Future Medical Workforce Project: phase 1 report

How do we improve workforce planning to best deliver high quality care to patients?

We asked doctors working in Scotland, how do we improve workforce planning to best serve the public and deliver high quality care to patients?

Decisions taken at local and national levels affect individual choices, fulfilment at work and the shape of a doctor’s career. We know that fulfilled doctors are more likely to sustain long careers. We also have a duty to ensure a national provision of services, in line with the onward reform of the NHS. Their views of doctors in relation to this question are summarised below beneath themed headings.

Attractive medical careers

Doctors spoke to the need firstly to ensure that medical careers are attractive, in order to ensure a future medical workforce. This links to themes explored earlier about how to ensure a medical career is fulfilling and sustainable. All doctors voiced concern about the impact of training bottlenecks on the supply pipeline of future doctors and the attractiveness of a medical career as a result.

• Medical students voiced concerns about the perceived lack of onward planning by government to account for medical school expansion. It was also noted that one of the consequences of this expansion was a deterioration of the quality of undergraduate education, with a strong view that no more expansion should be taken forward.
• Many doctors at all levels voiced concerns over the value for money element of bottlenecks with people ‘being lost overseas’. Some senior doctors however, recognised this as an opportunity to optimise use of other grade doctors like those in locally employed roles or SAS/Specialty grades.
• Resident doctors commented on rising International Medical Graduate (IMG) applications and perceived unfair treatment of UK graduates within national recruitment.
• There were comments about the ineffectiveness of national recruitment approaches and Royal College curricula in supporting flexibility and personal career pathways. In remote and rural areas national recruitment processes have meant people who want to stay in the area have not been supported to.
• There were calls for greater transparency of vacancies and posts, to counteract reported hysteria and fearmongering. Senior doctors reported that they were advising resident doctors to take as long as possible in training to give them a better chance of getting a job post Certificate of Completion of Training (CCT).
• Senior doctors typically referred to the importance that competition has always played and that perhaps the intention of government was to oversupply as a means to support recruitment in less popular specialties or regions.
• Some recognised a challenge to effective national workforce planning as a result of employment resting with NHS boards or individual GP practices.
• Clinical academics highlighted the challenge of ensuring research careers were accessible and attractive to all in the context of long dual training, highlighting that the lack of structured academic clinical training pathways may create barriers to participation and inequity. They highlighted the role for the clinical academic community to support effective workforce planning, using data to understand our service needs and model the opportunities for innovation and redesign of healthcare systems.

"As a trainee, what is making me worried is the lack of training numbers. I’m interested in cardiology, I’d like to be a cardiologist. I think the chance of me getting a cardiology job is slim." - FY2 doctor

Ensuring a national provision of service

This theme explored the tensions between ensuring a national provision of service and accommodating individual’s preferences over specialty or location. We asked participants how we best manage this tension.

Some supported a form of compulsory service, either by taking up posts or vacancies where there are gaps, or a certain length of return of service post-training. Overall, doctors who had completed their training voiced concern that such an approach could result in the wrong kind of people in those jobs, low job satisfaction and retention.

Those in remote and rural boards, who were thought to be the beneficiaries of such an approach, expressed a preference for early career exposure to remote and rural working to encourage voluntary take-up of roles by those with enthusiasm and interest. To address wider recruitment challenges in these areas, other supporting infrastructure needs requiring government support were referenced such as transport links, housing, education and childcare.

To ensure a national provision of service the idea of a social contract, whereby taxpayers pay for undergraduate and postgraduate training of doctors and in return doctors may be required to work in specialities or locations where there is population need, was discussed. Recognition by doctors of this kind of ‘give and take’ relationship was mixed.

Resident doctors were less accepting of the concept due to perceived job insecurity and the current approach to management of training creating geographic instability alongside personal costs incurred for professional examination fees etc. Senior doctors typically recognised this social contract as an implied expectation on the profession but commented that it was understandable that this was less accepted by junior doctors in the context of employment and career uncertainty alongside increasing workload pressures compared to their own experiences.

Survey respondents provided more insight into the components of a social contract with some commenting that societal and public respect of doctors is also a key component which has been eroded. Other respondents commented that such a contract also creates expectations on government to provide appropriate remuneration, training and employment opportunities as well as the resources to do the job well. It was felt that government failing to meet these expectations is in part to blame for the breakdown of the social contract.

"Our training is funded by the Scottish Government then it makes sense that we pay back by working in the Scottish system. I think the government… are obliged to give us job security." - Consultant, focus group attendee

"Most of us have spent our entire 20s working our guts out and actually, I think the idea that there is a social contract…is just dead now." - Consultant, focus group attendee

Most doctors were in favour of incentivised approaches to workforce recruitment challenges, particularly in remote and rural areas to account for relocation and high living costs with ideas that this could be linked to student loan forgiveness. Some referenced experience of success of incentivisation through provision of financial packages, or accommodation. However, it was felt that this could run the risk of attracting individuals for the wrong reasons who might leave after any return of service period.

Other ideas also included greater regional or flexible deployment aided by a single employer to help address structural HR issues. There were also views that GPs and Consultants need to have parity of status (and for some this also included pay) to avoid General Practice being seen as a ‘lesser’ specialty.

Ensuring value for money

Ensuring value for money, was discussed by participants with a view that government should be supporting the retention of individuals who have trained in Scotland to work in Scotland. There was also a view that ensuring value for money would come from keeping doctors working on those elements which are unique to being a doctor and not wasting time on administrative tasks.

All agreed that investment in primary care would fundamentally help the NHS and offer better value for money while improving patient outcomes. There were concerns about the value for money of the GP partnership model and the longevity of that model given perceived appetite of future generations to take on partnership roles.

Planning

Doctors expressed concerns about the quality of data used to workforce plan and whether workforce projections and future planning were considering the rising rates of LTFT working. Many spoke of a need to increase the number of GPs and/or all doctors to meet rising demand and enable doctors more time to deliver holistic care for patients.

The management of training was discussed by all grades of doctor with many improvements identified to help better support the future workforce. These included:

• Increase the number of training posts
• Better geographic distribution of training posts to support remote and rural recruitment
• Allow greater flexibility and formalise the locally employed route to gain competencies toward CCT – for those seeking more of a scenic route/variety
• Increase the opportunities for LED posts to create more flexibility of career route and opportunity for generalist training and breadth of experience before application to specialty training.
• Increase the number and value of SAS roles to offer diverse career routes, noting that not all doctors want to become a GP or consultant.
• Support trainers and educators through ensuring these roles are more effectively resourced and recognised within job plans.
• Regionalised specialist training centres to better ensure consistency and quality
• Increase overall training capacity (potentially mandating GP practices take some responsibility for training the next generation)
• Address Whole Time Equivalent (WTE) training gaps
• Create a Remote and Rural pathway for those who want to build their careers and skills in those locations
• Matching of training post distribution to future vacancies
• Undergraduate and FY exposure to interprofessional learning and hard to fill specialties and locations.

There were strong views expressed about inefficient NHS leadership and management, with concerns focussed on a lack of management understanding of what was happening on the ground and therefore a lack of suitability of new policies, initiatives or service redesigns requiring to be implemented. Almost all participants felt that they had limited means to influence local level change or decision making and that their views would not be listened to. Most commented that there was little visible evidence of any workforce planning taking place at a local level. Some also commented that there were too many NHS health boards and more efficiency could be gained if this was reduced. It was felt that service planning could be better supported with ‘optimised workforce models’ that made clear where and how wider MDT members were to be used.

Role of government

Strong views were shared by doctors on the failures of the Scottish Government, with comments focussing on a lack of honesty impacting the relationship between government and the workforce. It was felt that there needed to be a realistic conversation on what is achievable to deliver and a need to be transparent with the public. There were calls for government to take forward a national conversation with the public on what the NHS can deliver to set more realistic expectations.

"Maybe we are getting to a point where we can’t quite do everything. Maybe we need to aim for silver standard for everyone rather than gold standard for most." - Emergency rural physician

"The thing that frustrates me the most is the absolute disconnect between what the NHS can offer and what patients think it can offer." - GP

There was also discussion of the wider policies and decisions taken by Government which impact the medical workforce, like taxation, pensions, dis-investment from rural communities and a lack of action to address the obesogenic environment, housing crisis and social care reform.

There were also calls to de-politicise the NHS and take a long-term view to workforce planning which has political consensus.

"It’s not just about making things artificially better for a pamphlet that’s going to come out with the next election." - Consultant, focus group participant

"I would like to see the NHS stop being used a political football so we could actually have honest conversations about solving problems." - Consultant, focus group participant

"There has to be a 10/15/20 year workforce plan that we stick to regardless of who’s in power." - Resident Doctor, focus group participant