MR 13

Ymchwiliad i recriwtio meddygol

Inquiry into medical recruitment

Ymateb gan: Ysgol Feddygaeth Prifysgol Caerdydd

Response from: Cardiff University School of Medicine

Inquiry into medical recruitment

Health, Social Care and Sport Committee

Prepared by Dr Stephen Riley

Dean of Medical Education

School of Medicine,

Cardiff University

08/11/16

1.0 In response to the proposed consultation by the Health, Social Care and Sport Committee inquiry into medical recruitment Cardiff University School of Medicine has prepared the following.

1.1 Undergraduate medical education in Cardiff has recently made a huge stride towards addressing recruitment and retention of doctors in Wales by the reform of its medical curriculum. The programme is 4 years into a 5-year implementation and so will not have data as to whether these outcomes have been achieved for another 18 months. The C21 Curriculum has refocused itself, emphasising patient and community centred education and the learning of relevant science within these contexts. The purpose behind this is to produce doctors who understand patients and the communities in which we all live and work. The aim is to attract, train and retain resilient, patient focused doctors who can work in interprofessional teams, and who are fully equipped to deal with the complexity and uncertainty of modern medical practice.

1.2 However, the changes we made, although they have been successful in terms of improving the student experience, are only the beginning. Cardiff still has some way to go before we can confidently say that the changes have been fully embedded and that there will be a continued impetus towards improvement and excellence. We therefore cannot relax.

2.0 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 There are problems with recruitment and retention of GPs in Wales. This is particularly noticeable in rural and deprived areas. GP training schemes are under filled or empty. Even if we could fill all the schemes, there is no point spending effort recruiting more people if the health service cannot retain the workforce it already has. Thus work is required to improve the workload of GP’s by ensuring that the multidisciplinary team is available and trained to provide care delivery. Practices are running at maximum capacity and we are starting to see them refuse to be involved in teaching students as this is seen as an added burden. This threatens the future of medical education in General Practice in Wales. The same is true in hospital placements as medical teams are delivering increasing intensity of care, particularly in the winter months, undergraduate medical education and postgraduate training loses priority in favour of service delivery. As such the following seem pertinent.

2.2 More time for teaching for NHS doctors.

This seems paradoxical in the face of service pressures but we will never build capacity unless we train our future doctors quickly and efficiently. To do that, we need more and better teaching from people who are willing and trained to do it and given time to teach / train.

2.3 Further investment in teaching facilities in communities across Wales.

The South Wales Teaching Hospitals are at, or over, capacity but there is little justification for concentrating all our students in a secondary care location. A recent publication from a Community Based Medical School in the USA documents the recruitment potential of a rural located medical school(1). Graduates from these schools are more likely to adopt a rural practice or stay in health professional shortage areas. Investment in Wales for this type of approach might make a huge difference both in the ability to increase the number of medical students in Wales and educate them within the areas of need resulting in improved recruitment to these areas. The exact number of increased students would need to be determined. This will require additional staff to teach the students.

2.4 Give greater priority to developing the skills and competencies of the current workforce to better meet the needs of patients now and in the future.

Given the issues described above, it is likely to be relatively more difficult to attract senior practitioners, of all groups of the multidisciplinary team, to areas where there are currently shortages, therefore we need to attract junior staff and create an environment, which encourages them to improve their clinical abilities and remain in Wales. A series of postgraduate CPD courses which are either entirely eLearning or, in most cases, blended learning but with distributed teaching, whereby the face-to-face elements are not only taught in Cardiff but are also taught in medical centres throughout Wales. The latter can be achieved by either staff travelling to the Welsh regions or by the use of external teachers who are trained (or assessed for their suitability to teach at the appropriate level) and who use teaching and training material already created.

2.5 Ensure a robust, widening access policy of admission to medical school.

Ongoing work to develop the admissions process for medical school is required. The use of the multiple mini interview (MMI) is being implemented this year in the School of Medicine to help us further improve the fairness and transparency of our admissions system. Continued work with Welsh Schools and children to raise aspiration is necessary to ensure that we are able to recruit from all areas of Wales. This requires support for academic achievement so that we ensure successful progress through the medicine course.

2.6 To continue the innovations in medical education the Centre for Medical Education at Cardiff University School of Medicine will continue to review its programme delivery, utilising senior and experienced medical educators. We will utilise critical friends to help us move to the next phase of development, both at undergraduate and postgraduate level, to align the offering with the needs of the NHS in Wales to allow it to meet its goal of excellent, evidence based, prudent and patient centred healthcare. We have an excellent track record of programme development and delivery that could assist in training the workforce of NHS Wales.

3.0 The implications of “Brexit” for the medical workforce.

3.1 There is no precedent for the current situation with the UK relationship with the rest of Europe. The significant uncertainty makes predicting the implications difficult. The current admissions cycle for the study of Medicine in the UK has recently closed its initial applications and this has shown that the number of applications from Europe to study in the UK is down by 16% (1720 applicants), which is the lowest figure for at least 4 years (data from UCAS – 2016). In addition the number of international applicants from outside the EU is also down by 6% (3040 applicants). In an editorial published in the British Medical Journal, Prof Chris McManus describes how the demand for doctors in the UK has outstripped supply since the 1950’s(2). This has resulted in recruitment from abroad, meaning that 20% of all doctors working outside their training country are in the UK (only the USA has more at 60%). Although this has left the exporting countries with shortages, and consequent deficiencies in health delivery, a rebalancing of this shift could result in fewer overseas doctors in the UK leading to further shortages in hard-pressed posts.

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

4.1 This is a challenging area and we would refer you to the earlier discussion regarding the location medical education takes place and its influence on recruitment. As such developing prolonged, pre-registration medical education embedded within communities in Wales that are underserved may have positive effects on local recruitment. This would require an excellent, supported student experience to maximise this opportunity, in addition to aligned postgraduate training environment and support for families of the trainees. Cleland articulates this when describing the value placed, by doctors in training, on their posts(3).

4.2 Changing the expressed attitudes and culture of the NHS towards some of the hard pressed specialties, e.g General Practice and Psychiatry is also imperative to ensure that undergraduates and trainees are not discouraged during their training4. The School of Medicine is actively promoting community clinical learning within the course and a number of student led societies related to rural health and primary care have developed.

5.0 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.

5.1 This is a matter predominantly for the NHS and the Postgraduate Deanery. There does need to be a focus on the recruitment of excellent medical students from all over Wales. A coordinated strategy to ensure the best students from Wales are given the opportunity to study in Wales is essential. The recent S4C programme, Doctoriaid Yfory, detailing the life of medicals students as they study in and around Wales will hopefully help to raise expectations of the Welsh school children to consider a career in Medicine.

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

6.1 This requires a coordinated approach with data sharing from postgraduate programmes to work out which students are going into postgraduate training and where. By analysing data in this way we can develop new strategies to inform the provision of medical education to meet the needs of the population and the practitioners around Wales.

1. Phillips JP, Wendling AL, Fahey C, Mavis B. The Impact of Community-Based Undergraduate Medical Education on the Regional Physician Workforce. Academic Medicine. 2016.

2. McManus C. Hunt promises 25% more medical students in 2018. BMJ. British Medical Journal Publishing Group; 2016 Oct 11;355:i5480–2.

3. Cleland J, Johnston P, Watson V, Krucien N, Skåtun D. What do UK doctors in training value in a post? A discrete choice experiment. Med Educ. 2016 Jan 26;50(2):189–202.

4. Baker M, Wessely S, Openshaw D. Not such friendly banter? GPs and psychiatrists against the systematic denigration of their specialties. Br J Gen Pract 2016