The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd y cyfarfod am 09:30.
The meeting began at 09:30.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Bore da i chi gyd a chroeso i gyfarfod
diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn
y Cynulliad. A gaf i estyn croeso i’n tystion—a mwy
amdanyn nhw nawr yn y man—a hefyd estyn croeso i’m
cyd-Aelodau ar y pwyllgor yma, gan gofnodi bod Dawn Bowden yn
ymddiheuro? Mi fydd hi yn hwyr y bore yma, ond mi fydd hi’n
cyrraedd nes ymlaen. A gaf i bellach egluro i bawb yma a hefyd yn
yr oriel gyhoeddus bod y cyfarfod yma yn naturiol yn ddwyieithog, a
gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o’r
Gymraeg i’r Saesneg ar sianel 1, neu glywed cyfraniadau yn yr
iaith wreiddiol yn well ar sianel 2? A allaf i atgoffa pawb i
ddiffodd eu ffonau symudol ac unrhyw offer electronig arall
sy’n gallu ymyrryd ag offer darlledu, a hefyd i gadw’r
ffonau symudol yn ddigon pell oddi wrth y meicroffonau achos mae
rheini’n amharu? Nid oes eisiau cyffwrdd y meicroffonau: maen
nhw’n dod ymlaen ac i ffwrdd yn awtomatig. Nid ydym yn
disgwyl tân y bore yma, felly os bydd yna larwm tân,
dylid dilyn cyfarwyddiadau’r tywyswyr, os clywch chi ryw
sŵn uchel yn clochdar yn y cefndir.
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Dai Lloyd: Good morning, everyone, and
welcome to the latest meeting of the Health, Social Care and Sport
Committee here at the Assembly. Can I please welcome our
witnesses—and more about them in a moment—and I also
welcome my fellow Members on this committee, and also note that
Dawn Bowden has sent her apologies—she’s going to be a
little late this morning, but she will be arriving later on. Can I
please explain to everyone here and also in the public gallery that
this meeting of course is bilingual? Headphones can be used for
simultaneous translation from Welsh to English on channel 1, or for
amplification on channel 2. Can I please remind everyone to turn
off their mobile phones and any other electronic equipment that may
interfere with the broadcasting equipment, and please keep your
phones as far as possible from the microphones, please, because
they also cause interference occasionally? You don’t need to
touch the microphones: they come on automatically. We are not
expecting a fire this morning, so if you do hear the fire alarm,
please follow the directions of the ushers, if you do hear a loud
bell in the background.
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09:31
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Ymchwiliad i Recriwtio
Meddygol: Sesiwn Dystiolaeth 3—Cymdeithas Feddygol Prydain
(BMA) Cymru Wales a Choleg Brenhinol y Meddygon
Inquiry into Medical Recruitment: Evidence Session 3—BMA
Cymru Wales and Royal College of Physicians
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[2]
Dai Lloyd: Felly, gyda chymaint â hynny o
ragymadrodd, symudwn ni ymlaen i eitem 2, a’r ymchwiliad i
recriwtio meddygol. Hon ydy’n sesiwn dystiolaeth Rhif 3, ac
o’n blaenau ni y bore yma mae Cymdeithas Feddygol
Cymru—BMA Cymru—a Choleg Brenhinol y Meddygon. Felly,
rwy’n falch iawn i groesawu Dr Charlotte Jones, cadeirydd
pwyllgor meddygon teulu Cymru y BMA, Dr Trevor Pickersgill,
cadeirydd pwyllgor meddygon ymgynghorol Cymru y BMA, Dr Gareth
Llewelyn, is-lywydd Coleg
Brenhinol y Meddygon ar gyfer Cymru, a hefyd Lowri Jackson,
uwch-gynghorydd polisi a materion cyhoeddus yng Nghymru o ochr
Coleg Brenhinol y Meddygon. Yn ôl ein harfer, rydym wedi
derbyn eich papurau bendigedig chi ac wedi craffu yn ofalus arnyn
nhw, ac felly maen nhw eisoes yn rhan o’r ymchwiliad yma, ac
mae yna nifer o gwestiynau wedi’u paratoi yn seiliedig ar
beth rydych chi eisoes wedi’i gyflwyno i ni. Felly, gyda
chymaint â hynny o ragymadrodd, awn ni’n syth i mewn i
gwestiynau, ac mae’r cwestiwn cyntaf gan Jane
Bryant.
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Dai
Lloyd: So, with that much of an introduction, we’ll move
on to item 2, and the inquiry into medical recruitment. This is
evidence session No. 3, and before us today we have the British
Medical Association Cymru and the Royal College of Physicians.
Therefore, I’m very pleased to welcome Dr Charlotte Jones,
chair of the BMA’s general practitioners committee, Dr Trevor
Pickersgill, chair of the BMA’s Welsh consultants committee,
Dr Gareth Llewelyn, vice-president of the RCP for Wales, and Lowri
Jackson, senior policy and public affairs adviser for Wales from
the Royal College of Physicians. As is usual, we have received your
excellent papers and have looked very carefully at them, and so
they are already part of this inquiry. Many questions have been
prepared based on what you’ve already told us in your
submissions. So, with that introduction, we’ll move on to the
questions, and the first question is from Jane Bryant.
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[3]
Jane Bryant: Diolch. Good morning. Your papers that
we’ve had share a good amount of common ground, I think, on
the evidence that you’ve given, but where do you feel that
the key current and future pressure points are in terms of medical
workforce?
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[4]
Dr Pickersgill: I’d like to say that the issue is
really about under-doctoring of the NHS in Wales, but across the UK
as well, compared to similar countries in Europe and indeed
elsewhere in the States and the Commonwealth—Australia, New
Zealand et cetera. We have 50 to 100 per cent fewer doctors per
head of population than they have in those countries. And with
pressures on finances in the NHS, as there will be, I suspect, for
many years to come, that’s going to be a struggle to staff,
there’s no doubt about it.
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[5]
Dr Jones: Could I just add to Dr Pickersgill that I
completely concur with what he said, but I would expand that into
the wider primary healthcare team as well, including our practice
nurse colleagues, our district nursing and community nursing
colleagues and other allied healthcare professionals. So, those who
are supporting the doctors of the NHS, they too are facing
significant workforce problems. It’s across the whole piece
of the NHS in Wales, and across the UK, actually.
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[6]
Dr Llewelyn: I think that the college also appreciates that
it’s a whole workforce problem, from pharmacists, opticians,
everybody who works or who has contact with patients—this is
not just about doctors, but it’s one key issue.
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[7]
Ms Jackson: It’s also worth adding that it’s not
just that we can’t fund the doctors—actually 40 per
cent of consultant physician posts that we advertised in Wales last
year couldn’t be filled, and that was, in the majority of
cases, because there literally were no applicants. So, it’s
worth remembering that, actually, where the money is available, we
can’t actually get anybody to apply for those jobs in the
first place. It’s not just a Welsh problem: that is a UK
problem. The only part of the UK that doesn’t have a
recruitment problem, really, is London, so we have to ask: are we
training the right number of doctors to start with, and where are
they going at the end of their training?
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[8]
Dai Lloyd: Ocê. Rhun—yr ail
gwestiwn.
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Dai Lloyd: Okay. Rhun—the second
question.
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[9]
Rhun ap Iorwerth:
Bore da iawn i chi gyd. Er mwyn inni
allu cynllunio ar gyfer denu rhagor i astudio meddygaeth yng Nghymru, hyfforddi yng Nghymru
ac i weithio yng Nghymru, mae’n rhaid deall beth ydy’r
ffactorau sy’n gwneud i rywun fod eisiau dod yma—ac, yr
un mor bwysig, y ffactorau sy’n gwneud iddyn nhw beidio
â bod eisiau dod i Gymru. A ydy’r wybodaeth gywir yn
cael ei chasglu? Beth fyddech chi’n licio ei weld yn cael ei
wneud yn wahanol er mwyn gwneud yn siŵr bod y darlun llawn yna
gyda ni o beth ydy’r ffactorau sy’n dylanwadu ar
benderfyniadau pobl?
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Rhun ap Iorwerth: A very good morning
to you all. In order for us to plan to attract more people to study
medicine in Wales, to train in Wales and to work in Wales, we need
to understand what the factors are that attract people
here—and, just as importantly, the factors that would mean
that they perhaps wouldn’t want to come to Wales. Is the
correct information being gathered? What would you like to see done
differently in order to ensure that we do have that complete
picture of what those factors are that influence on
individuals’ decisions?
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[10]
Dr Llewelyn:
Diolch yn fawr. Rwy’n meddwl
mai data ydy un o’r prif broblemau sydd gyda ni. Nid ydym
ni’n gwybod yr atebion i rai o’r pethau rwyt ti
wedi’u gofyn, a heb hynny, mae’n anodd cynllunio. Y
sefyllfa, wrth edrych ar draws y gwasanaeth iechyd i gyd, yw bod
gyda ni broblemau efo pam nad ydy plant ysgol eisiau mynd mewn
i’r gwasanaethau iechyd, felly mae gyda ni waith i’w
wneud fan yna i hyrwyddo plant i feddwl am ofal iechyd fel maes
gyrfa. Rydym ni eisiau edrych ar bwy rydym ni’n denu mewn
i’r ysgol feddygol—a ydym ni’n denu pobl
o’r cefndir iawn, rhai sydd efallai’n mynd i aros yng
Nghymru? Pa fath o brofiad maen nhw’n cael wrth fynd o gwmpas
Cymru? A ydym ni’n rhoi profiadau da iddyn nhw pan maen
nhw’n mynd, dywedwch, o Gaerdydd i fyny i ogledd Cymru?
Wedyn, mae gyda ni’r meddygon iau—a ydyn nhw’n
cael y profiadau? A ydym ni’n edych ar eu hôl
nhw’n iawn? A ydym ni’n hybu pobl i ddod fewn? Ac
unwaith maen nhw i mewn, a ydym ni’n edrych ar eu hôl
nhw pan maen nhw i mewn? Mae’r rheini’n gwestiynau
mawr.
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Dr
Llewelyn: Thank you very much. I think data are
one of the main problems we have. We don’t know the answers
to some of the questions you’ve asked, and without that,
it’s very difficult to plan. The situation, looking across
the health service in its entirely, is that we have problems with
why schoolchildren don’t want to join the health service, so
we have work to do there to promote children to think of healthcare
as a career path. We should also look at who we attract to the
medical school—are we attracting people from the correct
background, people who maybe will want to stay in Wales? What sort
of experience do they have in going around Wales? Are we giving
them good experiences when they go, let’s say, from Cardiff
up to north Wales? Also, we have junior doctors—are they
getting the experiences? Are we looking after them properly? Are we
promoting people to come in? And once they're in, are we looking
after them once they’ve arrived? Those are big questions.
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[11]
Dr Jones: I think that’s all quite correct there, what
Dr Llewelyn says. I don’t think we’re capturing the
information properly around our workforce numbers. And it’s
not just about total headcount, it’s actually about the
clinical commitment that they’re able to give to the
NHS—and that’s across the whole workforce. I
don’t think that we are linking in enough with our
colleagues, who are perhaps capturing this in different ways across
the UK and wider, and looking at where that works and where it
doesn’t work and actually improving it for Wales.
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[12]
I think there have been some improvements in the last year with the
campaign. Certainly within general practice we are hearing that
there’s a rise in applicants. There was certainly a lot of
interest in posts across the healthcare spectrum and I think what
we need to do is to make sure that any expressions of interest are
followed through, not just those who apply but those who
don’t apply and why that is, and whether there are factors
that we can address for the future.
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[13]
We are promoting Living Well, Living Longer in Wales—I think
that’s fantastic; it’s a wonderful place to live and
work—but I don’t think we’re promoting highly
enough the quality of the training experiences. I think we have to
be cognisant that there are still some myths out there—that
you have to speak Welsh to work in Wales. Whilst we want to promote
and protect the Welsh language and improve the knowledge of the
culture of Wales, that can be done whilst one in working in Wales,
but we need to remove that myth that you have to physically speak
Welsh, but allow opportunities for developing that where they
can.
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[14]
We need to remove the myth that you will be placed anywhere in
Wales, because that can be a barrier for some people if
they’ve got no idea where they’re going to work in
Wales. We know that there is choice within the system, but we need
to promote that. I think we do need to be cognisant of many people
coming out of university these days with significant
debts—why it’s cheaper to live in Wales and you get a
much better work-life balance—and also looking at
opportunities for their partners and their children, because people
are coming out of postgraduate schools with partners and children,
and even from undergraduate schools. We need to make sure that
there are opportunities for their spouses, good childcare, good
schools, and that we’re promoting what’s available out
there.
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[15]
I don’t think we follow people through in training enough in
terms of where they end up working. I think we need to widen
access. I know that you have an expert coming in in the next
session to talk about how they’re working on widening access.
I think we need more places. I think we need to make it more
attractive for schoolchildren to choose to do medicine these
days—specifically on medicine—because if they’re
looking at medicine as a career across the piece and thinking,
‘Actually, if I’m a bright child, why would I choose
medicine?’, we need to say, ‘Choose medicine in Wales
because of the opportunities it brings to you and your
family.’ I think we need to link into those medical schools
that have Welsh students going to them and make sure that
they’re aware of the attractiveness to come back to where
they’ve got family links or links with a geographical
area.
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[16]
But, as I say, there has been some improvement with the initiatives
that have been brought, particularly for general practice, the
incentives around paying for exam fees has been very, very welcomed
by the profession. But more needs to be done and we need more
momentum—not forgetting about those healthcare professionals
we have working now and keeping them within our workforce and
making sure that they are able to do the job they’re trained
to do and that they’re enjoying their job, because that is
how we will foster excitement within the up-and-coming generation
to take on long-term careers in healthcare in Wales.
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[17]
Dr Pickersgill: Far be it from two neurologists sat here,
because we’re both in the same profession, speciality, to
blow our own trumpet, but in neurology training across the UK,
Wales has been top, I think, in four out of the last five years or
three out of the last four, and that kind of reputation gets people
wanting to come and work and train in Wales. General practice is
very good as well, in the top quartile consistently across the
whole of the UK. People don’t know that. If you’re
looking at that specialty, you will, of course, look into the
background, but we don’t make enough of that, I don’t
think, as a country, as a Government, that, actually, training here
is really good. And then there’s the lifestyle and the cost
of living and all the other things that are rather more obvious to
those of us who are here, but maybe not to those of us who are not
here.
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[18]
One of the points I think it’s worth
stressing—certainly, I saw it in the written evidence time
and time again—was that the number of Welsh applicants to
Welsh medical schools is going down and we really need to know why
and reverse that, because, when you come to medical school here,
you tend to stick, like you do wherever you go. And when the Welsh
schoolchildren go to Newcastle or London or Scotland, they’ll
probably stay there. Some will come back, but mostly they’ll
stay there.
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[19]
Rhun ap Iorwerth:
Beth rydw i yn ei weld yn ddiddorol
iawn, ac rydw i’n ddiolchgar i chi am eich atebion—beth
rydw i’n meddwl sy’n ddiddorol ydy ein bod ni’n
clywed hyn dro ar ôl tro. Mae’r ffactorau rydych chi
wedi’u crybwyll y bore yma yn rhai sydd yn cael eu codi yn
gyson, ac eto mae’n ymddangos nad ydy’r issues
yna’n cael eu taclo. Beth, felly, sydd angen ei wneud er mwyn
gallu defnyddio'r pryderon yna—y ffactorau yna rydych chi
wedi’u henwi—fel sail ar gyfer yr ymgyrch i ymateb
i’r heriau? Ai mwy o urgency gan Lywodraeth ydy o? Ai
ffurfioli’r ymateb i’r issues yna?
Beth?
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Rhun ap
Iorwerth: What I find very
interesting, and I’m grateful to you for your
answers—what I find interesting is that we hear this time and
again. The factors that you’ve described this morning are
ones that are raised regularly, and yet it appears that those
issues are not being addressed. So, what needs to be done,
therefore, in order to be able to use those concerns and those
factors that you’ve described as a foundation for a campaign
to respond to those challenges? Is it greater urgency from the
Government? Is it to formalise the response to those issues? What
is it?
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[20]
Ms Jackson: One of the things that we’ve been talking
about for a few years now is a more joined-up approach to
recruitment—that, actually, a lot of the messages are
different between health boards. Apart from the occasional one-off
campaign, we don’t have a very structured approach to
recruitment. Something that, I think, has come up in every bit of
written evidence that I’ve seen is that lack of a strategic
vision for what the NHS looks like in 20 years. If you consider
that it takes 15 years to train a doctor, it’s very difficult
to start training doctors now for the NHS in 20 years’ time,
without knowing exactly what the vision for that NHS is.
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[21]
We’ve been calling for a national workforce plan for some
time now, because, as far as we’re concerned—and I
think that was the point that you’ve just raised—the
data collection, the data sharing between health boards,
we’re not aware that that’s happening in any kind of
structured way and it is incredibly difficult, given that for many
of our specialties in Wales, we have very small numbers. Ideally,
we’d be looking at this on an all-Wales basis and saying,
‘Well, actually, does one health board need five specialists
and the health board next door only has one?’ Are those
health boards sharing that specialist load? Are they commissioning
that work between each health board? We don’t know—we
honestly simply don’t know. The statistics that I can give
you from our workforce paper, they are all gathered by the RCP
itself. So, those are our data. There are very little publicly
available data from NHS Wales or health boards. Even when you FOI
things, it’s quite difficult to get really robust
statistics.
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[22]
Rhun ap Iorwerth:
So, you are having to FOI in order to
find out the statistics that you need.
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[23]
Ms Jackson: We have FOI’d, but we also conduct—we
have a medical workforce unit that looks at the numbers across our
membership, across the UK, and we run our own census, we run
various medical workforce surveys, and a lot of the data that we
are able to then use to try and influence change, they are our own
data that we’ve gathered from our own members.
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[24]
Rhun ap Iorwerth:
What are your thoughts on you having to
FOI to find out data that you need to build up a picture of how to
take your profession forward?
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[25]
Ms Jackson: In an ideal world, it would be publicly available and
also, importantly, easily understandable. I imagine that it would
be pointed towards StatsWales or various NHS repositories, but, if
anybody’s ever tried to look through those Excel tables,
they’re not fun.
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[26]
Dr Jones: Can I just make a point that the workforce group for
primary care has made some significant improvements and the plan is
there? There’s not enough momentum at the moment, but I
believe that having the Minister leading that has meant that things
have happened perhaps sooner than they otherwise would have.
Because I have spent many years of my life, and hours of my time
that I will never get back, in workforce meetings, going round and
round the same difficult position all the time on the workforce for
the future. What we know is that we seem to focus on head count,
not actual clinical commitment—I think that’s across
the piece.
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09:45
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[27]
We know that we’re going to need more doctors, so we need to
be planning for that. We know that the current number of doctors
we’ve got is inadequate—focusing primarily on doctors
at the moment—so we need to expand that. And, as I said, we
need more momentum. We need to be linking into the workforce
statistics that are available, and using the resources of people
like Health Education England in England, but we need to be having
some robust workforce measurements coming from health boards, and I
would concur with Lowri that, actually, it’s very, very, very
difficult to get that information. It’s also very difficult
to get information on vacancies that are available outside of
primary care within secondary care, because you just cannot find
out. We know that there are consultant vacancies. The health boards
tell us that they have difficulty finding the right calibre of
applicants. They’re having difficulties finding the right
calibre, but, equally, they say there’s no point advertising.
But if I was training in England, thinking, ‘Well, I’ve
got family in Aberystwyth, I’ll have a look to see what jobs
there are’, if they’re not there to see, how on earth
am I ever going to come? There’s a lot of that that goes on.
I think we have to be transparent. Yes, there are job vacancies.
Yes, there are challenges for health boards. But, actually,
let’s be honest about it, and let’s find a way forward.
But you need to have momentum behind that. It’s pointless us
just talking about the problem; we need to actually find the
solutions, and, hopefully, we’re going to bring some of those
to you today.
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[28]
Dai Lloyd: Angela, some of this is partially answered, but
carry on.
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[29]
Angela Burns: Thank you, and thank you for your paper. A lot
of my questions have been answered, but I just wanted to raise your
eyes a little bit to national pay structures and national
recruitment structures. Last week, we heard some interesting
evidence from junior doctors, and, particularly in emergency
medicine and paediatrics, were talking about how they would further
their careers. You’ve cornered the market in neurology here,
which is excellent, but, of course, other specialisms are not in
that position. So, we were listening to a junior doctor, for
example, saying that she really wants to become a neonatologist and
move on, but she’s going to have to leave Wales in order to
pursue that career, more than likely—I mean, heavily more
than likely.
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[30]
So, I just wanted to get your views on the tensions that you think
exist between having a Wales national structure, a UK national
structure, and the banding issues and the impact that that might
have on speciality recruitment and training.
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[31]
Dr Pickersgill: The issue about the training rotations is a
very good one, and of course it depends what speciality, or
sub-speciality, you’re interested in. There is an increasing
tendency for surgeons, physicians, to not just concentrate on a
broad speciality, so gastroenterology for instance, but a very
small part of that speciality, so inflammatory bowel disease, for
the sake of argument, or neurology MS, like I do, or stroke
medicine, or headache or whatever. And, sometimes, if you really
want to be the top dog in a region in Wales, in Cardiff or
whatever, and an expert in a small area like that, you have to go
elsewhere for training, whether it’s post-graduate, or even
as a consultant getting experience elsewhere, going on sabbaticals,
et cetera. And that kind of thing does need encouraging, but you
need to ensure that the doctors who are making the commitment to
try and learn and be the expert in an area like that are encouraged
to (a) do that, but (b) return to, and bring their expertise back
to, Wales.
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[32]
The issue more generally about recruitment—you know,
emergency medicine, A&E, for want of a better expression, they
have about a 25 per cent, I think, vacancy rate in their
middle-grade doctors, the registrars, broadly. Paediatrics, child
health, it’s 10 to 15 per cent, and, in other specialities,
it’s higher. I heard yesterday from a surgeon in Gwent that,
for core surgical training this year, the number of applicants has
reduced by 30 per cent over about three years to Wales, and
that’s worse than it is England, although it is a picture
across the UK; applications are generally going down.
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[33]
The issue about cross-border rotations is a good one, and I’m
glad you raised it, because we have not just the issue about the
unattractiveness, for some people—but not everybody, of
course—of having to, in some specialities, rotate from north
to south Wales across a four or five-year training programme, which
is a big upheaval, actually, but the reluctance, I think, of
adjacent deaneries, so, for south Wales, the Wales Deanery and the
Severn Deanery, and, in north Wales, the Mersey Deanery, joining up
and making fantastic possibilities in terms of training rotations.
So, a year in Bristol for south Wales trainees, or
Oxford—it’s not that far—or Liverpool or
Manchester if you’re training in north Wales, depending on
the specialty. There are fantastic sub-specialty training
opportunities in all these cities in Wales and in England, but
we’ve got to make sure we’re not completely insular
about that, because, like the neonatologist you’ve just
talked about, they may not be able to get the right experience just
in Wales to make them attractive in the general job market, whether
they want to stay in Wales or not.
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[34]
And then you raised, I think, the issue of contracts. The new
junior doctors contract in England is, of course, not particularly
welcomed by the junior doctors in Wales and, as a general point,
that’s not something that the BMA or, indeed, junior doctors
would look forward to having. But the stance of the Government of
not wanting to impose—never wanting to impose—contracts
on any group of staff in the NHS in Wales is certainly very
welcome, and that’s something we keep telling everybody lots.
There is an issue about the basic salary scales, and, in
particular, for those small number of specialties where
there’s little or no on-call—so, pathology, I know
you’ve had some evidence on. Those guys could lose
£45,000 over a training rotation, which, when you’ve
got big student debts and are trying to buy a house and raise a
family, isn’t to be sneezed at, let’s be honest.
|
|
[35]
Angela Burns: And, as you go through your career, is there a
growing pay differential between England and Wales in terms of
salary that you might earn?
|
|
[36]
Dr Pickersgill: Charlotte will answer for general practice,
I know, but, in terms of specialist practice consultants, under the
current English and Welsh consultant contracts, there are
differences at different stages, but, over a whole career,
there’s not a lot in it. But the English consultant contract
is currently being negotiated. It may well be imposed by Jeremy
Hunt—who knows—and we don’t know what those
numbers will look like. But initial soundings are that there will
be a much more attractive salary scale for new consultants in
England.
|
|
[37]
Dr Jones: With respect to GPs, there is a differential;
it’s about £10,000 to £15,000. That is reducing,
but not reducing quickly enough to actually—. If
somebody’s on the border, say, in Newport, they may choose to
work in Bristol. If they’re interested in north Wales, they
may choose to work in Liverpool or Chester, and we have seen that
in action. What I would say, though, is that the main differential
is largely due to the expenses that GPs—. The money that
comes into the contract isn’t for GP earnings; it’s for
the provision of the entire contract there, and the biggest expense
there, as I’m sure you already know, is staffing. And a lot
of those changes have been imposed from Westminster in terms of the
expenses for staffing, which impacts greatly, actually, on general
practice, the income you can take back from that. But there is a
differential—we have to be honest about it. We can promote
the other benefits of living and working and training in Wales, but
we have to be honest about it and we are making strong
representations to address that through increasing resources into
the contract and addressing some of the expenses elements
separately. But practices do need additional resource and support
urgently in order to keep general practice going.
|
|
[38]
Dai Lloyd: Rhun, cwestiwn byr.
|
Dai Lloyd: Rhun, a brief question.
|
|
[39]
Rhun ap Iorwerth:
Is there a case for the introduction of
golden hellos at certain parts of a doctor’s career in order
to bring somebody in, in exchange for a five-year commitment, or
whatever it is, to the NHS in Wales?
|
|
[40]
Dr Jones: Certainly, within general practice, there is the
availability of incentives in those difficult-to-recruit areas, and
I understand that that has had a positive impact on recruitment,
which will start in the next year. Also, paying towards exam fees,
which are inordinately expensive for general practice trainees;
that has been welcomed as well. I actually had a golden hello way
back yonder when I started. It was a payment of £5,000 to
incentivise me to stay in general practice. There was no attachment
to it, from what I recall, in terms of duration of stay within the
area. I was going to stay anyhow, so I think what we need to do is
to actually target those payments to areas where they’re
having difficulties recruiting—or, actually, are we looking
at it the wrong way round? Should we be looking at the model of how
we provide general practice, and should we be looking at the
pressures that are making people choose maybe not to go into
practice in Wales or within a partnership, and actually looking at
how we could invest and use those moneys better? I think
there’s an argument for both, but we’ve got to make
sure any moneys that are used are used effectively, given the
constraints we all face in Wales.
|
|
[41]
Rhun ap Iorwerth:
And in secondary?
|
|
[42]
Dr
Llewelyn: A hefyd ar draws y gwasanaeth iechyd i gyd. Os oes yna arian
yn mynd i gael ei roi, mae’n rhaid i ni feddwl am yr holl
system, rydw i’n
meddwl.
|
Dr
Llewelyn: And I think across
the entire health service. If money is being given for this, then
we have to think about the whole system.
|
|
[43]
Rhun ap
Iorwerth: Yn enwedig pan fyddwn ni’n sôn am y costau enfawr
o gyflogi locums ac ati, mi fyddai gwneud taliad i ddenu
rhywun llawn amser i ysbytai yn gallu bod yn rhywbeth
deniadol.
|
Rhun ap
Iorwerth: Particularly when we
consider the huge costs of employing locums and so on, making a
payment to attract someone on a full-time basis to hospitals would
be very attractive.
|
|
[44]
Dr
Llewelyn: Ydy.
|
Dr Llewelyn: Yes.
|
|
[45]
Ms Jackson: It may be worth also remembering that, actually,
after a certain point, the money is less important to trainees than
the work-life balance. So actually, when we talk to trainees,
they’re earning very good money for people of their age
already, but they just don’t have any time to spend it. So,
our work with trainees tells us that actually the want mentorship
and leadership opportunities, they want more clinical leadership
and research and quality improvement projects. They want to free up
some of that time from providing that service to actually
developing themselves and their careers. So, while golden hellos
may be part of what might attract them in the first place, keeping
them here actually is a lot more nuanced, and actually improving
that work-life balance, and part of that then is making sure that
there are enough trainees so that they’re not constantly
covering trainee rota gaps.
|
|
[46]
Dr Jones: Can I just say something about the use of locums,
if you’d indulge me? I think that, whilst we understand why
locums have to be utilised within the whole of the healthcare
system, I think somebody somewhere should be asking the question:
why are we using a locum? What’s preventing that person from
taking up a substantive post?
|
|
[47]
That does bring me back to the advertising of vacancies. I have a
very good friend of mine who was a locum consultant in NHS Wales in
emergency departments and earning a very good salary, and wanted to
take a substantive post, but there were none being formally
advertised, and although he had informal conversations with health
board staff, and I think things are now moving, there was a whole
year when nothing was changing and he wasn’t being made aware
of when they were going to advertise any vacancy to actually apply
for one. That’s something we’ve got to
change—we’ve really got to change.
|
|
[48]
Dai Lloyd: Okay. Angela, briefly, then Julie.
|
|
[49]
Angela Burns: To Charlotte and Lowri, really: Crown
indemnity for GPs. Would that keep them and attract them?
|
|
[50]
Dr Jones: Well, for general practice, Crown indemnity
doesn’t actually exist.
|
|
[51]
Angela Burns: No, I know, but—
|
|
[52]
Dr Jones: So, the Welsh risk pool, would that help? The
Welsh risk pool is funded by the NHS in Wales, by the health
boards, so would they take on covering GPs at no cost? That’s
not something that’s ever been offered. The Welsh risk pool
itself does not actually cover every aspect of indemnity, so it
looks after the organisation rather than the individual. It only
covers clinical instances, so the other aspects of a complaint or a
claim, such as around disciplinary proceedings, GMC proceedings,
criminal proceedings, anything like that, or professional issues,
it does not cover. So, therefore, it would give you some cover but
not all cover. As we all know, when a complaint is made against the
profession, it often covers an array of areas and, actually, if you
have Welsh risk pool cover and additional cover, it may actually
cause the GP or the doctor to fall in the middle there and be a
little bit vulnerable to not having all aspects covered.
|
|
[53]
Angela Burns: I have to say that you are the first GP
I’ve spoken to who’s not a fan of trying to get them to
pick up the indemnity.
|
|
[54]
Dr Jones: Oh, it’s not that I’m not a fan of
picking up the indemnity. What I’m saying is that it’s
a very, very, very complex area. I’ve been intimately
involved in the negotiations in England and I’ve done
numerous papers for Wales. I’ve been involved in the
implementation of Welsh risk pool for out-of-hours care. It’s
not that I’m against it. It’s an extremely complex area
and what we have to do is make sure that what is in place for GPs
and any doctor is the right cover and that it covers them for all
aspects of a potential claim. So, it’s not that I’m
saying ‘no’. I’m saying it’s one of a range
of options. It’s actually in a paper that I’ve given to
Welsh Government. I wrote the ‘Focus on…’
document for the BMA as well in England, and you will see in that
that it’s something that we can’t just say,
‘Right, we’re going to do x’ without thinking it
through, because, say you bring in Welsh risk pool
tomorrow—great, they can go and get top-up insurance.
There’s a run-in and run-off period for claims, because they
come in up to six years later, and, as I say, we need to make sure
that the individual is having the right cover as is the
organisation and NHS Wales.
|
|
[55]
So, it’s extremely interesting. It’s probably worth a
whole committee hearing on its own, and I’m sure I could bore
you all to tears for a long time. I’m very happy to pick that
up separately if you’d like to, but it’s not quite as
simple as just having Welsh risk pool. Actually, a lot of people
think it is, and when you get into the detail of it, it really
isn’t. We are, though, committed to addressing that going
forward, and it will be part of our GP negotiations for 2017-18,
and I do actually have a date in the diary to take that forward. I
have to say that Welsh Government are committed to working on this,
because they know it’s a huge problem for GPs and the wider
teams they’re having to use, because, of course, we are
liable for those healthcare professionals that work delegated from
us.
|
|
[56]
Angela Burns: Is your paper in the public domain?
|
|
[57]
Dr Jones: I’m more than happy to share it with
anybody. It’s not private at all.
|
|
[58]
Angela Burns: Would that be all right, Chair?
|
|
[59]
Dai Lloyd: Yes.
|
|
[60]
Dr Jones: Yes, of course.
|
|
[61]
Angela Burns: Thank you.
|
|
[62]
Dai Lloyd: Julie, you’ve been very patient, and some
of your prepared questions have been asked.
|
|
10:00
|
|
[63]
Julie Morgan: Yes, thank you. There were a few things I wanted to
pick up on on the way, but they’ve sort of passed now. It was
just, really, following on what, I think, Lowri was saying about
GPs practising. I had a meeting with a GP in my constituency last
week, with small children, and, basically, she was saying that she
was really considering giving up because the burden was too great
managing the work-life balance, and was feeling that it almost
wasn’t worth doing. The number of patients hadn’t
increased, but the complexity of the patients had increased, and
she said it was difficult to get a new partner to come in when
somebody had retired. I just wondered if that was something that
you saw all over Wales and whether that is a typical sort of
situation.
|
|
[64]
Dr Llewelyn: I think that—not particularly for GPs; I
can’t speak for GPs—generally, the main issue is the
workload. In all the things that we’ve looked at,
that’s the key thing and, as Lowri was saying, getting that
life-work balance right. I think that we need to be a bit more
savvy about how we do that better. Charlotte will talk about the
general practice—.
|
|
[65]
Dr Jones: Goodness me. I could go on another day on this.
I’m surprised she says that she’s not seeing more
numbers. That’s certainly not something I’ve heard
anywhere else—.
|
|
[66]
Julie Morgan: It’s the complexity she said—.
|
|
[67]
Dr Jones: The complexity is going up, the workload demand is
going up significantly, as are the other challenges facing general
practice and, actually, the whole of the healthcare system. What we
need to do is to make sure that we address all the various
pressures, so that’s the workload pressure that we’re
facing, the recruitment problems that we’re facing and, of
course, the resource issues. There’s a perfect tsunami here
just waiting to happen. We’ve been warning about it for many
years. There have been some moves to address some of those
pressures. So, on the complexity of the care, we’ve got more
healthcare professionals coming in to work through clusters. We
need more of that because it’s not making enough of a
difference day to day. We need the resources to allow GPs to more
strategically plan and deliver care, and have the time to review
how things are working at their own individual practice level and
across the wider geographical area through the clusters. But we
also need the resources as well.
|
|
[68]
So, it’s not just about recruiting
GPs; it’s about the practice nurses to support, it’s
about having clinical pharmacists to support and physios, so
that, actually, GPs can do the job they’ve been trained to
do, which is what they want to do, rather than having to do the
complex care as well as, say, a form for picking the rubbish up
from the back door, or personal independent payment forms and
reports, for which, actually, the GP report has absolutely no
benefit to the individual claimant and is putting a huge problem
within the system of additional administrative bureaucracy that we
do not need. We are trying to work on those issues. They are,
again, very difficult ones to unpick and to get the right system in
place. But we are very aware of the challenges that individual GPs
and individual practices are having, and we are committed to
working on that and, again, working to solutions collaboratively
with Welsh Government to address those.
|
|
[69]
I would like to just bring in slightly
though here—and this will probably be of big interest to the
committee—that if we had a shared agreement going forward in
terms of a strategic vision—and we have an agreed plan for
primary care specifically, going forward—the implementation
of that at a health board level can be difficult. Actually, at
times, it feels that it is obstructed at the health board level,
and I ask you as a committee: what levers do you have to make sure
that health boards are taking forward the strategic vision for the
NHS in Wales? I think that’s something that does need to be
looked at, because the reports that I’m getting back and my
sense is that it’s not always followed through in, perhaps, a
timely fashion or in the way you would want it to. I would
specifically raise that the release and use of cluster monies to
transform general practice, I don’t think, have enabled the
transformation that was envisioned at a national level and,
certainly, general practices are not feeling the benefits of
that.
|
|
[70]
Julie Morgan: So, when you say it’s obstructed by the health
boards, you mean deliberately, sort of not—
|
|
[71]
Dr Jones: I’m not saying deliberately. All the health
boards are in a difficult financial situation and they’re
trying to balance their books. Sometimes it can be difficult to see
the wood for the trees because there is such pressure on services.
But I do believe that, if there is a shared vision, then that has
to be delivered, and I’m asking what levers you actually do
have to make sure that that is delivered in a timely fashion to the
healthcare professionals working on the ground. It’s not a
problem peculiar to Wales; I understand that similar is happening
in other parts of the UK as well. But I would ask you to make Wales
different and actually make sure that the transformation does
happen when an agreement is reached and the resources are
given.
|
|
[72]
Julie Morgan: I would have thought that was something we could
include in our report.
|
|
[73]
Dr Llewelyn: I think the issue, perhaps, has been that we’ve
all been looking at our own little bits—so, hospital care,
primary care—and that we’ve not actually, really worked
together in a more constructive way than perhaps we could have. I
think the report that we produced points towards that—that we
have to change the way that we work. So, general practice may mean
that we need to be moving physicians with special interests to be
doing more clinics in the community so that they can support
general practice a bit better. So, there are quite a few things
that we can do, because the patient cohort has changed
dramatically, hasn’t it, over the last 20 years? We’ve
now got patients with multiple comorbidities and the population is
much older, and, so, much of the care is being moved to a community
setting, and that’s what we want. It’s about how the
hospital bit of it can support that in a slightly different way to
what it’s doing, rather than just accepting patients in all
the time and trying to look after them.
|
|
[74]
Dr Jones: And I think it’s fair to say that, on a
daily basis, the pressures that are faced across the piece—we
actually need to build in strategic time for the clinicians who are
delivering services to have that time to actually look at: are we
providing services in the best way possible?
|
|
[75]
Dr Llewelyn: There are models—there are diabetologists
who do diabetes clinics in the community, looking after those more
complex cases. We’ve got an example in Cardiff and Vale. So,
there are good practice examples, and we just need to spread that
about a little bit.
|
|
[76]
Ms Jackson: That is the old story, though—there are
good practice pockets all over Wales. Whether those are then being
joined up, that’s another question. For example, on that
theme of the need for a strategic approach while also, I suppose,
firefighting, we’ve got a great project in north Wales where
we’ve collaborated with a team at Ysbyty Gwynedd on
delivering telehealth. So, specifically patients needing palliative
care, and a couple of others with chronic diseases, can now stay at
home in their village in rural Gwynedd and teleconference in to a
consultant at Ysbyty Gwynedd. It’s saving a lot of them up to
two hours driving each way and it’s saving their families
from taking a day off work to take them to those appointments.
We’ve got 80 per cent patient satisfaction with this new
approach. Everybody’s happy with it. But can the project team
get a meeting with the executive board to talk about how they could
expand that? Those meetings get bumped on a constant basis because
they’re firefighting. We appreciate that health boards are
busy at the moment trying to stop ambulances from lining up outside
the door, but, actually, what we’re not doing in a strategic
way is looking at those pockets of good practice and giving those
time to flourish, grow and to really expand to make sure that
they’re treating more and more patients. Because, every
single patient you can treat in a GP clinic through a telehealth
conference in rural Gwynedd, that’s one less patient coming
in to Ysbyty Gwynedd and sitting in a clinic for four hours while
everything overruns.
|
|
[77]
Dai Lloyd: Caroline Jones, y cwestiwn nesaf.
|
Dai Lloyd: The next question is from
Caroline Jones.
|
|
[78]
Caroline Jones: Diolch. Is it fair to say, though, that
change takes a long time to implement? You know, patients have to
get used to the changing environment of primary care, and
it’s going to take time to filter through. What are your
views on that?
|
|
[79]
Dr Llewelyn: Yes. So, the whole thing is changing—that
is, everything is moving. The patient cohort is changing, and
we’ve got to put in some more robust preventative planning
with diabetes, obesity, making sure that the population is
healthier. And the workforce is changing. In my era, you
wouldn’t take a gap year; it wouldn’t happen. So,
doctors now are looking more at their whole career pathway, working
until they’re in their late 60s, and they’re having
breaks. They’re having a year or two of a break, usually at
the end of foundation 2 year—at the end of core training 2
year, they will have a break, and we need to see what they are
doing—many go abroad. Can we get them back—making sure
that we’ve made connections there? So, workforce planning is
complex, and it’s something that you have to be on top of all
the time, because everything is shifting. It’s sort of
shifting sands, really, and we’ve just got to be on top of
the game with it.
|
|
[80]
Caroline Jones: I was thinking more in the line of educating
people, perhaps, to go to the pharmacy as opposed to the doctor. I
was looking at the type of change in that respect, which will take
time to implement, and once the public are educated in these
preventative types of ways, then the GPs and primary care will
eventually see the benefits. That’s the term that I was
looking for.
|
|
[81]
Dr Llewelyn: Yes. So, there’s a cultural change
isn’t there, and maybe we need to be a bit more vociferous,
really, in the way that we tell people that pharmacists—.
|
|
[82]
Caroline Jones: Communication.
|
|
[83]
Dr Llewelyn: Yes, communication too.
|
|
[84]
Dr Jones: I think, really, speaking on the self-care agenda,
there needs to be a robust plan for actually taking that forward. I
set up an out-of-hours organisation back in 2004—a very
successful one—building on the old co-operative model where
we’d all cross-cover everyone’s patients, and actually
I’ve seen, since that time, such a change in patient attitude
towards medicine. It’s more of a convenience and a want,
rather than a need and appropriateness, and we need to change that.
I think the clusters are an exciting opportunity in order to
educate the local population as well, and in terms of engaging with
our clusters—our pharmacists, our optometrists, our social
care, our voluntary sector—you know, in terms of actually
being aware of all these organisations, and how we can all help
each other maybe through social prescriptions as well, and through
changing people’s attitudes.
|
|
[85]
But I do think the self-care agenda needs a robust plan for that.
I’ve never seen one anywhere for taking that message forward,
because it is something that needs to be taken forward, given how
the media play into some of these things and actually make
situations worse. I’m thinking around measles and
meningitis—you know, parents reading these will see their
child’s got a temperature and they may have a bit of a rash,
and because they haven’t got mum, dad, the wider community,
friends or neighbours, who they would have otherwise used, maybe
years ago, for a second opinion, they will naturally default to the
service, whether they need to or not. I understand that, but we
need to start reversing that and get a proper robust self-care
agenda. Not making it an obstructive approach to healthcare, but
actually saying, ‘This is how we can provide it’, which
is appropriate and good for the future.
|
|
[86]
Caroline Jones: Thank you.
|
|
[87]
Ms Jackson: I think it’s also worth remembering that,
while there are huge pressures on general practice and primary
care, at the other end, what our doctors are finding—those
who are working on the general take—is that, actually, very
few of those patients turning up at A&E or at the acute medical
unit don’t need to be admitted, but they actually only need
to be admitted for two or three days, because they need to be
treated for an acute episode, but then, ideally, discharged within
two or three days. What we’re finding, actually, is that in
some hospitals—and it’s one of those examples of
‘statistics can prove anything’—the better they
get at ambulatory care, i.e. people arriving, turn them around and
send them home, the average length of stay is going up in those
hospitals. So, the better we get at ambulatory care—and we
are in some hospitals getting very, very good at
that—there’s a knock-on effect, because the people who
are being admitted are staying for 30 days or longer because of the
lack of social care options available to them. And, actually, when
you speak to our hospital doctors, they are telling us that the two
biggest things by far that are causing them problems are the
inability to recruit, but also the lack of social care options and
the inability to discharge patients once they’re—. So,
we talk a lot about people turning up at A&E inappropriately.
Actually, most people who come to A&E are there because a
health professional of some sort has told them to go, but they
don’t need to then stay in hospital for longer than a few
days. But they are then taking up a bed, because once you’re
in the system it’s difficult to leave the system.
|
|
[88]
Dr Jones: We find the social care challenges in primary care
very difficult, because sometimes there is no other option other
than to send them into hospital. There are some very, very good
examples of ambulatory care units working with our colleagues in
secondary care and primary care, and that’s working very,
very well; it’s exciting. Again, I don’t think we
promote how these exciting portfolio-type ways of working are out
there, again, to attract people in, saying, ‘You’re not
going to be doing just this avenue of work; there’re all
these opportunities out there.’ We don’t spend enough
time promoting what’s good about what we’re doing in
Wales.
|
|
[89]
Ms Jackson: The traditional model of training has always
been that you do five years undergrad, you do your four years
general, you do your five years specialty, and you do this quick
run-through, and you become a consultant by your mid-thirties.
Actually, increasingly, with the generation coming up now, they
don’t necessarily want that. As Gareth said, they want maybe
a gap year, maybe they want to do an MD, maybe they want to take a
bit of time out for research, and maybe they want to take some time
out to locum in different specialties while they decide what they
want to do forever. So, there’s much more openness to
portfolio careers, and I don’t think the NHS in Wales has
caught up with that. Really, we should be offering clinical
fellowships—you know, two days in the community, two days in
a hospital clinic, maybe a day doing research. We should be
building more of that. We’re operating on a scale that means
we could, in theory, come up with some really innovative job
descriptions and not just be advertising the same old job
descriptions with the hope that maybe this time we’ll find a
candidate.
|
|
[90]
Dr Jones: And, thinking about neonatologists, having
bursaries to allow them to go and get additional skills somewhere
else, or to take up a fellowship learning about the latest
techniques in New Zealand or Australia, but then bringing that back
to Wales and actually bringing that learning and teaching into
Wales, which will then attract other people thinking, ‘I want
to be a neonatologist; Oh, Dr Pickersgill did this training and
this fellowship out there, I’d like to go and work under him
to learn about that.’ Again, I think there are different ways
of, maybe, attracting people in.
|
|
10:15
|
|
[91]
Angela Burns: May I just make one very brief comment?
You’re absolutely right, but unlike a great many other
professions, the medical profession is quite unusual in that you
are at a much older stage in your life when you are doing what can
be seen as more training, more learning, all these sabbaticals, et
cetera, and then you’ve got the problem of the partner and
the family. And if you’ve got young children or a partner who
has got a good job somewhere, you don’t want your family
split up like that, whereas if you work for BAE or if you work for
pretty much any private sector company or most public sector
companies, you’re not having to move around quite so much,
and that’s the issue, and that’s what we need to
crack.
|
|
[92]
Dr Jones: I was in a joint medical family, and my partner
chose about three different specialties to train in before he
decided to stay in the one he was in. And he did move around,
because he had to go and find the opportunities to train as he
wanted to do. But I would say that the actual advice given by
medical colleagues in terms of what to do, how to do it and where
these fellowships and extra training opportunities were was great,
and actually, when you look at them, there’s no reason why
one couldn’t follow and temporarily leave a practice to go
and have a sabbatical and follow your partner. But I think we need
to make these, maybe, case studies and make them examples so that
people do understand that, once they come to Wales, they
don’t necessarily have to just stay here to develop their
skills; they can get them from elsewhere and bring them back here.
But yes, I think most of us who go into medicine actually view it
as a vocation, and always want to take that academic challenge.
It’s not a case that we do our A-levels, pop into medicine
and then we stop; we always want to carry on our learning. I think
that’s what is different, probably, about healthcare
professionals: you want to continue lifelong learning.
|
|
[93]
Dai Lloyd: Jayne, you’re going to wrap up this
session, although your question has been partially answered, I
would suggest. But feel free to drift wherever you want to go.
|
|
[94]
Jayne Bryant: Yes, it has been partially answered, but Dr
Llewelyn, you’ve mentioned that everything is changing, and
it was really interesting to hear the ideas about innovation in
staff development; I think that’s something that we’ll
all take on board. But the WIHSC report of 2012, I think, called
for new service models, such as increased centralisation at some
hospitals. Do you think that would be sufficient to ensure enough
doctors are available to staff current and future hospitals?
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|
[95]
Dr Pickersgill: I think there is an issue about
centralisation, which is—it’s been the elephant in the
room for donkey’s years. As has been said many times by you
and, indeed, us today, what are we going to be staffing in 10
years’ time? Medical recruitment, NHS recruitment and
workforce planning is baking a cake that takes 10 years in the
oven, but you don’t know what the temperature is, you
don’t know how big it needs to be at the end, or even what
flavour, but you’ve got to decide on the ingredients now.
It’s very tricky. And if there is going to be a wider
provision of more community-based ‘hospital services’,
and keeping people in the community who are ill with multiple
co-morbidities, rather than the current default: admit to hospital,
that’s going to need a very different workforce to the
primary care and secondary care workforce we’ve got now.
|
|
[96]
Then you’ve got to consider the—you mentioned WHSSC,
the specialist services commissioning body—well, the very
specialist services can’t be provided in every district
general hospital in Wales, or anywhere else for that matter.
Neurosurgery has been a classic example, which I know a fair amount
about, in terms of being involved with it, and Gareth’s
neuroscience and neurology delivery plan from a year or two ago is
a good example of how the health boards are not deliberately
obstructing, but kind of getting in the way of stuff that should be
happening. So, there was a defined need and central funding for
two, I think it was, extra neurologists—one in west Wales,
one in Cwm Taf—but it took over a year for all those
individual health boards along the M4 corridor to actually decide
how much of the central pot of money each of them was going to get
and how much of the pie they were insisting on having themselves.
They weren’t working together, they were battling for money,
and that’s a concrete example. But on the specialist services
in terms of training, doctors who want to train in a specialty will
want to go to a place where there is an active research department
with a good output in terms of conferences, where there are
academics and where there are sometimes, never mind British, but
world-leading experts in their areas. And staffing such rotas for
specialist services—whether it’s cardiology or cardiac
or brain surgery—out of hours means it can’t be done in
every hospital.
|
|
[97]
Dr Llewelyn: I think the centralisation has to happen, but I
think that we’ve also got a very rural population and, also,
one of the things that we’ve been trying to promote is that,
perhaps, Wales has a unique opportunity to develop rural medicine
as a speciality. We don’t have any problems staffing the
bigger hospitals; it’s the smaller hospitals where the
problems are. Rural medicine is not a speciality, and we’d
like to see that happen. We’ve got a unique opportunity to,
perhaps, develop that in Wales.
|
|
[98]
Ms Jackson: I think it’s also worth remembering
‘Shape of Training’, which was a four-nation-sponsored
review of postgraduate medical education, published in 2013. There
are parts of it that are UK-wide, there are parts of it that are
led by the GMC, and there are parts of it that could be carried out
on an individual nation basis. We haven’t seen a great deal
of progress on it for some parts of those recommendations, but
where, for example, the colleges have been told to go away and do
things, we’ve done those. So, in the RCP, certainly,
we’ve revised the curriculum for general medicine,
we’ve moved from a two-year general curriculum to a
three-year, and that will be implemented in the Wales Deanery from
next August—so, August 2018. So there are things happening.
There are moves towards a workforce, a medical workforce, with a
more broad-based skillset in general medicine, recognising that,
actually, as that base of patients with chronic, complex
multi-co-morbidities grows, we actually need physicians who are
able to handle a broad range of different general medical
problems.
|
|
[99]
Something, for example—. To go back to Trevor’s
point—well, to go back both to Trevor’s point and an
earlier point that was made around vision, the previous Welsh
Government committed in February 2015 to a 10-year medical
workforce plan. It’s two years later and we haven’t
seen anything. We’ve been following its progress with
interest and it keeps getting bounced around. Our understanding at
the moment is that it’s sitting with NHS Wales workforce
education and development services. They, we are told, are waiting
for the outcome of the parliamentary review. Actually, that’s
a process that we’d argue needs to be reinvigorated, because
if you’re constantly waiting for the next report to come out
before you take any action, you’ll be waiting a long time.
So, as Trevor said, having that goal, knowing what your service and
your workforce looks like in 15 or 20 years—. The Shape of
Training review did try to do that, to some extent, because it
tried to say, ‘Well, actually, what is the direction of
change and who are the doctors we need to start training?’
and so some of that work is happening at a curriculum and at a
deanery level, but it’s still not necessarily happening at a
national, strategic level.
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|
[100] Dai
Lloyd: Rhun.
|
|
[101]
Rhun ap
Iorwerth: Fe wna i symud ymlaen o hwn, os—
|
Rhun ap
Iorwerth: I will move on from
this, if—
|
|
[102]
Dai
Lloyd: Ie, go on.
|
Dai Lloyd: Yes, go on.
|
|
[103]
Rhun ap
Iorwerth: Yn sydyn, o ran cynyddu’r nifer o israddedigion
sy’n dod i astudio yng Nghymru, dechrau’r broses ydy
hynny, wrth gwrs, ond rydym ni’n gwybod bod yna llai o gyfran
o’n myfyrwyr meddygol ni yng Nghymru yn dod o Gymru o’i
gymharu efo Lloegr a’r Alban. Pa mor bwysig ydy
cynyddu’r gyfran yna sy’n astudio yng Nghymru a
chynyddu niferoedd absoliwt, yn cynnwys ehangu addysg feddygol i
lefydd y tu allan i Gaerdydd ac Abertawe?
|
Rhun ap
Iorwerth: Just quickly, then, in relation to increasing
the number of undergraduates coming to study in Wales,
that’s, of course, only the beginning of the process. We know
that fewer, as a proportion, of our medical students in Wales come
from Wales, compared to England and Scotland. How important is it
to increase that proportion that study in Wales and the absolute
numbers, including expanding medical education outside Cardiff and
Swansea?
|
|
[104]
Dr
Llewelyn: Wel, rydym ni eisiau mwy o lefydd, ac mae’r prosiect o
efallai cael ysgol feddygol ym Mangor—rydym ni’n
cefnogi hynny. Byddai’n rhaid inni edrych ar ba fath o ysgol
feddygol y mae hynny’n mynd i fod: a ydy o’n mynd i fod
yr un un model ag sydd gennym ni ar y funud, neu a ydym ni’n
mynd i drio creu rhywbeth gwahanol? A yw’n mynd i fod yn
ysgol ôl-raddedig, fel Abertawe? Achos efallai bod yna fwy o
gyfle, wedyn, i bobl sydd yn dod o Gymru i ddod yn
ôl—wedi gwneud graddau y tu allan i Gymru, wedyn dod yn
ôl i Gymru i wneud meddygaeth. Felly, mae’r prosiect
yna’n un diddorol, ac mae angen inni edrych arno, ac efallai
bod hynny’n rhywbeth y bydd Health Education Wales yn
ei wneud—a ydyn nhw’n mynd i edrych ar hwn fel rhan
o’i portffolio nhw? Nid wyf yn gwybod.
|
Dr Llewelyn: Well, we want more places
available for students and the project to have a medical school in
Bangor is one that we support. We would have to look at what kind
of medical school that should be: will it be the same model as we
currently have, or are we going to create something different? Is
it going to be a postgraduate school, such as the one in Swansea,
because perhaps there are further opportunities, then, for people
who are from Wales to return—having studied for their degrees
outside Wales, they can then return to study medicine. So that
project is certainly an interesting one that we need to look at,
and perhaps that is something that Health Education Wales will look
at as part of their portfolio. I’m not sure if they’ll
do that.
|
|
[105]
Dai
Lloyd: Fe wnawn ni’n siŵr eu bod nhw. Reit, rwy’n
credu ein bod ni wedi dod i ddiwedd y cwestiynau, felly diwedd y
sesiwn. A allaf ddiolch yn fawr i chi’ch pedwar am eich
presenoldeb, a hefyd am ateb y cwestiynau i gyd mewn ffordd mor
raenus ac aeddfed, a hefyd y papurau y gwnaethoch chi baratoi cyn y
cyfarfod? Maen nhw i gyd yn fendigedig a byddan nhw’n bwydo i
mewn i’r ymchwiliad. Yn ogystal â diolch ichi unwaith
eto, gallaf bellach gyhoeddi y byddwch chi’n derbyn
trawsgrifiad o’r sesiwn yma er mwyn ichi allu ei wirio fe. Ni
allwch chi newid eich meddwl am ddim byd, ond o leiaf medrwch chi
wneud yn siŵr bod pethau’n ffeithiol gywir. Felly, gyda
hynny, diolch yn fawr ichi gyd. Cawn ni egwyl am 10 munud,
rŵan, i’m cyd-Aelodau, cyn inni ddechrau’r sesiwn
nesaf. Diolch yn fawr iawn ichi.
|
Dai Lloyd: We’ll have to make
sure that they do. Okay, I think we’re at the end of the
questions, then, and therefore the end of the session. Thank you
very much to the four of you for coming and for answering our
questions in such a competent and mature manner, and also for the
papers that you prepared for us before the meeting. They are
excellent and they will feed into the inquiry. And as well as
thanking you, can I also tell you that you will receive a
transcript of this session so that you can check it for accuracy?
You can’t change your mind about anything, of course, but can
you please check that things are factually correct? Thank you very
much. We will take a short break now for 10 minutes, for my fellow
Members, before we begin the next session. Thank you very much.
|
|
Gohiriwyd y cyfarfod rhwng 10:25 a
10:37.
The meeting adjourned between 10:25 and 10:37.
|
|
Ymchwiliad i Recriwtio
Meddygol—Sesiwn Dystiolaeth 4—Coleg Brenhinol yr
Ymarferwyr Cyffredinol a GP Survival
Inquiry into Medical Recruitment—Evidence Session
4—Royal College of General Practitioners and GP Survival
|
|
[106]
Dai Lloyd: Croeso i’r sesiwn ddiweddaraf yma yn y
Cynulliad o gyfarfod y Pwyllgor Iechyd, Gofal Cymdeithasol a
Chwaraeon. Dyma’r bedwaredd sesiwn dystiolaeth, a hon o dan
eitem 3: ymchwiliad i recriwtio meddygol. O’n blaenau ni mae
tystion o Goleg Brenhinol yr Ymarferwyr Cyffredinol a hefyd o GP
Survival—goroesi meddygaeth deuluol, y buaswn i’n
meddwl. Reit, fe wnawn ni gyfarch yn swyddogol Dr Rebecca Payne o
Goleg Brenhinol yr Ymarferwyr Cyffredinol; Dr Isolde
Shore-Nye, hefyd o Goleg Brenhinol yr
Ymarferwyr Cyffredinol; Dr Linda Dykes, meddyg ymgynghorol mewn
meddygaeth achosion brys yn Ysbyty Gwynedd a meddyg teulu â
diddordeb arbennig mewn geriatreg yn y gymuned, Bwrdd Iechyd Lleol
Prifysgol Betsi Cadwaladr; Dr Sara Bodey, partner meddyg teulu,
Practis Bradley, Bwcle, sir y Fflint; a hefyd Dr Heidi Phillips,
partner meddyg teulu yn Fforestfach—adeilad rwy’n ei
adnabod yn dda iawn, yn Abertawe.
|
Dai Lloyd: Welcome to this most recent
session at the Assembly of the Health, Social Care and Sport
Committee. This is the fourth evidence session, under item 3:
inquiry into medical recruitment. And before us we have witnesses
from the Royal College of General Practitioners and from GP
Survival. I welcome Dr Rebecca Payne, from the Royal College of
General Practitioners; Dr Isolde Shore-Nye, also from the Royal
College of General Practitioners; Dr Linda Dykes, consultant in
emergency medicine, Ysbyty Gwynedd, and also a GP with special
interest in geriatrics in the community with Betsi Cadwaladr
University Local Health Board; Dr Sara
Bodey, GP
partner at Bradley’s Practice in Buckley, Flintshire; and
also Dr Heidi Phillips, GP partner in Fforestfach—a building
I know very well indeed, in Swansea.
|
|
[107]
Rydym ni wedi derbyn eich tystiolaeth
ysgrifenedig bendigedig chi. A oes rhywun eisiau dweud rhyw ychydig
eiriau fel cyflwyniad? Oni bai am hynny, fe awn ni’n syth i
mewn i gwestiynau. A oes rhywun eisiau dweud rhywbeth fel
cyflwyniad, neu a ydych chi’n hapus jest i dderbyn
cwestiynau?
|
We have had your written evidence, which was
excellent, thank you very much. Would anyone like to make any
opening remarks, by way of introduction? Otherwise, we will go
straight into questions. Would anyone would like to kick off with
some opening remarks, or are you happy just to receive
questions?
|
|
[108] Dr Dykes:
I’ve got one, if that’s okay.
|
|
[109] Dai Lloyd: Yes.
|
|
[110] Dr Dykes: I’m delighted to be
able to share with you some of the key lessons from the successful
recruitment scheme for clinical fellows in Bangor’s emergency
department. From my written evidence, you already know that
it’s possible to recruit doctors to Wales—it is
possible, even in the face of the UK-wide recruitment difficulties
in emergency medicine—but, we do have to work hard for each
and every recruit. We are selling posts, and it’s a
buyer’s market. We have to be realistic about that. Too many
medical posts are, quite frankly, dreadful, and it doesn’t
matter how fancy your full-page colour advert in the British
Medical Journal is, you can’t polish a turd. If I do
nothing else today, I hope to convince you of the need to build
posts around doctors and not the other way around.
|
|
[111] Doctors have
lives outside of medicine and anyone recruiting must understand the
psychology, the motivations, the life stages and other
push-and-pull factors of their potential recruits and ensure posts
meet those needs, or you won’t get anybody for them. We
designed our clinical fellow posts around the wish list of the
junior doctor we were targeting as our first recruit. It’s
also vital to grasp that the values and priorities of generation Y,
those born after 1985, are different to those of us who are
generation X, and to the baby boomers. Generation Y are almost all
of our junior doctors now, most of our younger GPs, and
they’re just emerging into the system as consultants.
|
|
[112] Finally, and
I’m very mindful this is a contentious issue, we have to be
honest and acknowledge that the perceptions held by those outside
of Wales of some elements of life inside Wales, such as our
education and language policies, exacerbate the normal reluctance
of any family to consider relocating and disrupting
children’s schooling. This can adversely affect the
recruitment of doctors in their mid-to-late 30s until the mid-50s
or so, and that’s in addition to the fact that many families
will not move anywhere when the kids are in school. Setting these
challenges aside, however, the Bangor ED clinical fellow scheme
demonstrates the power of creative, flexible, doctor-centric posts
to bring doctors to Wales year after year, and then they come back
as consultants, and then they bring their own students, and it all
goes from there.
|
|
[113] That concludes
what I had prepared to say to you and now I’m all set for
your questions. Thank you.
|
|
[114]
Dai Lloyd: Dyna ni. Sara.
|
Dai Lloyd: Thank you very much.
Sara.
|
|
[115] Dr Bodey:
Since I did my written submission there’s been a document
produced looking at foundation doctors and their career decisions.
I don’t know if you’ve seen this document. It just
reinforces the increasing trend for doctors at this stage to not go
on to speciality training. I’ve actually brought one of these
doctors with me, and he’s sitting in the gallery upstairs.
He’s somebody that I first met as a medical student in
practice with me. He’s currently an F2 doctor in Liverpool,
and like about 50 per cent of F2 doctors, he’s not going to
go on to speciality training. He wants to have some time out to
think about what he wants to do. He’s going to locum. He
can’t do that in a GP practice. He can’t get that GP
experience at that stage, because of the current regulations. He
can do anything else. If he could do it in GP, then he would do,
and if that was available in Wales, he’d come and work in GP
in Wales, in a supervised capacity. It’s what they’re
asking for. It fits in with what Linda’s saying about
responding to what doctors actually want to do as opposed to what
we design. That’s what I would like to get across today.
|
|
[116]
Dai Lloyd: Grêt. Diolch yn fawr. Heidi, wyt
ti’n hapus, neu wyt ti eisiau dweud rhywbeth?
|
Dai Lloyd: Heidi, are you happy, or
would you like to say something?
|
|
[117] Dr
Phillips: Yes, I’m Heidi, I’ve been a GP for 15
years. I’m also admissions director for Swansea
graduate-entry medical school and I’m doing a Master’s
in research in the recruitment and retention of GPs in Wales. So, I
think I’m uniquely situated to understand the retention and
the recruitment issues. From the work that I’ve done,
it’s showing that medical students need exposure to general
practice. Seventy-one weeks in the curriculum are spent in
secondary care and 11 weeks in primary care. The majority of the
taught course—and I’m talking over 90 per cent of the
theoretical course—is taught by secondary care doctors. All
the evidence and the literature show that if you want to influence
people to choose a career path, you need to give them good role
models and you need to give them exposure to those role models.
That’s what we need to be focusing on. We have a pipeline
from school to medical school to workforce, and we have a leaky
pipeline. We need to look at all the stages along that
pipeline.
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|
[118]
Dai Lloyd: Diolch yn fawr. Rebecca.
|
|
[119] Dr Payne:
I haven’t prepared anything to say, and what I’d like
to say is that, actually, when it comes to Sara and Linda, these
guys have made recruitment a success, so I’m very keen that
they have maximum opportunity to share what they have practically
done that has addressed many of the recruitment challenges we
face.
|
|
[120] Dai
Lloyd: Well, the avenues of questioning will tease out further
details. Isolde, do you want to—?
|
|
[121] Dr
Shore-Nye: I don’t particularly have anything additional
to add other than to say that I am a GP working within the area and
I’m a cluster lead as well, so obviously recruitment and
retention are high on my list of priorities as well as the
college.
|
|
[122] Dai
Lloyd: Excellent.
|
|
[123]
Diolch yn fawr. Reit, awn ni i mewn i
gwestiynau ffurfiol, ac mae yna ryw 50 munud gyda ni, i ddechrau
efo Julie
Morgan.
|
Thank you. We’ll go into formal
questions, then, please, and we have about 50 minutes for this
session. Can I start with Julie Morgan?
|
|
[124]
Julie Morgan: Thank you. Just to pick up what one of you said about
it not being possible to get a locum at a GP practice, I wonder if
you could expand on that. It’s not possible to do that.
It’s not built in in any way.
|
|
10:45
|
|
[125] Dr Bodey:
It’s not possible if you aren’t on the GP specialist
register or in a recognised training post. So, there are various
doctors who would want to gain experience in general practice who
don’t meet those criteria; and because of the performers
lists regulations, they’re not allowed to work in GP. You
can’t do even a supervised post if you’re not either on
a recognised training scheme or on the GP specialty register. So,
there’s a really small pool of people that we can then call
on to be doctors in a GP setting. There are lots of doctors who
would want to have that opportunity. I’ve been told by
somebody who has recently left the General Medical Council that the
performers lists legislation is within the gift of the Welsh
Government to change to make it possible. It needs to be in a
supervised and regulated way, to avoid abuse of such roles, but I
think it could easily be made possible. And certainly, I think the
evidence that I submitted gave you an idea of the number of doctors
who would be interested in that sort of role.
|
|
[126] Dr Payne:
Can I add some detail around that? Currently, the training scheme
is that a doctor will come out of medical school, do their
foundation years and then they may embark on some time out, which
is what Sara is describing—where people are spending time
locuming in psychiatry or any other specialty. That’s not
available to general practice at that level, as a very junior
doctor. In order to be a GP locum, you have to have gone through
the full training scheme and then locum. So, we’re talking
about something very different to what’s currently in the
system and something that doesn’t exist at present.
|
|
[127] Julie
Morgan: Right, but you think—
|
|
[128] Dr Dykes:
Can I give a little context that may help? So, we have a situation
in general practice at the moment whereby we make good use of
advanced nurse practitioners, paramedic practitioners and
non-medical clinicians, which is fantastic, but we have the
somewhat incongruent situation where we’ve got those, and
we’re quite happy for those to work mostly autonomously with
a little bit of paper-based supervision quite often, and yet we
won’t allow a doctor who has been at medical school for five
years and has at least two years of postgraduate training to work
in a supervised environment in a practice. It’s a little
incongruent and slightly insulting.
|
|
[129] Julie
Morgan: Thank you. Right; to move on, there’s been a lot
of publicity and concern about the pressures in primary care,
particularly recently. Do you think people do see general practice
as an attractive career option?
|
|
[130] Dr
Phillips: No.
|
|
[131] Julie
Morgan: No. Right.
|
|
[132] Dr
Phillips: I think there are two sides to that. You’ve got
the recruitment and the retention side. I’ve done a survey of
the Swansea medical students. One of my students actually did a
survey. They don’t see it as an attractive option because
they see what we see, which is a 10-minute revolving door, starting
at 8.30 a.m. through to 6.30 p.m., with no protected time for
education, no protected time for the expansion of other interests,
and no protected time even for administration. It’s
relentless. When you look at the other side of it, you see the
GPs—our role models—who, from the evidence I submitted,
are burnt out, exhausted, demotivated and demoralised. I’ll
show you this. I don’t know if you can see it. What you can
probably see is a page of green. That’s the second screen of
two screens of an on-call morning. A morning—8.30 to 11.30
a.m.. There are 59 extras. So, all the appointments have already
gone for the morning and, on the second page, there are 59 extras
and 11 house-call requests. That’s for one doctor. If
we’re talking about 10 minutes per patient, and 59 patients
demanding to be seen that day who can’t wait until tomorrow,
do the sums. We haven’t got that time to see them. So, as
well as that, we are trying to enthuse and motivate these students
to come through when we’re facing this. So, it’s a
multifactorial problem.
|
|
[133] Julie
Morgan: So, has anybody else got any comments on that?
|
|
[134] Dr Bodey:
General practice should be the best job in medicine. I think people
are attracted to the idea of what it should be, but the reality is
something different. Certainly, we hear from trainees that they
don’t want to work as hard as their trainers do, and
that’s the feedback at the end of training programmes. They
have a look at what we’re doing and say, ‘I don’t
want to do that.’ That’s one of the reasons that they
often choose to work part-time.
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|
[135] Dr Dykes:
There’s an added thing onto there, which is, because the NHS
across the UK now has been under pressure for seven, eight years,
really, and then the wheels really fell off in those parts of the
UK maybe four, five years ago, our students and our young doctors
have never seen it working properly. They have no idea what it is
like when the wheels were on the bus, and it’s all going
lovely. So, their entire perception is clouded by this, and we have
the same in emergency medicine—our guys look at us and go,
‘I’d love to do it, but I’m not doing what
you’re doing until I’m 68.’ So, it’s very
difficult.
|
|
[136] Dr Payne:
There’s also an impact on the retention as well. I’ve
been a GP now for 10 years, and the job I do now is completely
different to the job I did 10 years ago, and very different to the
job when I started my first placement in general practice as a
doctor in 2002. The level of complexity that we’re dealing
with, in terms of many, many more older patients with really
complex medical problems, but also in terms of the steps that
we’ve taken to diversify the people within the
practice—actually that makes it a lot harder, too. So, if the
nurse practitioner is seeing the more simple cases, that means
everybody who comes to sees me is complicated. In the past, I might
have seen people with sore throats, people who wanted a pill check,
and that would give me the catch-up slots so I could spend a bit
longer with people with mental health problems or more complex
medical needs. Once you take all of the easy stuff out, unless
there is then that expansion in the time available to deal with the
complex things, work becomes an awful lot harder.
|
|
[137]
Julie Morgan: So, all the patients you’re seeing are ones who
couldn’t be diverted to somebody else.
|
|
[138]
Dr Payne: Yes, they are.
|
|
[139]
Julie Morgan: They need to be seen.
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[140]
Dr Payne: Yes, and it also depends on the practice. So, some of
the smaller practices won’t have that larger workforce around
them, but they have the huge problems with volume because
you’re not diverting anybody off. But in some of the
out-of-hours settings I commonly work in, and other, bigger
practices, if you’ve taken off the simple cases, you’re
left with very complex decision making to do. It’s not just
the volume of patients, it’s the complexity of the decisions
and the need for a new decision with a patient every 10 minutes
that can be very, very difficult. At the end of the day,
you’ve just got nothing left.
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[141]
Dr Bodey: There’s a real danger of cognitive fatigue
kicking in, and errors creeping in because we’re exhausted
from making decisions.
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[142]
Dr Dykes: There is evidence on that. If you Google
‘Israeli parole board data’, then you will find a graph
of an Israeli parole board—thousands of thousands of cases
every year—and in the morning, when they’re fresh and
bright, they will let lots of people out of prison, and then by
lunchtime when they’re knackered—and you’re
making high-impact decisions: you know, if you let somebody out and
they go and kill somebody, then the parole board’s in
trouble—they won’t let them out. You see
it—it’s amazing. It’s like, over the morning your
ability to make decisions goes like that, and you feed and water
people, and it goes right back up again, and falls down. The
problem is that we’re probably running a great deal of our
medical workforce in all our settings, in the acute settings
particularly, on decision fatigue, they can’t do it, and then
you revert to the most risk averse way of doing it, and then you
end up with even more strains on the system. So, your judgment
ability goes, and then you end up admitting people because you just
can’t muster the mental energy to decide if it’s safe,
or to work out an alternative—talking to colleagues who are
in the same sort of position. But Israeli parole board
data—Google it, it’s fantastic.
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[143]
Dai Lloyd: Okay. Julie.
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[144]
Julie Morgan: I was just going to say, obviously there are not
enough doctors or GPs to do the job, but can you suggest what would
be your biggest priority in terms of improving the
situation?
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[145]
Dr Phillips: The elephant in the room is to improve the work-life
of current GPs, because we can talk about recruitment, and we can
pay £20,000 to get somebody to come in and work, but once
they actually are in the job and they realise what the job entails,
they can’t stay in the job. They can’t do what it is
we’re doing for years and years. That’s why,
apparently, the average age of a female GP leaving general practice
is 45. So, we’ve got to do something about it.
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[146]
Julie Morgan: How can you do it without more doctors if the number
of patients all need to be seen?
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[147] Dr Dykes: I
think it’s may be where the Bangor clinical fellow experience
helps. So, obviously, we were facing, as you’ll know from the
written evidence, going into 2011 with only one substantive doctor,
and he was trying to leave, on our middle-rate tier. I worked out
how I could do it, and I knew I’d be able to recruit to it,
and I said to my managers, ‘I want to set up this new breed
of doctor, and oh, by the way, we’ve got to let them out to
play’—it’s with Welsh ambulance, they’re
contributing to the health community—and he says, ‘But
we’re so short of doctors, how can you let them out to play?
You’ll end up with only 0.8 doctors rather than one’,
and I’m going, ‘Because if not, we’ll have 0.0
doctors—it’s not that difficult.’ So,
you’re recruiting to that, and then they have a
sustainable, fun time and then their mates go, ‘Hang on a
minute, I can go there too.’ And that’s the exact
situation we’ve had. So, you have to improve the lot of what
you’ve got to make the job attractive, and, sure, you will
have a temporary dip in capacity, but you have to take that if
you’re not going to, just, you know, ram more people in, and
we have a lag phase before we can suddenly conjure up more people.
But you can improve the lot of those whom you’ve got going
through at the moment and then that will actually help solve the
long-term problem. But getting over this blip is very
difficult.
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[148] Dai
Lloyd: Rebecca. Sorry, Sara.
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[149] Dr Bodey:
There are doctors there at this more junior level and at other
levels who could be a resource, but, at the moment, we’re not
making it possible for them to contribute.
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[150] Dai
Lloyd: Okay. Rebecca.
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[151] Dr Payne:
There are a few more practical steps that could be taken straight
away, and I’m aware that there is ongoing work in a number of
these areas, but it’s not come to fruition yet. So, the first
of these is indemnity, and, at the risk of sounding a little bit
geeky, this is absolutely imperative to sorting out the problem.
So, doctors have to pay for insurance to practice. My insurance
costs me £120 a day. Now, I need that insurance if I’m
going to go and do a locum for Isolde, but if I do a locum for a
health board practice or work in the out-of-hours setting, I
don’t have to pay that additional £120 a day. Now, what
that means is if I’m offered work in a non-conventional
setting, for example out of hours, or if I’m offered
work—I do some teaching of communication skills at the
university—there’s a real incentive for me to not go
and help Isolde, because not only is the insurance extremely
expensive, it’s also very inflexible. So, if I’ve
worked the maximum number of sessions I can work that month,
there’s nothing I can do to help Isolde, because I’m
just not insured, and I can’t just say, ‘Well, insure
me for one more session.’ You’re looking at then
increasing your premiums, going forwards.
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[152] So, that’s
having a real adverse effect, firstly on the ability of GPs already
in the system to up their hours, because the indemnity stops that.
It’s reducing our ability to flex up to help with winter
pressures or help colleagues in crisis, and, actually, it’s
estimated that you would have extra GP capacity within the system
if that was addressed. Because if somebody’s insured for,
say, two or three days a week and the average time that Welsh GPs
are working in general practice is 60 per cent, that’s their
insurance—that’s it. But if you had a solution to this,
they would be able to flex up. But once you increase your sessions,
you’re then committed to that for at least a month, so people
won’t want to do that if they just want to increase on a day.
They’ll just say, ‘Oh, I won’t work that
day.’ So, finding a solution for this would really help
immediately release extra qualified GP time into the workforce in a
flexible manner, able to provide assistance when it’s most
needed.
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[153] The other thing
to look at is how we do stuff within practices, and, as GPs, we
know that we need to do many things differently, and a lot of
surgeries are quite a long way down this road of transformation,
looking at how things like the letters coming into the practice are
handled and looking at which staff members see the patients.
We’re doing all of that already, but some of the practices,
particularly those that have really got their backs to the
wall—when you’re under huge pressures, that’s
when it’s hardest to take the step back and look at what
further you can do to transform. We need more active support from
health boards, and, to be fair, they’re already trying to do
this, but we need them to look at what can be given to practices to
help them analyse their workflow, analyse their patterns, explore
other options out there.
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[154] Not all the
answers will lie within NHS Wales. So, our colleagues over the
border are providing support for practices to look at the letter
system. They’re looking at services—there’s one
offered by an organisation—Care UK—I’m not
selling them; they’re just one of the organisations out
there. Shropdocs is too. I believe there is a small outfit in
Cardiff Bay that do this as well. So, they’re supporting
struggling practices to send some of their telephone consultations
out, so they’re handled by people elsewhere, and these
innovative solutions—. Individual practices are often
struggling to find out about them or to resource them, but the
health boards have got that clout and that buying power to look at
these.
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[155] There are also
things on the IT side that make it incredibly clunky and difficult,
things like accessing discharge summaries—I’m sure
you’ve heard this before—that can be a real challenge,
or looking at what’s happened to a patient in hospital.
Sometimes, the systems are really clunky, and asking NWIS to really
prioritise work relating to general practice would mean, if the
systems were less clunky, we could actually be more effective in
the time we have.
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11:00
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[156] So, there are
some simple solutions—well, I say ‘simple’.
They’re solutions that could be enacted right now with enough
sense of urgency on the agenda to really prioritise this. And also,
we need to see a shift of staff from the secondary care system into
general practice. The problem is everybody’s stressed,
everybody’s under pressure. There aren’t enough nurses;
with pharmacists, we’ve had a massive influx of pharmacists
coming in to general practice, but we’re now running out of
people to pull over. Every couple of years, it seems there’s
a different workforce that’s going to save general
practice—it’s the occupational therapists, it’s
the physiotherapists, it’s the pharmacists, it’s the
nurses, it’s the paramedics. We really value all of these
staff, but actually, as GPs, we provide a unique contribution, too,
and that needs to be recognised.
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[157] Dai
Lloyd: Okay. Angela, you’ve got a brief question, then
Jayne.
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[158] Angela
Burns: Yes. Can I go back to clinical excellence, because this
is what I don’t understand? I totally get your point that 10
minutes isn’t enough to see a person, it’s not enough
to build a relationship, to get to grips with, maybe,
comorbidities, et cetera, et cetera. So, there are massive changes
going on throughout the NHS, and I’m going to use paediatrics
as an example. So, now we have a situation where paediatricians are
being moved around the country, because what the royal college is
saying is that, in order to be trained in paediatrics, in order to
be a good paediatrician, in order to have further training, you
must train at a place that does a certain number of paediatric
births et cetera—obviously it’s paediatric births,
nobody else gets born; I don’t think you get born old,
although I feel like it at times. [Laughter.]
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[159] Dai
Lloyd: Some people are, but I digress. [Laughter.]
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[160] Angela
Burns: So, you absolutely have to be in that kind of
environment. So, who says that you can only have 10 minutes with
the patient? Why isn’t the royal college saying,
‘Actually, clinical excellence, clinical standards, which
thou shalt not break’—[Interruption.] I
understand that, but somebody, somewhere must have said it’s
okay to do 10 minutes. So, why aren’t the royal college
saying, ‘Actually, in a GP practice, you’ve got to have
15 minutes’, or ‘You’ve got to have 20
minutes’? Is it the health board that’s saying it, or
is it the Government? I understand the pressure of work, but that
doesn’t apply anywhere else, because if I just said,
‘Actually the pressure of work means you’ve got to have
full-scale paediatrics down at Withybush’, then the royal
colleges beef up their muscles and say, ‘No way, you’ve
got to go to Carmarthen.’ So, in that sense, they’re
all big and strong and say, ‘This is what you’ve got to
do’, and the Government meekly says, ‘No, you’re
absolutely right, and we’ll reconfigure everything to follow
that model’. So how come that’s not working here?
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[161] Dr Payne:
From a royal college perspective, we’ve debated some of those
issues in the past, including should there be a cap on the number
of patients a GP can see each day. The problem with that is the way
that the contracts are configured. So, as a GP partner, Isolde has
responsibility for the primary care needs of those patients on her
patch. So, if we start saying as a royal college to Isolde,
‘You have to spend 15 minutes with every patient’, what
happens when it gets to 6 o’clock and she’s still got
30 patients who need 15 minutes left? And that’s a very
practical difficulty we’ve run into. Now, that is because of
the independent contractor status, but we know that independent
contractor status brings huge, huge strengths. It means people take
responsibility for their patients, it means that practices have
been able to innovate and transform without the whole layers of
health board bureaucracy around things like recruitment, around
change, and all those areas. So, the difficulty is, although we
recognise the quality and the improvements in quality that will
come from 15 minutes, actually to mandate that would be to destroy
general practice, because you cannot do it with current workloads
in the current setting, but it’s not—
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[162] Angela
Burns: But if you follow that argument through, Rebecca, and we
talk about the drop-off and the fatigue et cetera, then you surely
run an enormous risk of actually a GP not picking up, or
misprescribing—
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[163] Dr Dykes:
That’s why the indemnity is so expensive.
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[164] Angela
Burns: Yes, because they are completely knackered and they
can’t do the job. So, at some point, there has to be, surely,
a balancing of the seesaw between the pressures of the job and the
actual reality and clinical safety of both you, as a practitioner,
and your patient. Is there not a case that, by trying to even that
up slightly, you then put the onus back on society, the system, to
actually say, ‘Oh my gosh, we’ve really got to do
something about getting more GPs in? Let’s look
at—’. Because whilst the status quo remains, and you
guys say, ‘Do you know what, it’s all right, I’m
going to end up having 51 extra patients and 11 house calls every
day, and I will just soldier on because there’s no
alternative’, then the system won’t change. In order to
effect system change in almost anything in the world, you’ve
got to have that revolution at the bottom, and somebody, somewhere
has got to draw that line in the sand and say, ‘This
can’t go on, because—’. And I would have thought
that clinical excellence and clinical standards and clinical safety
would have been one of the lines in the sand that could have been
drawn.
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[165] Caroline
Jones: But then how do you prioritise between
patients—who is urgent and who is not; who is to be seen and
who you are going to leave that day?
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[166] Angela
Burns: No, I agree, but it works in other areas, so I
can’t understand why we can’t do something about making
it work in general practice.
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[167] Dr
Phillips: One of my GP respondents, I can quote him as saying,
‘General practice is the cesspit of the health
service’, and those are pretty strong words. But,
essentially, what we’re seeing are the patients who
can’t see anybody else—so, if they want to see a
dentist, they can’t get to see a dentist, they go and see
their GP. If they’ve got problems with their housing, they go
and see their GP. If they’ve got problems with
neighbours—the GP. So, a small percentage of what I do is
what I trained to do and what I learnt in medical school. A huge
amount of what I do is sorting out the social ills of my patients.
And where do I draw the line? Do I, as this busy doctor at the end
of the day say, ‘Right, there’s this number
extra—who am I going to choose? Who am I going to value over
somebody else?’ And we can’t, not least because, if I
leave it and one person doesn’t get seen, they go to A&E
and then we get hit in the press, or I get a complaint, which I had
a couple of weeks ago because I couldn’t see a lady because I
had to go and see a patient at home with urinary sepsis. So, the
patient who turned up demanding to be seen, I asked if she could
please come back two hours later so I could go and see this ill
patient, and I got a complaint. That’s the reality. We are
expected to see everybody.
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[168] Angela
Burns: But don’t you think that’s why you need the
fire cover? Surely, that’s why you need the air cover from
somebody to say, ‘Actually, clinical excellence says that,
when you’re looking at the complex cases’—because
you’ve hived off the easier ones, the sore throats, to your
allied healthcare professional—‘if you are looking at
the complex cases, you’ve got to have extra
time—you’ve got to have the 15 minutes, you’ve
got to have the 20 minutes’. What I’m really trying to
understand is: who’s come up with the 10-minute rule?
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[169] Dr Dykes:
It was an improvement from five minutes. [Laughter.] I
remember when I first qualified, and that was when GP jobs were in
the BMJ as well, and it was a big thing: ‘We’ve gone to
10-minute appointments, woo-hoo’. I think it’s a very
fair question that general practice needs to get a grip
on.
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[170] Dr Bodey:
I think we’ve sucked up an awful lot of pressure personally
over the last few years that has hidden this until it’s got
to crisis point. It is the way the contract is designed. There
isn’t an option for us to say ‘no’, as it stands.
I know practices have been threatened with breach of contract if
they’ve tried to, but it’s a valid question and
it’s one that the profession needs to think about.
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[171] Dr Payne:
I’m happy to take it back to RCGP council to ask them to
revisit the issue. The difficulty is, within the current contract,
that would put the practice in breach of contract and the health
boards would have quite a lot to say about it. And I wonder if
it’s an area where it might be useful to get a health board
perspective on how they would respond, because it is that concern
that, by putting in these hedges and these safeguards, we would
destroy general practice as it is. And you say, ‘Well, you
could move to a salaried model’, but, actually, if you were
to look at the volume of work Heidi did that day and look at
putting a salaried GP in there who can only work a certain number
of hours a week—so, European working time directive, you need
to have certain breaks—in many salaried settings where
I’ve worked for a health board they haven’t been
encouraged to take that overall responsibility for the patients
that an independent contractor does. Actually, we would be worse
off rather than better off as a society.
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[172] Angela
Burns: I do totally understand, but it just strikes me that
what we have here is a vicious circle. In order to break any
vicious circle, you’ve got to make a cut in the system
somewhere to attract more GPs, and to make the work-life balance
and make people want to do this job, then you’ve got to start
changing something. And it strikes me that the thing to change is
the working practice so that you can get more people who want to
come and do it.
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[173] Dr
Phillips: Just to come back to you on that, if you changed my
working practice and gave me 15-minute appointments right up to
6:30, 7 o’clock, 8 o’clock, wherever you want to set
it, and that’s where I finish, who’s going to see that
extra demand?
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[174] Angela
Burns: Well, hopefully, there are more GPs that we can then
start—. You know, it’s ‘chicken and egg’,
isn’t it, but you’ve got to try and do both at the same
time.
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[175] Caroline
Jones: But that would impact straightaway. Patients would be
suffering, and so would our doctors’ reputations.
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[176] Dai
Lloyd: Isolde.
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[177] Dr
Shore-Nye: Can I just come back on the point about who makes
the 10-minute rule? I think one of the advantages of the
independent contractor status is that flex in the system, that
ability to model how you manage your patients depending on your
community and how your citizens utilise your service. If we had
those extra doctors or those extra healthcare professionals
available—. We audited our average length of consultation,
and it was longer than 10 minutes. So, actually, patients are
getting a longer than 10-minute appointment, and we have the
arbitrary 10-minute consultation because we have days like Heidi
has, where you are over and above your capacity. I think what
you’re also getting at is mentioning about how we manage that
ever-increasing demand, and that demand may be perceived by
healthcare professionals as inappropriate, but, by those service
users, it’s not deemed as inappropriate. We’re all
citizens ourselves, as well as healthcare professionals, and we all
live within our communities, and we can all understand why people
are using these services. So, it is beyond just having the extra
doctors. We can flex our systems, we can manage our services, we
can look, as the college, into workload, and how we act when we get
to the limit of our competencies, or burnout or overload, but,
actually, it also has to come from how we also manage that demand,
whether real or unreal.
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[178] Dai
Lloyd: Okay. Moving on, Jayne.
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[179] Jayne
Bryant: Diolch. I think Linda mentioned earlier about the
targeted recruitment campaign in Ysbyty Gwynedd. Perhaps you could
expand again on that really and just say what lessons could be
learned perhaps for primary care, to attract more people into
primary care.
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[180] Dr Dykes:
The starting point of our recruitment campaign was getting the job
right, because I think there is a great—. We fell for this
hook, line and sinker for several years, with bigger and bigger,
shinier adverts, before we actually realised that the reason why we
couldn’t recruit was because our jobs were appalling. So, the
first thing is you’ve got to make the job right, which, in
the general practice context, brings us back to problems
we’ve been discussing. What we’ve discovered in
emergency medicine is that, obviously, it’s a highly
pressurised environment. You’ll all be fully aware of the
difficulties we face as a speciality in EM at the moment, and,
actually, the time away from the hot zone, whilst still doing paid,
useful work for the NHS, is why we can still keep doctors willing.
Rebecca’s got a great quote, which is that, sometimes, you
feel like you’re a recruiting sergeant for the Somme, knowing
what’s going to happen. And it’s kind of true, if you
haven’t actually got the package of the job that means
it’s not just utter death, misery and mud and
destruction.
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[181] So, the starting
point has got to be getting the jobs right. After that, you start
to model everything through, and then, by the time you actually get
to the recruitment campaigning and the adverts, that’s the
last bit. If you’re doing it right, then word will get out
via the other means we now have. We’ve made—well,
I’ve made—extensive use of social media. My entire
2017-18 house of clinical fellows—I’m over-subscribed
again—has been done without a penny spent on advertising.
It’s just been through NHS jobs and lots and lots of social
media. It’s spent a lot of me—it’s many, many
hours of my time, but I’ve got doctors coming in. But it has
to start with getting the jobs right, and the jobs have got to be
moulded around the people you want to come to get them, or they
just won’t come. We’re seeing this left, right and
centre.
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[182] Dr Payne:
Can I just pick up on Linda’s point as well, because I
don’t think she ever says enough, actually, about the
personal impact that she’s had into that, in terms of
contacting people, following them up, setting up WhatsApp groups
for the new doctors coming into her department, and offering a
really personalised experience? A few years ago, I talked to a
Canadian recruitment organisation, and they wanted to know what I
wanted from life, what my husband wanted from life, what his job
was, what sort of school did I want my kids to go to, was I was
looking to be near the sea, and all this really, really
personalised hand holding—‘Let’s find the right,
not just job for you, but life for you.’ And, as a college,
we really welcome the fact that we’ve got the single point of
access now for shared services. I’ve been trying to find some
guinea pigs to phone up and see how it’s going. But,
actually, until you get the personal approach that Linda’s
been providing, you’re not going to be able to help people
envisage their new life in Wales. And all the things like help
finding schools, help finding accommodation—Linda’s
been phoning me up when she’s got nowhere for people to say,
going, ‘Can they stay in your house in Anglesey?’
That’s the level of individualised support that has brought
the doctors over. And, actually, it’s not a case of just
copying what she’s done without getting that really
personalised level of investment in.
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[183] When I was a
medical student, when I did a general practice placement, I was
living away from Cardiff, and the GPs—a different GP took me
home for dinner every single night, and I became a GP.
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[184] Dai
Lloyd: So shallow. [Laughter.]
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[185] Dr Payne:
And it’s those really personal approaches actually that make
a difference.
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[186] Dr Dykes:
It fits into that Generation Y stuff. I mentioned it earlier in my
little preamble. We know that our younger colleagues, we know that
they are different in their views and their values. We know that
they typically very much appreciate and need mentoring. They find
that very, very difficult to do independently. So, some of the
things that I do are, if I’m at a conference, I’m aware
how we recruit and how I pick up potential recruits, and even
people I will have a talk to and do some career counselling with
them, even if they’re not coming to me, they’re going
to say, ‘Hey, there’s that really nice consultant in
Bangor and she’s got some really good posts; go and have a
chat to her.’ It’s just networking. You go through with
them and you talk to them and they just need support and just some
guided decision making on things.
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11:15
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[187] The other thing
is it’s just networking. It just struck us before we came
into this room, when we were waiting in the waiting room. Look at
this: women network. That’s actually really, really
interesting. So, you’ve got people who—you know, those
of us who actually do it. I’ve fixed recruitment in my
department—it is constant and ongoing hard work, but I have
fixed it and, unless we actually now balls up, we’re home and
dry. It’s hard work continuing, but it’s all
networking.
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[188] Dai
Lloyd: Okay. Rhun on this point.
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[189]
Rhun ap Iorwerth:
I know about the great work that Linda
does in primary care as well as in ED in Ysbyty Gwynedd, but that
in itself isn’t sustainable. We can’t have a Linda
Dykes everywhere—somebody who’s willing to go above and
beyond. We can’t have somebody who’s willing to
actually cover those 59 other calls by staying there until
midnight.
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[190]
Dr Dykes: Which is why I’ve got no doctors.
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[191]
Rhun ap Iorwerth:
So, how do you formalise and who should
be responsible for formalising, making systemic, if you like, what
Linda, and others like her, are doing? Who should be doing
that?
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[192]
Dr Payne: I think that responsibility rests primarily with
Welsh Government to instruct the health boards in: ‘We have a
model, this works: copy it.’ Actually, a lot of what Linda
has achieved is by breaking the rules and doing stuff subverting
the normal mechanisms, having an unofficial website—I hope
you don’t mind me saying this, Linda.
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[193]
Dr Dykes: No, that’s fine. I don’t keep rules.
I’m a disruptive innovator. It’s called ‘being
naughty’.
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[194]
Dr Payne: So, how do you get something that works, that breaks
the rules, into a system that is absolutely rule-bound? Having
worked for health boards, it is so difficult to bring about change.
So, I would suggest that we actually have a cultural problem within
the Welsh NHS, where, so often, the default answer is
‘no’, and, unless you’re prepared to ignore it,
like Linda, it’s very, very difficult to get stuff done. So,
without that cultural shift, without a real focus, a national level
of learning from that case study, and commitment to industrialising
that approach, I don’t feel very optimistic.
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[195]
Dr Bodey: It needs to be the right people in the right place as
well. It needs to be flexible locally to respond to the specific
needs of each area.
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[196]
Rhun ap Iorwerth:
But the job spec for that person driving
that change has got to be right. In the same way as Linda wants to
get the job spec right for the doctor, we need to get the job spec
right for the person or the department or the organisation that
actually drives the change.
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[197]
Dr Dykes: See, I think it should be clinician
driven.
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[198]
Dr Bodey: It needs to be clinician-driven, yes.
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[199]
Dr Dykes: I think it needs to be clinician-driven. Hiving it
off to HR, who, by their very nature, because they have to do
it—I’m not dissing HR; there has to be attention to
detail, making sure, you know, the dots and t’s. That’s
just not the same skillset that gets the people in. It has to be
clinician-driven. Clinicians have got to take ownership of it. We
thought, before the penny dropped that the jobs were shit and it
was our responsibility, that it was HR’s job to find us
doctors—human resources; they’re resources that come.
That’s not how it works. So, within every patch or team,
you’ve got to have clinicians who will actually take
ownership of the problem, like I have. Now I can teach all the
clinicians how to do it, but some get it and some don’t. If
they don’t, then it’s just natural
selection—they’re just going to have to wither, and
then we’re going to have to find and mentor—.
I’ve taught my juniors how to do it and they’re now
coming through as consultants.
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[200]
Rhun ap Iorwerth:
What happens if consultants, clinicians,
are instructed that part of their job spec is to lead their
recruitment within their departments?
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[201]
Dr Dykes: I think that if you instruct anyone to do it, it
won’t happen. They’ve got to be inspired to do it. But
they have to have some time and space. I’ve done it mostly in
my own time with my own money and this is a problem. So, if you can
find a way that, actually, the Welsh NHS encourages, within some
job plan—it’d be quite nice not to be doing it all in
my own time—then you would probably find more people
enthusiastic to do it. The normal response I get when I tell my
colleagues throughout the UK what I’ve been doing is,
‘Well that sounds marvellous, but I’m not prepared to
put the work in’.
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[202] Dr Payne: And
also the consultants we’ve got need to be doing jobs that
they believe in, and they feel positive, they feel supported, they
feel like the system works, that they can do a good job. Because
the authenticity with which Linda speaks, having redesigned the
jobs to be jobs that people want to do: things
like—haven’t you got a coffee machine in the
department? You know, just access to a cup of tea. There are places
where you can work in Wales for health boards where you can’t
get a cup of tea all shift. Until those basics are right, it
doesn’t matter who markets it or how enthusiastically they do
it, you have to have the authenticity from believing that it is a
good job that you are recruiting people to.
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[203]
Dai Lloyd: Ocê. Mae’r amser yn llamu ymlaen
rŵan. Rwy’n credu ein bod ni wedi cyfro’r rhan
fwyaf o’r materion, ond mae yna’n dal i fod rhai
cwestiynau i ddod. Jayne, a oeddet ti eisiau gofyn dy ail
gwestiwn?
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Dai Lloyd: Okay. Time is running on. I
think we’ve covered most of the issues, but there are still a
few questions remaining. Jayne, did you want to ask your second
question?
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[204] Jayne
Bryant: Yes, thank you, Chair, just briefly. Do you think the
differences throughout the UK—the sort of things in England
with the junior doctor contracts—are having an impact here on
our ability to recruit and train?
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[205] Dr Dykes:
Yes. There was some work out just yesterday—I haven’t
read the full paper; I had a quick look at it. It came up on
Twitter yesterday. It’s in one of the British Medical
Journal journals. I’m not sure which it is; it’s
obviously not the main BMJ. I think it is an interview survey of
junior doctors in England. It actually looks like the contract
dispute there has driven this 30 per cent increase in general
practice applications, because the enforced new contract there is
more favourable to community-based working, but they’re now
fleeing from the same acute sector jobs, which is actually going to
bring emergency medicine and other acute jobs down onto their knees
even further. And of course, where have the emergency physicians
fled to? Well, they’re in Bangor. [Laughter.]
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[206] Dai
Lloyd: So, it’s your fault.
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[207] Dr Dykes:
Yes, it’s my fault. I just go poaching.
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[208] Dr Payne:
Could I answer that question, too? So, one of the challenges we
have in Wales is the fact that, I believe, last year, 70 new GPs
qualified. We need 200 new GPs a year to qualify. And, so, we have
been reliant on qualified GPs crossing the border. So, actually,
when there are woes in terms of recruitment in England, that will
affect us. Now, there are opportunities for us to capitalise on the
discontent of colleagues there because of the new contract, but
there are also concerns I think you may have heard about from the
BMA AiT rep last week, that it may result in a significant increase
in pay for junior doctors compared to in Wales. So, it’s hard
at the moment to know how those two are going to balance out and
what the impact on recruitment will be.
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[209] In terms of
recruiting GPs who have already qualified, all those factors about
jobs for spouses, about schools for children, and concerns from the
reporting about the Welsh education system, these are absolutely
key barriers that are stopping people coming to join us. And in
terms of ways to address that, actually, having that whole family
package, talking to people at an earlier stage in their
recruitment, ‘What does your partner do?, and these are the
opportunities, say, in academia and, say, in
education’—. I think, Linda, you’ve got an
example of a colleague who left because of his primary school
teacher wife.
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[210] Dr Dykes:
Yes, I’ve got a couple, actually, of really fantastic
clinical fellows. For some reason, lots of them are married to
primary school teachers, and they’re coming from England.
Obviously, this is a problem, because they don’t speak Welsh,
and you cannot work as a primary school teacher in Gwynedd or
Anglesey if you don’t speak Welsh, and then further over. So,
of course, they won’t settle. They don’t want a long
commute; one of the reasons they’re moving is for quality of
life reasons, and so, you know, it’s going to take a
significant time to train a primary school teacher to be as good in
a second language as you need to be to be able to teach children. I
mean, it’s just so key. So, he was like, ‘I’d
love to stay longer, but I just can’t’. His wife
couldn’t find any employment, even for bank work. She was
commuting back to Watford. So, he did his eight months with us. He
would like to have extended to 18 months, but he just
couldn’t.
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[211] We’ve also
discovered with our consultant recruitment—so a different
cohort from our clinical fellows—that we cannot recruit
anyone with school-age kids for love nor money. We’ve managed
to recruit those whose children are preschool, no
problem—absolutely no problem. The kids go to school, they
become bilingual, even at nursery, within two or three months.
It’s absolutely phenomenal; it’s not a problem. But
we’ve had others who will go, ‘I can’t move.
I’m not willing to move the kids, and I’m worried about
the schooling issue’. We’ve recruited one other
consultant with children, and then she waited until the youngest
was in sixth form. She actually wanted to come to us for five
years, but she would not move until the kids had finished their
main schooling. So, you either do something about that, or you just
say, ‘That’s not the target group’. You know, we
need to be going for the lifestyle changers; we need to be going
for the gay couples who are less likely to have children—of
course, many do, but less likely. And we need to be going for those
who are, you know, divorced or something and they actually now want
a fresh start. Or you recruit them before. You get them straight
out of training and you do all the sort of long-term nurturing
stuff that I’ve done with my medical students, because
that’s where the roots lay, actually, you know, 12 years ago.
But, you know, there are things you can do in a shorter timescale,
too. You’ve just got to cater for the market. As I said
earlier, it is a buyers’ market, and we are selling.
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[212] Dr Payne:
Also, on a similar note, younger doctors who haven’t yet met
somebody, a lot of them are really scared about, ‘If I move
to a rural area, will I meet anybody?’ There was a—
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[213] Dr Dykes:
[Inaudible.] dating service at RAF Valley.
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[214] Dr Payne:
There was a GP from Herefordshire who managed to recruit through a
dating agency called Muddy Wellies, which, apparently, specialises
in rural dating, and that’s how they found the next
doctor.
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[215] Dai
Lloyd: Sara.
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[216] Dr Bodey:
I just wanted to say a few things about the situation in England. I
think we do have an opportunity just at the moment to try and
increase recruitment to GP training in Wales. What happened
locally—. I’m a GP trainer on the Wrexham scheme and,
last year, having historically been under-filled for years and
years, we were full and we were turning people away. In Wrexham,
every single GP practice is on the edge and at a high risk of
having to hand back contracts. Yet, we were turning away GP
trainees who wanted to come and train in that area. We’ve
only got eight places on the Wrexham scheme. Wales is the only
country in the UK that hasn’t increased the number of GP
training spaces in recent years. I think it’s a real
opportune moment at the moment to try and increase the number of
spaces available for GP trainees, while we have a short-term,
potential increase in interest from across the border.
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[217] Dai
Lloyd: Okay. Heidi, as well, on this point.
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[218] Dr
Phillips: Every year, I have 1,000 applications for 70 places.
People want to be doctors. I’ve put a proposal in for a
primary care academy in Swansea, but it doesn’t need to be
just Swansea. Basically, 90 per cent of doctor-patient interactions
occur in primary care. We have this huge wealth of people who want
to be doctors. If we can recruit from Wales, from areas all around
Wales, into medical schools—our studies and studies abroad
show that they’re more likely to remain in Wales—then
we can actually keep doctors working in Wales. If we teach medicine
through a primary-care lens, rather than the secondary-care focus,
we will actually be exposing these students throughout their
journey to primary care and seeing patients at the point of coming
into the service. Then, they’re more likely to stay in
primary care.
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[219] The other thing
about the primary care academy idea is that, if you sort the job
out—so, you’ve got GPs working alongside community
nurses, PAs, social services—so, at the point of contact, the
patient gets directed to the right person, then you’re
freeing up your GPs to do the work that they trained for. They
re-motivate and re-enthuse and the students they’re bringing
up behind them are seeing that model.
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[220] Jayne
Bryant: I was just going to come back—I agree entirely
with what you’re saying, Heidi—to you Rebecca, when you
were talking about expecting OTs or physios to save GPs. On Monday,
I was at a GP practice in my constituency that has taken on a
prescribing physio. They said that they see a third of people with
musculoskeletal problems and that’s taken a real pressure off
the GP. I was just thinking, that’s such an important
point—to think that we can support our GPs in that.
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[221] The other point
I was going to make was, Heidi, when you were talking about turning
people away—no, sorry, Sara was talking about turning people
away, because you’ve got so many people applying for these
jobs or wanting to be part of it. Is there any way of directing
them to other places where there might be spaces or are there just
no spaces?
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[222] Dr Bodey:
The system does do that, but we lose some of them to England. Where
I work, doctors are often geographically set in that border
territory. So, they will potentially have significant others who
work in industry at Ellesmere Port or something like that, so they
want to apply in that area. If they don’t get their
first-choice scheme within Wales, they’re not going to want
to go to Haverfordwest or somewhere like that because of their
family ties. So, they might go to Chester, they might go to Mersey,
and we lose them from the Welsh general practice at that point. I
had a fabulous foundation 2 doctor last year who applied to Wrexham
and didn’t get in because we had this complete turnaround,
which I suspect was the effect of what was going on in England at
the time.
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[223] Dai
Lloyd: Okay. Rebecca.
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[224] Dr Payne:
One thing we haven’t touched on is the impact of the
performers list on recruitment. There are four performers lists
across the UK. You have to be on the one for Wales to work. So, we
have the situation where, if you are a locum on the border, and
you’ve trained, say, in Chester, the amount of paperwork and
bureaucracy has been a real deterrent. Although steps have been
taken to try and address this, actually that legacy of the
bureaucracy has been a real issue. I believe there’s now
something in place where people should be able to work for three
months, but it’s unclear if that is working as well as it
could.
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11:30
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[225] The other real
problem, particularly affecting north Wales, has been people who
are returning from places like New Zealand who cannot get back into
Welsh general practice. Although there is a returners scheme,
people have found it extremely difficult to access it. Linda has
got a doctor working with her in the care of the elderly team who
wanted to come back to general practice but was unable to do
that.
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[226] Jayne
Bryant: Why is that a particular problem in north Wales?
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[227] Dr Payne:
Because people want to come to north Wales because it is
lovely.
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[228] Jayne
Bryant: Come to Newport.
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[229] Dr Payne:
Linda could tell you more about—
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[230] Dr Dykes:
Yes. It is the wife of one of my clinical fellows, actually:
UK-trained, a UK GP, MRCGP, had been working in Holland in a very
similar health system in terms of epidemiology and clinical
practice for 11 years. She came back for a year, and because she
was only coming back for a year, frankly, nobody could be bothered.
You know what? They are really enjoying it, and I really think they
might have stayed. But, as it is, she will be going back to her
practice at the end of the time. We found a job for her as a
specialty doctor in care of the elderly in the community, and she
is doing an absolutely grand job. England is going to nail us on
this if we are not careful. In my report, I put a link in on the
PDF to the England—I can’t remember what the document
is called; Rebecca will help me out here. The have got a specific
new supporting returners scheme, and we are not going to get any
returners at all if England gets it organised. We are just going to
lose, and we’ve got to sort it.
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[231] Dai
Lloyd: Okay. Last two questions: brief questions and brief
answers, really. Dawn and then Caroline.
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[232] Dawn
Bowden: Okay. Thank you, Chair, and apologies for being late. I
have missed all your evidence, but I have read your papers so,
hopefully, I am up to speed. Just a general question around
training, really, for GPs. I noticed that, in your submission,
Sara, you talk about the difficulty that you can’t get in to
do locum work as a GP unless you have had various other types of
training first. The RCGP are talking about the need to have mutual
recognition of training, appraisal processes and validation. Can
you say whether you think the shape of medical training gives
sufficient opportunities in relation to GP and community medicine,
as opposed to hospital specialisms?
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[233] Dr Bodey:
Not at all. As Heidi was saying earlier, I think the focus is still
very much secondary care, all the way through medical school and
through foundation. One of the things that we don’t do well
in Wales is have doctors at foundation level having exposure to
general practice. Certainly, in the north-west deanery in England,
it is now compulsory. Historically, in Manchester, that has always
been the case. They have historically had a high recruitment into
GP specialty training, which is probably linked to that exposure at
postgraduate level. We don’t do that well in Wales. There is
an issue with concern about destaffing medical rotas if they were
to increase those jobs. My solution would be to increase the number
of GP specialty trainees who contribute 18 months of hospital care
as part of their training, which would then free up more junior
doctors to have the opportunity to do F2 posts in general practice.
There’s a real wish from doctors to do it, but it’s not
done very well. My proposal for having the stand-alone posts made
possible within general practice would potentially help to increase
that opportunity as well. Again, there’s a real interest from
junior doctors to have that opportunity to try general practice
before they commit to training in it.
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[234] Dr
Phillips: Another point would be to allow dual accreditation. I
trained as an anaesthetist, and I had to give up anaesthetics to
become a GP. I now only work two days a week in general practice.
There is no reason I couldn’t have done both and been a
part-time anaesthetist and a part-time GP.
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[235] Dawn
Bowden: Yes, that was the supplementary that I was going to
ask, actually—whether there is a barrier to doing that.
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[236] Dr Dykes:
A GP needs to dual [Inaudible.]. I have ended up dual
training, and I am dual qualified, but that was under previous
training rules, and I wouldn’t be able to do it now.
Desperate need—. It would also help the haemorrhage of
trainees out of emergency medicine because, actually, they tend to
go to general practice, funnily enough. That’s perceived as
the easier option. It’s a skill set that actually matches
incredibly similarly, and that also leaves you equipped to work in
the community, which I am doing now on secondment. There are no
pre-registration opportunities for doctors within community
hospitals or home settings currently in Wales, nor in most of the
country. So, there are huge opportunities, yes.
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[237] Dr
Phillips: But why are you forcing people to choose?
That’s basically what it comes down to. Why can’t they
do both?
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[238] Dai
Lloyd: Caroline can wrap up, and Isolde can answer it.
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[239] Caroline
Jones: Do you think the current structure and content of doctor
training is appropriate, or do you think changes could be made to
help with recruitment and retention?
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[240] Dr
Shore-Nye: I will answer that because I can answer that.
Actually, I was going to come in on the point about foundation, in
that the royal college is very supportive of having essentially as
many doctors as possible to do general practice within the
foundation phase. At the moment, it’s certainly our
philosophy that every doctor should experience general practice as
part of their training and, as such, that would enable people to
make a career choice that would most likely, and hopefully,
increase the number of people doing general practice. So, at the
moment, in Wales, no, I don’t think the trainee junior
doctors—
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[241] Dai
Lloyd: Rebecca, the absolute last word.
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[242] Dr Payne:
Okay. The other really important issue is parity of esteem. It is
still the case that we have junior doctors on the wards who will
not tell the consultants they want to be GPs because they will be
denied opportunities to do different complex tests on people and
they would be denied learning opportunities. And actually, if I
could pick one thing I’d like you to do today, I’d like
you to legislate so that people in hospitals cannot disrespect
general practice, because the effect that has on vulnerable medical
students and junior doctors, who have this drip, drip, drip
throughout the training of, ‘Oh, only stupid people become
GPs’, ‘Oh, you can do more than that’; it really,
really stops people going into general practice. So, yes, we need
parity of esteem.
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[243] Dr Dykes:
I’m going to break in: it is quite astonishing the difference
in how you get handled by specialty junior doctors in hospital when
you’re phoning as a GP, rather than calling as an emergency
department consultant. That’s disgusting.
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[244] Dai
Lloyd: Right, we’re out of time—over time. We were
all getting carried away with the unbridled enthusiasm of it
all.
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[245] Dr Dykes:
There is a lot we can do.
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[246] Dai
Lloyd: Yes.
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[247]
Felly, diolch yn fawr iawn ichi
gyd—gwerthfawr iawn. Fe gawn ni doriad nawr am bum munud.
Diolch yn fawr iawn ichi.
|
So, thank you all very much; it was very
valuable. We’ll take a break now for five minutes. Thank
you.
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Gohiriwyd y cyfarfod rhwng 11:36 a
11:43.
The meeting adjourned between 11:36 and 11:43.
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Ymchwiliad i
Recriwtio Meddygol—Sesiwn Dystiolaeth 5—yr Athro Dean
Williams
Inquiry into Medical Recruitment—Evidence Session
5—Professor Dean Williams
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[248]
Dai Lloyd: Croeso yn ôl i fy nghyd-Aelodau i’r
sesiwn ddiweddaraf o’r Pwyllgor Iechyd, Gofal Cymdeithasol a
Chwaraeon yma yn y Cynulliad. Mae Angela yn cyflwyno
ymddiheuriadau—mae hi wedi gorfod gadael, ac felly bydd rhaid
inni ymlwybro ymlaen heb Angela yn ein plith, ond rwy’n
siŵr y byddwn ni’n gallu ymdopi.
|
Dai Lloyd: Welcome back to my fellow
Members to the latest session of the Health, Social Care and Sport
Committee here that the Assembly. Angela has given her
apologies—she’s had to leave, and so we will have two
carry on without her during this session, but I'm sure that we'll
be able to manage.
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[249]
Fe wnawn ni symud ymlaen at eitem 4
ar yr agenda y bore yma, ac rydym ni’n parhau â’r
ymchwiliad i recriwtio meddygol: sesiwn dystiolaeth 5 nawr ac
o’n blaenau y mae’r Athro Dean Williams. Croeso i chi,
yr Athro Dean Williams o Ysgol Gwyddorau Meddygol Bangor. Rydym ni
wedi derbyn tystiolaeth ysgrifenedig ymlaen llaw, ac felly,
gyda’ch caniatâd, fe awn ni’n syth i mewn i
gwestiynau ar yr holl agenda yma. Felly, croeso i chi at y bwrdd,
ac mae’r cwestiwn cyntaf o dan ofal Dawn Bowden.
|
Let’s move on to item 4 on the agenda
this morning, and we continue with our enquiry into medical
recruitment: it’s evidence session 5 now and before us we
have Professor Dean Williams. Welcome to you, Professor Dean
Williams, from the Bangor School of Medical Sciences. We have had
written evidence from you in advance, so we can go straight into
questions, if that's okay with you. So, welcome to the table, and
the first question is from Dawn Bowden.
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[250] Dawn
Bowden: Thank you, Chair. Good morning, Professor Williams. Can
I just start with a general question, really, asking you about the
profile of students coming to your school? Are they primarily
Welsh? Do you have a lot of English? And, basically, where do they
go once they’ve finished? That's probably the biggest
question.
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[251] Professor
Williams: Yes. Expectation management. It depends. We have a
few different cohorts of students now. The school has grown over
the last four or five years.
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11:45
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[252] We started with
a BMedSci programme, initially, and we were just taking virtually
any student to get the programme up and running. It was very
important to get it up and running at that time, I felt. I’d
say that the demographics of the students are pretty much similar
to the rest of Wales, in many ways. We have a few Welsh from north
Wales, a few from south Wales, a few from England and some from
abroad. I think the change for us, more recently, has been the
physician associate programme, which we started with Swansea. We
got recent money for that from Welsh Government, and we’ve
got five Welsh speakers in that, out of 12, and nine, I think, are
from Wales out of the 12, so I’m very pleased with that
number. I’m trying very hard to get more Welsh people on the
courses, because of the obvious need.
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[253] In terms of
where they’re going, I think the biomedical courses that we
have running offer good employment opportunities in the labs
throughout the UK. It’s an accredited course. On the BMedSci,
some of them are still hankering to do medicine even though they
failed to get in first time around, and some of them are going to
courses in the UK, but very few. To date, only one in Cardiff, and
that was through negotiation. Of the rest that are doing medicine,
some are in Europe, one is in the States and one is in Ireland. The
rest, then, continue to do research programmes, or go into other
types of work. The key thing is for us to manage expectations,
because a lot of them think they can come into the programme and
hopefully do medicine, not realising, sometimes, that it is a very
competitive world, and that’s one of the key things, so that
we don’t get disappointed students reflected in poor student
surveys.
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[254] Dawn
Bowden: So, do they come with an idea that they want to stay
here, or are they just coming with the idea of wanting to study
medicine, or wanting to study whatever the specialty is, and they
make their decisions, then, as they go along—is that it?
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[255] Professor
Williams: Yes, I think the local students—certainly from
north Wales—a lot of them have chosen to go to Bangor, and my
impression is that a lot of them want to stay in north Wales, given
the opportunities. The ones who come from England, I think, are not
particularly wanting to stay in Wales. They’re just looking
for a good programme they can enter, and I think Bangor’s
been there a long time, so it’s still on the map as a place
that they can go to study. So, hopefully they select us based on
the profile, and the quality, and the surroundings for study. I
feel that, providing we can keep on recruiting local people,
hopefully they will stay, and we can offer those opportunities if
they arise, but at the moment, several of them disappear and we
never see them again. The important thing for us is that
we’ve learnt over the last few years to give quality
programmes, and the feedback we’re getting from students who
leave us is that once they’re gone, they realise how good it
was. They’ve told us that as well, which is nice to know, but
they should really tell us just before they leave rather than
afterwards. [Laughter.]
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[256] Dawn
Bowden: Okay. Thank you.
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[257] Dai
Lloyd: Julie Morgan.
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[258] Julie
Morgan: Diolch. So, do you raise much awareness in the local
communities about what you’re doing, or with the schools?
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[259] Professor
Williams: Well, yes. I’m also undergraduate organiser for
Cardiff medical school for the clinical placements up in north
Wales—for the ones in north-west Wales. We’ve had a
programme for quite some time where my manager, Kim, goes to the
local schools—several of the comprehensive schools—and
now, increasingly, younger groups as well, to push the medical
agenda for students who maybe think they’re not good enough,
or maybe aren’t thinking about medicine. So, we promote that
as part of helping Cardiff, trying to get more Welsh students into
Cardiff, but I’ve piggybacked onto that—I don’t
mind saying. The Bangor side, as well as having our own impact on
people, we also piggyback on that, so they’re aware of
what’s happening in Bangor as well, if they’re unsure
about medicine or want to do other courses. The school’s only
been there for a few years, and I think, because of that,
we’re new and sometimes the careers teachers in the schools
are not familiar with it, so it’s ongoing work, but the
profile is definitely improving.
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[260] Julie
Morgan: Right. Thank you.
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[261] Dai
Lloyd: Jayne.
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[262] Jayne
Bryant: That’s great to hear, that that’s
happening. I’m very pleased to hear that. How does this
school work with the local health boards and other medical schools
in Wales to achieve clinical placements for students?
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[263] Professor
Williams: Some of the courses are more clinically orientated
than others. I pride myself on introducing clinical exposure as
much as possible. The students really enjoy that clinical exposure,
it’s a key part of what of we do, and because I’m a
consultant vascular surgeon in Bangor, I really take them under my
wing so that they come up for clinical placements. My favourite
type of teaching is when they have some classroom teaching in the
hospital, and then I take them to the ward to see my patients who
have the conditions that I’ve just taught them on in the
classroom. I do that for Cardiff students as well. I’ve done
that for several years, and promoted that for a long time. So, I
use the board in that respect, with my dual roles, to make the most
of that opportunity that I have, but I get a lot of honorary
clinicians coming from not just Bangor but from Glan Clwyd and from
Wrexham in particular. They come over and teach for us. These are
clinicians who, in their fields, are very knowledgeable and they
bring the clinical edge to the teaching—mindful again about
not pushing it too hard, because some of these guys are not going
to be doing medicine eventually, but they might do things allied to
medicine. But I do use staff across the patch, being mindful of
being inclusive for all of north Wales and not just Bangor.
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[264] Dai
Lloyd: Dawn.
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[265] Dawn
Bowden: I just took a mouthful of biscuit, I do apologise. Can
you tell us a bit more about how the school works with the NHS and
higher education in England?
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[266] Professor
Williams: With England?
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[267] Dawn
Bowden: Do you have particular or special arrangements with
any—?
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[268] Professor
Williams: No, not at all, not with England. I mentioned about
the board connections already. With England, I must say I’m
not mindful of what’s happening in England. It might take
students away, rather than working with them, I would say. That
sounds a bit harsh, maybe, but that’s the truth.
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[269] Dai
Lloyd: Well, very wise. [Laughter.]
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[270] Professor
Williams: We obviously have connections with—. I mean,
we’re a long way from Cardiff, and in some ways—
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[271] Dawn
Bowden: Indeed, so it’s the north-west of
England—
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[272] Professor
Williams: Yes, but at the moment I see them as competition
rather than any friendly discussions, and we all watch what each
other’s doing anyway, naturally so. For my courses, I
don’t need them and I’m very happy with the provision I
have in north Wales. We have stunning teaching feedback for north
Wales, and clinical placements have been excellent for years now.
Cardiff are very reliant on this and very proud to be part of that
as well, outside the school of medical sciences, but as part of the
clinical placements for Cardiff students.
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[273] Dawn
Bowden: Okay, so you haven’t felt the need to go there
and make any kind of relationships with them.
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[274] Professor
Williams: No, not so far.
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[275] Dawn
Bowden: That’s fine. Okay. Thank you.
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[276] Dai
Lloyd: Caroline Jones.
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[277] Caroline
Jones: Diolch, Chair. With regard to medical recruitment, what
contribution can you see the school making now and in the future?
Do you feel the training needs to change in any way?
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[278] Professor
Williams: Obviously, I don’t train; I’m not
training medical students to be doctors. We are delivering medical
sciences and we have biomedical scientists being trained on
accredited courses with us. Obviously, it would be nice to think
that at some point we will—. It would be nice to have a
medical school in Bangor for north Wales and for the rest of the
UK, providing quality education. I would hope that would be—.
That would be an important part, I think, of the workforce issue
that we have. Recruitment and retention is a major problem for us
in the north. I know it’s a problem in many places, but by
golly, we’ve got it bad in the north. I would hope the reason
I’m so keen to pursue this—and it’s a lot of
work—is because I see the worth in it, and I hope others will
do too. In terms of the impact of the school, that would be—I
mean, I’m afraid that’s down to the politicians for the
most part, I think.
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[279] Caroline
Jones: Okay, thank you.
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[280] Dai
Lloyd: Rhun, speaking of politicians and stuff.
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[281] Rhun ap
Iorwerth: I, as you know, am a big supporter of the
establishment of a medical school in Bangor. We’ve discussed
it before. I see it as a medium-term goal. What I see as the
short-term goal—the immediate goal, actually,
probably—is to establish medical training within Bangor,
perhaps a new community model of medical training in partnership
with Cardiff. Do you see that as something that we not only could
but should be looking to introduce, almost immediately, in order to
build up the infrastructure of medical training in the north-west
of Wales?
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[282] Professor
Williams: A lot of things in there, Rhun. In terms of
infrastructure, we already have it. We’ve been training for
many years now for all clinical placements and done very well with
that. We know there was an announcement from Jeremy Hunt,
wasn’t there, about increasing medical student training, and
my concern is that if we keep on delaying things, we’ll miss
the boat yet again. I think we missed a great opportunity a few
years ago when they created the north Wales clinical school, when
Swansea then created a whole medical school. We missed out terribly
and that’s been of no use to us whatsoever in terms of
recruitment. The school of medical sciences is improving
recruitment a bit; people are coming to see me because they know it
exists. It’s nowhere near the impact that a medical school
would have, but it’s showing itself to be somehow—. I
think the news is beginning to get out there that we have something
brewing. I’m wary that, if we hold on to things as they are,
and hope that Cardiff will help us somehow, we’re going
nowhere in the longer term. As I see it—. You know, I look
after Cardiff medical students and we enjoy taking them, and
we’ve got a very enthusiastic group of teachers in north
Wales, and some Swansea ones and from Manchester and Liverpool now,
but I think that—. We would still have the same teachers for
medical students in Bangor. There wouldn’t be much of a
change. The clinical placements would be the same. But I’m
wary of how much workforce we’ll have left at this rate, and
there’ll be no point in training, because we’ll have
nothing to put them into.
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[283]
Rhun ap Iorwerth:
How important would you see the
development of rural medicine as a specialism as part of the
project of developing medical education in Bangor?
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[284]
Professor Williams:
I think it’s very important. The
centralisation agenda that’s ongoing is very damaging to
rural provision, because we don’t have the numbers. I think
we should be wary of the quality we deliver and not the quantity,
because otherwise we are going down the Swanee very quickly, and I
am very worried about that.
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[285]
On the rural provision, Cardiff has made
noises recently about providing more students for us for rural
provision, but it’s not the big numbers. It’s not going
to be a game changer for us. I think we’ll be in the same
trouble, or even worse, in a few years as a result of this. I think
there needs to be a bigger emphasis on what we’re doing up
there. I genuinely feel that these small, little bits of change are
not going to be game changers. We know this from around the world,
where health provision has been in real trouble. The governments
involved have made major changes, either in the type of provision
from the established medical schools or having new medical schools.
They definitely have provision focused on where the needs
are—either they’re rural, or, where there are
population differences, where they have to focus on getting doctors
of a particular minority back into those areas. There’s good
evidence from America and Australia on this, and I think the rural
provision is a key thing, but I really feel that politicians need
to recognise that, as you do. I think a medical school based on
rural provision would be an excellent thing, a little bit like what
they do in Scotland, where some of the students are told at the
start, ‘You’ll be going into rural provision straight
away’. So, either we need a game changer like that, or we
need to start thinking about a rural school for rural north
Wales.
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[286]
Rhun ap Iorwerth:
If we are able to, in the next year or
two, as soon as that, start anchoring medical students in
Bangor—be that third years, perhaps, starting in Bangor doing
the latter part of their medical training, or moving to get first
years coming there, or whatever it might be—how soon would
you expect us to see an impact on recruitment within the NHS?
Because surely that is what we are training doctors for—to
help work in the Welsh NHS.
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[287]
Professor Williams:
I think there are two aspects to the
impact. The first one is the fact that you have a medical school.
SMS has had some impact on this, but as soon as you have a medical
school, it has an immediate impact, because senior clinicians, and
indeed middle grades and junior grades—if you’ve got a
medical school, it makes it more attractive. There’s a silver
lining on the placements. It gives it a certain credence that
you’re going somewhere that has a medical school.
That’s an instant hit. I’ve had people come and see me
in the last few weeks—a new pathologist up in the north
who’s come to see me because he came partly to Bangor from
the north-west of England because he heard there was a school of
medical sciences that is making progress. So, it has an immediate
impact.
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[288]
The second impact then is, of course, the
students coming through. So, if the students are trained,
particularly from day one, in north Wales, it’s very likely
that they’ll forge roots and stay there, even if
they’re not from there initially. Although I’m very
keen on making the most of the local student population we have
from Anglesey, Gwynedd and north Wales in general. But once they
start there, they’ll tend to stay there. So, we’ll have
a house officer—. So, the golden handcuffs won’t be
such an issue, I don’t think, because they’ll already
be settled there. And why not settle there? If we’ve got the
jobs and the training, it’s a nice part of the world—my
wife tells me. So, I think we’ve got a very good product to
sell, and I think it would go a long way to solving the issues,
with the juniors coming through as well as the established
consultants coming along, really, I think, in big numbers when they
realise there’s something good going on.
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[289]
Rhun ap Iorwerth:
And it’s taking that first step,
because if you look at Keele University, which now has a medical
school, it started off as an offshoot of Manchester and they built
it up incrementally over not too long a timescale. You’re
confident that that can be done if we take some initial
steps.
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[290] Professor Williams: Yes, because we already have—. I mean,
I’ve talked to a lot of people about this, but because we
already have the clinical placements, and we have a Master’s
programme and a Bachelor of
Science programme, that actually is a curriculum in its entirety
for medicine.
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12:00
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[291]
Rhun ap Iorwerth:
You tell me when you want me to
stop—
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[292]
Dai Lloyd: Well I’ve got a question on the Bangor medical
school myself, but—. Having been intimately involved 15 years
ago with the development of the Swansea postgraduate medical school
myself, obviously a couple of things come into play: what comes
first, what comes after—chicken, egg; egg, chicken. Teaching
hospital, medical school; medical school, teaching hospital. Now,
obviously in Swansea we had Morriston and Singleton very well
established as teaching hospitals. How do you see the importance of
developing Ysbyty Gwynedd to fulfil an enhanced role like that?
Because obviously to fulfil—. And I want to see a medical
school in Bangor, all right? I would encourage dialogue with
Swansea, certainly. And along the lines of what you said about
Keele, well, we’ve seen that in Swansea University. Swansea
University has had its second campus now, and it’s going up
the ratings and that all started from having a medical
school—that’s what kick-started it. It was very much
backwater, with all due deference to my home university, but
it’s having the medical school that kick started everything,
and now it’s got a £450 million second bay campus on
the back of all of that. But it also did have well-established
teaching hospitals before we all started that, which was a
strength, obviously. So, I was just wondering what your thoughts
are about that, because we want to see this happening, lots of us
do. But there’s some groundwork to be done,
obviously.
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[293]
Professor Williams:
Yes, of course, but I think we’re
fortunate in that—coming back to Rhun a little
bit—we’ve been taking Cardiff students and Swansea
students now for quite some time, and the feedback is very, very
good. The Cardiff guys come up and they have nothing much to say to
us. They have a traffic light type of system where you go from reds
and then to whites—I know there’s no white in traffic
lights—and you go amber, then green, and we show greens
across the patch. They just look at us and say ‘Wow.’
This is for students who were kicking and screaming initially to
come out to north Wales, because it’s a long way away from
their base in Cardiff, and we end up with stunning feedback. I
think this is a reflection of the enthusiasm north Wales has, and
the ability to teach. I know that these scores are not the be-all
and end-all, but what we have is a group of people who are not paid
particularly extra—the board gets the money; we get SIFT
money, of course—but these are enthusiasts. We get these
students, and we’re very keen to see them. We hope some come
back, of course. Some do, but not many. We had six last year, and
we had over 100 in north Wales all together. But I think the
quality is already there—absolutely. I think nobody would
challenge that. I think we have stunning results for somewhere so
far away. They could go to London much quicker than they come to
us, and a lot of them really resist coming to north Wales, for
understandable reasons—it’s so far away. So, I think I
can justifiably say we have some excellent teaching, so that
groundwork is all done. The only thing we don’t have are the
superspecialties like cardiothoracics and neurosurgery. But of
course, that makes up a very small part of the curriculum. That can
be done in Cardiff—that would be fine—or even Liverpool
or Manchester if need be.
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[294]
Dai Lloyd: Okay.
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[295]
Rhun ap Iorwerth:
That leads me to on to something else I
wanted to ask you about. Either working together alongside medical
training in Bangor, or saying, ‘Scrap that, that
doesn’t happen,’ what is the role of Liverpool and
Manchester universities in terms of training people for the Welsh
NHS? What’s the potential there? Even by getting them to
introduce elements of rural medicine, Welsh language provision,
whatever it might be through those institutions, that were for many
years, of course, seen as the north Wales medical
schools.
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[296]
Professor Williams:
Yes, well, my wife went to Manchester
medical school because it was a lot closer than Cardiff, and my
wife’s very Welsh speaking and very Welsh cultured. But we
get placements from Liverpool and Manchester. Less so in Bangor,
because there are distances involved, but certainly in Wrexham and
around Glan Clwyd, and particularly in general practice, there are
quite a few students from Liverpool and Manchester. From my
experience, in the west it’s limited. But, absolutely, there
is no reason why—if they were going to expand—we
wouldn’t welcome them, in terms of placements, and it might
help us with recruitment. But, personally, I’ve always had a
hankering that there should be a Welsh solution to this, rather
than going to England. I know it’s closer than Cardiff, but
I’ve always liked—politics aside—that somehow
there could be a Welsh solution to this, rather than going to
England to look for our solutions.
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[297] Rhun ap Iorwerth: And you make that case very strongly. Is there an
argument that, actually, Liverpool and Manchester
universities are using up fairly hard-to-find placements in some
areas that you would want in a medical training facility in
Bangor?
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[298] Professor
Williams: Well, I’ve talked about this before, I think,
with one representative from the Government. Of course, one of the
major issues here—if we were to develop a medical school in
Bangor, we would need placements. Now, we could be very careful.
Some of the reasons why we have very good feedback is because I
limit the number of placements to a number of students. We
don’t oversaturate the placements with too many students,
because that results in poor experience. If we were to develop
something in Bangor, that means that there would be fewer
placements for somebody else and that could well be Cardiff. Now,
Cardiff, with its expansion, and with Swansea’s
expansion—it means they really do need the north Wales
placements. If you are going to have things in Bangor, it means
that—actually, there isn’t the capacity to take many
more, I feel. We might be able to, but, based on what I understand
about placements, this could be a bottleneck, and we’ve got
to get, at the end of the day, the best conditions we can get from
a training programme for our health. So, you can stuff them in, but
I think that might be, possibly, detrimental. One of my concerns
with the whole process is that Cardiff medical school does well
within the rankings, but I’m worried about would there be any
pressure—that they’ll know that they would lose
placements if Bangor was to develop its own school.
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[299]
Rhun ap Iorwerth:
But that suggests that, maybe, a formal
partnership between Bangor and Cardiff would be a way forward that
actually—
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[300]
Professor Williams:
Absolutely. I’ve been trying to do
that for—. But to get from the start—. I mean, if it
was a combined—. I’ve been to Swansea in the past,
I’ve talked to them about this, but they were concerned a
little bit about their own future at that time. But, absolutely, if
there was an all-Wales solution to this, I’d be all
ears.
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[301]
Dai Lloyd: Obviously, when you do get a medical school, then at
least some of the local consultants, if not most of them, have some
sort of teaching commitments and they become tutors/professors, and
that’s an encouragement—
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[302]
Professor Williams:
That’s right. That’s the
silver lining—we all like to recruit—
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[303]
Dai Lloyd: High-quality medical staff in that area.
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[304]
Professor Williams:
Yes, absolutely. Quality as well as
quantity.
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[305]
Dai Lloyd: Yes, absolutely. Can I just ask, before we finish,
about your physicians associate course? Let’s talk about now
a bit and what you do—just expand on that. How common is that
sort of course? Obviously, it’s the sort of stuff
that’s starting to happen.
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[306]
Professor Williams:
That’s mushrooming. That is a big
area. Barefoot doctors, of course, came from—it was China or
India, because they couldn’t get doctors to go to rural
areas. Doctors trained and went off to the big cities. I recognise
that theme even today. So, they decided on having barefoot doctors,
who had minimal training, not as much as a medic, but enough to
make them useful in the community to look after the ailments of the
population. In the States, they’ve been going on for quite
some time—many years now. I think there are some 50,000 or
60,000 physicians’ assistants or associates, whatever you
want to call them, really to bolster the workforce, because
they’re still short of doctors, and in particular
areas.
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[307]
In the UK, I think, if I remember
correctly, they think it’s going to be 1,000 PAs coming out
in the next two, three years to help with the real shortfall in
medical provision. So, they are seen as part of the medical
workforce, as being part of the medical teams, but also in general
practice. They are trained for two years under a medical
model—pretty intensive. They are all graduates in life
sciences or appropriate subjects. I’ve just been doing an
exam paper this morning while I’ve been waiting, just to get
up to speed. We’ve got 12 in Bangor. It’s a
pilot—the Welsh Government gave us money for 12 in Bangor and
there were 15 allocated to Swansea. I think there are around 27
universities across the UK now where they’re all having PA
programmes starting, and there’s more interest from Wales as
well, as we speak. But I haven’t had any confirmation, any
further moneys from Welsh Government, because it was a pilot.
I’m hoping for some good news, hopefully soon.
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[308]
Dai Lloyd: Just in terms of the record, how are PAs thought to
slot into the medical workforce? Because, in terms of—are we
talking paramedics? What are their indemnity and clinical
responsibilities? If they’re attached to a GP practice,
it’s still the GP who carries the can, or—
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[309] Professor Williams: Yes. They are not generally seen as independent
practitioners. So, one of the issues has been, I think, there was
some worry about advanced nurse practitioners and stepping on toes
a bit between the roles. They are independent in terms of their
practice, but, ultimately, there’ll be a senior keeping an
eye on them. But, if you like, the amount of supervision they
require depends on their seniority. So, for me, I’d really
like one on my firm, but I can’t be greedy, because I train
them—I can’t train them and take them. But to have one
on my team whom I could leave, just like a house officer,
because, ultimately, the junior doctors are under my care as well,
but there ought to be indemnity as done for any health
professional—. There’s still a discussion about the
governance. They don’t actually have the GMC or anything yet
at this time, but I think it’s coming. Scotland were a bit
hesitant, but I think they’ve taken them on board now as
well. And because they are generically trained, they can fit into
any specialty. So, as news is spreading, because people are saying,
‘Oh, we could do with one of those’, because they can
be trained generically and then focus on a particular area. So,
that’s a big advantage, I think anyway, and I think other
people are beginning to see that.
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[310] Dai
Lloyd: Okay. Rhun.
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[311]
Rhun ap Iorwerth:
I’ve been talking to one of your
physician associated students—
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[312]
Professor Williams:
You did, yes.
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[313]
Rhun ap Iorwerth:
It’s a postgraduate course, of
course, and we have the issue in Wales of postgraduate loans not
being available. I have the e-mail from Government that came a day
after I raised this in the Assembly, so clearly taking all the
credit, but—. How difficult has it been having that
postgraduate course for jobs that we need in the NHS, but without
having that student finance support in place?
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[314]
Professor Williams:
Well, that last thing you particularly
talked about, it’s a struggle, really; she struggled hard
with that one and is still struggling, I think, to some extent,
which is why I’m very grateful that you’ve helped her
with that. The money side is important, of course, because these
guys are not earning a huge amount of money. The Government have
given us fees, so they’ve paid for the course, which is
great, so they’re not out of pocket that much, but it’s
another two years on top of graduating, so there are financial
penalties. But, of course, at the end, provided you get through the
national exams and Bangor’s exams, they have an opportunity
to earn £30,000 or £35,000 a year, which is reasonable
money for people who are coming out after five years. But the issue
of costs is a constant pressure on all of them, apart from the
privileged few who have enough money to one side. Most of them are
watching their pennies, and it’s not the best place to be. Of
course, these jobs didn’t come and go in handcuffs; my
concern is they might disappear at the end. So, I’ve got to
hope that the salary they get at the end is actually competitive
with what they could get in
England.
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[315]
Rhun ap Iorwerth:
But, certainly, this announcement today
is welcome.
|
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[316]
Professor Williams:
Thank you.
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[317]
Dai
Lloyd: Grêt. Rwy’n credu ein bod ni wedi gorffen y
cwestiynau, so rydym ni ar ddiwedd y sesiwn. Diolch yn fawr iawn i
chi, a diolch am y wybodaeth yn ystod y sesiwn yma a hefyd am y
wybodaeth ysgrifenedig a gawsom ni ymlaen llaw. A allaf i jest
gyhoeddi hefyd y byddwch chi’n derbyn trawsgrifiad o’r
sesiwn yma i’w wirio i wneud siŵr eich bod chi’n
hapus bod pethau’n ffeithiol gywir? Yn naturiol, allwch chi
ddim o reidrwydd newid eich meddwl am unrhyw beth, jest gwirio y
ffeithiau—bydd hynny’n iawn. Felly, gyda chymaint
â hynny o ragymadrodd, a allaf ddiolch yn fawr iawn i chi am
eich presenoldeb? Diolch yn fawr.
|
Dai
Lloyd: I think we’ve
come to an end with the questions, so we’re at the end of the
session. Thank you very much, and thank you for the information
during this session and the information you sent us previously. Can
I just also say that we will send you a transcript of this session
so you can check it for factual accuracy? Of course, you
can’t change your mind about anything, but if you could just
check it for the facts, that would be great. So, with those few
words, may I thank you very much for your attendance? Thank you
very much.
|
