Policy responses and statements
Background: The future of the medical workforce has been the subject of scrutiny and debate for years, not just in the UK but internationally. Recent changes have had a significant impact on how doctors train and work, providing an opportunity to fully engage employers in this debate. The discussion paper, drafted in consultation with key stakeholders, including members of the NHS Employers Medical Workforce Forum, has recently been circulated to Medical Directors and HR Directors in NHS Trusts and SHAs across England. The paper aims to bring together key issues and influences and engage employers in the debate by setting out broad thought provoking questions about how they believe these are shaping the future role of doctors in the health service. NHS Employers invited views on the issues raised by the discussion paper to help them to understand the key priorities for employers and inform their work in influencing policy in this arena. When feedback has been collated, NHS Employers plans to hold workshops in the next few months to explore further the priorities and concerns that have been identified. The discussion paper set out some of the current issues and the questions they raise. The questions were designed to prompt thinking at a local level. COMMENTS ON The Royal College of Physicians of Edinburgh is pleased to respond to NHS Employers on its discussion papers on The future of the medical workforce. The College believes that the paper, although helpful in terms of seeking to gather contemporary evidence of employers’ experience and intentions, is too narrow in its focus and misses the opportunity to promote the benefits of clear clinical leadership and the professional role of doctors in the cultural change necessary in the NHS. The College has referenced specific comments to the questions posed in the paper. 1. Do you anticipate major changes in the numbers of doctors you employ or the way they train or work as a result of planned reconfiguration? The College expects that more significant change in terms of the way doctors work will result from advances in medical practice and technology than from a change of location or team as a result of configuration. However, reconfiguration will influence the training and recruitment of doctors in a number of ways:
The recruitment of some consultants in local hospitals will be more difficult if the professional rewards of specialist practice are not available – this may also affect the viability of some undergraduate medical schools. In addition, the pressure for long day or 24 hour working will increase the demand for consultant posts, exacerbated by the expected continued increase in requests for flexible working by a predominantly female medical workforce. 2. What are the implications for training and employment arrangements of more care being delivered outside hospital? Planners should take care not to confuse the difference between hospital and community care with specialist or generalist care. The focus should be on the clinical competences and experience required, irrespective of the location of care. This will influence the numbers and training of general physicians (hospital consultants and GPs) and clinical specialists. Accredited specialists (currently working in hospital settings) may be required to undertake more locally based work. It may be more difficult to be certain of maintaining standards and clinical supervision if training is delivered across a number of different providers. Indemnity arrangements for trainees and trainers may need attention, particularly for practical skills specialties eg gastroenterology and cardiology. Foundation acute hospitals may be disinclined to accommodate the training needs of more than their own minimum replacement requirements, opting instead to deliver service (particularly out of hours) through trained doctors and “buying in” ready trained doctors from other providers as required. The importance of experience in emergency and acute specialist care (including out of hours work) should not be underestimated, and securing appropriate training opportunities for all doctors in these areas is important. Offering training with minimal exposure to emergency out-of-hours needs would be a retrograde step. Clearly, any increase in working across different locations will require an enormous improvement in IT systems. 3. How have you integrated the Modernising Medical Careers plans into a wider health community reconfiguration plan for service? No direct comments. 4. Do we need to do more to recruit and retain more GPs? The College recommends that workforce assumptions are based on service demands before determining whether the need is for more community based generalists or community based specialists. Only then can the numbers of GPs, GPs with specialist interests or community based specialists be safely determined (see point 2 above). However, if more specialist chronic care is required in the community by the current cohort of GPs then appointment times will need to lengthen, requiring more GP hours. The level of uplift cannot be determined until the future shape of the medical workforce is clear. The College is confident that with careful planning and as a result of the new GP contract, the community base physician role (whether GP or accredited specialist) will be attractive to young doctors, particularly those seeking flexible work opportunities. 5. What is the impact on the medical workforce of more autonomous providers and a more pluralistic system of healthcare? It will be more difficult to secure comprehensive training packages with adequate clinical experience. For example, the College is concerned that Independent Treatment Centres (ITCs) will limit training through capacity and/or patient type. ITCs must be given a training responsibility, accessing trainers, who are themselves “trained in train” in the UK system. The same may apply to emerging “medical chambers” where the emphasis may be on elective routine cases, leaving the NHS to support acute and complex chronic work. 6. What are the implications of an integrated workforce across a range of employers for the way in which we train and employ doctors? See previous comments. 7. What is the future for private practice? Individual patient demand will decline with waiting times, but if NHS use of the private sector increases through commissioning then private practice will flourish. Standards must be maintained across the plurality of providers and the private sector must be commissioned to participate in training (see point 5 above). 8. Will we see medical “chambers” where doctors are self-employed? This may be a helpful solution for shortage services and where remote working is feasible ie radiology or some pathology services. Procedure based specialties may also take this route, but it would be important to ensure that training and other responsibilities were factored into contracts (see point 5 above). 9. Who should be setting the agenda on the future shape of the medical workforce – commissioners, providers or both? This cannot be achieved by any single agency in isolation. Medical Royal Colleges, with their focus on standards, are essential players here. Enhanced careers advice to young doctors is essential to ensure the professional rewards of all medical careers are understood and to improve recruitment generally. 10. Are you confident that our medical workforce is shaped to support the healthcare needs of an ageing population? Demographic changes will influence the balance of future services and the needs of an elderly population cannot be met by generalists alone. Indeed, a significant amount of current hospital based care is delivered to older patients and, as the “baby boomer” generation reaches retirement age, patients will be more demanding for specialist care. 11. Are you taking a long-term view of recruitment? The College sees no evidence of this. 12. Is there enough flexibility in the medical workforce to allow for the trend towards flexible working? As demographic changes in the medical student population filter through, it is essential that medical careers can cope with flexible training and work opportunities. Flexibility in community-based careers with limited out of hours work requirements will be attractive, leaving some hospital based specialties at risk of difficult future recruitment. NHS employers must support flexible work opportunities in the hospital sector and ensure that all job plans include sufficient capacity to support the necessary professional activities that benefit the wider NHS ie training, planning, interviewing etc, much of which is currently scheduled out of hours. Planners must take account of the number of training places required to support the future medical cohort where an increasing number will wish to work part time. 13. Should all UK graduates be guaranteed a Foundation training post? Some competition is helpful to promote high standards but there must be a balance, given the costs to the UK of educating medical students. Competition through selection into specialty is introduced after the Foundation Programme, and for UK graduates to have their training stopped abruptly after graduation would be a huge waste of resources and talent, and would discourage able candidates from applying in the future. The College assumes that the omission of Northern Ireland in this section is an oversight. 14. Have you made plans to accommodate more Foundation Programme doctors? No direct comments. 15. Do you believe a modest oversupply of graduates would be a good thing? This question hinges on the definition of “modest”. The College feels strongly that it is not in the best interests of the UK generally to invest in medical schools and then create a regular surplus of UK medical graduates. Medical students enter universities with the intention of following a career in medicine, and planners must accept that in a global market place our best graduates will move away if circumstances force them. 16. Do you believe that current medical workforce planning is effective? If not, what could be done to improve it? The College understands the complexity of medical workforce planning, but believes it is currently ineffective and needs to model backwards from estimated future doctor requirements through training programmes to medical student numbers, using all available data. This must be a shared activity. 17. Are you sufficiently involved or represented in the commissioning of medical training, from establishment of medical school places through to specialty training programme posts? For Colleges, this is mainstream business and must remain so. 18. Do you envisage recruiting and employing doctors from outside the EEA in the future? This may be necessary in the less popular specialties in less favoured locations, particularly if UK graduates elect to move abroad rather than move into these areas. 19. Has the recent change in work permits and EU membership had an impact on your medical workforce? The NHS risks losing applications from high quality graduates from overseas, and some specialities may not be able to recruit the best candidates as a result of the immigration changes. 20. Will increased EU mobility have implications for your medical workforce? College Fellows have confirmed a significant increase in trainees applying for posts from the EU and Postgraduate Deans have had to cope with the challenges of cultural and language inductions. 21. Does your trust need any support to comply with the 48-hour week by 2009? If so, what would you find most helpful? No direct comments. 22. Do you believe doctors in training will gain all the necessary skills and experience for safe practice in reduced hours? The College has some concerns about standards being maintained as a result of reduced hours, particularly for the acute specialties. 23. Which specialties are most challenged by the Working Time Directive? No direct comments. 24. Have you considered how your Trust can benefit from the introduction of Modernising Medical Careers? The challenges of introducing MMC has caused some tension between hospitals and Deaneries over the required input from consultants into implementation ie selection processes etc. It is important that senior hospital managers support the process, particularly as it beds down. 25. Have you incorporated the increasing number of trained doctors into your workforce plans? The College has seen no real evidence of this in the hospital sector. 26. How will the new fixed-term specialty training posts fit into your structure? These posts are intended to be short lived, and it is important that workforce planning becomes sufficiently sophisticated to deliver run-through training programmes for the vast majority of UK graduates. 27. Will all trained doctors in secondary care be consultants? This is critical, or fully accredited specialist doctors will leave. 28. Do you believe all new CCT holders are fit to work immediately as consultants? CCT holders should have all necessary skills, but may benefit initially from a more experience mentor as they start work as consultant. 29. Is there a need for a new specialist grade below consultant? No. 30. How do you envisage the career options for doctors once they are on the specialist register? Fully trained doctors will be interested in the consultant posts for which they have been trained. It seems likely that accredited specialists will continue to develop over their career in line with service requirements and changing technology. Further training and “credentialing” will be required to allow for this future development. 31. Has MMC changed your relationship with your deanery? No direct comments. 32. Do you believe medical students and doctors in training receive adequate career advice? Careers fairs are not enough, and service pressures limit the opportunity for young doctors to undertake “taster” session in areas outwith their current rotations. 33. How can we put in place a better workforce planning system to account for this? What would it look like? Who should be responsible? This should be led by the Departments of Health across the UK, with input from the professions through the Colleges and the employers. 34. How will trained doctors whose knowledge and skills are no longer relevant access retraining? Who should be responsible for planning and funding retraining? Major change is rare, with more common changes in the balance of roles. Ongoing development will be required as an integral part of specialist recertification. Such training must be government funded to make best use of valuable clinical experience (see point 30 above on “credentialing”). 35. Are the new training curricula taking sufficient account of new technology and treatments? Training curricula are continually updated to reflect modern practice. The NHS must ensure that appropriate resources are available to ensure patients benefit. 36. Should more of the current work of doctors be taken on by others, for example nurse consultants, medical secretaries or other healthcare professionals in newly developed roles? The College welcomes extended roles for other healthcare professionals, each with their defined competences and training support, and supports the development of multi-disciplinary teams. Doctors are trained to be leaders within these teams and have ultimate responsibility for the patients. The importance of all team members (clinical and non-clinical) should not be underestimated, both in terms of quality of care and efficiency. 37. How will the development of the wider clinical team affect medical training programmes? No direct comments. 38. Would you like to see the current consultant contract amended and, if so, why? This is not directly College business, but it is important to ensure that job plans within these contracts continue to support professional activities for doctors. 39. Will the working practices of non consultant career grade doctors change as a consequence of their new contract? No direct comments. 40. Do you expect a significant number of doctors to move on to the specialist register through the Article 14 route? It is likely that this will continue in the short term. 41. What will the doctor of the future look like? Largely female, with well-developed team building and leadership skills. Hospital doctors will be increasingly specialised but working in larger teams across sector and organisational boundaries, but retaining their professional duty of care to individual patients. Training responsibilities will be shared between team members. Careers will develop with roles changing with experience, new technology and physical capability. 42. What skills and attitudes will employers be looking for? Skills and competences consistent with practising a high standard of medicine. 43. What roles and procedures will doctors perform in the future? What will be needed from medical training to deliver this? Colleges try to ensure training curricula and programmes reflect new developments as quickly as possible. Copies of this response are available from: Lesley Lockhart, Tel: 0131 225 7324 ext 608 [28 February 2007]
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