A sustainable NHS workforce for the whole of Wales - 1000 extra doctors - Consultation Paper
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
1"
"
!
!
!
A sustainable NHS workforce for the
whole of Wales –
1000 extra doctors
Consultation Paper2"
"
Background – the staffing crisis in the NHS
It is becoming ever clearer that there has been a major failure in planning within the NHS.
Shortages of staff are being blamed for mistakes in medical procedures, ward closures, and
the inability of the Welsh NHS to offer core services at a wide range of district general
hospitals. This is the background behind Plaid Cymru’s recent pledge to recruit 1000 doctors
over two terms of government. By 2025, the NHS would have 1000 extra doctors under two
terms of a Plaid Cymru government.
The shortages go beyond specific specialisms. Many services are already only just about
coping and there are several significant challenges on the horizon that will jeopardize the
ability of Wales to have a comprehensive NHS. It is not feasible to “solve” the impending
crisis in access to GPs in rural and peripheral parts of Wales by centralising GP services in
fewer surgeries that patients will have to travel to. Recruitment in Wales must be increased
if the Welsh NHS is to have a future.
In considering medical staffing, it makes sense to look at the separate categories of medical
staff, as there are specific issues related to each.
Medical recruitment and training
Shortages in medical staff (doctors) are the most chronic and the most difficult to resolve .
This ranges from junior doctors right through to senior specialist consultants. The issues
behind these shortages are well documented and largely agreed upon:
• Impact of European working time directive – this has a particular impact on Junior
doctors and the available hours they have to work.
• Global shortage – consultants can choose where to work and doctors are essentially
picking places to develop a career. Many doctors are leaving the long hours and target
driven culture of the NHS for Australia, Canada and elsewhere.1
• Growth of lucrative career pathways in private medicine means that consultants are
able to offer the NHS fewer hours.
• Lack of alternative career paths in the sciences (e. g: Pharmaceutical industry)
available in Wales for those who decide not to go onto to becoming practicing
consultants.
• Over-reliance on junior doctors means that many junior doctors do not have
protected training time. As a result, the pass rates have been lower in Wales than
elsewhere. This can deter students from applying to study medicine in Wales.
• Culture in Welsh NHS not conducive to clinical research. Consultants build careers
through carrying out and publishing research. This also means access to more
modern treatments and technologies.
• Rural and peripheral areas suffer the additional barrier of the relative attractiveness
of major city locations in terms of recreation and quality of life, including for
family/spouses.
• The inverse-care law that means deprived areas often receive inferior health services,
as many medics choose to work in more affluent areas.
• There are greater prospects for professional development in hospitals linked to
medical schools, which tend to be located in cities.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
1
"See"http://www.bbc.co.uk/news/health624396884"for"3"case"studies"of"doctors"who"have"left"the"UK."3"
"
Specific problem areas
Although the problem of recruitment is across the board, estimates of the areas in secondary
care having difficulty in recruitment are contained in the Longley report and reproduced
below2:
Specialty No. HBs with National shortage?
recruitment difficulties
A&E 6 Yes
Paediatrics 6 Yes
Mental Health/CAMHS 6 Yes
Clinical Radiology 4 No
Medicine/Geriatrics* 4 ?
Anaesthetics 3 Yes
Microbiology 3 Yes
Obs and Gynae 3 Yes
These shortages are often used as a reason why services need to be reconfigured, as health
boards want to use their existing workforce in a more consolidated manner. However staff
shortages are more than just difficulties in recruiting to some specialisms, they stretch across
the NHS and into primary care. In other words they will exist after centralisation of services,
and could pose an obstacle to having types of service reconfiguration that would involve
delivering services in the community.
The Longley report demonstrates that there are wider problems than just consultant level
posts:
“Outside hospitals, the situation with GPs is also posing difficulties. Many GPs in Wales
are likely to retire over the next few years, and recruitment for GP training posts is
already proving problematic in some parts of Wales (an area where Wales has
previously been strong). This will also pose a challenge for hospital services, where the
aim is to transfer some services to the community.”3
These areas are not just rural parts, in the south Wales valleys up to 40% of GPs may
retire in the next decade without being replaced4. Overall about 20% of the medical and
dental workforce is over 50, and expected to retire in the next decade5. This, combined
with an expected growth in demand for general practice due to demographic changes,
poses a serious problem.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
2
"Professor"Marcus"Longley,"The"Best"Configuration"of"Hospital"Services"for"Wales"2012,"Summary"Paper,"page""
Longley"report,"summary"page"20."Hereafter"referred"to"as"the"Longley"Report"
3
"Longley"Report,"summary"page"21"
4
"See"http://www.walesonline.co.uk/news/health6news/2009/09/12/wales6facing6shortage6of6gps6as6more6
doctors6head6for6retirement691466624669232/""
5
"Longley"et"al,"The"Best"Configuration"of"Hospital"Services"for"Wales"2012,"workforce"paper,"page"15"4"
"
International Context– How Wales compares to the rest of Europe.
The graph below illustrates the issue. Wales has one of the lowest levels of doctors per
head in the EU.
Graph showing number of physicians in relation to population in EU6
Number!of!physicians!in!rela6on!to!popula6on!
in!the!EU!
60"
50"
physicians!per!10,000!
40"
30"
20"
10"
0"
Beligium"
Austria"
Spain"
Sweden"
Bulgaria"
Czech"Republic"
Germany""
Lithuania"
France"
Estonia"
Malta"
Scotland"
Slovakia"
Finland"
Latvia"
Luxembourg"
United"Kingdom"
England"
Northern"Ireland"
Slovenia"
Wales"
Romania"
Poland"
Cyprus"
Hungary"
Italy"
Denmark"
Training
Wales has the lowest rating for training experience, and too often in the past trainees have
been used inappropriately – with too much time spent in hospitals to fill rotas and not
enough time training. There are also concerns about a lack of supervision from more senior
doctors. Because of this, the GMC survey of trainees highlighted that in Wales, trainees work
more hours than anywhere else in the UK.7With medical schools in Cardiff, and more
recently Swansea and Bangor, that still leaves a great deal of hospitals too far from training
centres to make placements in more peripheral areas viable.
Recruiting people to undertake postgraduate training is a crucial part of ensuring there are
sufficient numbers of medics to provide a service, as people who complete postgraduate
training are more likely to stay practicing in Wales. In 2010 a Wales Deanery report
suggested 95% of doctors will stay in Wales after completing training8. Several issues act as
barrier in attracting trainees:
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
6
"Source'of'figures'is'World'Health'Organisation,'world'health'statistics'2013,'
http://www.who.int/gho/publications/world_health_statistics/EN_WHS2013_Full.pd'Wales'stats'derived'from'stats'wales"
7
"See"the"GMC’s"2011"Trainee"Survey"–"cited"in"Longley"report"workforce"paper,"page"5"
8
"Longley"workforce"paper,"page"5"5"
"
• There is a perception that places in Wales outside of the cities may lack the facilities
and resources available elsewhere, with some suggesting Wales has an image
problem.
• The medical schools in Swansea and Bangor are relatively new and do not yet have
the reputation that Cardiff has for teaching.
• The perceived lack of career opportunities for science graduates makes Wales
unattractive – we need to also be increasing opportunities for science graduates so
that students who decide medicine is not for them can switch to the other sciences
and have a reasonable prospect of employment.
It is clear that the above reasons are speculative. Without a proper rigorous analysis of the
reasons why students are not choosing Wales, reasons will remain speculative.
Nursing and the ‘non-medical’ workforce
The issues in nursing recruitment are very different. There is no shortage of people wanting
to work as nurses in Wales. The issue has been the lack of new nursing posts created by
health boards due to financial pressures. In recent years health boards have started to reduce
the number of senior nurse posts due to a feeling that there were too many nurses on senior
bands, and that reducing the number would save money. The Welsh Government has also
abolished the bursary as a means of supporting trainee nurses.
Nonetheless, there are issues to be addressed:
• Financial constraints have meant the loss of experienced nurses and advanced nurse
practitioners. This has meant that trainees have not necessarily had the mentoring
that has always been an informal part of nursing training.
• Health boards have also not invested in training and developing specialist nurses for
helping deliver care in community settings. At a time when health boards
propose to move services into the community, the number of specialist
nursing posts is being reduced.
• Furthermore there is an issue that trainee nurses are giving significant amounts of
unpaid work in the NHS as part of their training – this can reduce morale and it
increases the temptation for health boards to rely on trainees where a fully qualified
nurse is needed. This affects patient care and contributes towards students dropping
out.
• Rigid career structures mean professional development is limited.
• 29% of Nursing and Midwifery staff in Wales are over 50 years of age, and 12% are
over 55 years9. There is, therefore, an ageing workforce that needs to be replaced.
This is not yet at crisis stage, but there is a need to ensure nursing is an attractive
career option.
• The ageing workforce is cited by Longley as posing a challenge to the supply of
community nursing.10
• Although progress has been made in giving advanced nurse practioners additional
responsibilities such as prescribing drugs, there remains opposition from other
professions (for a variety of reasons) towards Nurse substitution.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
9
"Longley"workforce"paper"page"6"
10
"Longley"report,"summary"page"22"6"
"
Other health professionals
As with nursing, there is no shortage of people who want to become physiotherapists,
occupational therapists, mental health counsellors and so on, and to practice in Wales. The
issue is regarding health boards being able to fund the necessary posts and putting the
finance in place to use their role as part of community based services. Integration of health
and social care remains problematic and this is affecting development of these parts of the
workforce.
Healthcare support workers (HSW)
Recruitment of HSWs is not a problem, but the lack of training and career development
offered by some employers to HSWs is. There is an issue when some employers have used
them irresponsibly in place of nurses for financial reasons, as this can lead to a deterioration
of patient care. HSWs do play a part in delivering services, but recruitment is not an issue.
Additional Issues
There are additional issues that must be considered:
• The changing nature and delivery of services needs a high quality workforce which
can respond flexibly to new ways of working and new roles, and new developments in
how medicine is practiced.
• Healthcare is competing with other science based industries for young adults,
including graduates interested in science, and therefore requires a clear and
attractive career structure for the healthcare science workforce.
• Many of the issues identified are about ensuring the NHS workforce is planned
competently, with clear training and professional development for the workforce.
Conclusion
Wales faces a number of issues with training and workforce development that will threaten
our ability to provide an NHS in many parts of Wales over the next 10-20 years. Primary
care and community based services as well as some hospital services will be
particularly affected. We must be creative and innovative in how we solve these
problems, not just accept the arguments for removing services from peripheral areas. The
Welsh Government’s approach of centralising some services on fewer sites simply will not
work in primary and community based services.
Policy Proposals to solve the issues identified
There is no one single answer to the problems of recruitment, and the policies outlined must
be considered as each forming part of a coherent strategy of workforce planning. There is no
magic solution, but the policies will all contribute towards easing the pressure. Furthermore,
it should be borne in mind that once some of the policies start to see results, the Welsh
NHS will begin an upward spiral that sees it easier to recruit again. It will be
easier to recruit the 1000th doctor than it will be to recruit the 10th doctor.
This is because the pressures the service currently faces due to staff shortages are themselves
contributing towards the problem. Trainees do not get protected training time and
supervision when on site because of problems with short staffing. Hence they look elsewhere7" " to obtain this training. Beginning the process of increasing recruitment will ease this pressure. The more doctors we have, the easier it will be to introduce working practices like protected training time, better work-life balances, and opportunities for clinical networking. The proposals we have fall into a number of categories, although they are all linked and should be considered as part of a whole strategy. The policies fit into 4 main themes, although there are overlaps and links between them all: (1) Use of financial incentives to recruit and retain staff, (2) An innovative NHS that can attract staff, (3) Revamping and investing in training to attract the next generation of medics including home grown doctors, and (4) International Recruitment to plug the gaps over the short term. Some of the policies would start to alleviate the pressure on some problem specialisms, and these would be an obvious priority for the health service from day one. The full benefits of these policies would be after two terms of a Plaid Cymru government, once the initial set of trainees we had attracted had come through training and developed into fully qualified doctors. As problems have been stored up by successive governments in both Cardiff and London focusing on the short term, addressing them will require long term thinking and will show results after a duration of time. It will take ten years to fully turn around the problems of workforce planning. Nonetheless, all of the policies outlined below could start to be implemented from the first day of a Plaid Cymru government. Indicative estimates of how many doctors we would expect each theme to produce are given below along with estimated timescales of when results could be expected. Theme 1 – Financial Incentives for postgraduate recruitment and hard to fill vacancies We have seen earlier that there are challenges in recruitment to some parts of Wales, but also some specialisms. However the Wales Deanery survey finding that 95% of doctors who complete training in Wales will stay in Wales11 indicates that specific workforce problems can be resolved by ensuring postgraduate trainees train in the areas and specialisms where there are predicted to be shortages. One major policy that will help us to achieve these is for the Welsh Government to offer financial incentives for recruiting doctors to areas and specialisms where there are, or are predicted to be, shortages. For example, GPs in the South Wales Valleys. One approach to this type of policy initiative is the New Zealand bond scheme12. The Voluntary Bonding Scheme is run by the New Zealand Ministry of Health. It is an incentive payment scheme which rewards doctors who agree to work in hard-to-staff areas or specialties by making payments against the graduates’ student loan (or directly to the graduate if there is no student loan) and will provide sufficient payment to allow a doctor to have repaid the loan within four or five years. With the average debt for leaving medical school at £75,00013, this is no small incentive. In Wales we could adopt a system whereby doctors who agree to undertake postgraduate training receive a financial incentive to study in Wales. This could take the form of having a """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 11 "Cited"in"Longley"Report,"workforce"paper,"page"6." 12 "See"http://www.healthworkforce.govt.nz/our6work/voluntary6bonding6scheme"for"more"information"on"this" scheme" 13 "See"http://fds.oup.com/www.oup.co.uk/pdf/medicine/Cost_Medical_school.pdf""
8"
"
fixed amount of a student loan repaid for each year of service, once a qualifying period of
training had been agreed – in New Zealand a doctor has to spend 3 years in the
area/speciality before any payments are given. It is worth noting that a similar scheme
operated successfully under the One Wales government for the recruitment of
dentists which led to an additional 200 dentists being recruited14.
Other uses of financial incentives we propose to adopt include:
Golden hellos/bonuses for hard to fill vacancies
Where health boards had specific hard to fill vacancies, the Welsh Government would make
funding available to offer a ‘golden hello’ or additional financial incentive to fill the vacancy.
This would have to be administered nationally by the Welsh Government, and safeguards
built in to ensure posts genuinely were hard to fill. It would also be conditional on
guaranteed terms of service.
Directly salaried GPs
There is a long standing and historic problem with attracting GPs to work in specific
geographical areas. GPs are currently contractors to the NHS, and receive funding depending
on how they meet specific performance targets. Many GPs do not want the hassle of running
their own business or being self-employed, so establishing directly salaried GPs in such areas
could tackle the problem. This was how the number of dentists undertaking NHS work was
increased under the One Wales government. We would allow Local Health Boards to directly
fund these posts where they felt it was necessary.
Free training in exchange for contractual service obligations
About 70 countries in the world, including Norway and a number of Canadian provinces,
have financial incentives or mandatory registration requirements in favour of spending a
portion of a doctor’s training and early employment in an under-served area. This could be a
condition of receipt of free medical tuition. A point expanded upon in the section on training.
A Plaid Cymru Government would begin to offer these incentives as soon as possible,
prioritising areas and specialisms with immediate recruitment problems. However we also
expect the need for such policies to continue beyond the first term of a Plaid Cymru
government. We expect these policies to be able to recruit 350 doctors (200 in first term, 150
in second term).
Theme 2 – An innovative NHS to attract more doctors
This theme is an umbrella for the ideas Plaid Cymru has for creating a 21st century health and
social care system. These ideas must be viewed as part of a holistic approach towards
attracting new doctors, and there are clear links between the ideas here and the ideas
expressed later in the proposals for revamping and improving the quality of training. This is
a package of measures that should be seen as part of the whole.
With England’s NHS undergoing the most radical restructuring and shake up since it was
formed, and with many uncertainties over the role of private companies and GP consortia
commissioning, there is an opportunity to do things differently in Wales. An opportunity to
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
14
"See"http://wales.gov.uk/docs/statistics/2011/110818sdr1382011en.pdf."9"
"
retain the positive ethos of a service that is free at the point of delivery, and an opportunity to
create a health and social care service that looks after patients in all settings.
There are several things we need to do to make the NHS more appealing to work in, which
will contribute towards attracting people. These policies include:
Attracting more research funding
A major appeal to doctors who are choosing where to work is whether they have the ability to
conduct clinical trials and author research. Clinicians also like to work with the latest
technologies and treatment, which are sometimes only available as part of conducting
clinical trials. As noted, healthcare competes with other science based career paths, and
there is a need to offer an attractive environment for potential postgraduates to pursue
alternative careers if medicine does not work out. Opportunities to conduct research are
crucial to this. We have already proposed in our 2011 Assembly manifesto a number of
policies aimed to increase the amount of research money coming into Wales. These policies,
as well as further options outlined below, would help to attract research funding:
• An increase in spending on R+D as finance allows, with all Welsh government
departments being asked to contribute towards making Wales research friendly.
Areas of priority would include health, the life sciences and the digital economy.
• Research Councils would be called to account over persistent complaints that
proposals for Wales-focused research are not being funded. If there is no
improvement, we would seek the devolution of research funding on a per capita basis.
• Establishing closer links between these medical schools and existing hospitals so that
we can begin to improve the training experience. Mainstreaming clinical research
(see below) within the everyday practice of the NHS will help with this.
Mainstreaming Clinical Research within everyday practice
As noted earlier, clinicians choose where to work. Ambitious junior doctors want a career
path that is challenging and fulfilling. Many want to carry out clinical trials and get published
so that they can advance their own careers. Offering them the opportunity to do so will make
Wales a more attractive destination for a career in medicine. Furthermore it will attract
investment from research councils, industry and the life sciences. This would mean that the
NHS could begin the upward spiral needed to make it an attractive place to work.
There are also several innovative ideas that have emerged about mainstreaming clinical trial
research in recent years. Currently there is a limited evidence base for some treatments,
particularly in emergency settings, and there are problems with the representativeness of
samples in many clinical trials. There has been an emergence within the medical profession
of ideas of how real time trials can be conducted within a clinical setting15.
Modern technology makes it possible to conduct real time clinical trials across a variety of
locations. The computerisation of medical records makes both short term studies of what
works in emergency situations and longitudinal studies of treatments delivered in a
community viable. An article in the British Medical Journal explains the benefits of such
trials:
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
15
"For"more"details,"see"Ben"Goldacre,"Bad"Pharma,2012."10"
"
“Where there is no evidence to guide the decisions of doctors and patients, it is ethically
acceptable and actively desirable to offer willing patients the option of randomisation to
assess which treatment is preferable. General Medical Council guidance requires doctors to
resolve uncertainties about the effects of treatments, and good medical practice requires
that doctors communicate evidence clearly to patients. Randomisation with systematic
data collection is the most rational and ethical way to resolve uncertainties. Embedding
randomised evaluations within usual clinical practice can achieve this goal, and increase
the likelihood that clinicians will declare honestly to their patients when there is
uncertainty about the relative merits of alternative treatment options.”16.
Technology also means that clinical trials no longer have to take place in the top university
hospitals. The Welsh NHS could be a world leader in conducting trials as a core part of its
activity. A research friendly culture would not only improve the quality of treatment
available as more knowledge was gathered, but would attract clinicians hoping to be involved
in research, and also attract research money and associated life science industries.
This is one area where the poor health of the population of Wales could be turned into an
advantage. Areas such as the south Wales Valleys could be pioneers in adopting new
treatments for respiratory conditions due to the high levels of such conditions in these areas.
GPs in the valleys could be involved in monitoring the long term effects of treatments (with
computer software already built to ensure minimal additional work for the GP if he or she
chose not to be closely involved in the studies), with the Royal Glamorgan Hospital acting as
a research centre for these conditions. Elsewhere in Wales, Bronglais and Withybush
hospitals could act as research hubs for studies of rural health and innovative ways of
delivering health services to communities where these services are at risk.
To encourage a culture of research we could adopt additional policies such as:
• Ensuring universities form links with health boards for conducting research. All
medical staff should be made aware of opportunities to participate in research.
• Developing and enhancing single electronic patient care records.
• Rolling out the software for recording trial results to GP surgeries – software has
been developed and the cost of rolling out is small.
• Establishing a Welsh journal of medicine for the recording and publication of trial
results. This would also help to stimulate economic activity around medicine as
private research companies would view Wales as a location where research happens.
Scottish Example
In Scotland there has been a substantial effort made at attracting the top researchers in
medicine, and also in mainstreaming clinical research. The ‘Get Randomised’ campaign17
aiming to increase patient participation in research is one such example and part of the
reason Scotland has been able to attract investment from the Sciences generally, as outlined
below. This is one reason why Scotland has been able to increase its levels of doctors to EU
levels.
Merging Health and Social Care
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
16
"Pragmatic"randomised"trials"using"routine"electronic"health"records:"putting"them"to"the"test,"BMJ'
2012;344:e55'available"from"http://www.bmj.com/content/344/bmj.e55""
17
"See"http://getrandomised.org/"for"more"details"11" " The case for integrating health and social care services for adults is a strong one that has been discussed for many years. Plaid Cymru will be consulting on the precise structure of the new health and social care service separately. It is increasingly clear that such a merged service will undoubtedly prove to be attractive for those doctors increasingly concerned about the artificial barriers that their patients are facing in accessing care. A Paperless NHS Wales needs to lead the way in introducing a paperless NHS. This will enhance the attractiveness of the NHS to staff, by demonstrating that the NHS is innovative and wants to free up staff to care for patients rather than face bureaucracy and paperwork. A common problem faced by staff is the excessive bureaucracy and paperwork that needs to be completed, and is justifiably a source of constant complaints. This could be reduced with significant investment in ICT. For example, we are all familiar with the problems in the ambulance service, but this is partly due to ambulances being out of action as a result of Paramedics having to complete duplicate paperwork on various incidents. A simple tablet computer could reduce time spent completing paperwork and mean more ambulances back in action. A second benefit is that technology would enable clinicians to communicate without being on the same site, test results and x-rays can be electronically sent, and clinical advice can be given by a consultant remotely. This is especially helpful in the delivery of health in rural areas, where travel times to hospitals can be lengthy. It also enables smaller hospitals to maintain safe services as they can have access to consultants to provide advice for middle grade doctors remotely. A paperless NHS will not only save money to re-invest in patient care, it will enable patient records to be easily shared and lead to better treatment. In the context of this paper on recruiting doctors it must be noted that a paperless NHS will also be popular with the staff who have pages of paperwork to be complete each day. A paperless NHS will reduce the time doctors spend on paperwork, freeing up time to doctors to care for patients, conduct research, or undergo further training. Options for Nursing and other health professionals An innovative NHS is also an NHS that will value the role of other health professionals. Whilst this paper focuses on medics, other health professionals also need to be encouraged to play a more important role in the NHS. Using the expertise and support provided by other health professionals will enable medics to focus on using their skills. Ensuring a greater role for other health professionals will also therefore increase the attractiveness of Wales to work as an indirect benefit. A network of specialist nurses is increasingly an essential part of any health and social care service that seeks to be preventative and enabling people to stay in their homes. Unlike in medical recruitment, the main issue with regards to specialist nursing is the posts health boards are willing to fund. Although not the focus of this paper, it is important to outline that we have policies designed to improve the number and role of specialist nurses and other health professionals that include:
12"
"
• A separate ‘invest to save’ fund for health to enable health boards to finance the
creation of specialist nursing posts as part of wider changes designed to help manage
conditions in the community. The introduction of three year rolling budgets will help
here.
• A greater role for specialist nurses/other health professionals within GP surgeries to
reduce reliance on GPs (patients could book directly with specialist nurses)
• Buchanan18 suggests that we need to broaden the recruitment base for nursing –
arguing that reliance on young women as stereotypical nurses is holding the
profession back.
• Carrying forward the agenda of nurse substitution where clinical evidence suggests
doing so would be safe and lead to patient improvements. This would also help to
reduce the reliance on doctors to cover rotas when not necessary and would be part of
an alternative to centralising services.
• Ensuring continuous professional development for nurses to ensure career
progression. Many of the problems identified in relation to junior doctor training
(over-use, lack of supervision etc) also apply to nursing.
Wider promotion of Wales as a place to live/work
Many of the policies outlined in this paper are essentially about promoting Wales and
developing expertise in Wales. Contrast this with the Welsh Government’s intention to move
specialist neo-natal services to England, which is essentially an admission of surrender to the
idea that Wales should be developing expertise. Above all, we need far greater
appreciation of our existing strengths. Why can we not aim to develop expertise and
specialisms to attract patients from England?
With services in Shrewsbury and Chester under threat because of English NHS reforms,
there is an opportunity for Wales to develop these services. A firm commitment to retaining
and repatriating specialisms from the English NHS would send a clear signal about the
commitment of Wales to retain and invest in a truly public health service whilst England’s
service disintegrates into various competing private health providers.
However, promotion of Wales requires wider work. The idea that Wales is perceived
negatively by potential doctors needs to be addressed. The Health Service could contribute
towards challenging such negative myths through:
• Far greater promotion of our strengths, including marketing of our existing centres of
excellence to patients in England (taking advantage of the patient choice agenda in
England)
• Promoting Wales’ natural beauty to attract people to live in Wales.
• Quality of life - A doctor’s salary in Wales will go further than in the South East of
England and enable somebody to have a better lifestyle.
But there are also policies the Welsh Government needs to adopt to contribute towards
making Wales an attractive place to live, including:
• Investment in the broadband network beyond cities.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
18
"See"http://eresearch.qmu.ac.uk/16/1/bmj2.pdf""13"
"
• Better public transport so that junior doctors living in rural areas can access the
attractions of cities such as Cardiff.
• Ensuring cultural activities are available outside of Cardiff (doctors enjoy cultural
activities like any other profession)
• Taking advantage of other successes (such as premier league football) to promote
Wales on the international stage.
An innovative NHS, using all of the ideas above, is an important part of attracting and
retaining doctors. However the benefits of these policies will be felt in the longer term. It will
take time for word to spread amongst the profession, and for doctors to be able to see the
benefits of some of the policies. Hence we think in the first term around 50 doctors will be
recruited as a result of these policies (although patients will benefit as well), but a further
200 in the second term of a Plaid Cymru government as word gets around and the full
benefits of the outlined policies.
Theme 3 – Improving Doctor training and investing in the next
generation of Welsh Doctors.
Improving training capacity is a crucial part of recruiting and retaining students. Longley
writes:
“A considerable proportion of all professional education is done after initial
qualification, and delivering such continuing professional development requires close
cooperation between the NHS and the Universities – to release staff for new roles while
they are still under pressure in their current role, and to anticipate what new skills are
going to be required.”19
The existing capacity for training in the Welsh NHS is based on medical schools in Swansea,
Cardiff and Bangor, with Swansea and Bangor relatively new facilities. To attract the next
generation of doctors there are several policies we propose to adopt to build on the new
facilities and revamp the training experience.
Investment in developing Welsh Medical Schools
As well as Cardiff’s excellent reputation that needs to be utilised more, in recent years there
has been an expansion in medical schools in Swansea and Bangor,. These medical schools
must be considered as a key part in training the next generation of Welsh doctors.
The success of these medical schools can be illustrated by the fact medicine as a course is still
over-subscribed, leaving many prospective Welsh students forced to study in England or
Scotland, and many students from elsewhere unable to study in Wales. Having developed
friendships and relationships outside Wales they are more likely to stay there in future. So
expanding the number of places at the Welsh medical schools will increase the number of
likely applicants for Welsh posts, and should be regarded as essential. We would therefore
propose to expand the number of places at all three medical schools, starting with an
immediate increase of places annually.
To further attract and retain medical students we would also consider making medical school
free for Welsh children, in exchange for contracted compulsory service upon graduation.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
19
"Longley"Report,"Summary"page"21"14"
"
This would be a similar scheme to the financial incentives discussed earlier, and would
operate alongside them.
Medical students currently leave training with an accumulated debt (including fees,
accommodation and living costs) of around 75k. Clever use of the kinds of financial
incentives mentioned in theme 1 can significanty increase the attractiveness of Wales as a
place to train and work.
Although we aim to attract more medical students from all parts of the UK, as medical
students with a local connection are more likely to seek training places and employment at
Welsh institutions, it would make sense to focus on increasing the number of welsh students
who attend medical schools.
We propose that all our medical schools have a quota for Welsh students to ensure that
students in Wales who want to remain here to study medicine have the opportunity to do so.
We need to increase the bilingual ability of the medical workforce. Therefore we propose that
appropriate quotas for Welsh speakers are set, subject to those students meeting the
required academic standards.
We would also adopt the following policies to ensure that the medical schools were linked in
with the operation of the NHS and that education and research were more closely embedded
in the NHS:
• Investment in ICT technology to ensure students can gain from the knowledge and
expertise of consultants in units outside of areas served by these medical schools.We
would encourage senior consultants to take a bigger role in training and mentoring
younger doctors.
• When finance allows, we would fund small satellite campuses at rural and peripheral
hospitals so that students would be able to spend some of their time training in
different environments.
Improving the training experience for postgraduate doctors
The over-use of trainee doctors to fill rotas has led to Wales having one of the highest failure
rates in the United Kingdom. Because too many trainee doctors have been used to plug gaps
in the rotas there has not been the focus on protected training time, trainees have had little
supervision from consultants and as a result have not been able to pass exams. There has
been a knock on effect with students, therefore, looking elsewhere to institutions where pass
rates are higher, and they will have the time available to train.
The Wales Deanery has taken steps to address this through reducing the number of sites in
which trainees have been working. This has inevitably led to a knock on effect on the types of
services available in those hospitals where trainees are no longer being supplied. Indeed, the
lack of trainees has been one of the drivers behind proposals to centralise services. With
trainees no longer available to plug the gaps in rotas, some hospitals have been left with staff
shortages
Plaid Cymru remains unconvinced that centralising crucial services such as Accident and
Emergency away from peripheral hospitals is an appropriate response to staffing shortages,
and this paper on workforce planning is partly offering an alternative way. The poorer15" " transport, rural and scattered nature of the population, and higher prevalence of poor health make centralising such services too risky for patients in our view. However we acknowledged the concerns of the Deanery, and accept that changes to the way trainees are used is important. The Deanery is merely playing with a poor hand and has been required to take action following years of neglect by the Welsh Government. We do, however, believe that the concerns of the Deanery can also be addressed, in relation to some services, through other means. We would ensure through regulation that all trainees had protected training time and health boards would be required to ensure that their rotas were not reliant on trainees. We also think there is a case for ensuring trainees can gain experiences in different communities, and would be reluctant to centralise trainee placements purely in urban areas and cities. A Plaid Cymru government would therefore acknowledge the need for trainees to have protected time and consultant supervision, but would engage in discussions with the Deanery to ensure that this was not at the expense of providing doctors with the experience of delivering healthcare in rural or peripheral hospitals. This point is explored further in the conclusion of why centralisation is not the answer. The Greenaway Review The Greenaway review20 into the future of training provides a timely contribution to the debate. Professor Greenaway has argued that training needs to be revamped to meet the needs of the future NHS, with far more focus on generalists and training doctors with the skills necessary to move between specialities Greenaway concludes that the: “Public need more doctors who are capable of providing general care in broad specialties across a range of different settings” To achieve this, Greenway recommends that: “Postgraduate training needs to adapt to prepare medical graduates to deliver safe and effective general care in broad specialties... Medicine has to be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers.”21 Greenaway’s report is intended to drive medical training for the future needs of the service, and emphasises in several parts that local patient needs should drive the training in particular local areas. The context of an ageing population with multiple co-morbidities (multiple chronic conditions) requires doctors to be generalists if they are to manage these patients. Although highly specialised doctors will always be part of the NHS, the future medical workforce will include far more generalists to work alongside these specialists. Currently reconfiguration of training is partly driven by the desire to create opportunities for everyone to specialise, and not enough focus is given to generalist doctors. The future workforce requires both, and the training offered needs to reflect this, with trainees experiencing different healthcare environments. Wales can offer both opportunities for trainees to develop specialisms for those who wish to pursue this. The demographics and """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 20 "Professor"Greenaway,"Securing"the"future"of"excellent"patient"care,"2013"available"from" http://www.shapeoftraining.co.uk/reviewsofar/1788.asp"" 21 "Greenaway"2013,"page"5"
16"
"
scattered nature of the population offers a better opportunity for Wales to develop the
generalist doctors Greenaway identifies as necessary.
Welsh medium medical training
A crucial point to consider in the future workforce planning of the Welsh NHS is the
requirements of Welsh Language speakers and how to ensure that sufficient numbers of
health professionals, including doctors, can speak Welsh.
Communicating with patients is an essential part of delivering good quality care. Many
elderly patients or those with learning difficulties lose the ability to be bilingual (and need to
be cared for by Welsh language professionals. It is essential that a share of the extra doctors
are recruited Welsh speakers and that the service continues to consider the needs of the
Welsh speaking population.
Whilst opportunities to learn the Welsh language should be provided to all, to increase
Welsh language provision over the long run medicine should be promoted as a career option
for students from Welsh language communities, with bursaries and guaranteed places in
medical school for Welsh speakers who meet the requirements.
We would therefore propose that specific efforts are made to promote medicine in Welsh
medium schools. We would also propose considering the following:
• Medical schools, working with Coleg Cymraeg, would be encouraged to increase the
number of modules delivered through the medium of Welsh
• We would establish quotas for medical schools to offer a number of places to Welsh
speaking students, subject to them meeting the required academic standards.
• Bursaries and financial incentives to ensure Welsh speaking students can undertake
medical courses.
Promotion of Medicine and the sciences in Wales
If we are to succeed in solving our recruitment options, and in particular in ensuring we have
Welsh language staff, then we need to do more to promote medicine and the sciences in
Welsh education. This needs to involve marketing of the sciences more creatively in Welsh
schools. In particular medicine should be promoted as a career option for children from low
income families who are more likely to want to study locally. This is because the length of
training involved in becoming a doctor may be acting as a barrier to children from low
income families choosing degrees in medicine over alternative subjects. We need to identify
talented Welsh children at younger ages and establish mentoring schemes to encourage them
to study the sciences and choose medicine as a career.
Attracting life sciences to Welsh Universities
Medicine does not exist in a vacuum, and the success of medical schools requires a wider
pro-science environment. If potential medical students also see careers in the sciences
available to them in the same location, it will enhance the attractiveness of a specific medical
school. There will also be wider benefits to the Welsh economy.17"
"
We should also be looking at attracting the top names to Welsh universities as a starting
point for attracting research money and spin-off science industry. The example of the revival
of some universities in Scotland is an excellent example here:
Scotland
In Scotland, the SNP government has made attracting research funding and mainstreaming
research a key part of their economic strategy. They seek out the experts and ask them to set
up research teams. One example of this is the successful efforts they made to recruit Sir
Phillip Cohen. Professor Sir Philip Cohen22 is one of the most important scientists working in
the UK higher education sector today. He has been the key influence in developing the
College of Life Sciences in Dundee from a converted stable block with 11 scientists to a
complex housing almost 800 staff from 53 countries.
Sir Philip's contribution has been the outstanding catalyst for the economic regeneration of
Dundee into one of the fastest growing biotech clusters in the UK today. He has developed a
strategy for attracting some of the best scientists to Dundee (more than 1% of the world's
most cited scientists in their field are located there) and has been instrumental in raising
more than £35m over the past 10 years to ensure that world-class facilities and scientists are
the norm in Dundee. He has been instrumental in attracting a range of biotech and
pharmaceutical companies to site their headquarters in Dundee resulting in more than 15%
of the local economy now being derived from life sciences. As a result of this, Dundee will
attract medical students who will go on to practice in the Scottish NHS.
These policies will take time to produce the additional qualified doctors due to the time
needed to train. We would expect to see an increase in training numbers immediately – as
one of the first acts of a Plaid Cymru government would be to increase the training posts
available. In the second term of a Plaid Cymru government we would start to see the benefits
of these policies, and would expect the first set of trainee doctors to arrive on the wards, with
as many as 300 doctors from this policy.
Theme 4: International recruitment from within and outside the EU
The previous themes are aimed at having a medium to long term impact, as medical training
takes several years. But as highlighted earlier, there are specific specialitisms that need
additional staff immediately. Therefore international recruitment has to be seen as part of
the answer to recruitment problems, particularly in the short term.
At the same time, stricter immigration controls imposed from Westminster have hindered
the ability of the NHS to recruit from places such as India and Pakistan – countries that have
historically supplied doctors to the UK. So this section explores how a Plaid Cymru would set
about plugging the gaps through international recruitment.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
22
"See"http://www.dundee.ac.uk/externalrelations/40/cohen.html"for"full"details"18"
"
Recruitment from within the EU
As immigration controls do not apply within the EU we propose that far greater use of the
EU is made to plug the gaps. Recent FOI releases23 have revealed just how little use has been
made of the EU in Wales. The table below shows this in detail:
Health Recruitment drives and events attended
Board
Aneurin None
Bevan
Abertawe One trip to Spain in November 2012 – 14 posts offered and
BMU being processed
Betsi Used an agency for limited recruitment in Hungary 2011
Cadwaladr
Cardiff and Trip to Romania in 2010 (when restrictions applied)
Vale
Cwm Taf None
Hywel Dda Two trips to Spain
Powys None
More use must be made of our EU membership, and a Plaid Cymru government will make
more use of recruitment from within the EU to fill vacancies. The successful results of
ABMU’s trips to Spain show that using the EU is an avenue that must be further explored to
plug short term gaps. We would ensure that this recruitment drive was undertaken centrally
by the Welsh Government, rather than being content to leave matters to local health boards.
At the EU level, Plaid Cymru would work to ensure the portability of medical qualifications
to address any barriers that may exist for recruiting staff. Furthermore a Plaid Cymru
government would ensure that our medical schools established exchange schemes with
medical schools in the EU so that students could benefit from different environments. We
would propose that the Welsh NHS extended such exchange schemes to existing staff.
Increasing the links would then mean doctors considering moving would already have
cultural links to Wales. With austerity likely to remain in Southern Europe for several years,
many doctors would enjoy working in a Welsh NHS where there are vacancies, opportunities
for training, and a government committed to a National Health Service.
Further Recruitment Internationally
Further afield there are many examples of such exchanges. Cuba exports doctors in
healthcare and has agreements with about 90 countries around the world, including
countries like Germany. It has recently sent 4,000 doctors to Brazil to address lack of
provision of healthcare in rural areas. Other countries have made similar arrangements to
facilitate sharing of information. Countries that adopt such exchanges can mutually benefit
from sharing information and best practice.
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
23
"Freedom"of"information"requests"submitted"in"July"2013"by"Plaid"Cymru"to"all"seven"health"boards"You can also read
