Medical staffing pressures as a key driver for reform and therefore the medical workforce is the main focus of this paper. The reshaping and development of the healthcare workforce is fundamental to the successful implementation of the Welsh Government’s vision for the NHS, and is vital for the future affordability of the NHS.
We have an aging workforce and 20% of the medical and dental staff are over 50 years of age. If the NHS is to avoid future skill shortages, it must make the best possible use of its people and their skills. Staff will need to work differently – delivering more of the same through traditional roles and ways of delivering care is not an option. New immigration rules have made overseas recruitment more difficult and the flow of doctors from the EU has also been limited. The future supply and availability of medical staff is crucial to the future range, shape and organization of health services. While there may be an increase in doctor numbers, there will also have to be a different funding model to accommodate this. The amount of money available to the NHS is unlikely to rise, and the historical rate of year-on-year growth in the workforce will not continue. The current service configuration and hospital network spreads the medical resource very thinly – especially at middle grade. This has been compounded by the European Working Time Directive’s restrictions on working hours. In 2007 there were 2,748 junior doctors in NHS Wales with a total of 134, 206 hours worked per week. In 2011 the total number of junior doctors had risen to 2,810 but as a result of the introduction of the EWTD 48 hour week the total numbers of hours worked per week had fallen to 126,651. Therefore the average junior doctor now works 2.85 hours less per week or put another way a total of 7,555 less hours are worked every week.
The impact of future service models on the numbers and types of medical staff will need to be assessed to determine if they are affordable within current and future financial constraints, and can actually be staffed, given the known future supply of doctors and other professionals. We are experiencing shortages of some medical staff in Wales, as well as difficulties in recruiting doctors in particular “hot spots” such as West and North Wales. The medical, education and training environment in the UK is undergoing significant change. In Wales we are not looking to increase medical school numbers. Indeed there may well be a reduction across the UK going forward.
Reduced numbers of training places for medical staff must inevitably lead to redesign of service delivery. Recruitment in Pediatrics has been down for the last 2-3 years. There is no expectation either in Wales or the UK that this situation will be resolved in the short to medium term. This poses particular problems as there are too many pediatric inpatient units and too many medical staff rotas. We are now unable to staff the rotes in a compliant way and this is the immediate problem being faced in three of the health boards and their ability to give proper legal cover to trainees and provide them with the training and education they need. In the current recruitment round there are 11 acceptances for 20 vacancies; this clearly is a pinch point of immediate concern. The GMC survey shows that the workload for Paediatric trainees in Wales is amongst the highest in the UK and we are the lowest and second lowest in the UK for Working Time Directive compliance. The Deanery wishes to reduce the number of training sites for Pediatrics. Core Surgical Training in Wales has been a long-standing problem. There is an oversupply of Core Surgical Trainees who have no hope of progressing through to higher training. This has a knock on effect, to recruitment into these posts, but the service seems to be reliant on their presence. The examination results are poor in Core Surgical Training and our competition ratios going forward into higher training are amongst the highest in the UK. The GMC survey2 shows Wales as the worst in the UK for overall satisfaction and one of the lowest for adequate experience. The Deanery are reducing the number of Core Surgical Trainees over the next two years with the aim of bringing down competition ratios, improving the quality of the applications and reduce the number of sites that the Core Trainees will be available to work at. However, the Deanery is not reducing the higher training numbers so Wales will be producing the same number of qualified surgeons.
Emergency Medicine is a problem UK wide. The GMC are currently undertaking a review of the cover in Emergency Medicine in all departments across the UK. There are particular concerns around the supervision of Foundation Doctors overnight in A&E departments. The Deanery has sought to minimise this in Wales, but there is a need for an urgent review of where training is actually placed as it is spread too thinly across too many departments. Service planning suggests a similar change to trauma centres and more substantive A&Es within each of the Health Boards with different arrangements for cover at the current sites. The GMC survey shows the workload in A&Es in Wales to be the highest in the UK. This does not help recruitment as this will mean that they really are providing service as opposed to being trained. Wales is towards the bottom half in Working Time Directive compliance. This year there are half the number of middle-grade doctors in the appointments process and we have appointed to only 11 out of 20 vacancies. Psychiatry training is another UK wide issue with reduced numbers across the UK, and is particularly prevalent in Wales. The Wales service model is very dated and actually does need a substantive overhaul, which is more imperative than any changes to training from the short to medium term. Again, with this specialty there are too many sites with Junior Doctors unsupervised out of hours. The Deanery will be reviewing these in the coming months and removing Junior Doctors from out-of-hours cover. This will by definition affect service delivery, but is in line with the GMC requirements. Overall satisfaction from the survey is low in Wales and so is adequate experience with poor educational supervision, again all from the GMC survey.
Overall with regards to examination results for the specialties of Paediatrics, Surgery and Medicine, we find that after round two of the recruitment programme candidates are poor and that high calibre candidates are not being attracted at that stage to any of the specialties. The poor exam results reflect globally on Wales, as do the higher than average competition ratios for higher training. This has a detrimental effect on recruitment to Wales. Thus, the Deanery is committed to reducing the number of sites on which training occurs with an overall small reduction in number of core trainees across relevant specialties. This should improve our compliance with the working time directive; give us robust rotas, better education supervision and better access to clinical material. More robust rotas mean improved teaching time, which hopefully will also lead to an improvement in our pass rates. The GMC believe that the current Certificate of Completion of Training is not fit for purpose. If this does change then many of the current workforce assumptions will be subject to a complete review.
Successfully retaining qualified doctors is key to safeguarding the future supply to NHS Wales. Unless posts are made sufficiently attractive for Welsh-trained doctors to apply for, increasing the number of medical undergraduates and postgraduates is unlikely to translate into additional numbers of middle-grade and-consultant-level doctors. Medical workforce planning has always presented significant challenge because of the long training time associated with training medical staff. The lead-time varies significantly by individual medical specialty.Evidence has shown that the time differs between specialties, and typically varies between 5 years (e.g.Psychiatry specialties) and 8 years (e.g. Paediatrics). This is a critical factor in the development of robust workforce plans and the assessment of the realistic possibility of the medical staff supply pipeline meeting future demand.
Over the past two decades the proportion of female graduates has increased and many of these will become mothers during the years of training, i.e. early 20s to late 30s. Each year in Wales, 80-100 doctors in training take maternity leave and 50% of them request less than full time training on return to work. At the current time there are approximately 203 (7.5%) of doctors in training working less than full time. This means that they take longer to complete training programmes and may be working reduced hours in a full time post, which has service implications. A 2010 Deanery research project found that 95% remain in Wales after completion of training.
A meaningful discussion on the number of General Practitioners needed in the future and the possible impact that changing to a 4 year training programme will have on the capacity of current practices to train.The real costs of moving to a more community based care system as this is currently impeded by the lack of transferable resources from secondary to primary care. Circa 29% of Nursing and Midwifery staff in Wales are over 50 years of age, and 12% over 55 years. A key risk with any service reconfiguration may be increased attrition. Increased migration of UK trained nurses, and reductions in the recruitment of international nurses, has resulted in a net outflow of nurses from the UK.The ageing workforce poses risk to supply, particularly in community nursing.
A key strategic goal is to realise the maximum potential of nurses, midwives and specialist community public health nurses in order to meet, in partnership with others, the changing health needs of people in Wales. The aim is to develop existing and new roles and flexible career pathways that provide a matrix of opportunities to cross boundaries and participate in clinical practice, education, research, management and/or policy development to enhance care delivery and job satisfaction. Healthcare Scientists and the Allied Professions provide important services that underpin the changes needed in the delivery and organisation of healthcare in Wales. They too face changes in the way they work.Circa 32% of Healthcare Scientists are over 50 years of age, and 17% over 55 years. Circa 22% of the Allied Professionals are over 50 years of age and 21% over 55 years.
However, despite this challenges there has been rapid growth in inflow of nurses to the United Kingdom from other countries. In recent years, 40–50 percent of new nurse registrants in the United Kingdom have come from other countries, principally the Philippines, and South Africa. Outflow has been at a lower level, mainly to other English-speaking developed countries—Australia, the United States, New Zealand, Ireland, and Canada. The United Kingdom is a net importer of nurses. The principal policy instrument in the United Kingdom, the Code of Practice on International Recruitment, has not ended the inflow of nurses to the United Kingdom from sub-Saharan Africa.
Given the increasing globalization of labor , it is likely that the historically high levels of inflow of internationally recruited nurses to the United Kingdom will continue over the next few years; however the “peak” number reached in 2002/2003 may not be repeated, particularly as large-scale active international recruitment has now been ended, for the short term at least. New English language tests and other revised requirements for international applicants being introduced by the Nurses and Midwives Council from September 2005 may restrict successful applications from some countries and will also probably add to the “bottleneck” of international nurse applicants
Putting history to the forefront would help policymakers construct historically-evidenced agendas that could aid health manpower planning and improve equity and opportunity for significant numbers of health workers.