MR 14

Ymchwiliad i recriwtio meddygol

Inquiry into medical recruitment

Ymateb gan: Coleg Brenhinol y Meddygon

Response from: Royal College of Physicians

Inquiry into medical recruitment

RCP Wales response

We need to show vision and national leadership

· Develop an ambitious long-term vision for the NHS in Wales.

· Increase investment in new models of integrated health and social care.

· Develop a national medical workforce and training strategy.

· Show national leadership on the balance between service and training.

· Work with physicians to redesign acute and specialist medical services.

· Ensure that hospitals work within formal, structured alliances to deliver integrated care.

· Establish the role of chief of medicine, supported by a chief registrar.

· Publicly support and promote the patient-centred Future Hospital model of care.

· Increase health spending and invest in clinically led innovation and prevention.

We need to invest in the medical workforce

· Take a strategic approach to workforce planning.

· Ensure that the acute admissions workload is more evenly distributed between all specialties.

· Train a greater proportion of doctors in the skills of general medicine.

· Support physicians working in non-training jobs to develop their careers.

· Invest in data collection to provide a robust evidence base for medical recruitment planning.

· Make staff health and wellbeing a national priority.

We need to support the clinical leaders of the future

· Promote Wales as an excellent place to live and work as a doctor.

· Focus on addressing recruitment and training challenges.

· Increase the number of undergraduate and postgraduate training posts in Wales.

· Develop training pathways specialising in rural and remote healthcare in Wales.

· Increase the number of medical school places offered to Welsh domiciled students.

· Improve the support available to junior doctors in rural areas.

· Invest in clinical leadership and training programmes.

· Appoint chief registrars in every health board to give trainees a voice.

We need to develop a new way of working

· Encourage health boards to implement the RCP Future Hospital workforce model.

· Deliver more specialist medical care in the community.

· Invest in new innovative ways of working across the entire health and social care sector.

· Lead the way by developing new integrated workforce models in rural communities.

· Develop the role of community physician.

· Address nurse shortages and develop other clinical roles in the NHS workforce.

· Further embed telemedicine into everyday practice.

Inquiry into medical recruitment

1. Thank you for the opportunity to respond to the Health, Social Care and Sport Committee inquiry into medical recruitment. Following the recent launch of a new RCP Wales report on the medical workforce, Physicians on the front line (published on 17 November 2016) we would be extremely keen to give oral evidence on this inquiry to the Health, Social Care and Sport Committee. We would be very happy to organise evidence from consultants, trainee doctors or members of our patient carer network.

2. The Royal College of Physicians (RCP) aims to improve patient care and reduce illness, in the UK and across the globe. We are patient centred and clinically led. Our 33,000 members worldwide, including 1,200 in Wales, work in hospitals and the community across 30 different medical specialties, diagnosing and treating millions of patients with a huge range of medical conditions.

The capacity of the medical workforce to meet future population needs

3. The NHS in Wales is facing a number of urgent challenges. Hospitals are struggling to cope with the combination of an ageing population and increasing hospital admissions. All too often, our most vulnerable patients – including those who are old, who are frail or who have dementia – are failed by a system that is ill equipped and seemingly unwilling to meet their needs. Furthermore, levels of ill health increase with levels of area deprivation. In general, those in the most deprived areas report the worst health. The rural geography of much of Wales means that some medical services are spread very thinly. This is having a negative effect on the quality of training and on workforce recruitment in some specialties. In addition, patient expectations are increasing as financial constraints grow tighter and, while advances in technology can save lives, the cost of providing specialist acute care continues to rise.

4. Legislative changes to working hours mean that we need more junior doctors to cover hospital rotas. This has happened at the same time as a reduction in training time due to the modernising medical careers programme, and a fall in international medical graduates coming to the UK. In 2011, almost half of the higher specialty trainee physicians told us that since the introduction of the European Working Time Directive, the quality of both training and patient care was worse or much worse.

5. As the population grows older, and an increasing number of people develop complex chronic conditions, there is an increased need for consultants with qualifications in general internal medicine so that patients can be managed holistically. However, in Wales, only 43.7% of consultant physicians contribute to the acute rota while 52% participate in the general medical rota. There is also a great deal of variation between RCP specialties. For example, almost all consultants working in stroke, respiratory or acute internal medicine in Wales participate in the acute take. However, the figures for renal medicine (36.4%) and cardiology (36.8%) are much lower, and in some specialties, there are no consultants at all who participate in the acute take in Wales. In the future, the acute admissions workload will need to be more evenly distributed between all specialties in order to allow more flexibility and prevent the unmanageable workload of acute medicine falling on the few.

6. At the same time, the composition of the workforce is also changing. More consultants are working flexibly or part time. To some extent, this is because there are now more women in the medical workforce – between 2007 and 2012, the number of female doctors under 30 years old increased by 18%, and in 2012, 61% of doctors under 30 years old were women. The 2015 census of consultant physicians found that 33.3% of female consultants in Wales work part time, compared with 8.8% of male consultants. This trend in changing working patterns raises issues about the total number of doctors that will be required in the future if the proportion of those working part time continues to grow. If a consultant works part time, their relative contribution to the acute medical take can vary hugely. We will need to see an increase in training posts to allow for an increase in less-than-full-time working in the future.

7. Trainee rota gaps are reported by 42.9% of respondents in the 2015-16 RCP census of consultants in Wales as ‘frequently causing significant problems in patient safety’ and by a further 45.8% as ‘often [causing problems] but there is usually a work-around solution so patient safety is not usually compromised’. Only 11.3% of respondents told us that rota gaps infrequently or never cause a problem. More than a third of higher specialty trainees told us that they regularly or occasionally act down to cover gaps in the core medical trainee rota. Almost two-thirds of these specialty trainees told us that they feel as though they are sometimes, often or always working under excessive pressure, with 63.2% telling us that this was down to insufficient trainee numbers.

The implications of Brexit for the medical workforce

8. The RCP is keen to engage with both the UK and Welsh governments on the implications of Brexit, especially its effect on the medical workforce. Above all, patients must be the first priority. The UK government must guarantee that EU nationals working in the NHS will be able to stay in the UK and continue to deliver excellent care for patients. Non-UK doctors must not be restricted from working in the NHS. Both governments should engage with health and social care employers, royal colleges, professional bodies and trade unions, as Brexit negotiations continue.

9. Furthermore, the UK’s withdrawal from the EU must not affect patients’ ability to participate in high quality research and clinical trials. Patients must continue to have access to innovative new technologies, and the UK must continue to be a world leader in medical research through the ability to access Framework 9 (FP9) funding as well as regional development funds and bursaries. The UK should also retain the ability to influence EU legislation that affects medical research. Finally, those EU frameworks that underpin the protection of public health must be protected. If replaced, these should be strengthened and enshrined in UK or Welsh legislation.

The factors that influence the recruitment and retention of doctors, including any particular issues icontinue.

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

10. It is worth noting that there are difficulties recruiting for many specialties in most parts of the UK, not just in Wales, and 72.7% of higher specialty trainees would still choose to train in Wales if they could turn back time. However, there are trainee vacancies in every acute hospital rota in Wales, and last year, the NHS in Wales was unable to fill 39.8% of the consultant physician posts it advertised. In a majority of cases, health boards were unable to appoint because there were simply no applicants.

What can we do to recruit doctors in the short-term?

• NHS Wales should adopt a more joined-up, nationally coordinated approach to recruitment.

• Health boards should invest in physician associate roles which can free up trainee time for education.

• Health boards should reinvest unspent trainee money in new roles, eg clinical fellowships.

• Community placements for medical students and trainees should be further developed.

• Graduate entry into medical school should be encouraged, especially for Welsh domiciled students.

• Both undergraduate and postgraduate medical training should focus on long-term conditions.

• Accreditation and structured support for teaching hospitals should be considered.

• Using technology in a more innovative way, especially in rural areas, should be encouraged.

• Rural medicine, especially in mid-Wales, should be developed as an advanced medical specialty.

• Structured CESR conversion courses with structured mentoring and support for SAS doctors.

The development and delivery of medical recruitment campaigns

11. Wales currently struggles to recruit enough trainees to fill hospital rotas; 33% of core medical trainee places were unfilled in 2016. The 2015–16 census found that 16.7% of higher specialty trainees have considered leaving the medical profession entirely in the past year, and only 31.7% think that they are finding an appropriate balance between training in general medicine and in their main specialty. Even worse, 11.6% of higher specialty trainees told us that they rarely enjoy their job, and 62.8% said their job sometimes, often or always gets them down.

What could we offer junior doctors in Wales?

• Structured mentoring and support programmes

• More clinical leadership and quality improvement opportunities

• More innovation and academic research opportunities

• Taught MSc and MD degree opportunities

• More flexible working patterns and training pathways

• One-off grants to ease the financial burden of professional exams

12. This problem must be tackled head on; the Welsh government and NHS Wales must take action to promote Wales as an excellent place to live and work as a doctor. However, we are concerned that medical recruitment campaigns are not involving all relevant stakeholders or learning from good practice elsewhere. We are worried that the Welsh government has previously taken a narrow approach to the problems in medical recruitment by focusing on one area of the medical workforce without considering how we might build resilience in other areas at the same time. We would welcome more innovative thinking about how we develop the future NHS workforce, especially how we might support our GP colleagues – by developing specialist physician roles in the community, for example. We have a real opportunity in Wales to drive this agenda and show real vision, but it will need an open and inclusive conversation with a wide range of stakeholders, including all the royal colleges.

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

13. It is important that future investment into the health service does not go towards propping up the old, broken system. Spending money on the existing system will not change anything in the long term; health boards must invest in the prevention and treatment of chronic conditions and allow clinicians to innovate. Those living in rural and remote areas must not be forgotten either; it is these areas where the crisis in primary care is hitting hardest, and where a new ambitious model of care has the most potential.

14. A clear, refreshed strategic vision for NHS Wales should be developed, based on rigorous data collection that provides a robust evidence base. This must put clinicians at the very centre of change and should be developed bottom-up through patient and professional groups. Successive reviews in the past few years have repeated this call to action (including the health professional education investment review and the Jenkins review of the NHS workforce) yet it is still not clear how the Welsh government intends to work with patients and clinicians to do this.

15. We need to move away from a workforce model in which we invest in either primary or secondary care, and towards more integrated team working – the hospital without walls – where specialists hold more of their clinics in the community, and GPs spend part of their time working with colleagues at the front door of the hospital.

16. The Welsh government must now lead the development of a long-term plan for the future of the Welsh health service. Ministers must show national leadership to create stability and support the long-term transformation of the health service. This will require better communication and real investment, especially in clinical delivery plans. All spending decisions should be underpinned by a long-term objective to increase investment in new models of integrated health and social care. Above all, we need a clear vision of how the service will look in the future in order to plan effective medical training.

17. All of this will need a drastic change in mindset. The RCP has long called for more clinical leadership and engagement, and more joined-up thinking between service planning and training needs. Now it is time to rethink how the future NHS workforce will train, develop their skills and practise medicine – and health professionals, including doctors, must be involved and genuinely engaged from the very start.

More information

18. We would like to submit the recent RCP Wales report, Physicians on the front line, as an appendix to this consultation response. All the statistics in this evidence are referenced in this report. It provides a great deal more detail about our research, the 2015-16 RCP census results and the case studies we have gathered about the future of the NHS workforce in Wales.

19. More information about our policy and research work in Wales can be found on our website. We would be delighted to provide oral evidence to the Committee or further written evidence if that would be helpful. For more information, please contact Lowri Jackson, RCP senior policy and public affairs adviser for Wales, at XXXXXXXXXXXXXXXXXXXXXX.