Scottish Government

Securing Future Practice: Shaping the New Medical Workforce for Scotland

7 HOW DO WE SECURE THE WORKFORCE?

Why is there a need to secure the workforce?

90. We quickly became aware that there were immediate pressures on the medical workforce. Across the country we learned of difficulties in retaining and recruiting consultants and general practitioners and in growing this workforce of 'trained doctors'. Standards of healthcare are being compromised. We feel these are matters that have to be addressed now for inevitably they:

• impact on service reform and on any plans to reshape the structure of the medical workforce; and

• make the task of estimating and planning our needs for doctors five to ten years ahead more difficult. We have already indicated that to plan for the future, we require intelligence informed by the needs of Scotland. But that can only be meaningful if we understand better what is happening now.

91. At first sight the reasons for current difficulties are not clear. We appear to have:

• numbers of graduates from our medical schools sufficient for Scottish needs, though this disguises the fact that our universities have always educated UK students intending to practise elsewhere in the UK. Prior to the recent expansion of medical school places in the rest of the UK, places in Scottish schools were some 18% of the UK total. By the time that expansion is complete that figure will have reduced to around 12%, but note that the Scottish population is 8.5% of the UK total.

• number of doctors per capita, while not generous by international comparisons, higher than that of our neighbours ( see Table 1); and

• more doctors than other UK countries in NHS employment ( see Table 5).

The medical workforce represents about 10% of the total NHSScotland workforce.

Table 5

UK NHS Doctors per 100,000 Population

92. We are also growing our workforce though perhaps not in the most effective way. We already have proportionately more doctors in training than elsewhere in the UK but annual growth in training grades since 2001 (in part in response to New Deal pressures) was more than double that achieved in the consultant and GP principal grades. Growth in the training grades has been mainly in response to service delivery needs and pressures on working hours, mainly in the SHO grade. This position is unsustainable and in part reflects lack of an effective and coherent policy for medical workforce planning ( see Table 6).

Workforce Growth by Grade, Scotland and England

What then is the problem?

93. Demand In Future Practice the factors influencing our ability to forecast demand have been set out. They are incomplete and merit further evaluation. We support the recommendation made in that Report that there is an urgent need to 'establish working assumptions for the numbers of specialists and other doctors required and to keep them under review'. We feel the need to do this is even more pressing. We have already recommended that: more consultants are required and that the current target should be revisited ( see paragraph 61); and that there is an an urgent need to plan the increase in general practitioner numbers ( see paragraph 62).

We already know the primary causes for increasing doctor demand:

• working hours;

• waiting times;

• quality of life issues;

• improved patient access; and

• training reforms.

We also recognise that some factors may decrease demand:

• service redesign;

• teamwork and skillmix;

• improvements in information technology; and

• changes in clinical practice.

94. Supply While there are undoubted pressures arising from an increased service demand we feel current problems faced by the medical workforce also reflect challenges to our supply of doctors and how they are managed. The evidence for this is persuasive.

95. As an indicator of what is happening we can look at flows across the service grades in 2002. These are set out and summarised in Annex D ⁴⁵ and show the extent of flows into and out of the NHSScotland across the workforce. This information helps us understand that:

• the medical workforce is dynamic with particularly significant movements shortly after graduation and in the training grades;

• there is considerable cross-border flow both ways which can work adversely when trying to secure the Scottish workforce; and that

• the SHO grade is large providing significant service and with major flows to and out of NHSScotland.

This has always been the case. Scotland has traditionally been a net exporter of doctors (particularly new graduates), but it is now clear that Scotland cannot afford a continuing loss of this magnitude.

96. Consultant recruitment - analysis of 373 Advisory Appointment Committees. ⁴⁶ The key findings are:

97. General practitioner recruitment - analysis of 180 appointment processes for GP partners in practices. ⁴⁸ Key findings are:

Of those GP partners appointed:

• 31% had been previously employed as GP locums;

• 18% had just completed their vocational training;

• 15% had been GP partners elsewhere;

• 10% had been employed as GP assistants elsewhere; and

• 10% had already been employed by the practice.

There is currently no target set to increase the GP workforce in Scotland, although a target has been set for an increase in the number of consultants. This is against the background of:

Workforce modelling suggests we would need to train and retain more GP registrars simply to maintain the current workforce, this before considering what the increased needs might be as a result of the proposed shift of work from secondary care and the demands that will be generated by Scotland's increasingly ageing population and the effect of the gender shift.

98. To help understand the problem better we sought information from consultants, GPs, and specialist and general practitioner registrars who left NHSScotland last year. Those who had retired or had died were excluded. 43 consultants, 150 specialist registrars, 178 general practitioner registrars and 53 general practitioners were identified. Some of the specialist and general practice registrars are likely to have rejoined NHSScotland subsequently. The response rate varied across these groups: from (18-21)% GP and specialist registrars; to (49-59)% consultants and general practitioners. The key messages from those leaving were:

• they only ever intended to train in Scotland ( common across all grades);

• there was a lack of suitable posts within the doctor's specialty or which offered an opportunity of immediate promotion ( around half of specialist registrars);

• career aspirations were best served by leaving ( around half of GP principals, consultants and specialist registrars);

• they were headhunted by other NHS employers ( over a half of consultants and one third of specialist registrars);

• advice was provided on personal career management ( two-thirds of specialist registrars and half of GP registrars); and

• lack of suitable part-time GP posts ( one-third GP registrars).

But despite that Scotland is a good place to work as a GP ( more than 75% of GP registrars or principals) and NHSScotland is a good employer ( more than half of consultants and three quarters of specialist registrars);

Key factors that might have persuaded them to remain were:

• a redesigned job ( around half of principals and consultants);

• more flexible working arrangements ( about half of principals and one-third GP registrars);

• better facilities and working conditions ( about half of consultants);

• improved training and development opportunities ( one-quarter of GP registrars and one-third of specialist registrars);

• career advice and management ( one-third of GP and specialist registrars).

Around one-third of specialist registrars and half of GP registrars indicated an intention to return to work as part of the Scottish medical workforce in the future.

What does this mean?

99. We face challenges in securing the staff that we need for substantive career grade posts in hospital, community and general practice. A number of factors conspire to cause us to lose more of our supply than is desirable. This impacts on the service provided by consultants and general practitioners making it more difficult to:

• maintain the service by replacing those who leave or retire; and to

• grow the service to meet new demands.

100. Although our findings vary across Scotland and across disciplines we noted that the number of vacancies for trained doctors, is growing. We believe some of these posts may be 'unfillable' and may only become attractive through service redesign.

101. We believe that the potential of our supply of doctors is not being realised. This has four consequences:

• service delivery is put at risk by our inability to staff the service to the level we currently require;

• standards of care can be put in jeopardy as employers struggle from often meagre fields of applicants to recruit the staff to fit a particular situation;

• our capacity to retain staff is diminished - our existing staff can become de-motivated and we lose them; and

• longer-term workforce planning becomes difficult.

102. Of course Scotland continues to attract staff from elsewhere but the balance of those who leave to those who are recruited is currently to our disadvantage.

The reasons for this are complex and varied but we believe the leakage of staff from our workforce is too great - there is hole in our bucket!

What should we do?

103. It is clear that there are major flows into and out of Scotland - particularly across the training grades. This volatility makes workforce planning and development challenging.

Opportunities arising from implementing the programme of reform set out in Modernising Medical Careers will help stabilise the workforce and contribute to securing a fit-for-purpose trained doctor-based service.

104. Scottish medical schools make an important contribution to NHSScotland: at least 66% of our consultants and 81% of GPs graduated from our five medical schools. However, many doctors who train in Scotland never intend to work here; others will leave to benefit from private practice opportunities not available in Scotland. To balance this we must expect to recruit doctors from outside Scotland and to invest in their recruitment. Retaining our own workforce is ever more important. Factors that could influence this include:

• the domicile of Scottish graduates - around 50% of current graduates from Scottish medical schools are Scottish domiciled yet we know they are around 2.25 times more likely to be working in Scotland 10 years later than graduates who are not Scottish domiciled;

• the pool of school leavers in Scotland - this will decrease by some 20% over the next 20 years; and

• moves to widen access to medical schools for Scots which could in the long-term support eventual retention.

We need to secure an adequate contribution to service delivery from those that we do train here - both undergraduates and postgraduates.

Strategies to retain and recruit

105. The Scottish Executive has acknowledged the importance of this area and commissioned a short life working group to oversee action on recruitment, retention, and careers across the whole NHS workforce. We strongly support the development of a strategy to deal with this issue and urge action.

106. We recognise that the medical workforce is at its most dynamic in mid-career: when doctors are mobile - searching for career and training opportunities; at other times when for family reasons career breaks are sought; and again, towards the end of careers when retention can become important to the service. The following elements of this strategy should apply across the doctor journey:

• A range of incentives These must be relevant, should be readily available, widely promoted and tailored to particular situations. They include:

  • flexible career and employment packages;

  • family friendly policies, e.g. better childcare;

  • step-down options, e.g. providing doctors with greater flexibility towards the end of their careers, allowing them to change roles and, when it is appropriate and is their choice to do so, to continue to contribute to the NHS rather than retire early. This is an important strategy that should be implemented quickly;

  • financial rewards taking advantage of new contractual arrangements for consultants and general practitioners;

  • support and recognition for training;

  • improved working conditions; and

  • correcting the over-supply in the SHO grade in a managed way which will help to produce greater numbers of trained doctors - GPs and consultants - and will also help to retain in Scotland those staff trained in Scotland.

• Better career advice and counselling This must be available throughout training and professional practice linking individual needs for career development to service demands.

• Robust promotion of careers in medicine in Scotland This requires a broad ranging approach engaging school children, medical students, postgraduate trainees and trained doctors and their families in Scotland and elsewhere. It will benefit from effective intelligence of current and anticipated vacancies linking to the output from training programmes. It is an approach that needs to be coordinated across Scotland and other professions taking into account the needs of specialties and geographical areas under particular pressure: for example we recognise particular needs in remote and rural areas and for academic medicine.

Effective workforce planning

107. The medical workforce faces short and long-term change as pressures to introduce new reforms are accommodated. Without sound workforce planning that task will be made more difficult. We will need to agree:

• what kind of doctors we need and how many and when;

• if we are succeeding in meeting actual and projected demand;

• when intervention is required to meet our goals and what form it should take; and

• how to encourage, evaluate and accommodate new solutions to service delivery including multi-professional working and new professional roles;

108. The case for improved workforce planning was set out in Future Practice and the recommendations accepted by the Scottish Executive. We welcome the commitment made to it in Partnership for Care.

109. We recognise that workforce planning is not an exact science and that there are limitations. But it retains a vital role in setting priorities and a direction of travel, in monitoring progress and in anticipating areas where service could be compromised. It has to be able to look to the long term as well as to inform more immediate challenges.

110. Although progress has been made we learned of a widely held view that a coherent approach to workforce planning in Scotland remains absent - a planning void, a lack of leadership. We believe that delivering effective workforce planning and development remains a priority. We are conscious that this agenda is pressing and that new arrangements introduced recently by the Executive will take time to mature.

111. Scotland needs to support and deliver workforce planning in both the short and long term, to look across the whole workforce and yet to retain the ability to focus on specific needs. This process must be robust, informed and authoritative and enjoy the confidence of the public, of Parliament and of partners within the service. Its goals must be clear and will have to be revisited and refreshed. We recommend that workforce planning requires central leadership working in partnership with local and regional planning groups. It is that capacity to plan and to deliver change in the workforce that is crucial now.

112. There is an urgent need to examine how these new arrangements can be better supported and geared to meet the needs of the changing service and in particular to communicate and deliver a more, strategic, cogent and integrated approach in Scotland.