How do we safeguard and improve the healthcare workforce for doctors?
2nd March 2020
Chair: Colin Elton (Consultant Colorectal Surgeon)
Expert Panel:
Prof. Derek Alderson (President Royal College of Surgeons)
Dr Katherine Henderson (President Royal College of Emergency Medicine)
Prof. Mayur Lakhani (Past President Royal College of General Practitioners)
Dr Ben Mearns (Chief of Medicine, Surrey and Sussex Healthcare NHS Trust)
Dr Clare Stephens (GP Barnet CCG, Clinical SRO NCL Cancer Programme)
Dr Nick Dattani (GP Clinical Lead Barnet CCG)
Dr Vishal Sharma (Cardiologist and BMA Pensions Committee Chair)
Mr Ray Stanbridge (Accountants and Tax Advice for Medical Accountants)
Dr Alka Patel (Lifestyle and Medicine Physician)
Ms Tara Kent (CEO of Champs, Positive Wellbeing at Work)
Ms Megan Annetts (President Barts’ and The London Students’ Association)
Opening discussion by Chair:
NHS is 5th largest employer in the world – 1.7M employees (1.4M employees in 2010)
1 million patients seen every 36 hours
150,000 doctors working in NHS, through hospital, community and primary care
In 2018, 290,000 doctors registered in UK (9000 registered aged over 70)
Headcount of hospital medical staff grew from 87,000 in 2004 to over 120,000 in July 2019 – a 38% increase. The number of hospital consultants rose by 67% (from 30,650 to 51,250).
In 2016/17, total cost of NHS staff was £47.6 billion - 44.9 % of NHS budget
Problems identified:
UK lost 441 GPs last year and 11,576 unfilled vacancies for doctors as of June 2019
Workforce numbers are not keeping pace with increasing workload
Low Morale
Increased levels of stress and feelings of “not being valued”
Bullying and harassment
Pensions
Summaries from expert panel:
Derek Alderson
There is a difficulty in recruiting. Less people are interested and there is less competition into surgical training. There is a feeling of dissatisfaction. Young surgeons’ training skills are not recognised and they feel less appreciated. We need to attract people to enter the job, to enjoy and feel valued within the industry.
Katherine Henderson
In Emergency medicine, we have doctors with the qualifications. There is not a recruitment problem, but a problem with retaining them. We are good at training our doctors, but when they go abroad for work and experience, they decide not to return. We need to hold onto our doctors and nurses. We also need to encourage multidisciplinary teams and teamworking. There is a strong need to provide a stable workforce to deliver good care and this stems from good organised training.
Mayur Lakhani
There is a very serious problem of unhappy doctors worldwide, being overworked. We are short on solutions. Doctors are driving for change to give the excellent care they have been trained to do. There is too much of a divide between professions. We require an ABC of Autonomy, (America design job plan) to have some control on workload. We can’t have over 100 patients for one doctor. Doctors are being overworked and with no sense of belonging. Competence and clinical excellence makes the profession. I would suggest:
“Free parking for all doctors, £280 a month for car parking. A laptop for each doctor.”
Having to share one computer that barely works, results in daily struggles. This creates twice as much time on administration and system problems. We need a clinically led model in primary care. I feel that we should have a medically-led NHS, and we should have clinical roles running hospitals.
Ben Mearns
There is 13% more emergency work compared to last year. The complexity is high, with more complex cases. We need more capable doctors and to have increased clinical capacity.
We need diverse teams, having the right skills. What is very important is to widen the target for recruitment. We need to ask: “Which clinician can do what for each patient?”
Happiness is important, a sense of being valued. We need to be as one team looking after the staff and the patient. The happier the staff are, the better the care. We need to show students and young doctors that they can have a happy career.
Clare Stephens
Primary care is losing its value. We have accepted structures and reviews on the wrong premise. European working time directive has changed our practice. Junior doctors reflect how they feel that nobody values them. There is a lack of clinical continuity. Doctors used to be viewed as one of the highest ranks of faith within the public and this has changed. We need more clinical leaders and a clinical leader should practice in their chosen profession.
Nick Dattani
Our GP workload has increased substantially. We can receive discharge summaries from 17 doctors. We commonly work five days a week, resulting in over 60 hours a week. It is not sustainable to work that many hours. As a result, GP morale is very low. There is not enough investment going into primary care NHS. Problems are always thrown back at the GPs. We need to consider sharing the healthcare budget between primary and secondary care. We need to invest more in training, rather than just working to registration. We are investing in paramedics as GP’s, but there needs to be financial support for a better budget.
Vishal Sharma
In the last twenty years of the NHS, this is now the worst morale amongst doctors. Although the headcount is increasing, the capacity has gone down. People are doing less work. The issue of pensions has contributed to the crisis. 140,000 registered doctors are not working in the NHS although there are a small number of doctors over the age of 70. Doctors in their late 50’s would like to work but have been forced out to retire due to poor working conditions and pension changes.
Ray Stanbridge
Due to the current Pensions changes, there are the following consequences:
Retrospective information creating uncertainty and difficulty for individuals.
Reluctance of consultants to take on new sessions.
Reluctance of consultants to take on promotions/merit awards.
Growth in numbers ‘opting out’ of pensions.
Consultants switching to private sector.
Growth in trading through limited liability companies.
Increasing numbers going ‘part-time’ in the NHS.
Shortness of supply of doctors in the system. Doctors are under more stress. There are failed IT systems and not enough investment in improving care. Doctors are unable to whistleblow, they are worried about management and the future of their careers.
Alka Patel
We are negligent doctors if we neglect ourselves. We should focus on self-compassion, and widen the compassion to others (work colleagues and patients). We should be part of a team, within our trust and the NHS. We should aim to make a change in our own lifestyle. 1 in 3 of us will suffer burnout. We need to identify the triggers for stress and develop our interior to handle the exterior.
Tara Kent
We need to identify early warning signs, because burnout is a real risk. We need to support organisations to see what others do differently and learn from each other. Belonging and forms of support have gone astray. The healing profession should help and support you. We need to try and stop people from going on the wrong track.
Megan Annetts
Medical school admissions have increased. Students with increasingly better A-level results, A*/A, are signing up for medicine before they really know what it is. Students drop out when they realise this career is not for them. Students are overworked. They have exams, presentations, placements etc to develop resilience, but the work and pressure are pushing some students to a braking point before they have even started their career. Commuting and financial pressures for students are significant including the cost of exams and qualifications. In hospital, there is a loss of identity and team structure which worries students.
Medical student years
Background:
33 medical schools in UK (25 in England, 5 in Scotland, 2 in Wales, 1 in NI)
5 more medical schools announced, with 1,500 more students by 2020. Increase from 6,000 to 7,500 places.
23, 710 students applied to study medicine for Sept 2020 (increase of 6% compared to last year) ; (18,500 applicants from UK (up 5%), 1,680 from EU (up 1%), 3,530 outside EU (up 10%))
11 or 12 applicants for each place
Requirements to enter medical school – 3 AAA at A’Level. Additional tests: UCAT (United Kingdom Clinical Aptitude Test), BMAT.
205 of UK schools are providing 80% of medical students.
An article in BMJ 2017 looked at Secondary schooling on subsequent medical school performance. The UKCAT scores added value above and beyond secondary school achievement. Findings suggest that academic entry criteria should be relaxed for candidates applying from the least well performing secondary schools. In the UK this would translate into a decrease of approx.. 1-2 A-Level grades. Some medical schools offer grade discounts to applicants from less well-performing schools.
Research from Royal Medical Benevolent Fund found that 60% of medical students have experienced financial pressures with 70% having experienced mental health pressures.
More than 1000 medical students have withdrawn from their course over last 5 years – ( Nov 2018 data). 300 of the UK’s 6000 medical students quit each year (5%). Another 1600 are asked to leave for poor academic performance.
What are the challenges in medical schools
Megan Annetts:
Workload for student - assessments, exams, tests, placements, requirements.
Receiving the wrong type of hospital teaching - standing and observing.
Grade requirements are increasing.
Those only who are academically good rather than those who excel at extracurricular activities.
Mental pressures. Stigma at medical schools. High pressures before you are even a doctor.
Financial pressures, with no income. Travel fares, e.g. TFL, whilst on placement.
Statistics show 5% students quit, due to being unaware of what they are getting themselves into. At a young age to decide about one’s career, there is such a large amount of debt.
Alka Patel: There is a struggle for the correct training. We need to encourage good doctors, who are able to share emotions, experiencing life situations. Assessments do not reflect real life.
Clare Stephens: I would suggest bringing back consultant appointment panels.
Medical students are part of the team and need to feel a member of the team. Ther needs to be more clinical training.
Mayur Lakhani: Students need role models in medicine, showing passion and pride. Senior doctors should be encouraged to teach students. The current system grinds them down with the lack of value and support, so there is a constant pressure which prevents the involvement of teaching.
Students have sense of confusion, frustration, uncertainty about their future.
Working 6 years with exams of multiple choice in final year, (situation and judgement). Medical ethics are given a disproportionate importance upon final results. This then determines whether you can be an F1 doctor.
Students feel that they have no control about where their 1st F1 job will be.
Daren Francis: Debts for students. Can result in £100,000 - £120,000 debt by the end of medical school. A huge decision and commitment for someone of such a young age. We need to make it more exciting, we have to tackle the debts and we have to engage with people.
Clare Stephens: Apprenticeships. Contribution is necessary, to help them be competent and have confidence.
Learn from mentorship
Alka Patel: - Technology has developed but we have not changed how we learn.
Clare Stephens: Huge anxiety of where they are going to be allocated. This needs to be changed. People should stay in the area where they have trained. It is sensible to work where you have been trained. It might work out better for them because doctors will feel confident about working with F1s who have trained with them.
Training is inflexible. They do not know where they are going to be for their next job. It becomes unfair when there are last minute changes. There are often long distances to travel. Students have to change their lifestyles, move etc.
OUTCOME: We need to provide better financial support for students. Consider free travel from TFL. We need to provide better welfare support within medical schools for mental health. We need to provide better training, particularly from senior doctors. We have to avoid an F1 placement lottery and plan jobs better. We should bring back student assistantships, paid jobs in last year of medical school to replace the F1. We need to attract students to careers and provide better career advice and nurturing.
Junior Doctors
Report from GMC in 2018:
There were 52,800 FTE hospital doctors in training9, an increase of 2.4 per cent (1,250) since 2016.
In 2017, 57.4% of Foundation Year 2 doctors did not enter higher training posts and 9000 doctors quit the NHS entirely.
2011 – 71.3% of FY2 doctors progressed into higher training.
2016 – 50.4% of FY2 doctors progressed into higher training.
2018 – 42.6% of FY2 doctors progressed into higher training.
Problems cited:
Changes to doctors’ salaries
Hours worked
Reduced investment in training
Inflexibility with schedules
Lack of consistent teamwork
Understaffed service
Lack of feeling valued and supported
3/10 doctors said they feel unsupported by management each week, and mentoring provided to them as part of their role has decreased.
The EWTD (European Working Time Directive) came into force in October 1998: a limit of an average of 48 hours worked each week. In August 2004, it was introduced for junior doctors, but only reached an average of 48 hours by August 2009.
THE NHS LONG-TERM PLAN – Published January 2019:
The NHS Chief People Officer, working with the national workforce group will take action for all NHS staff to:
• improve health and wellbeing, building on the NHS Health and Wellbeing Framework that includes recommendations from the Stevenson/Farmer review of mental health and employers, and to support improved health and wellbeing of staff and management of sickness absence;
• support flexible working, including clarity on the proportion of roles to be advertised as flexible; and the ability to express preferences about shifts further in advance enabled by e-rostering technology introduced over the next year and associated applications;
• clarify expectations on induction and other mandatory training;
• enable staff to more easily move from one NHS employer to another;
• set expectations for the practical help and support our staff should receive to raise concerns, or inappropriate behaviours, confidentially.
Research by the Nuffield Trust found that the number of GPs per 100,000 people across the UK has fallen from a high of around 67 in 2009 to 60 in 2018. That’s a similar number of GPs per person today as there were in 2004.
And based on data specifically from England, there has been an increase in part-time working. GPs were employed to work on average 82.1% of a full-time contract in September 2015, compared to 79.8% in December 2018. This would be equivalent to around a 1,000 fall in headcount across 42,000 GPs.
Across the UK, the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s.
The fall in number of GPs has been particularly marked in certain regions of England such as NW London and East of England. These regions have the lowest total number of GPs per 100,000 people, whereas Scotland has the highest.
The fall in GPs from 64.9 per 100,000 to 60 per 100,000 means the average doctor now has 125 more patients to look after than they did in 2014.
The Nuffield Trust believes another 3,500 GPs would be needed to get the NHS back to where it was in 2014.
There are just over 42,000 working currently, down by nearly 1,500 in four years
The fall in GPs reflects insufficient numbers previously being trained and going on to join the NHS; failure to recruit enough from abroad and more GPs leaving for early retirement.
While training places are now being increased, in the region of one in three posts for specialty GP training don’t result in a GP joining the NHS.
More than 20,000 extra physiotherapists, clinical pharmacists, nurse practitioners, paramedics, physician associates and support workers are being recruited to help see GP patients in England. 5000 recruited in last 3 years.
Is this now a time to change the culture from within the NHS? Working patterns, behaviour of colleagues towards each other and the way management interacts with the medical workforce?
Ben Mearns: At the end of the F2 year, we need to reach out to these doctors and to do more. They need more education, and we could try to fill them within F3. We could manage these doctors correctly, as some end up wanting to do something completely different.
Katherine Anderson: There are not just Doctors but nursing staff are also under stressful conditions. They are not being given enough time to (i) do the job, (ii) do the training, (iii) think about it and develop.
There should be an understanding within management that doctors need nurturing and are not just numbers to provide a service.
Is it time to bring back the firm structure?
Vishal Sharma: We should aim to work within a multidisciplinary team.
Derek Alderson: I agree that a multidisciplinary team structure works. We need alternative training pathways, non-traditional training. Structured training needs to be rethought. There are varied skill sets and we should adjust work according to these different skills.
Clare Stephens: We need IT that works, so that everything is ready for when the doctor sees the patients. We need more clinicians, and good-experienced clinicians teaching them. This means more investment. Space is important for doctors, not working in cramped conditions.
Tara Kent: There are lots of different people within the system and there needs to be enabling of clinicians to ask others: how it is going?, to be heard and valued. This aspect is needed to help support systems with this industry.
Vishal Sharma: It is important to have a role model and to provide enough time for those doing the training. All grades of doctors should have a mentor. We should provide development, on communications skills, simulation. There could be a replacement of elements of apprenticeships. We should aim for protected time for those who are training and help with all aspects, e.g. problems outside of work life.
We should consider creating professional teachers during medical careers.
How do we direct medical students and junior doctors to fill the most severe workforce gaps?
Derek Alderson: Having the right workforce in the right place. Students could stay in the areas they enjoy most and have learnt about.
Bijen Patel: We offer an undergraduate MSc course to medical students with hands on practical training in surgery: suturing, bowel and vascular anastomoses. We get them at an early stage of learning, helping them with competenceies and skills that can be transferred into the workplace and they absolutely enjoy it. We hope to extend this with gynaecology.
Mayur Lakhani: For GPs, there is an inability to control demand and the workload. There is an issue of quality of excellence and time to do their job.
Nick Dattani: For some GPs, there is not enough patient exposure. We need to encourage doctors to know that this is a flexible career. There needs to be more integration of GP’s into hospitals. We should attract shared care, bringing morale back, and this helps to stop burnout.
Alka Patel: We need more GP Fellowships to help people into handling the workload. The value of a GP should not be determined on having those ten minutes with each patient.
Ben Mearns: We should aim to treat each other with respect. I don’t think the system is treating students with respect: “We value you, however you won’t know where you are going to be working”.
Mayur Lakhani: We need physician leadership. We need to think about all other aspects, housing, depression, etc.. Training and support is needed. For GPs, we should change the way they work, increasing the time with each patient.
OUTCOME: We need to consider better planning for placements of medical students. We should have more GP Fellowships. We should have mentors for doctors at every grade and consider appointing professional teachers. We could expand MSc degrees for undergraduates with practical skills that direct them to particular careers.
At the end of the F2 year, we need to reach out to these doctors and, if necessary, we could try to place them within F3. We need to concentrate on supporting the junior doctor and letting them know that they are valued.
Consultants
Consultants have found their understanding of what a consultant is, slowly eroded. This used to be the pinnacle of a hospital medical career and one to which we all aspire to. However, things have changed. Loss of the secretary, loss of an office in many institutions, no protection from the busy workload as the service has become consultant delivered. Loss of the firm structure so there is no continuity of care with patients. Increasing computer / paperwork, service requirements, busy on calls which means that a consultant is almost living in the Accident Emergency Department for the busy specialties: General Medicine, General Surgery, Emergency Medicine, Obstetrics. Constant pressure and sometimes bullying and harassment from management whose style is often aggressive and disrespectful. Difficulty in providing the training to junior doctors. Complaints. And then there is the Pensions crisis. I know several consultants who say: “I come into the hospital every day, to my work, and then leave. Nothing more.” That’s a sad state of affairs for such highly talented, previously motivated individuals.
Consultant numbers stood at 45,800 FTE, an increase of 3.4 per cent (1,490) since 2016.
Latest figures show 49,068 Consultants (published January 2020) – largest doctor workforce:
How can we improve the culture towards consultants?
Vishal Sharma: We should try to reduce the amount of administration and emails.
Alka Patel: Consultants give back. We should give leadership to the consultants. They should be able to run the ward. Consultants should shape the working day for their teams.
Katherine Henderson: This does not reflect real life. This is not what happens in hospital. There should not be consultants deciding things; they have a job to do; we need to make sure people are doing the right job. Different hospitals practise differently. Professionalism is the most important thing and making sure we are doing things right.
Protecting consultants
Professional development should happen throughout whole career, ‘what’s next for myself?’ We also need time for research.
There needs to be more training in leadership? We are focused too much on our clinical job. There is limited time to develop skills. We need to have different things to maintain interest.
Redesign job plans
When clinicians retire, how do we keep their talent within the NHS?
Do we consider zero-hours contracts? Should we have more Teaching and Mentoring posts? We need to have flexible-contracts for some senior clinicians e.g. agreement by departments as to when to come off the on-call rota.
Vishal Sharma: Partners are important, being told what you must be doing. The consultant career is about phases, different steps e.g. “Felt like he stopped and what does he do next?” People go through that and think, “what can I do next?”
Research can be managed between consulting teams, so new research is varied and covers different things for patient care.
Pensions
Vishal Sharma: lifetime allowance tax charge 55% .
Retire and then come back and do reduced sessions.
In the NHS Benefit schemes, you have no control how your pension grows.
There are high incomes towards the end of their career, especially with management roles.
Suddenly, £10,000 more tax becomes £40,000.
To stop having such high tax bill, consultants are reducing the work they are doing which impacts the industry.
There is an announcement in the budget next week.
The threshold is likely to be raised to £150,000. There shouldn’t be an annual allowance.
These are not appropriate taxes that should be applied.
OUTCOME
Reduce administration and emails. Protect consultants from bullying and harassment. Redesign consultant job plans: Flexible job plans: coming off on-call for senior doctors, zero-hours working, teaching and mentoring posts.
Empower consultants as leaders, provide leadership training.
Work to solve the Pensions crisis as soon as possible.