planning for risks in the medical workforce and looking for opportunities to mitigate risk.  We are involved in the current interim process for consideration of medical training numbers pending the establishment of a new single organisation as described by the HPEI Review and contributing to the NHS Wales plan to consider the numbers of medical staff required for a sustainable medical workforce for the future.

 

4. The development and delivery of medical recruitment campaigns, including the extent to which relevant stakeholders are involved and learning from previous campaigns and good practice elsewhere

4.1     The Wales Deanery has been heavily involved in the recent major medical recruitment marketing campaign led by Welsh Government with input and support from the Health Boards and NHS Shared Services.  This collaboration has enabled all stakeholders to share the high level of expertise, resources and knowledge in support of the campaign and to check that the correct information and appropriate language and terminology was used.  The Wales Deanery welcomes the opportunity to build on this in the future.

 

4.2     The current “Train, Work, Live” campaign focuses on the quality of the training (for trainee doctors - responsibility of the Wales Deanery); what it is like to work in Wales (for trainee and experienced doctors – responsibility of the NHS); and what it is like to live in Wales (for all - responsibility of WG).  This campaign should not be considered a one-off or simply in response to political pressure.  There is a need for a three to five year ongoing strategic marketing plan with the aim of increasing the positive profile of Wales as a destination of choice for students, trainees, qualified doctors and other healthcare professionals.  Any ongoing programme of marketing should use multiple strands and make use of a variety of marketing methods which appeal to the target market.

 

4.3     Recruitment is an all Wales process, but we need to be able to permit individuals to have the flexibility to choose their rotations and geographical locations.  Arguments purporting that rotations are an issue for recruitment and retention are falsely claimed.  There are a group of training programmes where trainees are still required to rotate between North and South Wales.  Within these programmes in the last twelve months 52 trainees (approximately 2% of Wales’s trainees) were required to rotate from either North to South or South to North Wales to obtain the required experience as mentioned previously in Section 2.9.  The Wales Deanery is currently exploring options regarding these specialties as part of the reconfiguration of training programmes.  This is a programme of work streams and activities that aim to reconfigure medical training delivered across Wales to ensure it is high quality, sustainable, attractive to potential applicants and appropriate for the future needs of the NHS in Wales.  There are a significant number of training programmes that do not require trainees to rotate from North to South Wales or out to England.  This is because the entire training curriculum can be delivered within a given region, e.g. Core level training programmes.

 

4.4     These medical workforce capacity issues are complicated and some are long standing.  Many of the issues are regularly cited in the media, thus reinforcing negative messages about the profession.  It is likely that recent media headlines about GP recruitment, the strain on the NHS and the junior doctors’ contract negotiations in England will work against the promotion of NHS Wales as a positive career choice for students and doctors from pursuing a medical career in the UK.  Good news stories have equal potential and power to create a positive and attractive proposition for doctors seeking employment here.

 

5. The extent to which recruitment processes/practice are joined up, deliver value for money and ensure a sustainable medical workforce.

5.1     It does not necessarily follow that having joined up recruitment processes/practice will ensure a sustainable medical workforce as there will always be some medical staff that are not recruited because they have not met the criteria or standards set.

 

5.2     There are those who argue that Wales should opt out of the national (UK) recruitment process.  The evidence is that despite anecdotes that reverting to local based recruitment would not solve or improve the recruitment position and that the strength of the national processes is that if trainees don’t meet an agreed standard they are not appointed.  These standards are there to ensure patient safety.  Current UK recruitment processes are streamlined and more cost effective than the models previously in place whereby organisations competed for the same applicant pool.

 

5.3     As part of the Wales Deanery’s strategy to improve recruitment and retention and deliver high quality training programmes we have developed the Educational Contract which is (EC) a unique selling point for Wales.  This is an agreement between the Trainee, the Local Education Provider (LEP) (Health Boards and Trusts in Wales) and the Wales Deanery. The EC is monitored via a real time online web application system, the EC Attendance System (ECAS) that trainees can use on their mobile devices.  This allows live data gathering of the trainees experience on a day to day basis and whether they are working in an environment that allows delivery of the relevant curriculum.  The ECAS system acts as early warning system allowing timely changes to be made leading to improvement in the trainees’ experience.  The EC has been described by the GMC as an exemplar and other parts of the UK are keen to adopt similar strategies.

 

5.4     Devolution is increasingly impacting on medical and dental training.  The previous collaborative relationships with individual Postgraduate Deans in England in particular have to some extent been eroded as a result of HEEs recent unilateral decision making.  There is a significant risk that the gaps widen leaving some training programmes at risk.

 

5.5     There are however potential opportunities and benefits for example with the recent and on-going issues in regard to the junior doctor contract in England.  Wales needs to be agile enough and have funding and educational process in place that allow us to be proactive and innovative in order to counter and manage competition with England.

 

Appendix 1

 

Table One: Overall Satisfaction Score by UK Country:

 

Overall Satisfaction

(Mean Score out of a maximum of 100)

Year

Wales

England

Scotland

Northern Ireland

2016

83.33

81.39

82.50

83.22

2015

82.58

81.68

81.60

82.64

2014

81.9

81.1

81.50

82.5

2013

81.5

80.6

81.30

81.4

2012

81.0

80.2

81.10

81.6

 

 

General Medical Council National Training Surveys - 2016: Key Messages for Wales.  Wales Deanery, Quality Unit (August 2016)