The workforce challenges facing the NHS are now the greatest current threat to the provision of quality health care in the UK. While the number of consultant posts in NHS Scotland has increased by about 15 percent in the past 5 years, these posts remain unfilled due to a shortage of doctors.
A recent report by the Scottish Academy of Medical Royal Colleges showed that in 2018, 38% of advisory appointments panels for vacant consultant posts were cancelled. The vast majority of these – 88% – were cancelled because there was no suitable applicant. In addition, figures from NHS Scotland’s Information Services Division (ISD) show that of the 428.6 whole time equivalent vacancies for medical consultants in June 2018, 62% were vacant for over six months.
That’s why our College has worked with the Scottish Academy to produce a plan for addressing this growing crisis. Our recommendations, which are detailed below, are an attempt to explain and address the multiple factors that are combining to create the current unsustainable situation where growing workforce shortages are in turn creating unbearable workload pressures on health care professionals in the NHS.
Our report evaluates the current situation, what processes and policies are already in place, and what changes are required to effectively join up the various career stages in the working life of health professionals. We conclude that we need to ensure that the transitions between University and the foundation stage, foundation and core training/specialty training and between trainee and career grades are managed effectively and efficiently. We also make some suggestions and recommendations which we believe would help us better understand the Scottish medical workforce and the choices that individuals make better than we do now and to use this to think about improvements to our systems and processes which will aid workforce planning.
One of the key challenges we had in completing this report is that some elements of workforce planning are based on incomplete data and assumptions. This raises real concerns about their accuracy, and has a knock-on impact on the effectiveness of planning. We need better information at our disposal if we’re to effectively address this situation in the long-term.
Our first and key recommendation is that the Scottish Government establishes a single planning group with representation from the Universities, Deaneries, NHS Employers, BMA, Colleges, Faculties and Specialist Societies to advise on and oversee medical workforce planning in Scotland. Only by adopting a coordinated, whole-system approach can we hope to collate accurate and complete data, and plan and provide a medical workforce which is fit for the future. It is also clear that a more sophisticated and cohesive approach to workforce planning is required if we are to fully realise the opportunities to develop flexibility into the system; incorporate less traditional training routes; and cover the full spectrum of the medical workforce from undergraduate to consultant.
While the workforce challenges that face the NHS are acute, it is vital that we take action now to build solid foundations for the NHS workforce in Scotland.
In 2018, 7129 medical students graduated from UK medical schools, including 774 in Scotland. This number is set to rise by about 1500 across the UK and by 190 in Scotland each year over the next five years. Of these students, most will apply for one of the 7500 Foundation places. The number of Foundation places is aligned to medical school output because it is a requirement to ensure that there are places in programmes to enable students to complete full registration with the GMC after FY1.
The Scottish Medical Career Cohort Study (SMCCS) data has shown that approximately 95% of Scottish domiciled students – including students from widening access programmes and those who gained graduate entry to medical school – intended to pursue further medical training in Scotland, while 40% of non-Scottish domiciled students planned to go to other UK countries for Foundation training.
SMCCS further predicted that 90% of the Scottish-domiciled group of the cohort would stay in Scotland for core training/specialty training with attrition of those from outside Scotland rising to 60%.
This data also shows that the rate of retention for overseas graduates staying in Scotland almost equates to Scottish-domiciled students. Without this group of doctors, it would be very hard to approach fill in Foundation and later programmes in Scotland.
That’s why although we believe that it’s vital that while the number of medical school places should be further increased, we also need to grow the proportion of Scottish domiciled entrants to medical school, including those who gain their place though widening access programmes and graduate entry programmes.
The numbers of Foundation programme doctors progressing directly into training has dropped from 83% in 2010 to 38% in 2018. Although those not entering formal training schemes follow a variety of paths, the vast majority return to specialty training within three years.
Many of those who choose not to progress to core or specialty training remain within the health profession, but the reasons for these rates of deferment and return to training are not fully understood. Family duties, further studies, desire to travel or volunteer and increased flexibility are all cited as possible factors in this.
It’s with this in mind that our report concludes that further research is required to gain a better understanding of why Foundation Programme doctors do not directly progress to further training, while recognising that more flexibility is required during the early stages of medical careers in order to attract and retain staff more effectively within the training system.
We understand that the desire for flexibility and autonomy may limit the enthusiasm of junior doctors to be tracked and proper data collected and so we recommend that the NHS looks at a combinations of different ways to address this issue, from access to an ePortfolio; allowing deferment of appointments to training posts; more flexible recruitment; shortened recruitment time-frames; creating a centralised resource for advertising suitable roles and coordinating applications and appointments, including for overseas posts.
Core and specialty training
In 2018 there were 9,376 first year Specialty Training posts advertised across the UK, compared to 7,563 doctors completing their foundation training the same year.
This issue is particularly challenging in that a comparison by specialty of ISD data with specialty-collected figures has highlighted significant discrepancies, largely due to coding issues. For example, posts coded as general physician in the past may now be in reality acute medicine, general internal medicine, and a variety of other specialties dealing with acutely ill patients.
Some data are simply inaccurate – investigations by the Scottish Specialty Training Boards in Diagnostics and Anaesthesia, Emergency Medicine and Intensive Care Medicine showed discrepancies of up to 100%. This poses issues for workforce planning that rely on an accurate baseline for future predictions.
We are also concerned that there is no inbuilt capacity to increase posts in line with service demand in the current system. Specialties which count activity like histopathology can show that whilst specimen numbers increase by around 2% per year, sampling of specimens increases by twice that number and slide numbers by twice that. This vastly increased workload is a result of compliance with national best practice guidelines and is set to increase further because of the linkage of laboratory findings to specific gene targeted therapy. Other research has also showed that the information conveyed in reports doubled between 1991 and 2001 and again between 2001 and 2011. This is reflected neither in trainee nor consultant establishment in the specialty.
That’s why we believe that individual specialties should have access to robust data in order to allow them to contribute their expertise to workforce planning.
While increasing the number of doctors in the system by increasing medical school places is a viable long-term solution to address workforce shortages, in the short term the NHS will still be required to fill vacant posts with candidates from outside the UK. While we welcome the removal of the cap on Tier 2 visas has recently been removed to facilitate migration of international doctors to work in the NHS, from outside EU, we remain concerned that the removal freedom of movement for health professionals coming to the UK following the UK’s exit from the EU will have a negative impact on the number of doctors from the EU coming to work in the UK – currently around 10% of doctors working in NHS are EU nationals. Improvements to the operation of the Medical Training Initiative (MTI) – which allows doctors to enter the UK from overseas for a maximum of 24 months, so that they can benefit from training and development in NHS services before returning to their home countries – could also help improve international recruitment challenges.
At the same time, we support the re-establishment of permit free training, which was abolished in 2006. This would allow postgraduate deans to provide 2-year visas and a structured training offer to international graduates.
Working conditions and wellbeing
It is in the interest of both doctors and the patients they care for to ensure working and training environments which promote positive wellbeing amongst NHS staff. Developing the right type of workplace requires a multifaceted approach involving clinical leadership, educational governance and an improved physical environment.
Health professionals should feel valued and part of a team and have rotas that are predictable, produced well in advance and without gaps. Other basic factors can contribute significantly to workplace wellbeing, including availability of workstations and reliable IT, access to secure lockers, changing facilities, access to food and refreshments (including out of hours), sufficient car parking provision and good transport links to hospitals and other places of work.
Ensuring positive workplace culture and wellbeing of medical staff should be a priority action for all, which is why we’ve called for NHS employers to appoint two Non-Exec Directors – one with responsibility for workplace culture and wellbeing and one for educational governance.
We recognise the professional research that has already taken place on this area, and so we believe that that the findings from the GMC Wellbeing Advisory Group should be implemented in full, while access to less than full time and flexible training and working opportunities should be expanded.
Retaining consultants in the NHS
At a time when consultant recruitment is limited, as highlighted above, it becomes all the more important that consultant staff are retained in the workforce.
In a recent BMA survey of 4000 consultants, 58% over 50, 10% over 60, 83% working full time, highlighted that 60% intended to retire before the age of 60. If realised, this situation would greatly exacerbate the critical workforce shortages that the NHS in Scotland currently faces.
For 70% of those who responded to this particular survey, work/life balance was the most important factor influencing their decision.
That’s why we need to address the issue where some health boards continue to advertise contracts which do not allow for sufficient professional development or training opportunities. This practice creates additional stress on doctors. It is in direct contradiction to the Consultant contract and letter of advice from Chief Medical Officers and creates a tier of unattractive posts which are harder to fill. No consultant post should be advertised as a 9:1 contract.
The second most important factor in those seeking early retirement is the current pension regulations as they impact on the NHS pensions scheme. Because of the potential punitive financial penalties on NHS consultants as a result of changes to pensions rules 50% of consultants are less likely to take up or have already given up doing extra Pas. The significant scale of recent tax bills has contributed to decisions about staying in work and decisions to retire, sometimes very prematurely. We welcome moves by the UK Government to address this issue, but full reform is required to undo the serious unintended consequences of previous changes.
A growing proportion of consultants will seek to “retire and return” to ensure their pensions do not shrink while their tax burden increases. This provides a mechanism for retaining their expertise in the workforce. They require continuing annual appraisal and a Responsible Officer for revalidation which may be difficult to access.
Recent research has shown that NHS activity in the UK is growing at around 3.6% per year. We believe that the medical workforce in Scotland must reflect this growth. While we recognise the value of multidisciplinary working and of emerging roles, it is essential that we have adequate numbers of doctors with appropriate training, skills and experience if we are to maintain patient safety and provide the world-class service demanded of us.
Our recommendations provide a routemap to addressing this crisis.
This is what our public and patients expect, and what everyone in the health professions wants to provide.
1 – A single workforce planning group should be established
2 – The proportion of Scottish domiciled entrants to Scottish medical schools should be increased
3 – The number of medical school entrants should be further increased
4 – The proportion of medical students from widening access programmes and Graduate entry programmes should be increased
5 – A better understanding of the attributes of Foundation Programme doctors who do not directly enter training is required
6 – More flexibility is required at early stages of career and recognition of various types of training needs to be developed
7 – The accuracy of consultant data held by ISD should be improved. Electronic job planning should improve this
8 – Specialties should have access to data to facilitate their input into workforce planning
9 – A process for data confirmation is required and a pathway specialty should be used as a pilot
10 – The MTI should be expanded and process of matching improved
11 – While immigration is a reserved power, the possibility of reinstating permit free training should be reviewed
12 – Ensuring positive workplace culture and wellbeing of medical staff is a priority action
13 – Employers should appoint a Non-Exec Director with responsibility for workplace culture/wellbeing and one for educational governance
14 – The findings from the GMC Wellbeing Advisory Group should be implemented in full
15 – LTFT and flexible training opportunities must have wider access, and the impact on training and consultant numbers addressed
16 – No consultant post should be advertised as a 9:1 contract
17 – Improved flexibility of job plans is required in later stages of consultant career with options to reduce to LTFT and withdraw from out of hours work
18 – Pension and tax regulations require urgent reform
19 – Further research is required to identify factors which would help retain consultants in the workforce
20 – Process of appraisal and revalidation should be facilitated for consultants who wish to retire and return