Response to Welsh Government Consultation on Medical recruitment
Swansea University
Respondents: Suzanne Edwards, Andrew Grant, Marguerite Hill, Paul K. Jones, Keith Lloyd,
Heidi Phillips & John Rees.
Collated by: Andrew Grant
Prepared for: Health Social Care and Sport Committee, Welsh Government
Date: January 9, 2017
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.
1. In some areas of Wales where the medical workforce is aging the medical workforce will not be able to meet current population needs. One quarter of the GP workforce is expected to retire in the next ten years particularly within the Hywel Dda area. There are many other shortage specialties in Wales and recruitment to a range of specialties is problematic outside the major urban centres.
2. In South West Wales ARCH, a Regional Collaboration for Health offers significant opportunities for a novel and multidisciplinary approach to workforce planning, recruitment and retention, from attracting Welsh school leavers schools, through to undergraduate degrees, graduate entry medicine, and postgraduate recruitment and retention. This approach could form the basis for new ways of working to promote recruitment and retention.
3. The reduced capacity of the workforce is being addressed, in part, by the training and employment of professionals who are not medically qualified. These include advanced nurse practitioners and physician associates. Other schemes in Wales involve the use of pharmacists and optometrists to enhance the capacity of the medical workforce
4. At Swansea University we will also introduce a primary care track within the graduate entry medical programme. Students on this track within the four-year medical programme will focus on general practice and primary care even more than the rest of the cohort.
5. As well as providing primary care focused training the primary care track will offer students a better insight into the complexities, challenges and rewards of a career in general practice. A GP who is facilitating a case-based learning group will be able to support students’ learning from their own knowledge and clinical experience and from the general practice perspective.
6. Undergraduate medical teaching offers variety in working patterns and stimulation from student contact. For this reason, recruitment of GPs to practices involved in the primary care track will be enhanced.
7. To increase the number of medical students entering medical careers in Wales, we will contextualize the admissions process to maximize admission of students who are Welsh domiciled.
8. The learning environment for all medical students, not just those who express an interest in a career as a GP on admission needs to be more orientated towards primary care.
9. 30 training places for general practice have remained unfilled in the past year, with Vocational training schemes in mid and west Wales having no applicants. If vacancies for retiring GPs are unfilled, there is extra pressure on remaining younger GPs who, in turn, are increasingly likely to move to part time work or to leave the profession.
10. While these places remain unfilled we will ask the GP trainers and programme directors to use their knowledge and expertise to teach and enthuse medical students. However, it is expected, in time, that their time and energy will be, once more, required to provide training for GP registrars (i.e. the next generation of GPs for all parts of Wales).
11. In order to recruit to more doctors to remain in Wales post qualification, We recommend:
a. A significant expansion of graduate entry medicine at Swansea University as graduates from our four year course are significantly more likely to remain in Wales for their F1 and F2 posts than students from undergraduate courses. They are also significantly more likely to remain in the UK for their specialist training and to go into general practice according to the UK foundation survey. Swansea’s medical school has on average 1000 applicants of whom around 300 are interviewed for 70 places.
b. Contextual admission or ring-fenced places for Wales-domiciled students studying medicine or allied medical professions
c. Repayment of Welsh domiciled students’ loans, over a period of years post qualification, to encourage doctors to stay/return to work in Wales
d. That Local Health Boards sponsor medical school places for applicants from their areas
e. Every foundation doctor in Wales could spend at least 4 months in a general practice – or other specialty where recruitment is problematic.
f. Development of a “Primary and Urgent Care Academy” at Swansea University with specific GP focussed training, recruiting into it students who express the desire to pursue a career in General Practice via the primary care track (notwithstanding the award of a full PMQ)
12. The possibility of more professionals being able to offer healthcare through the medium of Welsh should be explored with reference to the Welsh Government document “More than just words”.
The implications of Brexit for the medical workforce.
13. Across the UK, EU immigrants make up approximately 10% of registered doctors and 5% of registered nurses – according to GMC, 6% of GPs are from the EEA. Immigrants from outside the EU make up larger proportions (approximately 25% of the medical workforce is trained outside the UK), but as restrictions on non-EU immigrants have affected NHS recruitment, this suggests that the same could happen if there were limits on EU immigration.
14. Withdrawal from the EU may inhibit British graduates from emigrating to EU countries. Similarly, EU-born staff may leave the UK pre-emptively due to the uncertainty created when migration restriction becomes possible. Less favourable exchange rates may also make UK (including Wales) a less attractive destination for healthcare workers to live and work.
15. Depending on how any new immigration policy is developed and implemented, there could be opportunities for attracting talented medics from other countries (Asia, Africa and the Americas, as well as the EU and EEA countries) to rural Wales.
16. There is uncertainty about whether the Barnett formula will continue to be used, changed or abandoned in post-Brexit deals. If the Barnett formula is maintained, then Wales is more likely to be worse off unless government uses the entire value of EU contributions for devolved purposes.
17. If working time legislation is repealed it may lead to an increase in doctors’ working hours resulting in a disincentive for recruitment.
18. Potential for reduced investment in infrastructure (following from withdrawal of EU structural funds), which could reduce the appeal of parts of rural Wales.
19. There is a risk that lower economic growth post-Brexit will have implications for public spending that will have a significant impact on NHS funding
The factors that influence the recruitment and retention of doctors, including any particular issues in certain specialties or geographic areas.
20. Increased and unsustainable demand – fuelled by past incentives to offer appointments within 24hrs has raised public expectation.
21. The transfer of work from secondary to primary care with no re-allocation of resources
22. The partnership model – requiring GPs to “buy in “ to premises, often having to borrow money at well above market mortgage rates – this on a background of incurred student debt due to university fees and loans and at the time when a new GP principal has to buy their home and support a young family.
23. While working in rural Wales may be attractive for individuals – the work situation needs to take into consideration the accessibility and availability of work for their partners and dependents.
24. Trainees are more likely to remain in Wales after completing their training scheme if that scheme is based in Wales. Some schemes are UK-wide. While admission to these schemes is very competitive, trainees are very likely to return to their native part of the UK on completion.
25. While it is important for there to be a presence of trainees in Wales financial incentives could also be offered to doctors who have done some or all of their training in other parts of the UK but who wish return to Wales to practice as consultants and GPs.
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.
26. The presence of more doctors in training does not necessarily translate into more doctors in the NHS - significant numbers leave the UK for other countries such as Australia. As proposed by NHS England, could it be helpful to require a commitment to practise in their country of study post-graduation for a fixed number of years? There is increasing evidence that graduates from the Swansea graduate entry programme are more likely to remain in Wales than those from undergraduate courses. The ethos of the course and its use of placements in South and West Wales will help recruit and retain doctors there. An increase in activities focusing on retention is planned.
The extent to which recruitment processes/practices are joined-up, deliver value for money and ensure a sustainable medical workforce.
27. Stronger links are needed between medical school places, foundation numbers and work force planning As mentioned above ARCH, a regional collaboration for health, offers a model for joined up service and workforce planning between the NHS and university partners who provide that training.
28. Partnerships between Welsh medical schools and Welsh secondary schools, particularly those in areas where recruitment of doctors is difficult but where few local school leavers apply for medicine need to be created and strengthened. Welsh students leaving university with a good first degree should be encouraged to consider the option of graduate entry medicine. This will require partnership between medical schools and other Welsh universities.