MR 08
Ymchwiliad i recriwtio meddygol
Inquiry into medical recruitment
Ymateb gan: Coleg Brenhinol Pediatreg ac Iechyd Plant
Response from: Royal College of Paediatrics and Child Health

Royal College of Paediatrics and Child Health

Submission to the Health, Social Care and Sport Committee’s Inquiry into Inquiry into medical recruitment, November 2016

1. Introduction

1.1 The Royal College of Paediatrics and Child Health (RCPCH) is pleased to contribute to the work of the Health, Social Care and Sport Committee and its aims to understand and explore the issues around medical recruitment in Wales.

1.2 The RCPCH works to transform child health through knowledge, innovation and expertise. We have over 550 members in Wales and over 17,000 worldwide. The RCPCH is responsible for training and examining paediatricians. We also advocate on behalf of our members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards.

1.3 For further information please contact Gethin Jones, External Affairs Manager for Wales: XXXXXXXXXXXXXXXXXX or XXXXXXXXXXXXX.

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

2.1 While children’s health has improved greatly in the UK over the last 30 years, the UK continues to lag behind much of Western Europe and performs poorly on several measures of child health and wellbeing, including mortality[1]. The RCPCH’s Why Children Die[2] report highlights a need to better manage sick children and recommends that measures are taken to improve recognition and management of serious illness across the healthcare service.

2.2 Infants, children and young people (ICYP) aged 0 to 18 make up around 20% of the UK population[3] and they are high users of healthcare services; accounting for around a quarter of a typical GP’s workload[4] and more than a quarter of emergency department attendances.

2.3 The vast majority of children’s illnesses are minor, requiring little or no medical intervention and a significant number of these emergency attendances may be deemed unnecessary or inappropriate. Unnecessary attendances are distressing and disruptive to children and families and also a wasteful high-cost intervention in a resource-limited health service, putting additional pressure on the hospital.

2.4 The RCPCH has also continued to express serious concerns about the sustainability of the paediatric workforce and services across the UK and the latest data show that gaps on paediatric rotas are increasing[5].

2.5 From the data we currently have from the RCPCH 2016 Rota Vacancies and Compliance Survey, we estimate that there is currently an 11.2% gap in the paediatric rota at tier 1, which is higher than England (10%) and Scotland (10%). There is also a 13.1% gap in tier 2 in Wales compared to 21.7% in England and 11.8% in Scotland. 42.9% of clinical directors said they were “very concerned” that the service would not be able to cope with demands placed on it during the next six months.

2.6 Responses to our most recent workforce census show that recruitment issues are the most often cited source of pressure on units. Pressures cited included difficulty in recruiting consultants, trainees, nurses and other allied health professionals.

2.7 The RCPCH’s Facing the Future: Standards for Acute General Paediatric Services[6] and Facing the Future: Together for Child Health[7] make the case for whole system change in paediatrics to meet the needs of ICYP. The model recommends fewer, larger inpatient units which provide consultant delivered care and are better equipped to provide safe and sustainable care. These units need to be supported by networked services and more care delivered closer to home through community children’s nursing teams and better paediatric provision in primary care.

2.8 Where children do need to be cared for in a hospital setting we need to ensure that all those delivering urgent care are following consistent guidelines and make sure that all emergency departments have the appropriate skill mix and workforce to deliver safe, effective and efficient care. The RCPCH is currently revising the Intercollegiate Standards for Children and Young People in Emergency Care Settings[8] (last published in 2012) which provide healthcare professionals, providers and service planners with measurable and auditable standards of care applicable to all urgent and emergency care settings.

3. The implications of Brexit for the medical workforce.

3.1 5.6% of paediatric consultants in the UK in 2013 were graduates from the European Economic Area (EEA); and 5.1% of paediatric trainees are EEA graduates compared to 3.6% of trainees across all medical specialities[9]. However, 18.7% of paediatric trainees are international graduates compared to 11.7% of all trainees; hence any restrictions on immigration from outside the EU would have a larger impact on paediatrics.

3.2 The freedom of movement of people has meant that the NHS in Wales has been able to recruit healthcare professionals from across the EU without visa restrictions. On a UK level, we believe that the Westminster Government must reassure EU staff of their value and make clear that EU citizens currently employed in the NHS will have the right to remain after Brexit, to stop their significant departure and to maintain services.

3.3 Before the referendum, leading Brexit campaigners suggested that the UK could introduce an Australian style points system which would enable highly skilled professionals such as paediatricians from around the world to work in the UK. However, as the details of this potential new system are being discussed, we will continue to need EU and other overseas staff in clinical and non-clinical posts at all levels to maintain services. We do not want the availability of medical staff from the EU to be restricted.

3.4 We welcome the announcement made by Jeremy Hunt in England earlier this year to introduce 1,500 new medical training places to make the NHS ‘self-sufficient’ by 2020. However, it is not clear what this means for Wales. We are not clear as to whether this action will be in partnership with the Welsh Government and that the NHS across the whole of the UK will be ‘self-sufficient’ . It should be noted that it takes at least seven years to train new students to enter practice so many will not be in place until 2023/24 at the earliest and 1,500 new places is unlikely to fill the current vacancy rates across the medical profession as a whole.

3.5 The RCPCH is concerned that recruitment figures will fall as the UK begins the process to leave the EU. Prospective trainees may be hesitant to join what is already a depleted and highly pressurised workforce and EU citizens residing in or planning to move to the UK will quite likely be putting career plans on hold until their future in this country is certain.

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

4.1 There are significant changes planned for the process of recruiting trainees. In the past, all Deaneries delivered their own interviews for trainees at levels ST1&2. In future, applicants will be able to apply regionally. This will give applicants greater choice of preferences where to go and more scope to receive offers without having to go through additional interviews or clearing. We hope this improves fill rates, as the applicant gets a better range of possible places having interviewed for only one. We also hope this delivers better value for money, requiring fewer interview centres for fewer days.

4.2 The Welsh Government has announced the creation of an arm’s length organisation, provisionally called Health Education Wales (HEW) to oversee strategic workforce planning, workforce design and education commissioning for NHS Wales. We hope that this will be accompanied by a clear strategic vision for the recruitment and retention of the medical workforce in Wales and a strategy to realise this.

4.3 We also hope that the Welsh Government will plan for the interim period between now and April 2018, when it is envisaged that HEW will become operational, given the possible disruption. We would welcome clarity as to how the Welsh Government will ensure that this transition does not negatively impact on recruitment.

4.4 We would also emphasise the need for HEW to plan for long term demand and implementation of the Facing the Future standards in the context of the realities for paediatric trainees, including less than full time working, maternity and paternity leave etc.

4.5 Key factors that we know have a significant influence on the recruitment and retention of doctors are rotas (gaps on wards discourage trainees) and how good training is. We asked a panel of RCPCH members representing each region in Wales whether they could identify factors relating to geography, rural or urban areas, or areas of deprivation. The feedback we received included the following statements from RCPCH members:

4.6 “Biggest contributors towards recruitment and retention: rota gaps at tier 2 level are the biggest factor lowering morale across the 4 nations as they are having a material effect on the amount of work for trainees and the amount of time they spend out of hours. They also contribute to a feeling of being mainly for service delivery rather than training. All steps that can help ease this should be considered.”

4.7 “Often the adverts say you will be based at one hospital but you may be expected to travel all over the Health Board if necessary (or words to that effect). As travel times in rural areas are not as simple as judging it on the mileage this again is a factor.”

4.8 “Emphasis on training – for all medical groups.”

4.9 “I personally believe that the factors that influence the recruitment and retention of doctors in general is that there simply isn't enough doctors when you consider that people leave medicine to pursue other careers, people leave the UK for a perceived better quality of life.”

4.10 “From a Wales point of view, for prospective training doctors like myself, it is a large deanery in terms of geography and I don't think that it is clear to those from outside that if you train in Wales you can opt for either South Wales or North Wales (and link with Mersey for tertiary care). That to me is a major point to sell as it means that even though it's a huge deanery, from a practical point of view you can set up home somewhere central to the North or South and know you can commute easily to any placement in that area.

4.11 “I think the major card in Wales hand at the moment is the fact that the junior doctor contract is not being implemented here and that the Welsh Government are in discussions with the doctors.”

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

5.1 RCPCH does not manage recruitment campaigns. Positions are advertised through the Oriel website centrally. RCPCH staff and members do, however, frequently attend careers fairs. These are primarily organised locally, sometimes by hospitals. We are not aware of a central strategy or campaign to organise this work, either in Wales or at a UK level.

5.2 We asked a number of our members, particularly trainees with recent experience of going through this process or consultants who have been involved in recruitment work, for their feedback. Their responses are below:

5.3 “We rely heavily on overseas doctors which ethically means we're taking doctors from parts of the world that need them, and practically with the current political situation in the UK means that we'll be less attractive to overseas doctors soon, especially when we leave the EU.”

5.4 “Medical recruitment campaigns… have not been fruitful in my experience. These have generally been undertaken by medical professionals themselves (not really their job to do this surely?) with some help from staffing departments and have often taken a good deal of time and energy… Clearly there may be better strategies for targeting these recruitment drives but in my view these should be a short term solution to manpower shortages... increased production of local trainees must be the better long term plan. We need to move away from the concept that some clever recruitment strategy will provide the answer.”

5.5 “I don't know how 'joined up' we are in terms of recruitment but it certainly feels like we are not very joined up at the moment with the obvious workforce inadequacies.”

[1] Wolfe et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reform. BMJ 2011; 342: d1277

[2] RCPCH, National Children’s Bureau and British Association for Child and Adolescent Public Health. Why Children Die: death in infants, children and young people in the UK. 2014 http://www.rcpch.ac.uk/sites/default/files/page/Death%20in%20infants,%20children%20and%20young%20people%20in%20the%20UK.pdf

[4] Hippisley-Cox J et al. Trends in consultation rates in general practice 1995 to 2006: analysis of QRESEARCH database 2007. Cited in Wolfe et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms? BMJ 2011.

[5] RCPCH. Rota Vacancies and Compliance Survey. 2016

[6] RCPCH. Facing the Future: Standards for Acute General Paediatric Services. 2015 www.rcpch.ac.uk/facingthefuture

[7] RCPCH,RCN, RCGP. Facing the Future: Together for Child Health. 2015 www.rcpch.ac.uk/togetherforchildhealth

[9] GMC State of Training 2015 http://www.gmc-uk.org/publications/somep2015.asp