A sustainable NHS workforce for the whole of Wales – 1000 extra doctors

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A sustainable NHS workforce for the whole of Wales – 1000 extra doctors

Consultation Paper

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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: • •

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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.

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See http://www.bbc.co.uk/news/health-­‐24396884 for 3 case studies of doctors who have left the UK.

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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 A&E Paediatrics Mental Health/CAMHS Clinical Radiology Medicine/Geriatrics* Anaesthetics Microbiology Obs and Gynae

No. HBs with recruitment difficulties 6 6 6 4 4 3 3 3

National shortage?

Yes Yes Yes No ?

Yes Yes 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.

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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/health-­‐news/2009/09/12/wales-­‐facing-­‐shortage-­‐of-­‐gps-­‐as-­‐more-­‐ doctors-­‐head-­‐for-­‐retirement-­‐91466-­‐24669232/ 5 Longley et al, The Best Configuration of Hospital Services for Wales 2012, workforce paper, page 15

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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 50 40 30 20 10 0

Austria Spain Sweden Italy Beligium Bulgaria Czech Republic Germany Lithuania Denmark Hungary France Estonia Malta Scotland Slovakia Finland Latvia Luxembourg United Kingdom England Northern Ireland Cyprus Slovenia Wales Romania Poland

physicians per 10,000

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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:

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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 8

See the GMC’s 2011 Trainee Survey – cited in Longley report workforce paper, page 5 Longley workforce paper, page 5

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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: •

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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.

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Longley workforce paper page 6 Longley report, summary page 22

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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: •

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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 elsewhere

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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

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Cited in Longley Report, workforce paper, page 6.

See http://www.healthworkforce.govt.nz/our-­‐work/voluntary-­‐bonding-­‐scheme for more information on this scheme 13 See http://fds.oup.com/www.oup.co.uk/pdf/medicine/Cost_Medical_school.pdf 12

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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

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See http://wales.gov.uk/docs/statistics/2011/110818sdr1382011en.pdf.

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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: •

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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:

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For more details, see Ben Goldacre, Bad Pharma,2012.

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“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

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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 Â Â 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:

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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: •

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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.

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See http://eresearch.qmu.ac.uk/16/1/bmj2.pdf

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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.

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Longley Report, Summary page 21

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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: •

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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 poorer

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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

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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.

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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

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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 Board

Recruitment drives and events attended

Aneurin Bevan Abertawe BMU Betsi Cadwaladr Cardiff and Vale Cwm Taf Hywel Dda Powys

None One trip to Spain in November 2012 – 14 posts offered and being processed Used an agency for limited recruitment in Hungary 2011 Trip to Romania in 2010 (when restrictions applied) None Two trips to Spain 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

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Developing countries would also benefit from an arrangement where we trained doctors from those countries, for them to return to their country following training. Whilst training of course, they would be providing additional cover in Welsh hospitals, thus enhancing the service.

There are advantages to the developing country in exporting doctors for temporary periods – the doctors benefit from high quality training in the latest techniques and will develop experiences in complex treatments that they would be unlikely to gain at home. The key is to make the relationship between Wales and the developing country work in the interests of both parties.

We would propose that doctors recruited from such countries were employed on a temporary basis. We would also compensate the developing countries financially and explore ways of sharing knowledge through exchanges and ensuring staff returned home as better doctors. Such arrangements would also offer our own doctors the opportunities to undertake development work, which may contribute towards making the Welsh NHS more attractive to those doctors who would want this option.

Using international recruitment to recruit doctors could be a policy utilised in the first term of a Plaid Cymru government, and could be used to plug gaps whilst we trained a new generation of Welsh home grown doctors. Hence we would expect 75 of these doctors to come within the first term of a Plaid Cymru government, and a further 25 in the second term of a Plaid Cymru government.

Financial Considerations There are several policies proposed in this paper that would have an impact on the finance available to the health service. Many of the policies proposed would have positive financial impacts over the long run (for example: a paperless NHS, bringing research money into the NHS and merging health and social care). Furthermore, the net result of an extra 1000 doctors would be better patient care through safer levels of staffing, services available locally, and better access to GPs to enhance community provision of health care.

It is vitally important that people recognise that cutting staffing levels in the NHS is a false economy – there may be immediate savings from reduced salary costs but lack of staff means patients spend longer in hospital. An experienced nurse observing a patient for complications can mean the difference between a patient spending a week in hospital rather than a month in hospital. Good patient care costs less in the long run.

Moreover, as health boards themselves have been pointing out, reconfiguration has never been motivated by finance, but by staffing shortages. Centralising services will lead to an increase in costs. The South Wales programme, if it decides on a 5 site model, will add £14 million to staffing costs as it requires an increase in doctor levels to deliver24. World health Organisation research also suggests that bigger hospitals are more inefficient, leading to diseconomies of scale. The optimal hospital size, according to the World Health Organisation, is between 200 and 600 beds. To illustrate this size, the Heath Hospital in Cardiff has roughly 1000 beds, and Morriston has roughly 750 beds. Royal Glamorgan, by

24

Information given at Consultation event June 2013 in Llantwit Major

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contrast, has around 580 beds. Placing more services into Cardiff and Morriston will result in increased costs.

Finally 1000 extra doctors would reduce expenditure on agency and locum staff, which is currently around £60 million a year. There are, therefore, savings that would be generated from some of the policies above.

However, adding 1000 doctors to the payroll of the NHS is not an insignificant cost.

Estimating this cost is an imprecise science. The biggest difficulty here is the sheer variety of salaries available – there is a such a variety of roles and within the context of a 9 point scale and there are salaries as low as 22k and up to 102k. Contradictory information on salaries is also unhelpful25. However, to provide estimates for this paper, we have taken the midpoint/median of the salary scale. On the advice of the Assembly Research Service we’ve also added 20% to our estimates to cover additional costs such as employer NI. The precise makeup of the additional 1000 doctors will be dependent on a variety of factors.

However the calculations below illustrate what some potential costs could be 100 consultants (82k) to maintain services in DGHs: £8.2 million 200 middle grade doctors (associate specialist)(62k): £12.4 million 300 fully qualified GPs (70k): £21 million 400 junior doctor posts (33k): 13.2 million Total for 1000 = £54.8 million Add 20% for employment costs: £11 million This would give a total of £65 million to be added to the salary costs of the NHS. Within the context of a budget line of £6 billion, this is around a 1% increase in the budget. Inflation in salaries would increase this over the long run, so we should really regard the costs as between £50 million and £200 million.

As we are also proposing to use financial incentives such as a bond scheme that they use in New Zealand to pay off student debt for hard to fill posts we should also estimate a cost for this. If we assume we pay 20% of the debt for each year of service/or deferred until X years service given to NHS. It would be possible to avoid these costs entirely within the first term of government if we adopt the deferred wipe out scheme, but for the purposes of estimating potential costs we should, assume a 50% wipeout after year 3 and then 10% each additional year. So with average student debt for medical school estimated to be £75k26, this would be an additional cost of £52.5k for wiping out 70% of debt per doctor.

If we assume such a cost is needed for 250 posts then this would be a one off cost of £13.1 million over the course of one term of government.

These costs could be absorbed within the existing health budget, particularly as they would provide an alternative to costly reconfigurations as well as giving health boards options to improve capacity and invest in prevention of ill health. However, with austerity likely to remain on the horizon regardless of which who wins the 2015 Westminster election, it would make sense for Wales to start examining separate sources of revenue to start funding these policies before the public finances start to improve from 2018 onwards.

25

See http://www.nhscareers.nhs.uk/explore-­‐by-­‐career/doctors/pay-­‐for-­‐doctors/ and http://bma.org.uk/practical-­‐support-­‐at-­‐work/pay-­‐fees-­‐allowances/pay-­‐scales-­‐associate-­‐specialist for contradictory salaries 26 See http://fds.oup.com/www.oup.co.uk/pdf/medicine/Cost_Medical_school.pdf ),

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Pigouvian Taxes It is a well established principle that governments use pigouvian taxes on harmful substances. Such taxes have both the characteristic that they reduce consumption of a product and also raise revenue. Taxes on cigarettes and alcohol have been used in the UK for decades, and the revenue raised has funded public services.

Obesity is now widely regarded as the next major public health challenge, and will be costing the NHS billions every year if it is not tackled. Yet sugary drinks and unhealthy food remain untaxed. A tax on sugary drinks has been proposed in several U.S states and the republic of Ireland, and remains under consideration in several European Countries.

We estimate a tax of 20p per litre would raise £60 million. This is one source of revenue we could use to pay for 1000 doctors. Explicitly linking taxation on unhealthy products with spending on the health service is one way to highlight the benefits of such taxation. It would help to tackle obesity. With diabetes costing around 10% of NHS costs27, it is quite clear that consumption of unhealthy food must be addressed.

When the full benefits of the other policies we propose come to fruition, this revenue can then be re-invested elsewhere in the health service.

Under the proposals of the silk commission, we expect the Welsh Government to have the power to levy these kinds of taxes. The policies outlined in this paper are examples of the kinds of policies that could be funded through these kinds of taxes.

Conclusion Why centralisation of services is not the answer to poor workforce planning.

It remains the belief of many within health boards, that in order to recruit more doctors, we have to centralise services so that we can improve the training experience and make Wales more attractive to study medicine. The argument is that by operating services on fewer sites, we will have large enough rotas to ensure protected training time, and enough patients through the door to ensure trainee doctors can develop the skills to pass exams.

It is an argument that has some merit – it is not acceptable to deny junior doctors time for training and development because of a wider shortage of staff. But improving the training experience does not have to mean removing core services from rural and peripheral hospitals. Even the panel set up by the Minister to examine service changes in Hywel Dda stated clearly (in relation to neo-natal services): “The non-availability or limited availability of trainee doctors does not preclude the delivery of a Level 2 neonatal service. Alternative models include consultant and/or post Certificate of Completion of Training non-consultant/SAS (Staff Grade, Specialty Doctors and Associate Specialists) delivered services (RCPCH 2012).”28

27

See http://www.diabetes.org.uk/In_Your_Area/Wales/Diabetes-­‐in-­‐Wales/ Scrutiny Panel Report on service change proposals in Hywel Dda 2013, available from http://www.senedd.assemblywales.org/documents/s21388/September%202013%20Report%20-­‐ 28

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It is worth also highlighting that the service change plans in the South Wales programme also do not require every site to be providing training. The South Wales programme has specified only three sites will have trainees on the rota. It has also emerged that there are only enough doctors to be able to provide a full rota of staff on these three sites, and that delivering a fourth or fifth site will involve a significant increase in recruitment. Hence if it is possible to significantly increase recruitment to deliver a reconfigured service, it should be possible to recruit further medical staff to a few extra sites to maintain current service provision if we adopt the additional policies outlined above. In other words, reconfiguration is not necessary to ensure protected training time for trainees.

This leads into the second reason why the minister has stated reconfiguration is needed, which is that trying to provide the services across too many sites will mean that there are not enough patients to enable doctors to maintain and develop their skills.

We believe such an approach to be short sighted one which exposes an inability to find creative solutions. With an ageing population, an increasing prevalence of chronic conditions, and our emergency care system already overstretched, it is absurd to pretend that our district general hospitals simply will not have enough patients. Doctors in A+E departments are already dealing with an overstretched service. By definition, an accident and emergency department will have to deal with a range of conditions that come through the door, and identifying the appropriate treatment is a core part of the service. Many patients who self-present can initially be wrongly diagnosed through triage as having conditions that a nurse could treat, but the presence of doctors makes these kinds of mistakes less dangerous. It would thus be equally absurd to pretend that the patients are the ‘wrong kind of patients’.

This argument, however, becomes more valid when we consider other, more specialist, – services such as neo-natal services. Here, the logic of ensuring a sufficient volume of patients is more compelling. However there is a caveat here. We would argue that the number of patients needed applies to each individual doctor, rather than to a specific hospital. After all, a doctor who has been out of the workplace for a period of months will not have seen any patients, even if the hospital he or she works at meets the required patient numbers. If this is the case, then many rural and peripheral hospitals would actually have a higher number of patients per doctor, because they have fewer doctors on site.

Furthermore, if patient volume is the sole determinant of whether doctors can maintain and develop skills, then the Welsh Government needs to answer questions about how it can ensure the safety of part time doctors who quite clearly do not have the same volume of patients as full time equivalents.

We have been told by some within the profession, who have asked to remain anonymous, that the Welsh Government is exaggerating the importance of the patient-volume argument.

We have been told that these standards apply to junior doctors and those in training, and are not an exact science, but a general observation that to pass exams, trainees need to see sufficient amounts of specific patients. The Welsh Government needs to be far clearer about the argument it is making here.

%20The%20Scrutiny%20Panel%20Report%20on%20Proposed%20Service%20Change%20Proposals%20at%20G langwili%20.pdf

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Nonetheless, putting these questions aside, we believe there are creative ways in which each doctor could ensure meeting the minimum patient number without losing services from rural or peripheral hospitals. These include: •

•

•

Clinical Networking – this would mean rather than centralising services on specific sites, we centralise rotas and operate single teams from many sites.

This is an alternative suggested in the Longley report, and would apply to many specialities.

Trainee placements in high volume centres – trainees/junior doctors working in rural/peripheral areas that would not see the required patient volume could simply make up the numbers through completing placements in areas of high patient volume. For example, a doctor working A+E in the Royal Glamorgan may fall 10% short of the number of patients required, but could easily make up the remaining numbers through spending a month or two working in Cardiff. This would mean trainees would see the required numbers and also be able to learn from different consultants in Cardiff.

Protected training time to ensure that doctors in smaller hospitals were able to attend training events held in larger hospitals

The above shows that creative alternatives are available and the policies we have outlined will solve the recruitment challenges Wales faces. Once they start to make a difference, we can then adopt a series of policies like protected training that will further enhance the attractiveness of Wales. By demonstrating that we are committed to an NHS for all, we will also ensure the next generation of doctors can come through and work in an NHS for everyone in Wales.

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Consultation Feedback – how to have your say We hope that the ideas outlined above have demonstrated that there are practical solutions to addressing the problems with the NHS workforce. We are keen to hear from anyone with a view on this paper to contribute to the further development of these policies. We are particularly interested in hearing from people working within the NHS, who are welcome to contribute anonymously if they wish. Many of the ideas outlined above have initially come from staff members in the NHS who are frustrated by the lack of ambition shown by the Welsh Government, and it is clear the NHS staff are the ones who are best positioned to offer new ideas and constructive comments on our ideas.

Outlined below are questions for you to consider in your response.

1. Do you agree that there is a problem with NHS recruitment in Wales? Do you have any evidence or examples of this?

2. How would you improve the quality of medical training?

3. Do you have any comments on non-medical staff recruitment?

4. Do you have any views on Advanced Nursing or the broadening of other non-medical roles?

5. Do you have any views on the specific ways of tackling medical recruitment that we have outlined? a. Bonuses b. Direct salaries c. Free training for contractual service obligations d. International recruitment 6. Do you have any other views or comments on how to attract medical staff?

To comment on the paper please e-mail Heledd Brooks-Jones, Policy Co-ordinator, heleddbrooks-jones@plaidcymru.org.