MR 20

Ymchwiliad i recriwtio meddygol

Inquiry into medical recruitment

Ymateb gan: Cymdeithas Feddygol Prydain (Cymru)

Response from: British Medical Association (Wales)

INQUIRY INTO MEDICAL RECRUITMENT

Inquiry by the National Assembly for Wales Health, Social Care and Sport Committee

Response from BMA Cymru Wales

18 November 2016

INTRODUCTION

BMA Cymru Wales is pleased to provide a response to the inquiry by the Health, Social Care and Sport Committee into medical recruitment.

The British Medical Association (BMA) is an independent professional association and trade union representing doctors and medical students from all branches of medicine all over the UK and supporting them to deliver the highest standards of patient care. We have a membership of over 160,000, which continues to grow every year. BMA Cymru Wales represents almost 8,000 members in Wales from every branch of the medical profession.

RESPONSE

We note that this short, focussed inquiry into medical recruitment forms part of the Health, Social Care and Sport Committee’s wider programme of work on the sustainability of the health and social care workforce. Committee members will be aware that BMA Cymru Wales has already submitted written evidence to this wider inquiry,[1] and our submission already focussed primarily on the medical workforce.

This submission should therefore be read in conjunction with that earlier response, which in many ways forms the basis of our response to this new inquiry.

In addressing this additional call for evidence, however, we have given consideration to the issues contained within the new inquiry’s terms of reference and wish to submit some additional points for the Committee’s consideration as follows:

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:

A key point we would wish to highlight is the need for the development of a strategic vision for the NHS in Wales around which effective and sustainable workforce planning can be undertaken. Indeed a key finding of the 2015 report of the Welsh Government-commissioned Health Professional Education Investment Review,[2] carried out by a review panel chaired by Mel Evans, identified the need for ‘a refreshed strategic vision for NHS Wales which provides the longer term context for shaping the workforce of the future’. We would reiterate the point we have made previously that we would welcome a concentration on how this current lack of a strategic vision for the service, and its impact on effective and sustainable workforce planning, might now be addressed.

As we also outlined in our submission to the wider inquiry into the sustainability of the health and social care workforce, the capacity of the medical workforce is failing in many regards to keep pace with increasing demand and is already therefore under strain in relation to current demand. This is particularly the case within primary care where there is an increasingly acute recruitment and retention challenge amongst GPs against a backdrop where demand is continually increasing as a result of an ageing population and an increasing prevalence of chronic disease.

There are also increasing recruitment and retention challenges amongst certain specialties within secondary care which have been the driver for various service reconfiguration proposals in recent years across different health board areas. Increasing use of locum doctors, and increasing overtime costs being reported by health boards amongst medical staff, are also signs that the current workforce provision is under severe strain.

As we referred to in our earlier response, Welsh vacancy rates have not been published officially since 2011. Data acquired through the use of Freedom of Information (FOI) requests by the BBC,[3] however, showed a vacancy rate of 7.8% for doctors in Welsh health boards in December 2015, having risen sharply over the preceding year, and with significant variation across health boards.

Through our own use of FOI requests, we have additionally collected data on locum consultant usage. These revealed that such usage equates to 7.5% of whole time equivalent (WTE) consultant posts. While there are issues around when and for how long locum use is the most cost-effective solution, this does suggest the true vacancy rate will be higher than the headline figures. The Welsh Government-commissioned NHS Wales Workforce Review[4] also confirmed this increase in locum use, with an increase in agency and locum spend (not just at consultant grade) of 62% in 2014-15 to a figure of £88 million. Moreover, there appears to have been a fall in the number of doctors per head in Wales to 2.8 per thousand population from 3.1 last year.

Within the last year, the BBC has also uncovered a 61% increased cost of overtime payments for consultants in Welsh hospitals over three years,[5] which reflects existing staff having to undertake additional work to cover for vacancies and rota gaps.

Taken in the round, these indicators suggest that the workforce is struggling in many regards to provide for current health and care needs, and these challenges will no doubt become greater in the medium- to long-term as demand for service provision increases.

As we have already noted, an ageing population and an increasing prevalence of chronic disease are contributing to this increase in demand. Other factors that can also fuel increased demand include improvements in technology and the development of new treatments.

Other challenges can result from changes in the make-up of the workforce. For instance, the proportion of medical staff who are female has rightly been increasing. Whilst we would certainly view this as something to be celebrated, it does need to be recognised that female doctors are, quite reasonably, more likely to choose to take career breaks or work less than full time for family reasons. In addition we have previously suggested that work should be commissioned to explore the multifactorial complexities behind why 40% of female GPs in the UK have left the profession by the age of 40. These factors mean that a greater number of doctors needs to be trained and/or recruited to maintain workforce provision.

The current age profile is also a cause for concern in regard to certain sections of the medical workforce where an increasing proportion are nearing retirement age. For instance, in 2014, 23.4% of Welsh GPs were aged 55 and over. Another example from secondary care can be found within the specialty of radiology. Figures recently published by the Royal College of Radiologists[6] suggest that around 30% of Welsh consultant radiologists will retire between 2015 and 2020, compared to a UK average of 20%. By the same token, 12% of current Welsh consultant radiologists are aged 60 or over, compared to an average of 8% across the UK as a whole.

BMA Cymru Wales believes there is a clear and immediate need to invest more into general practice in Wales. As we previously touched upon in our written evidence to the NHS Wales Workforce Review (which was attached as Appendix 1 to the evidence we submitted to the committee’s wider inquiry into the sustainability of the health and social care workforce), the share of NHS Wales expenditure that is allocated to services within Welsh general practice commissioned through the General Medical Services (GMS) contract has dropped from 10.3% in 2007. The latest figures supplied to us by the Welsh Government shows that it now only constitutes 7.6% of expenditure on the NHS in Wales. This is despite the fact that the number of consultations within general practice has increased by around 20% over the same time period.

This failure to increase the funding going into Welsh general practice to match increasing demand is contributing to a substantial increase in workload for GPs in Wales. This is undoubtedly contributing to more Welsh GPs suffering from burnout and leaving the profession early, thereby placing further strain on the GP workforce. This, in turn, is impacting negatively on the attractiveness of general practice as a career choice for new trainees. The funding shortfall for general practice needs to be addressed as a matter of priority, in our view, if we are to stand a chance of breaking out of this cycle.

The implications of Brexit for the medical workforce:

The outcome of the referendum on the UK’s membership of the EU has created great uncertainty for EU nationals currently living and working in the UK regarding their future status. Reassurance and clarity is vital, particularly in key public services such as the NHS, to aid workforce planning to and ensure safe staffing levels are maintained. While we acknowledge that the exact terms of the process by which the UK will depart the EU are unclear and may remain so for some time, it is vital that these individuals are offered the clarity and reassurance they deserve regarding their future status.

The UK’s decision to leave the EU may also result in a domestic economic downturn, or in the very least, economic uncertainty. This in turn, is likely to reduce public spending in general and, specifically, the level of funding which is available to the NHS in Wales. This could clearly have an impact on staffing levels.

A significant number of EU nationals work in health and social care organisations across the UK, including here in Wales. The EU’s policy of freedom of movement and mutual recognition of professional qualifications facilitates this, helping NHS organisations ensure gaps in the medical workforce are filled quickly by qualified workers with the appropriate level of training and education.

In 2014, more than 10,000 doctors working in the NHS across the UK (6.6% of the UK medical workforce) received their primary medical qualification in another European Economic Area (EEA) country with additional staff working in public health and academic medicine – these individuals are vital to our NHS and the health and success of the country.

The ongoing political uncertainty surrounding the future of EU nationals living and working in the UK will inevitably lead to some of these doctors choosing to leave. While we welcome comments from the UK Secretary of State for Health that the UK Government wants these doctors ‘to be able to stay post-Brexit’, governments must offer these highly skilled professionals the confirmation and reassurance they need regarding their rights to live and work in the UK. Specifically, we believe these highly skilled professionals should be granted permanent residence in the UK, although we appreciating that this is a matter for the UK Government. This would, however, provide stability both to these individuals and to NHS workforce numbers.

The UK’s decision to leave the EU will have wide ranging consequences for current EU students studying at UK medical schools and their family members. These include funding arrangements, transferability and recognition of medical degrees, and postgraduate medical training.

Following the UK’s departure from the EU, we believe it is essential that the immigration system remains flexible enough to recruit doctors from overseas, especially where the resident workforce is unable to produce enough suitable applicants to fill vacant roles.

In relation to science and medical research, BMA Cymru Wales is deeply concerned about the impact of the UK’s decision to leave the EU. Safeguards must be put in place to maintain access to research funding, the right regulatory environment, and the mobility of research staff.

There may be wide ranging ramifications for the regulation and education of health professionals, including language testing, clinical skills and knowledge testing, and the transferability and recognition of qualifications for doctors. This will need to be urgently addressed.

BMA Cymru Wales is satisfied with the European Working Time Directive (EWTD) and the measures it has introduced, including a reduction in the maximum hours worked to an average of 48 per week, as transposed into the UK Working Time Regulations. We urge governments not to repeal these Regulations for new workers.

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

Our views on these issues were largely outlined in our earlier submission to the wider inquiry on the sustainability of the health and social care workforce, including on issues impacting on recruitment and retention in certain geographic areas. We would therefore refer the Committee to the points that we previously made.

One additional factor that may also now need to be considered, however, is the impact of the new junior contract being imposed in England. BMA Cymru Wales very much welcomes the reassurances we’ve received from the Welsh Government that it won’t impose a new contract here and wants to proceed by dialogue and agreement. We feel this presents a great opportunity to promote Wales to junior doctors as a more welcoming place to train and work.

In the case of a few specialties, however, the differences which will now start to exist in the way pay is structured between Wales and England may pose a barrier to recruitment on this side of the border. This largely impacts on posts which are ‘unbanded’, which means they do not attract a banding supplement on top of the basic rate of pay. Banding supplements are paid to remunerate junior doctors in posts where they ordinarily are required to work more than 40 hours of week and/or are frequently required to work antisocial hours.

With England moving to a pay structure which offers all trainees a higher level of basic pay, this will mean the pay offered for such unbanded posts in Wales may no longer be seen as competitive because holders of these posts only receive basic pay. The Welsh Government may have to give thought to how this pay disparity can be addressed for these specific posts, including for a specialty such as histopathology where posts are unbanded throughout the entire length of the time a junior doctor undertakes specialty training. This might, for instance, be achieved through the use of a market supplement for such specialties, similar to the supplement which is currently paid to GP registrars so that trainees working in GP practices maintain pay parity with their hospital counterparts. In raising this point, however, we would wish to make it clear that this should not be interpreted as us advocating the overall adoption of a pay structure similar to that introduced by the new English contract.

As we outlined in our earlier submission on the wider topic of the sustainability of the health and social care workforce, factors which can influence where junior doctors choose to locate to undertake their training include: high quality training; access to funded study leave; evidence of exam success; research opportunities; access to a good social life and quality of living; availability of good career opportunities for their spouses or partners; and access to good schools for their children.

In England, we are aware that provision has now been established for junior doctors who are partners or spouses to be able to submit linked applications. This can assist them to secure training posts within the same geographic area. We would support such an initiative also being introduced in Wales.

One factor that could be worth building upon going forward is the fact that Wales scored highest amongst the four UK nations for trainee satisfaction in the GMC’s most recent national training survey.[7] We need to ensure Wales develops and build upon a good reputation for medical training. It is important that education and training are viewed as core values of the NHS in Wales alongside high quality patient care.

With regards to staff retention, which in many ways may be more of a concern than recruiting new staff, we would reiterate the points we made in our earlier response. There is a need to address the factors which are driving doctors to reduce their working hours, leave the profession or retire. These include: workload pressures; working conditions; the extent to which doctors feel valued and empowered to influence decisions or be listened to and able to raise concerns without fear of recrimination; the bureaucracy around processes such as revalidation; pension changes, including the impact on pensions of those doctors continuing to work beyond a certain stage in their careers; and worsening sustainability challenges for many GP practices.

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.

Taking these two topics together, we would again refer the Committee to our earlier submission on the wider topic of the sustainability of the health and social care workforce where we made a number of points in relation to both recruitment and retention and the factors which will impact on our ability to attract and retain doctors at different stages in their careers.

[2] Evans M, Phillips CJ, Roberts RN & Salter D (2015) Health Professional Education Investment Review. Available at: http://gov.wales/topics/health/publications/health/reports/education-investment-review/?lang=en

[3] BBC (2016) NHS doctor vacancies are 7.8% in Wales. Available at: http://www.bbc.co.uk/news/uk-wales-35686903