Future Medical Workforce Project: phase 1 report

What makes a medical career sustainable and fulfilling?

We asked doctors in Scotland what does a modern medical workforce need to sustain fulfilling careers?

It is vital that we nurture and support our current workforce so that they are best enabled to evolve to future needs and sustain fulfilling careers. Their view from the focus groups and the survey are summarised below beneath themed headings.

• Job fulfilment comes from feeling valued and respected by patients 96.8% strongly agree/agree
• Job fulfilment comes from feeling respected and valued by colleagues 98.1% strongly agree/agree

Feeling Valued

Doctors felt personal autonomy: a sense of control over one’s career and work pattern, contributed to a sense of feeling valued. This included being supported with the resources eg. IT and administrative support to enable doctors to perform their role effectively. Senior doctors reflected that the advent of job plans, mandated breaks and rota compliance monitoring all contributed to a sense of de-professionalisation where doctors were no longer allowed use their professional judgement to manage and prioritise their own time. The sense that the doctor’s role is valued by society was particularly low for early career doctors with only 49% of F2 and Core trainees showing a fall from 64% in F1. This is interesting to consider what influences the decline in sense of value in the early years of training.

"I think doctors often don’t feel respected and valued by the nhs, making it harder to give the level of commitment and energy required to perform our roles. I think the impact of feeling valued is overlooked." - GP trainee, survey respondent

Job security also contributes to a sense of being valued, and particularly amongst resident doctors and students, there was a real sense of injustice related to the perception that job security has diminished, impacting their ability to develop roots in local teams and communities.

Doctors, particularly resident doctors and medical students voiced a wish to have choice and influence over where they work and expressed concern that current recruitment processes across the training pipeline have eroded that choice. Opportunities to address this include the potential benefit of local recruitment or a degree of local input which can support a sense of belonging and team with opportunities for mentoring.

Doctors of all grades described a sense of holding all the responsibility but none of the control. They expressed frustration at being able to see opportunities for change and improvement but without a mechanism to influence change within or across board structures or regions. The description of siloed funding and bureaucracy left many feeling it was almost impossible to achieve change.

There was a clear theme of the clinical voice not being heard, and decisions being made with a top-down, target driven agenda where clinical insights and experiences were not valued. Some described that trying to gain access to the rooms where they contribute could be challenging. This was further reflected in the survey where 82% of doctors agreed that a culture of indifference or tension from senior management was leaving doctors feeling undervalued or unable to facilitate change. A clear divergence between clinical leaders and other grades was noted with only 52% of clinical leaders agreeing with this statement compared to 89% of SAS grades and 85% of resident doctors.

Doctors described repeatedly a sense of erosion of respect for their role and that this too has decreased their sense of feeling valued. This was described as:

• A lack of organisational respect whereby doctors felt like they were a faceless number rather than a respected professional. Absence of conducive working or rest areas, access to hot food, breakdown of team structures, lack of effective IT resource and lack of job security were all seen to reflect lack of organisational respect. This extended to effective onboarding in the context of new roles or rotational placements. Frustration was voiced over experiences of delays and errors in pay and a lack of effective NHS HR systems.
• A reduction in societal respect, influenced by both social and mainstream media and the public perception of doctors as gatekeepers withholding access to services in the context of waiting lists and under-resourced services. As doctors are often the face of the NHS to the public, they describe the moral injury of being left to face the blame, distress and backlash when there are inadequate services, delays or cancellations while managers are hidden from view. Many commented on the lack of support from government in addressing misperceptions or establishing realistic public expectations of what the NHS can deliver with current resource.
• A lack of respect within the medical profession. While there were many respectful doctors acknowledging the challenge in each care setting, there was an evident divide with GPs highlighting perceived inefficiency and wastefulness of secondary care services, while secondary care consultants felt workload had been transferred inappropriately to secondary care.
• A further challenge was raised as to how SAS and specialist doctors are valued within the current workforce model. Their contribution and potential levels of seniority were felt to not be adequately valued particularly by members of the multidisciplinary team. A perceived assumption and pressure for SAS and Specialist doctors to aspire to portfolio pathway was felt to devalue their personal choice.

"There must be a commitment to equity – ensuring that all roles, including SAS doctors, have access to progression and recognition. It is degrading and demoralising when experienced SAS doctors are overlooked, especially when colleagues in other professions progress with structured support and minimal effort." - SAS doctor, survey respondent

Pay

Doctors’ pay was seen as financial reward or compensation for the challenging role and high expectations and responsibilities of doctors. Mixed views were expressed as to current pay scales with some senior doctors calling for differential remuneration which reflects individual contribution or intensity of workload. This was seen as potentially divisive and some challenged that the route to address this is standard setting and performance management where required, alongside a mechanism for recognition and reward for all roles. There was a recognition that doctors are highly paid within the public sector but that there is competition from private employers in a global market. While some feel pay is fair and adequate, a minority expressed that doctors are overpaid whilst others, particularly resident doctors, referred to their view of relative decline of pay as compared with 20 years ago and called for pay restoration.

Senior doctors were more likely to express concern regarding the impact of tax and pension rules noting these potentially disincentivise working fulltime or retention of senior doctors, contributing to loss of experienced doctors across both primary and secondary care.

While pay was seen as a proxy for respect and value, it was felt that if working conditions and job stability were addressed, then pay would be a less prominent issue.

Survey responses indicated that only

• 1.6% of respondents considered pay to have been the most important influence in their decision to study medicine, and only
• 1.7% of respondents ranked pay as the top influence in their career path to date.

Working Conditions

It was recognised that feeling valued as professionals is closely tied to having working conditions that enable individuals to perform their roles effectively and utilise their skills and training. Increasingly there was a sense that administrative burden and inadequate clunky IT systems were impacting doctor’s efficiency and taking them away from direct patient care. Basic provisions such as access to working computers, desk space and a call for IT systems which communicate across organisations and the primary secondary interface were all highlighted as opportunities for improvement.

"The IT...i think we do all lose a lot of time and people get very frustrated because we’re dealing with really old clunky systems that don’t talk well to each other, and actually that costs time and energy and people get frustrated."- GP, focus group attendee

Job fulfilment

Job fulfilment centred on patient care and a sense of making a difference to individuals or the wider system directly or indirectly through quality of care provided, leadership, training or service development.

Some senior doctors voiced a real sense of privilege to be allowed insight into patients’ lives and describe personal joy and fulfilment when they see a positive outcome for their patients. Some voiced a particular sense of fulfilment from working in areas of deprivation or particular need. This provided an opportunity to contribute but caution was noted that in the absence of societal shifts or addressing fundamental issues such as poverty, the inability to transform outcomes can make such roles unsustainable due to risk of burnout.

"I’m so privileged to be a doctor...I get to hear people’s stories. I get to be part of their lives... I get to find out their joy, when they’re having a baby, they show me their wedding photos, I’m invited in when their loved one is dying to help them to help their family and to help that individual. What a privileged position." - GP, focus group attendee

Doctors told us that fulfilment comes from providing high quality care and feeling you’ve done your best for your patient; this requires time and autonomy and is at risk in a system which they reported currently feels so stretched with limited capacity and long delays, that this is leaving doctors with a sense of ‘moral injury’. Particular challenges were highlighted in primary care as GPs try to identify the correct point of referral for increasingly complex and multimorbid patients who can fall between different subspecialty teams, leaving GPs frustrated at a system which was felt to hinder onward care.

The increased role of the multidisciplinary team within primary care was thought to have made some improvement but GPs also reported the unintended consequences of disrupting the continuity of the GP/patient relationship, such that GPs are more likely to focus on more complex cases but without the benefit of a long-established relationship supporting shared decision making and realistic medicine.

Secondary care doctors also described frustration in a system which leaves them without capacity to see complex patients between planned reviews and lacks a patient centred approach supporting continuity of care. For resident doctors, working patterns can limit continuity or ability to follow the patient journey reducing job fulfilment as they may not observe the patient outcomes. A further impact of the introduction of the MDT review in primary care was noted by secondary care doctors who felt increased referral rates based on protocolised care could be adding to the challenge of waiting lists and poor flow, whereas early triage by an experienced GP tended to support a more effective use of resource.

Feeling trained and prepared for the clinical role allows doctors to feel they can make a difference, but many expressed frustrations that they were underprepared for the nonclinical elements of the GP or consultant role – such as leadership, service development & financial/business management. Doctors felt that an increased focus on training in these elements could improve confidence and competence in senior roles and the ability to influence change and outcomes.

Belonging

A sense of belonging in a supportive nurturing environment was felt to be important in ensuring a sustainable and fulfilling career. Belonging to a cohesive supportive team was identified as key: allowing for personal support through periods of professional or personal challenge, role modelling of professional behaviours and expectations alongside mentoring of learners.

There was a recognition that the disruption of short training rotations and shift work can impact on that sense of team and opportunities for development of trainer/trainee mentorship and trust which allows effective delegation of tasks and responsibilities for learning and personal development. The GP model of training was felt to offer more stability with a longitudinal model of educational supervision across the programme. In secondary care, short duration of placements might impact that sense of belonging and security for both trainer and trainee and reduce trust in the event of challenge.

The rotational nature of foundation and specialty training was felt to create both risk and benefit. Short placements were felt to impact the sense of belonging in a team and prevent the establishment of trusting mentorship which in turn supports delegation of caseload supporting training opportunities and development of clinical confidence. This limits the satisfaction for both trainer and trainee. Furthermore, rotations were unpopular with resident doctors and students who expressed a wish for geographical stability and job certainty – this was further confirmed in the survey results.

Early career doctors were twice as likely to identify geographic location as the most important factor influencing career choices compared to older age groups.

"There’s a huge benefit in variety which can also be fulfilling…for training, that sounds like there’s probably benefit in circulating around to some places to see how things work and are done slightly differently but there’s also huge benefit in building an informal network…mentorship…trust." - Consultant, focus group attendee

"Take into account trainee preference (where we live, driving status, children etc) when allocating rotations rather than random, and have longer rotations from one base to enable us to build relationships with the team." - Trainee, survey respondent

It was acknowledged by both resident and senior doctors the breadth of experience gained by exposure to different teams and sites through rotation is positive for skills development and learning, and early career exposure to remote and rural sites can influence career direction.

The threat of adverse feedback through training surveys and GMC processes was felt to deter senior doctors from providing honest feedback about professional behaviours reflecting a loss of psychological safety in the team. It was recognised that team culture was key for mutual respect and learning both for training and also for effective care. A recurrent theme was highlighted around poor communication and, at times, overt disrespect between doctors and managers, with non-clinical managers sensed to neither understand nor respect the role of doctors and to enforce decisions while leaving doctors to face those patients impacted.

A further element of belonging discussed was inclusion and accessibility for learners and staff with disabilities or additional support needs. Significant variance was noted between settings and boards, and a call was made for greater consistency and access to practical support, advice and expertise.

"At the moment we are just numbers in a system due to rotational training and never feeling part of a team. I think there is a need for simplifying things and basing people in places for longer to allow them to become part of a team, which in turn makes people invested in them and enhances the feeling of job security." - GP trainee, survey respondent

Confidence and competence

As Doctors are held to high professional standards with personal accountability for complex care and decisions, ensuring competence and confidence through training, experiential learning and personal development to undertake the role was seen as key to sustainable fulfilling careers.

Current undergraduate training programmes develop graduates who have the potential to choose a wide range of career paths and this breadth was felt to be important recognising that even the core decision to enter medicine is undertaken at an early age with limited life experience. Opinions varied on whether current postgraduate training programmes are too long, short or appropriate in duration. Alternative models of training around the world were highlighted to suggest other options are possible. A particular challenge was highlighted regarding the length of training for clinical academics who are required to combine periods of research with specialty training. It was felt the long duration and lack of job certainty contributed to the recognised decline and gender imbalance in the clinical academic workforce. There was a call to review training curricula and pathways to map the training and skills to the workforce need, reflecting the changing population health needs, and future service models and to embed clear pathways for clinical academia, medical education and clinical leadership development.

An observation by consultants was that with the change in working hours, NHS boards have introduced increased numbers of locally employed doctor roles to support service delivery while ensuring curricular training requirements can be met for doctors in training programmes. This was felt to have led to an increasing narrative amongst resident doctors that training should be protected and a reported conflict between service delivery and training. There was a strong sense voiced by senior doctors that training is delivered through service, and skills and knowledge are developed through experiential learning and time on the job and a need for realistic shared expectations around this. It was suggested by doctors of all grades that innovation or alternative models of delivery might minimise those elements of the job which neither require a doctor nor add value to the training experience, and that there is a need to ensure that resident doctors in locally employed roles, outwith training programmes, are supported and recognised in their personal development and experiential learning, promoting flexible routes to progression.

Ensuring time and opportunity for continuing professional development and study was felt to be a key requirement for all stages for medical carers and a lack of time and funding were highlighted as barriers.

• Resident doctors highlighted the significant expense of key postgraduate training courses and professional examinations required for competitive application to training programmes and senior roles. Some voiced that this should be fully funded as an essential component of the job. Other resident and more senior doctors considered that personal development supports competitive advantage for recruitment and therefore there is a balance between appropriately self-funded development and public funding of essential requirements.
• With increasing numbers of locally employed roles supporting our services, there was a strong call for ensuring access to development opportunities for these doctors who are often at formative stages of their career.
• Ensuring equity of access to development opportunities and funding for SAS doctors was highlighted, with calls for fair access to mentorship, structured training opportunities and leadership development to support progression and recognition
• Development opportunities and protected time for trainers was also highlighted to ensure we retain and value motivated educators to support and train the next generation of doctors. Consultant capacity to support training was reported, by resident doctors, to be reduced in the face of increasing service pressures.
• Leadership development was felt to be a priority, noting that clinical leadership roles were often seen as challenging and thankless, but require dedicated time and training to support doctors in these roles and to have most impact.

"On the job teaching, training and support has also plummeted due to high clinical burden of seniors." - FY2, survey respondent

Attraction & Retention

There were mixed views expressed on whether medicine remains an attractive role, and notable that many consultants and GPs acknowledged they would hesitate to encourage their own children to enter the profession. Key elements influencing this aspect included the perceived decline in respect for doctors across society, accompanied by concerns about relative decline in pay and the impact of pension and tax rules. This was seen as both a concern and an opportunity whereby Scotland could aim to position itself favourably as an employer within the four UK nations. It was also acknowledged by students and doctors of all grades that the high visibility of pay disputes has been challenging and may have influenced popular opinion of doctors.

Flexibility was seen as an increasing feature of the current workforce reflecting changing attitudes of the younger generation and impacting the attractiveness and sustainability of careers and career choices. Many GPs referenced the increasing rate of LTFT working in general practice, noting that the increased intensity and complexity of their caseload had required them to move to LTFT to prevent burnout, reporting decision fatigue by the end of each clinical day. There was a challenge that the current expectation of LTFT for resident doctors would be considered fulltime working for most other professions, and perhaps there is a need to reset the working hours expectations. Survey responses identified support for the contribution of healthy work life balance in a fulfilling career, with particularly strong agreement from resident doctors and SAS & specialist grades.

The call for better work/life balance to support a more sustainable career was suggested to require addressing current workload either through redistributing current elements of the role that might be supported by other members of the clinical team or to require investment and recruitment of more doctors.

A further element of flexibility referred to the opportunity and wider benefit of supporting travel and experience outwith Scotland both within other parts of the UK and around the world. However, resident doctors and senior doctors reported the challenges experienced in trying to re-enter the system, which was adding to the risk of loss of Scottish graduates from the workforce.

The top ranked influences on sustainable career mapped across all responses were supportive teams, workplace culture and effective leadership, with some variation noted amongst different grades and roles. Clinical academics identified the opportunity to influence change as the top influence, while leaders prioritised (after supportive teams) diversification of job role and effective leadership above workplace culture, perhaps reflecting their own career choices. For all roles, use of technology was considered the least important influence. Across all doctors, LTFT working was ranked 4^th in terms of influences contributing to a sustainable career, however variation was noted by role with resident doctors, SAS grade and GPs 2-3 times more likely than consultants to cite LTFT working as the most important influence.

Resident doctors, SAS grade and GPs 2-3 times more likely than consultants to cite LTFT working as the most important influence.

In terms of retaining doctors, many consultant, GPs and SAS doctors voiced concerns about the sustainability of acute roles as the retirement age increases. They recognised that roles which require complex decision making and fine motor skills out of hours despite sleep deprivation become increasingly challenging to sustain with increasing age. There was enthusiasm for the opportunity to explore diversification of roles, but caution noted that a generally held assumption that senior doctors will diversify into leadership or education could not be expected of all. For many, the clinical role is what brings joy to the job, and a mechanism to support a slower pace of delivery or daytime sessions only in the latter years of work might retain experienced doctors thereby bringing benefit to the wider team and service.

"... considered at some point becoming a salaried GP rather than being a partner because then I can go in and do the job I love but take away all the other responsibilities of being a partner: the managerial stuff, the admin stuff and I might do that as i get closer to 60... " - GP partner focus group attendee