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 09:29.
The meeting began at
09:29.
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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 a chroeso i gyfarfod diweddaraf y
Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad.
Rydym ni mewn ystafell wahanol y bore yma, ond, wrth gwrs,
mae’n ddigon hawdd ymgynefino â’r sefyllfa
wahanol. A allaf i estyn croeso i fy nghyd-Aelodau? Mae gennym ni
ymddiheuriadau oddi wrth Angela Burns heddiw. Nid yw hi’n
gallu bod yn bresennol. Fe allaf i bellach egluro bod y cyfarfod
yma yn ddwyieithog. Gellir defnyddio’r 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 trydanol arall a allai ymyrryd â’r offer darlledu
yn y gornel wrth ein hochr ni? Hefyd, nid ydym ni’n disgwyl
larwm tân y bore yma. Os bydd yna larwm tân yn canu,
mae’n golygu bod yna rhywbeth mawr o’i le a dylem
ddilyn cyfarwyddiadau’r tywyswyr i adael yr adeilad. Felly,
dyna bob peth o dan eitem 1.
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Dai Lloyd: Good morning and welcome to
the latest meeting of the Health, Social Care and Sport Committee
here at the Assembly. We’re in an alternative room this
morning, but, of course, we will get used to our new surroundings.
May I extend a warm welcome to fellow Members? We received
apologies from Angela Burns today as she’s unable to be with
us. May I further explain that this meeting will be held
bilingually and 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 switch off their mobile phones
and any other electronic equipment that they may have that could
interfere with the broadcasting equipment in the corner there?
We’re not expecting a fire drill this morning, so if you do
hear a fire alarm, then it does mean that something’s amiss
and that we should follow the instructions of the ushers and leave
the building. So, that’s item 1 dealt with.
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09:31
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Ymchwiliad i Recriwtio Meddygol: Sesiwn
Dystiolaeth 6—Coleg Brenhinol Meddygaeth Frys a Choleg
Brenhinol y Radiolegwyr
Inquiry into Medical
Recruitment: Evidence Session 6—Royal College of Emergency
Medicine and the Royal College of Radiologists
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[2]
Dai Lloyd: Eitem 2 ydy’r parhad efo’r
ymchwiliad i recriwtio meddygol. Hon yw sesiwn dystiolaeth rhif 6.
O’n blaenau ni'r bore yma mae tystion o Goleg Brenhinol
Meddygaeth Frys a Choleg Brenhinol y Radiolegwyr. Felly, a gaf i
groesawu i’r bwrdd, felly, Dr Robin Roop o Goleg Brenhinol
Meddygaeth Frys Cymru; Dr Amanda Farrow, hefyd o Goleg Brenhinol
Meddygaeth Frys Cymru; Dr Toby Wells o Goleg Brenhinol y
Radiolegwyr; a hefyd Dr Martin Rolles o Goleg Brenhinol y
Radiolegwyr.
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Dai
Lloyd: Item 2 is our inquiry into medical recruitment,
and this is evidence session number 6. Before us this morning, we
have witnesses from the Royal College of Emergency Medicine and the
Royal College of Radiologists. So, may I welcome to the table, Dr
Robin Roop from the Royal College of Emergency Medicine Wales; Dr
Amanda Farrow, also from the Royal College of Emergency Medicine
Wales; Dr Toby Wells from the Royal College of Radiologists; and
also Dr Martin Rolles from the Royal College of Radiologists.
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[3]
Rydym ni wedi derbyn eich tystiolaeth
ysgrifenedig gerbron a diolch yn fawr iawn am hynny. Mae’r
cwestiynau wedi’u paratoi yn seiliedig ar beth rydych chi
eisoes yn sylfaenol wedi’i ddweud wrthym ni. Felly,
gyda’ch caniatâd, awn ni’n syth i mewn i
gwestiynau, ac mae’r cwestiynau cyntaf o dan ofal Caroline
Jones.
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We’ve
received your written evidence, and thank you very much for
providing that. The questions have been prepared based on what you
have already provided us with. So, with your permission, we will
move immediately to questions and the first questions are from
Caroline Jones.
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[4]
Caroline Jones: Diolch, Chair. Good morning. In terms of the
medical workforce in emergency medicine, clinical oncology and
radiology, where do you think the key pressure points are and how
can they be tackled?
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[5]
Dr Wells: To clarify, sorry, the question was—
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[6]
Caroline Jones: Regarding the medical workforce in emergency
medicine, radiology and clinical oncology, where do you consider
the key pressure points to be and how can they be tackled?
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[7]
Dr Wells: In clinical radiology, which is what I represent,
the key—the only—pressure point is the absolute
shortage of radiologists. There are just not enough radiologists to
do the work. The number of complex scans being requested has
increased 10 per cent year on year for the last five years, whereas
the workforce has only increased between 1 per cent and 2 per cent.
So, mathematically, there’s a shortage.
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[8]
In terms of solutions, it’s very difficult. We’ve come
up with various options. We’ve tried our best to recruit from
overseas, but there’s an international shortage of
radiologists. Wales is no worse off than the rest of the UK. The
number of radiologists per capita is similar to every other area.
It’s slightly better than East Anglia and slightly worse than
London. But there’s no radiologist sitting around anywhere
that we can poach, so recruitment is limited. We’ve had to
outsource a lot of work to private companies because there is no
other solution. The only long-term sustainable solution is to
increase training numbers.
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[9]
Caroline Jones: Okay, thank you.
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[10]
Dr Roop: From the Royal College of Emergency Medicine point
of view, we know that our population is rising and attendances to
emergency departments are increasing as well. The case mix of
people who attend emergency departments is also increasing in terms
of the over-65s who need to be seen more frequently in emergency
departments. That’s one of the pressure points. We find that
we need to have the appropriate staff levels within departments to
deal with these more complex patients who have different needs. We
are also in a position where our numbers are not sufficient to deal
with these pressures.
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[11]
Dr Rolles: I think it’s about bodies on the ground
essentially. I think the situation is the same. I think
there’s an added dimension that hasn’t been mentioned,
which I think is generalisable possibly, in that we are
particularly vulnerable in the south-west and the north, where
recruitment is difficult and the departments are small, and
there’s an added requirement to provide a service to a rural,
geographically distributed population. So, there’s a loss of
economies of scale that one might find in a large department and
there are extra requirements. So, the metrics in terms of staffing
numbers per million population, which have generally worked out for
places like the English midlands, where you’ve got a
relatively consistent high-density population, really don’t
apply to rural Wales.
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[12]
Dr Farrow: May I add to that? Just to reinforce what Robin
said, for emergency medicine, staffing is an issue and, again,
mirroring what Martin said about oncology with north Wales and west
Wales, in particular. I work for the Wales Deanery as part of my
role, so I’m the head of school for emergency medicine. So, I
deal mainly with training, and we have very good training, but we
actually have a very small number of training posts, so we do rely
on a lot of non-training doctors, and that’s where the
problem is with staffing. But also currently a big pressure point
for us would be the crowding that is facing all emergency
departments on a daily basis, which has a very negative impact on,
you know, burnout and stress to staff, including nursing and other
staff. So, that has to be tackled to make sure that emergency
medicine people can function and work in good, supportive
environments as well. So, I think staffing is a problem, but also
it’s getting the system correct.
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[13]
Caroline Jones: Okay, thank you. What do you consider to be
the influencing factors on where doctors choose to study, train and
work, and how do you think this information can be
substantiated?
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[14]
Dr Farrow: So, we had a survey done recently by our
trainees, and, actually, a lot of the reasons they choose to stay
in Wales were because of family reasons and work-life balance. And
if we manage to get them into a training programme, then generally
they stay in Wales as consultants. So, it’s attracting them
in the beginning and, obviously, retaining them, but a lot of
choice is for reasons that aren’t necessarily due to the
medical side of things, so it’s often the family work-life
balance. There are a number of doctors who want to work in north
Wales and live in north Wales, but there are also a lot of doctors
that want to work in south Wales, and therefore don’t want to
have to rotate during their training programme. So, we’ve got
two separate training programmes now, really—one for south
Wales and one for north Wales.
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[15]
Dr Roop: Being a small country as well, we have a lot of
district hospitals, and there was this sort of homely-type
environment, so the experiences that these doctors had in these
units made them want to stay and become really loyal to the units
that they were working in. So, you do have to give these doctors a
very good experience as well, so that’s why there have been
attractive schemes in different parts of the country, and that
keeps people in.
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[16]
Caroline Jones: Thank you. Anyone else?
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[17]
Dr Rolles: Just to echo those comments, there’s a
definite sort of a—. If we train people and they live here
for at least five years, there’s a reasonable chance
they’ll settle down, but it has to be recognised that people
are free to move around and there is a national and international
market for jobs. People who are high-calibre, which is what we want
here, will tend to look everywhere. So, there’s a diffusion
back across the border. We’ve also got to ask, ‘How do
we attract people from England?’ because we’re not just
looking at indigenous trainees. And there are a number of issues
that I don’t think have necessarily been enumerated here, but
if you’re someone who’s lived and trained in the home
counties, there’s almost a Socratic question, ‘Why
would I want to go and work in Wales?’ I think we have to get
back to those basics, and we’ve got to work very, very hard
really to get people to want to come here. I mean, the attractions
are obvious for some of us, but not for everybody.
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[18]
Caroline Jones: Okay, thank you. We’ve received
evidence about the length of time it takes to recruit and appoint
medical staff. Do you think there’s a need for more clinical
ownership and involvement in the recruitment process, and would
that help to address the sort of time delay, do you think?
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[19]
Dr Wells: It wouldn’t address the time delay;
there’s a fixed amount of training time that can’t be
adjusted. And I don’t think there’s an awful lot we can
do to recruit people from outside Wales to come to Wales. In
radiology, everywhere is so short of radiologists that you can
phone up any department and say, ‘I’d like to work
there’, and they will give you a job. And it’s very
hard to attract someone from an area to another area, because
they’ve set down roots. It’s a five-year training
scheme, people buy houses and have kids, and they’re in
school, so why would you want to come to another area? And if
you’re recruiting from abroad, why would a Polish radiologist
choose to come to Wales, much as I love it? They know London
better. They get paid a little more in London, and they would
choose to go to London rather than Wales.
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[20]
Caroline Jones: But the cost is so much higher in London,
isn’t it?
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[21]
Dr Wells: I know, and to me it’s an obvious choice,
but coming from Poland, nobody’s heard of Swansea and
everyone knows London, and they’re just as short of jobs in
London, unfortunately.
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[22]
Caroline Jones: Okay.
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[23]
Dr Roop: Coming back to your question on more clinical
ownership of these recruitment schemes, there is quite a lot of
ownership from the clinicians in terms of—we are the ones who
can direct what we expect from that post. As a college, and our
head of school, and the school of emergency medicine in Wales, we
plan exactly what type of training scheme we would like to have for
our trainees. So, there’s a lot of clinical engagement into
identifying how the jobs are done.
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[24]
Caroline Jones: Thank you.
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[25]
Dai Lloyd: Julie, you had a supplementary.
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[26]
Julie Morgan: Yes. It was just on what Dr Wells said about if you
were a radiologist, and you contacted any department—in the
UK I presume you’re talking about—you’d be able
to get a job.
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[27]
Dr Rolles: Almost.
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[28]
Julie Morgan: Almost, yes. [Laughter.] How does Wales
actually compare with the other departments? Are we worse off or
are we—?
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[29]
Dr Wells: In terms of numbers or in terms of
attractiveness?
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[30]
Julie Morgan: In terms of
numbers.
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[31]
Dr Wells: The number of radiologists per capita in Wales is 3.8
per 100,000, which is almost bang on the average for the UK. In
East Anglia it’s down to 3.2 and in London it’s up to
nearly 5. But we’re bang on average. The problem is the
distribution. All of our 3.8 are in south-east Wales, and in
Llanelli they haven’t appointed a UK-trained radiologist for
22 years. Again, because our training scheme is based in Cardiff
currently, most people set up their lives in Cardiff, and then
it’s hard to attract them to somewhere they’ve never
been.
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[32]
Dai Lloyd: Dawn.
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[33]
Dawn Bowden: Thank you, Chair. I was just wondering whether you
have particular problems around recruitment in rural areas, and if
that is mirrored with recruitment in rural areas in
England.
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[34]
Dr Wells: To some extent. King’s Lynn was the classic
example—no-one worked in King’s Lynn, in the far corner
of north East Anglia. They couldn’t recruit for upwards of 10
years, and that department was failing, and then they built the
Norwich Radiology Academy and shifted their training scheme to be
centred near there, and now they have no problems with recruitment,
because these radiologists set up their lives in the south-east,
away from London, and that solved their issue.
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[35]
Dawn Bowden: Okay. That’s fine. Thank you very
much.
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[36]
Dai Lloyd: Symudwn ymlaen at yr adran nesaf.
Rhun.
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Dai Lloyd: We will move on now to the
next section. Rhun.
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[37]
Rhun ap
Iorwerth: Bore da i chi i gyd. Nid ydw i’n gwybod ai ‘adran
nesaf’—mae popeth yn llifo i mewn i’w gilydd mewn
difri, ond os allwn ni drio manylu ychydig bach mwy ar rai
o’r meysydd sydd wedi cael eu crybwyll yn barod. Pa opsiynau
sydd yna ar gael sydd wedi cael eu hystyried neu, o bosibl, ddim
wedi cael eu hystyried yn ddigon eto ar gyfer cymell rhai i ddod i
gael hyfforddiant yng Nghymru ac i weithio yng Nghymru? Rydw
i’n eich gwahodd chi i fod mor agored eich meddwl ag y
gallwch chi fod—popeth o gymhelliad ariannol, er enghraifft,
i gyfleoedd ymchwil ac yn y blaen. Beth ydy’r foronen yna a
allai wneud Cymru fod yn neilltuol wahanol pe bai’r ymdrech
yn cael ei wneud go iawn?
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Rhun ap
Iorwerth: A very good morning
to you all. I don’t know if it’s the ‘next
section’ as such; everything seems to flow into each other,
if truth be told, but if we can try and focus a little on some of
the areas that have already been mentioned this morning. What
options are there available that have been considered, or perhaps
haven’t been considered in enough detail yet, in terms of
incentivising people to come to train in Wales and to work in
Wales? I would invite you to be as open-minded as possible in terms
of all the options, from financial incentives, for example, to
research opportunities and so on and so forth. What is that carrot
that could make Wales a particularly attractive place if the effort
was put in place?
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[38]
Dai Lloyd: Design your own recruitment policy.
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[39]
Dr Roop: For emergency medicine, we do have a restriction in
terms of having to follow the national guidance on consultant
contracts—that’s for one. So, we do have that part we
have to stick to, although we can still be a little bit inventive
in terms of things that you can do to attract, from the
trainee’s point of view all the way up to consultants.
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[40]
One of my colleagues, my equivalent in Scotland, needed to attract
people into his posts, and they were moving from the south of
England, and there was a husband and wife team, so they had two
people. They had a house that was on the market and so the chief
exec said, ‘Well, we’ll pay the mortgage while you all
get settled.’ So he had to take probably a small hit for a
bigger gain, and those people stayed with him, and they managed to
get their house sold. So, you have to be a little bit inventive. If
you’ve found the correct person for your post, then you need
to make sure that you can look after them and be able to give them
something in return. It’s not always all about money as well.
It’s about making sure that they have a work-life balance, as
Amanda was saying, because one of the big parts of emergency
medicine at least is it has to be a sustainable job, because we
don’t want doctors, by the time they’re in the middle
of their 40s, to be burnt out—then you’ve lost another
good 20 years of medical practice, emergency practice, from those
doctors. But you also need to ensure that they feel valued within
their departments, and part of the morale in emergency departments,
again, comes back to if you have departments that are congested all
the time. So, it’s a full-system problem that we’re
dealing with. You have to have departments that are actually
working like emergency departments and not like wards.
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09:45
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[41]
Rhun ap Iorwerth: On the idea of paying a mortgage for
somebody to make the move easier, that was an ad hoc situation. Are
there structured, strategic things that could be offered in Wales
that become the norm that makes Wales stand out, be it that kind of
financial incentive or jobs for spouses or whatever it might
be?
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[42]
Dr Roop: I think there are good ideas around the country, in
the UK, in terms of—some people have been given golden
handshakes, all sorts of things, and just getting them going and
making sure that you can—. If you can keep them for a fixed
period—you have to be with us for this fixed period—it
would help a lot with your further recruitment, because once you
have a stable workforce, more people come in.
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[43]
Rhun ap Iorwerth:
Okay. Any thoughts from you?
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[44]
Dr Farrow: Can I—?
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[45]
Rhun ap Iorwerth:
Yes, please.
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[46]
Dr Farrow: So, we don’t have a problem recruiting junior
doctors to specialty training posts within emergency medicine, but
our rotas are made up of a number of different sorts of junior
doctors, which include GP trainees. The problem with GP recruitment
has an impact on our actual rota and therefore the experience of
our doctors. But we have had 100 per cent recruitment to our actual
specialty training posts for a number of years, so we don’t
have a problem recruiting them. We actually do retain most of our
specialty trainees, but I’m talking about very small numbers,
so, as an actual workforce, we’re all having to look at other
opportunities with developing other roles like advanced nurse
practitioners, so having a mixed workforce to make sure
there’s enough different types of staff to staff around the
country.
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[47]
But emergency medicine in Wales has
raised its profile in the last few years with the introduction of
initiatives within Wales like the emergency medicine retrieval and
transfer service, the EMRTS, which has, actually, positively
recruited consultants to come and work from outside Wales. So,
it’s hosted by Abertawe Bro Morgannwg University Local Health
Board. They may work in England as a consultant in anaesthetics or
critical care and emergency medicine, but they’re actually
employed and work some shifts on the helicopter, which has enabled
quite a lot of networking and raising the profile. Also, we have
our first professor of emergency medicine who was employed in the
University Hospital of Walesa couple of years ago, and we have
now—from that, one of our trainees has been working on
developing a BSc. So, we’re looking at other options to try
and raise the profile within Wales. So, I think, we do recruit
people, we do retain them, but we need more money to get more posts
to be able to get more people to meet the numbers better. I’m
aware that they have introduced a financial incentive for GP
training this year in some areas of Wales, and it would be
interesting to see if that does have any impact on increasing the
numbers attracted to GP.
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[48]
But I think we’re very open to
trying to introduce some flexible working. So, we also have a
medical education Fellow who works in emergency medicine
who’s been involved in some research with the college, so
we’re looking at supporting any ideas for creating more
interesting training posts as well.
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[49]
Dr Wells: We have a slightly different, but related, problem.
Again, we don’t have a problem with recruiting people to
train in radiology. There are nine applicants per place, and if
they train locally, they usually stay here. So, we have the problem
of not having trainees because there aren’t enough posts. But
we have another problem in that the NHS is competing against other
sectors for radiologists’ time, and a lot of our radiologists
work for outsourcing companies and can get paid a lot better
sitting at home doing reporting. So, at the age of 60, we need to
try and keep our radiologists and stop them retiring and having an
easy life working for an outsourcing company and, equally, if
anyone’s got any extra spare capacity, we’d rather they
did extra sessions for the NHS than for an outsourcing company. The
only way to do that is to make it a better job, working in the NHS,
be that doing some sessions from home with homeworking, which Gwent
have tried, or, somehow, making it more attractive to stay in the
NHS. For a lot of us, the patient contact is what keeps us
working for the NHS, but we need to promote better the benefits of
working for the NHS because a lot of people see staying at home and
working for an outsourcing company as an attractive
alternative.
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[50]
Dr Rolles: I don’t disagree with anything anyone says
at all. I think we’ve got to distinguish between trainees and
fully qualified consultants—they’re two different
things. Trainees are much more likely to stay in Wales, if
they’ve been here, and put down roots. So, it’s an
important thing, but you’ve got to accept that you start your
training on a scheme that is normally five years, but certainly for
oncology, it’s now seven to eight years because of
postgraduate research and things like that. Again, it’s a
real success story for Wales. It has very highly reputed training
schemes, which are oversubscribed, but our outputs are about two
consultants a year, which is not enough to fill our existing
vacancies or our projected requirements or projected increase in
workload. So, actually, if we could increase the number of
trainees, it would be a good strategy.
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[51]
Rhun ap Iorwerth: I just
wanted to press you on that, if you’ve got more to add,
because a number of you made that suggestion in your
submissions—
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[52]
Dr Rolles: But that’s not a quick fix, that’s a
strategic thing. So, you’re looking at half a decade or a
decade down before you—. Even if we start now, it’s a
long-term strategic thing, but it’s probably worth while and
it’s a stable strategy long term. The second thing is: how do
we get qualified consultants? There isn’t a single way of
doing this. It’s a multifactorial thing, and you’ve got
to just keep—. There are marginal gains here and there. So,
Wales can be promoted as a place to live and
work—that’s one thing. The advantages of working in NHS
Wales, as opposed to NHS England—there’s been a bit of
a distinction there—are pretty clear for a lot of us who work
here. That can be played up and, you know, ‘Why come across
the border?’
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[53]
The other thing is opportunist headhunting. You don’t just
put an advert out in the British Medical Journal and see who
applies. You’ve actually got to identify people who might
come along, and start working on them before they get there.
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[54]
Rhun ap Iorwerth: I think
as a committee we realise there is no quick fix and that
we’re looking into the medium term, but I wonder, if we were
able to increase training places—and you all seem to suggest
that you wouldn’t have a problem filling those places; so it
would be just a matter of building that capacity in whatever
way—if that strategy was in place now, which wouldn’t
actually deliver trainee doctors for a number of years, would that
in itself be an attractive proposition for medics who wanted to
come to Wales? Because, okay, maybe they’re still struggling,
like the rest of the UK now, but, you know, what they’ve got
to plan— ‘In five, six, seven or eight years’
time, I’ll be working in an NHS that is properly staffed and
has a strategy.’
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[55]
Dr Rolles: I don’t think there’s any doubt about
that. Actually working in an environment where you are training and
have trainees—there’s a chance to speak and to develop
the sort of ethos of the system, and it’s a chance to get
more research done. It makes the whole thing much more attractive.
It takes it beyond just being a jobbing doctor, which, actually, is
one of the disadvantages that Wales has, especially in the smaller
units. It’s just working very hard to sort of do the
bread-and-butter work. There’s got to be a bit more than that
to make it attractive.
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[56]
Dr Wells: That is exactly what we’re looking to do in
radiology, and this is why we proposed this radiology academy that
I wrote about in our written evidence. That’s a step change
in how attractive it is to work as a radiologist in Wales. It
instantly becomes an attractive place to work, and will not only
increase training numbers but it will attract other people to come
and work and teach in an academy.
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[57]
Dr Farrow: Just one thing to say: the Welsh consultant
contract is actually a very supportive reason to work in
Wales—the sort of recognition of the need for SPA
sessions—that’s our supporting professional activity
sessions—versus the direct clinical care. In England, there
has been a huge drive to reduce the number of SPA sessions, which
is an absolutely essential part of our workload for looking after
trainees. So, within the Wales Deanery they’re trying to push
professionalising education. So, having dedicated time where
consultants have time to spend with the trainee doctors makes the
environment much more useful. It makes the training better. So, I
think the Welsh consultant contracts is an excellent thing. The
more we promote it and maintain it is to attract consultants from
England.
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|
[58]
Dr Wells: I trained in England and moved to Wales partly
because of that—the 3:7 ratio of SPAs to DCCs is very
attractive. The pay scale points are lower in Wales than in
England. Starting off as a consultant in Wales, you start off a
couple of thousands less well off than in England, which does put
people off, for a small amount of money. Perhaps that would be
worth looking at, but promoting the SPA thing is a good plan.
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[59]
Dai Lloyd: A wyt ti wedi gorffen?
|
Dai Lloyd: Have you finished?
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[60]
Rhun ap Iorwerth: I could go on and on.
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|
[61]
Dai Lloyd: Yes, we’re aware of that, Rhun, but
I’ve got a committee to run. Julie.
|
|
[62]
Julie Morgan: I wanted to ask about—. There’s
obviously links with the north-west of England for the clinical
radiology and the clinical oncology training. Does that mean there
are problems of retaining staff in Wales because of those
links?
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|
[63]
Dr Wells: Yes, it does, absolutely, because they’re
exposed to the north-west of England, where there is also a
shortage of radiologists, and a lot of people are tempted to stay
there because it’s a better work environment—more
research, bigger hospitals, more specialties. But, you can also
sell north Wales as an attractive place to live. But we can’t
do anything about that. Because of the geography of Wales, they
will always have to go to north-west England to do some of their
training.
|
|
[64]
Julie Morgan: Right. So, would you say we lose quite a lot
of people that way?
|
|
[65]
Dr Wells: I don’t know the figures. There are only two
radiology registrars in north Wales. So, percentage wise, if both
of those went, obviously, you’d lose a 100 per cent. I
don’t know the figures, but it is a significant problem and
the recruitment is as bad in north Wales as it is in the south-west
of Wales.
|
|
[66]
Dr Rolles: And for clinical oncology, historically
there’s been one clinical oncology trainee in north Wales
who’s Welsh—under the Welsh deanery—but is de
facto part of the Mersey team, so really rotated and trained
largely in Liverpool with some work in Rhyl and other places.
That’s gone up to three. Hopefully, that will provide some
exposure, but we’ve got to just accept reality. These
guys—their peers are in Liverpool and the Wirral.
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[67]
Dr Wells: There’s a threshold factor where a
department gets so short that, beyond that threshold, they will
struggle to ever recruit again because they’re so short
it’s such a miserable life working there, and we need to
prevent that from happening in north Wales.
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|
[68]
Julie Morgan: Thank you. You’ve mentioned the Welsh
consultant contract. Obviously, there’s been a lot of
publicity and issues about the junior doctors contract in England.
Have you seen—or do you anticipate that having any effect on
recruitment to Wales?
|
|
[69]
Dr Wells: Well, it’s been resolved, but when the
issues were going on, a lot of people were looking—. We
recruit nationally for registrars in radiology and I still have
links in England and I know that a lot of people thinking about
applying to radiology pushed Wales up their preferred first choice
of place to come and train, purely because of the uncertainty and
the way that junior doctors felt they were being treated in
England, and Welsh doctors were being treated much better. That
worked very well in our favour.
|
|
[70]
Julie Morgan: So, you think we did get—
|
|
[71]
Dr Wells: We didn’t get any more numbers, because
we’ve still got the same numbers and we always fill them. So,
it didn’t make any numerical difference, but it did help to
make Wales more attractive.
|
|
[72]
Julie Morgan: Right, thank you. The other question I wanted
to cover was the impact of Brexit and how you see the impact of
Brexit on how we function in Wales.
|
|
[73]
Dr Rolles: My view is that one of the great joys of working
in a national service is that it’s cosmopolitan. It’s a
very good international organisation, it recruits internationally
and it contributes internationally to knowledge of medicine in the
world. My colleagues are international in west Wales, and
everywhere I’ve ever worked, and it’s a pleasure and a
delight. And they’re not just there to do their jobs;
they’re there because they contribute to the development of
the service and the expertise and they bring a huge amount in.
|
|
[74]
So, if you think about—. The great concern about Brexit is we
have a very major EU component to the NHS workforce in the UK.
It’s going to likely affect the UK, and what affects England
is likely to affect Wales more severely. It’s just a
generalisation, but in terms of staffing shortages for UK-trained
doctors, what affects the UK affects Wales and the peripheries
more. Why would it be any different for EU or overseas
recruits?
|
|
[75]
There’s also a question really about—. It’s not
just about can we recruit and are there going to be visa problems
or bureaucratic hurdles; it’s about the general atmosphere.
If people start to feel unwanted or that it’s less friendly,
then they’re less likely to stay.
|
|
10:00
|
|
[76]
Dr Roop: One of the things about emergency departments is
that we have very big teams and we work in a team fashion, so we
value all of the people within our teams. A fair percentage of our
workforce is from outside of the UK and whilst there may be a
little bit of uncertainty around what’s happening with them,
we’re still going to try to support them because it will
be—. If we can keep our people, we will still be able to
recruit more in. Like Toby was saying, if you don’t have a
stable workforce within your department, you can never really
recruit in again, so good makes good, basically.
|
|
[77]
Julie Morgan: So, you’re having to make efforts to make sure
that people are valued.
|
|
[78]
Dr Roop: Yes.
|
|
[79]
Julie Morgan: Finally, I think, Dr Wells, you mentioned the
radiology training academy and you said that in your written
evidence, but are you able to fund—is that going to be
funded?
|
|
[80]
Dr Wells: That’s a good question. The business case has
been submitted and it’s been reviewed by scrutineers in Welsh
Government and we’ve had positive feedback. They had some
minor questions, which we’ve addressed. So, it looks very
promising that we will have the capital investment to buy the
building and fit it. The ongoing issue is of ongoing revenue,
because we need extra money for consultants to teach there and for
staff to run the academy and we will also need more trainees to
work there. So, we’ve asked the health boards. The Welsh
Government has told us that they can’t fund the ongoing
revenue. So, they’ve told us to go back and ask the health
boards, which we’ve done and they’re thinking about it,
but, obviously, the health boards have got a shortage of capital.
But they are now aware that radiology is a particular pressure
point and it’s impacting on everything else. So, hopefully,
they will cough up the ongoing revenue, but then that still leaves
us with the issue that we might have an academy that is well funded
and with consultants to teach there, but no registrars to train
there and that’s up to the deanery to give us more trainees,
effectively, with their limited and finite resources.
|
|
[81]
Dr Farrow: Could I say something about the radiology
academy?
|
|
[82]
Dai Lloyd: Yes, carry on.
|
|
[83]
Dr Farrow: I just think that it would be a benefit to a number
of specialties, because obviously in emergency medicine we do a lot
of radiological investigations. We have a number of doctors who
would need training with that. We do use ultrasound and we have
emergency nurse practitioners and there are lots of other
specialties that do now use their own ultrasounds. So, I think that
the radiology academy would have a huge impact on improving
training for a number of specialties and not just radiology in
Wales.
|
|
[84]
Dai Lloyd: Okay. Lynne Neagle.
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|
[85]
Lynne Neagle: Thanks, Chair. Do you think we’ve got the
actual structure of health service division right in Wales?
Obviously, we’ve had some reconfiguration. It’s always
very difficult to take forward reconfiguration and I’d just
be interested in your views on whether there’s a need for
more reconfiguration to ensure that we can staff the provision that
we’ve got.
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|
[86]
Dr Roop: I had a college study day last Friday in north Wales,
and some of my equivalents from Scotland and England came to this
day. I mentioned to them the different health boards that we have
in Wales and one of the things that they didn’t know was
where these places were, so they wouldn’t know how to apply
for a job. In terms of the reconfiguration, because of the multiple
reconfiguration patterns that have happened in various health
boards, and various areas as well, it does make it a little bit
uncertain, even for fixed consultants within departments. They are
not sure what exactly is happening with their jobs in terms of
whether they’re going to have to cross-cover sites or whether
they’re going to be on one site. That bit of uncertainty
around reconfiguration can have an impact on how you recruit and
then mainly how you retain people.
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[87]
Dr Farrow: I think there does need to be consideration for some
areas in particular—say, west Wales for emergency
medicine—because it’s unlikely that the traditional
model of how we staff departments in the south-east area of Wales
would be mirrored successfully in west Wales because there
isn’t enough staff and it’s not an attractive place for
a whole number of people to go at the moment. Similarly, we
don’t have people doing specialty training in west Wales, so
therefore, it’s not on their radar for applying for
consultant posts. I know they’ve changed the way that the
department works in Llanelli with upskilling GPs, who are providing
a minor injuries service. I think in areas in west Wales and maybe
some areas in north Wales, they
are going to have to look at different workforce options. Within
south-east Wales, we’re already looking at different
workforce options with emergency nurse practitioners and advanced
nurse practitioners. So, I think one model fitting all departments
in all areas of Wales isn’t going to be the future; everybody
is going to have to try and work out their population needs are and
look at what services are available. So, some reconfiguration
for—. You know, it’s going to have to be different in
different areas, I think.
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|
[88]
Dr Rolles: Can I just ask for clarification on your question?
When you say ‘reconfiguration’, are you talking about
the idea of health boards or the provision of local
services?
|
|
[89]
Lynne Neagle: I think it was more really about the provision of
local health services, rather than the actual management
structure.
|
|
[90]
Dr Rolles: Okay. I think there’s a dawning realisation
that despite the intense wishes to keep local services local, some
services cannot be provided in a traditional district general
hospital model, where a bit of everything was provided locally. It
doesn’t fit modern practice for some things and, actually,
that’s obviously caused a lot of local angst—not in my
specialty particularly, but it’s pretty obvious, especially
when you go to places like Withybush hospital or Aberystwyth. So,
the point is that you’ve got to have a service that’s
sustainable; if you pretend it’s not sustainable, it will
collapse and then that’s not good for that population. There
have to be innovative ways of working, and some services need to be
provided on a regional basis rather than on a county basis. And to
some extent, that’s been driven by lack of staff. We’ve
actually found that we can’t provide—. I can’t
send oncologists up to Aberystwyth because it’s too far for
them to drive there and back and do a clinic. From Swansea,
that’s sometimes a five or six hour round trip. They could
see 60 patients in that time. It’s a nice idea, but it
doesn’t work. So, you innovate; you have expert nurse-led
clinics locally, you have a local physician or non-consultant grade
to try and provide services. We’ve been doing teleclinics,
and some patients come down to a centre. So, you know, it’s
changing the way we do things, especially for tertiary specialties.
And you probably find the same for invasive radiology, don’t
you?
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|
[91]
Dr Wells: Yes. Radiology, in theory, should be able to solve
this problem easily, because we can network. We should be able to
transfer images between departments and get it reported wherever
the radiologists are. We can outsource to Australia, but I
can’t see images from west Wales, because they’re on
different IT systems. We cannot see their images, because
there’s been a woeful lack of investment into the IT
infrastructure in Wales. We can’t yet provide the networking
solution. But another benefit of the academy is that, as part of
that project, there’s a bid for IT support that will allow
better networking centred in the academy, wherever it may be, that
should allow access to imaging from wherever so that
sub-specialists can go to the academy and report the imaging from
north Wales or west Wales from there.
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|
[92]
Lynne Neagle: So, are you saying—? I’m aware that
Australia is used, from personal experience, which I found quite
shocking, really. But are you telling me that we can have somebody
in Australia looking at them, and not somebody in west
Wales?
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|
[93]
Dr Wells: Yes, because the outsourcing company have invested in
their IT infrastructure, so they can come in and set up a system
where, somehow, they can see the images in Australia. But we have
yet to manage it.
|
|
[94]
Lynne Neagle: Okay, thank you.
|
|
[95]
Dai
Lloyd: Rhun, a oeddet ti eisiau dod nôl? Mae gen i gwpwl o
gwestiynau os wyt ti’n—
|
Dai
Lloyd: Rhun, did you want to
come back? I have a couple of questions if you—
|
|
[96]
Rhun ap Iorwerth:
I was keen to ask a question about the
national UK-wide selection process, and I’ve heard
suggestions that, certainly in surgery, but maybe across the board,
it’s time to consider withdrawing from national selection in
that it is a system designed to provide for the workforce in the
NHS in England, and perhaps it doesn’t really work for Wales,
with problems as basic as difficulty in getting interviewers from
Wales to go to London for the interviews because of problems with
the reimbursements of costs—even at that basic level. Do you
have any thoughts on the future of the national selection process?
To give a little bit more context, we were at a meeting a couple of
months ago held by the dermatologists, who were concerned
that lots of people were using, from England, the very high
standard of training that we have in Wales to get trained, yet
never having an intention of staying in Wales, and that somehow, if
we were able to have more control over that selection process, we
might be able to tailor it more to our needs.
|
|
[97]
Dr Farrow: For emergency medicine, we do have national
recruitment for speciality training at the ST1 level, which is
hosted by the London Deanery but, actually, we have four sites that
do the interviewing. So, we are linked up with the Severn Deanery
and Peninsula and Wessex. So, we actually go to Bristol to do our
interviews. So, we don’t have a problem at all sending
consultants for interviews because actually that’s a
day’s trip. It’s run very well locally in Bristol.
|
|
[98]
Rhun ap Iorwerth: I’m
not suggesting that’s the main problem with it, but I’m
just suggesting that it could be one.
|
|
[99]
Dr Farrow: Yes. So, I think there is a benefit to the
national recruitment from the point of view of maintaining a
quality standard, but also it does mean that there are probably
fewer consultants that need to go for a national process. So, it
does work well for emergency medicine. For our higher trainees,
that’s hosted then by Yorkshire, which means a trip up to
Sheffield, but that’s only once a year. Again, we only have
to send three people. If we were running our own interviews for
that, we’d need to send more. So, I think it works for
emergency medicine. I think the evidence, from the fact that most
of the trainees we have that start off as an ST1 complete their
training and stay as a consultant in Wales, shows that, for us, I
think the national recruitment process works currently.
|
|
[100] Rhun ap Iorwerth: Just to clarify, if
somebody wants to go into emergency medicine—and somebody
from Wales who wants to go into emergency medicine—would they
go into a recruitment process in Yorkshire?
|
|
[101] Dr
Farrow: So, at ST4 level, which is a registrar level, we
don’t have that many people entering, actually, at that level
generally anymore because most of them start off at the beginning,
at ST1.
|
|
[102] Rhun ap Iorwerth: But at the lower level, then, somebody would
go to Bristol.
|
|
[103] Dr
Farrow: To Bristol.
|
|
[104] Dr Roop:
Yes. So, at a lower level it’s a national recruitment. So, if
you were in Scotland but you had roots in Wales or you wanted to
work in Wales for some reason, you’d go to the closest
interview centre to you. So, that might have been in Sheffield. You
do your interview and you’re on a national grid, therefore,
and then you get ranked. Then, where you’re placed in your
ranking, you get your top choice, your second choice or whatever.
So, you’re all in one pot, really.
|
|
[105] Dr
Farrow: So, where you get interviewed isn’t to do with
where you apply for a job. It’s just the opportunity to be
interviewed relatively locally. So, they have four centres for
interview. But for the higher level, for ST4, because there are
such small numbers, it’s just in one place, which is
Sheffield. So, everyone from the whole of the UK would go up to
Sheffield. It’s only once a year, though, and with very small
numbers.
|
|
[106] Dr Wells:
It used to be a big problem. We’d take radiologists—the
first year SpRs in radiology—in Wales, and they clearly never
wanted to be in Wales. They’d put down Wales as their third
choice and got it because their first choice—London—was
full. Then, as soon as anyone dropped off the training scheme in
London, they would transfer back to London. We’ve recently
made it more difficult to do that. There have to be very good
reasons to transfer between training schemes, and that’s
reduced it to some extent. Since that change was made, the last two
years of radiology registrars starting have all been Welsh born and
bred and keen to stay in Wales. So, that has helped enormously.
Whether it would help further having a separate recruitment
process, I’m not sure.
|
|
[107] Rhun ap Iorwerth: Because Northern Ireland have their own, I
think.
|
|
[108] Dr Wells:
I don’t know about Northern Ireland.
|
|
[109] Rhun ap Iorwerth: Is it the KSS system that they use?
|
|
[110] Dr Wells:
I don’t know—maybe.
|
|
[111] Dr
Rolles: For clinical oncology, it’s an analogous system.
So, there’s a national recruitment programme. I think there
are two sets of interviews a year. People rank the places they want
to work. Actually, lots of people put Wales as No. 1. Some of our
local F2 pre-registrar, pre-trainees have delayed applying until
they know that there are places coming up in Wales. So,
that’s a good thing. We’ve discussed whether or not
Wales should pull out of this, whether it’s not responsive
enough. Scotland, I think, have withdrawn from the national scheme
and are doing it themselves. I think that the overall conclusion
from my colleagues that are actively involved in this is that Wales
is probably a bit too small to do this and it risks becoming
marginalised. One of the things Wales can’t afford to do is
to be seen as being too different in terms of training and
outcomes. Because people will come here because they want to be
trained, and then they have to be marketable and competitive for
jobs afterwards. They’re less likely to come if they think
they’re going to get something that’s different and
will not equip them to apply for jobs elsewhere. Not that they want
to go elsewhere, but you’ve got to be seen as being at a high
standard compared to everybody else.
|
|
10:15
|
|
[112] Dr Roop:
One of the things with emergency medicine is that we could probably
recruit three times over. So, the people who want to come to Wales,
we’d probably be able to fill our posts three times over if
we had enough posts, very easily.
|
|
[113] Rhun ap
Iorwerth: How do you create those training posts?
|
|
[114] Dr Roop:
Head of school.
|
|
[115] Dr
Farrow: By meeting with medical directors often.
|
|
[116] Rhun ap
Iorwerth: What’s the barrier to having more training
posts?
|
|
[117] Dr
Farrow: It’s money. Well, I think there is currently a
lack of a system for this to be dealt with. So, it’s
unclear—as someone who has to write updates on workforce to
submit to the deanery to be submitted to the
Government—exactly what the process is. So, a number of years
ago, after Modernising Medical Careers, a number of posts were set
up and a number of them were 50 per cent funded by the deanery, 50
per cent funded by the health board, and the health board pays the
banding. Since then, essentially, it’s been health
board-funded posts that we’ve created, and that’s by
local negotiation.
|
|
[118] Rhun ap
Iorwerth: Is the capacity there, or potentially there, to train
more?
|
|
[119] Dr
Farrow: Absolutely, yes.
|
|
[120] Rhun ap
Iorwerth: So, the capacity is there. It’s the funding
more than anything.
|
|
[121] Dr
Farrow: Yes.
|
|
[122] Dr Wells:
In radiology, I think we’re at capacity as we stand, without
an academy. That’s why we need an academy to increase our
training numbers significantly.
|
|
[123] Rhun ap
Iorwerth: I find your idea particularly interesting because you
have what you perceive to be the answer. It may not solve
everything, but this academy is a proposal, a strategic way
forward. How close are other parts of the medical world in Wales to
having that kind of proposal with—? I presume you have a
price tag on that.
|
|
[124] Dr Wells:
Yes.
|
|
[125] Dr
Farrow: We have a very good training scheme. We, actually, in
the GMC national training survey last year came out as the top in
the UK for overall satisfaction for trainees. We had a number of
positive outliers with regard to our access to education resources
and training programme. So, we do have a very good training
programme. Obviously, I think the academy for radiology is slightly
different because of the way radiology works. You know, in
emergency medicine, we’re in an emergency department, all of
us as a team are seeing patients—that’s what we do.
Whatever comes through the door, we deal with it. So, we provide
dedicated training, we give a lot of support to our trainees, and
we’re quite innovative with the training. When there’re
changes in the college for exams, we then change the training. We
do train our trainers, but I’m not sure a different strategy
is needed similarly to the academy.
|
|
[126] Rhun ap
Iorwerth: So, it’s capacity and paying for the additional
training. If we had 200 extra qualified junior doctors coming
through in Wales every year—as they’re the kind of
numbers I think we’re talking about with the kind of
proposals for introducing community medical training in other parts
of Wales, or increasing capacity in Cardiff and Swansea—are
you confident that you would be able to turn those 200 in Wales
into specialists across the board?
|
|
[127] Dr Wells:
Only if we’re given the money to train them.
|
|
[128] Rhun ap
Iorwerth: Yes, of course.
|
|
[129] Dr Wells:
If we were given the budget, then absolutely, yes.
|
|
[130] Dai
Lloyd: And access to helicopters, obviously. [Laughter.]
Dawn, you had a question.
|
|
[131] Dawn
Bowden: Well, I think most of it’s been covered,
actually, in Rhun’s questions. But I’m just interested
to see in the Wales Deanery’s evidence that they were talking
about—. They were pretty much operating in a buyer’s
market was the way they described it. They said that,
|
|
[132] ‘due to
less applicants than posts trainees are able to select and
preference where they wish to work and live’
|
|
[133] at the moment.
What would be the one thing that you think the Welsh Government or
the NHS in Wales could do that would attract people to train, work,
stay and live here, rather than go to work in the English NHS?
|
|
[134] Dr
Farrow: I think that buyer’s market relates to other
specialities than ours. So, I think that’s mainly GP core
medical training. So, our three specialities, clearly—
|
|
[135] Dawn
Bowden: They’d be different.
|
|
[136] Dr
Farrow: They are slightly different in that we obviously manage
to recruit and retain. I think it is about raising the profile of
Wales. So, you know, raising the profile of the success that we
have. Already, radiology and oncology and emergency medicine are
doing very well, but it’s getting the word out there as
well.
|
|
[137] Dawn
Bowden: So, how could that be done more effectively than it is
now? What would you say?
|
|
[138] Dr Roop:
One of things we need to recognise is that the new generation of
doctors are different—from a different millennium, basically.
These millennials, they do things and they understand things very
differently. They need that support mechanism and structure and
social media—all sorts of things. You need to engage with
them at their level. What Amanda has done on her training programme
is that she’s ensured that she can reach out to these doctors
properly, so that’s why they enjoy the training programme
that we have in emergency medicine. Our GMC survey, as she says, is
the best in the UK. So, we know that once we get the trainees in,
we can look after them really well, but what we need to do is to
have trainees. But if you have 20 more trainees and you don’t
have enough consultants there to train them, then their training
programme or their training experience isn’t going to be as
good. So, if you put the current number of consultants to deal with
a new bunch of 20 more people, they just won’t be able to
manage it. So, it has to be a seamless expansion as well. There
must be top-level trainers as well as the trainees. So, it is a
work in progress.
|
|
[139] Dawn
Bowden: Does it go back further than that? Does it actually
start with doing more to promote Wales in schools, perhaps, in
terms of the place to—? If you’re going to take this
career choice, this is the place to be and to stay. All right,
thank you.
|
|
[140] Dai
Lloyd: Ocê. Pawb yn hapus?
Diolch yn fawr. Diolch yn fawr am ateb y cwestiynau. Diolch yn
fawr, hefyd, am roi o’ch amser gwerthfawr i ni bore yma, a
hefyd am y dystiolaeth ysgrifenedig gerllaw. O leiaf rydym ni wedi
rhoi cyfle i goleg meddygaeth frys, radiolegwyr ac oncoleg i gael y
sylw haeddiannol ar eich llwyddiannau chi y bore yma. Felly, diolch
yn fawr iawn i chi. Gallaf i bellach gyhoeddi y byddwch chi’n
derbyn trawsgrifiad o’r dystiolaeth y bore yma er mwyn i chi
allu gwirio ei fod yn ffeithiol gywir. Ond gyda hynny o eiriau,
diolch yn fawr ichi am eich presenoldeb. I fy nghyd-Aelodau, fe
wnawn ni dorri am egwyl fer rŵan o 10 munud, cyn i’r ail
sesiwn ddechrau. Diolch yn fawr.
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Dai Lloyd: Okay. Everyone content?
Thank you very much. Thank you for responding to our questions and
thank you for giving your valuable time to join us this morning,
and for the written evidence presented as well. At least we have
given the opportunity for the Royal College of Emergency Medicine
and the Royal College of Radiologists to have due attention paid to
their successes this morning. So, thank you very much. I can also
announce that you will receive a transcript of this morning’s
evidence so that you can check it for factual accuracy. With those
few words, I thank you for your attendance this morning, and
I’ll inform my fellow Members that we will now break for 10
minutes before moving to the second session. Thank you.
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Gohiriwyd y cyfarfod rhwng 10:21 a
10:37.
The meeting adjourned between 10:21 and 10:37.
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Ymchwiliad i Recriwtio
Meddygol—Sesiwn Dystiolaeth 7—Coleg Brenhinol y
Seiciatryddion a Choleg Brenhinol Pediatreg ac Iechyd
Plant
Inquiry into Medical Recruitment—Evidence
Session 7—Royal College of Psychiatrists and the Royal
College of Paediatrics and Child Health
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[141]
Dai Lloyd: A allaf i groesawu’r Aelodau yn ôl
i’r sesiwn nesaf o’r Pwyllgor Iechyd, Gofal
Cymdeithasol a Chwaraeon? Ac rydym ni’n symud ymlaen nawr i
eitem 3. Rydym ni’n parhau gyda’r ymchwiliad i’r
recriwtio meddygol. Hon yw’r sesiwn dystiolaeth 7, ail sesiwn
dystiolaeth y bore. Ac o’n blaenau ni nawr mae Coleg
Brenhinol y Seiciatryddion a Choleg Brenhinol Pediatreg ac Iechyd
Plant. I’r perwyl yna felly, a allaf i groesawu’r Athro
Keith Lloyd, sydd yma yn cynrychioli Coleg Brenhinol y
Seiciatryddion heddiw, a hefyd Dr Sakheer Kunnath o
Goleg Brenhinol Pediatreg ac Iechyd Plant? Croeso i chi’ch
dau. Rydym ni wedi derbyn eich tystiolaeth ysgrifenedig ymlaen
llaw, ac mae pobl wedi darllen pob gair yn fanwl. Mae gyda ni nifer
o gwestiynau yn seiliedig ar y dystiolaeth honno. Felly,
gyda’ch caniatâd, awn ni’n syth i mewn i
gwestiynau, felly, ac mae’r cwestiynau cyntaf gan Dawn
Bowden.
|
Dai Lloyd: May I welcome Members back
to this next session of the Health, Social Care and Sport
Committee? And we move on now to item 3 and we continue with our
inquiry into medical recruitment. This is evidence session No. 7,
the second evidence session of the morning. And joining us now are
the Royal College of Psychiatrists and the Royal College of
Paediatrics and Child Health. May I therefore welcome Professor
Keith Lloyd, representing the Royal College of Psychiatrists today,
and Dr Sakheer Kunnath from
the Royal College of Paediatrics and Child Health? A very warm
welcome to you both. We’ve received your written evidence,
and Members will have read every word in detail. We have a number
of questions based on that written evidence. So, with your
permission, we will move immediately to questions, and the first
questions this morning are from Dawn Bowden.
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[142] Dawn
Bowden: Thank you, Chair. Good morning. Can I ask you first of
all to expand a little bit more? Because we’ve received your
evidence, as the Chair has said, but can I ask you to expand a
little bit more on where you believe the key pressure points are,
and the barriers in terms of the medical workforce in your two
areas of speciality, and, perhaps more importantly, what you think
needs to be done to tackle that? Because I think it’s easy to
identify the issues—it’s perhaps not so easy to
identify the solutions, is it?
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[143] Dr
Kunnath: If I may start, from the evidence we have submitted,
you may see that infants, children and young people aged between
zero and 18 make up around 20 per cent of the UK population.
Children represent around 20 per cent of the general practice
population and they have a higher use of healthcare facilities. At
some point, they may represent 40 per cent of the GP workload. I
also draw your attention to one of the papers cited in the
submission, that is, ‘Improving child health services in the
UK: insights from Europe and their implications for the NHS
reform’. So, the opening statement here is that:
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[144]
‘The care provided by UK
children’s health services is inferior in many regards to
that in comparable European countries.’
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[145] And they have
given a lot of evidence as to that. One of the graphs they have
given is the mortality rate, and in that you get drops, even
though, in 30 years, tremendous progress has been made. And there
are so many other parameters. So, that is a basic point. Why this
is happening, we do not know.
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[146] The royal
college did a rota vacancies and complaints survey in 2016 that
showed there is a gap of 12.2 per cent in paediatric rota tier 1,
which is the first on-call rota populated by SHOs and lower
trainees. In tier 1, that is slightly worse than England. In tier
2, it is 13.1 per cent, which is better than England. But tier 2 is
populated by higher-grade trainees and they are highly skilled
people and they do manage the basic workload in the hospital, and
that is impacting tremendously on the quality of care.
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[147] If you go back
10 years, before the major visa rule change happened, the tier 2
rota used to be populated by a category of doctors—they are a
known training category grade of doctors called staff grade and
associate specialists. They used to make up the backbone of that
category of doctors. On top of that, trainees used to come and go.
They were—on one account, they were about 59 per cent foreign
graduates, that’s non-UK, non-EU graduates. So, that category
of people is dwindling. There’s no supply of that category
anymore and now the rota is purely dependent on trainees and the
trainee numbers vary.
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[148] The study has
also shown that 20 per cent of consultants are non-EU, non-UK
trained and 5 per cent are EU trained. So, there’s a lot of
reliance on foreign graduates in paediatrics. It may be general in
other specialities as well. So, the restriction of immigration,
especially from outside the EU, and now, post Brexit, from the EU,
will have a big impact on the supply of—
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[149] Dawn
Bowden: Sorry, can I stop you there? Has it already had an
impact or is it—
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[150] Dr
Kunnath: It has already had, when the visa rule changes
happened 10 years back, for non-EU—
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[151] Dawn
Bowden: Yes, so that had an impact at that time.
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[152] Dr
Kunnath: Yes, so, on top of that, when Brexit happens,
there’ll be—I don’t know what the outcome will
be. It was somewhat mitigated by the recent arrival of EU
doctors.
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[153] I heard that
Jeremy Hunt has promised that there’ll be a 1,400 increase in
medical students, but that will take at least a decade to reach
that level of training, because medical school training itself is
six years, and then there are two years of foundation training, and
to reach the middle grade they need another four years. The total
paediatrics training is eight years. Paediatrics has got the
longest training. The paediatric workforce is also 70 per cent
female, so that increases—most of them opt for flexible
training and flexible working. So, that also will have an impact on
the availability of doctors.
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[154] Dawn
Bowden: These were training places for England, yes?
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[155] Dr
Kunnath: It’s in general.
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[156] Dawn
Bowden: Okay. Okay, sorry to interrupt you.
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[157] Dr
Kunnath: I am a community paediatrician. In community
paediatrics, because of the problems in acute paediatrics, the
community paediatric workforce has also dwindled over time. One of
my colleagues told me that, in Flintshire, there used to be eight
to nine whole-time equivalent doctors in 2002. Now, it’s down
to 5.8 whole-time equivalent. That is because the attention goes to
acute care because the crisis is more acute and severe there.
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[158] Dawn
Bowden: Can I ask you what is it that you think has brought
about this particular crisis, as you refer to it?
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[159] Dr
Kunnath: I don’t have an answer to that, but what I can
see in the middle grade rota is there was a dip in the foreign
graduates and a lot of problems in recruiting.
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[160] Dawn
Bowden: So, that’s been a factor.
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10:45
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[161] Dr
Kunnath: Yes. Now, because, for the service to run, this has to
be filled, what most of the health boards and trusts are doing is
to fill by locum at huge cost, because these vacancies cannot be
left alone, because it will impact service provision, quality of
care, and, sometimes, it may end up closing the wards. Beyond
finances, it has also impacted on the morale of the workforce.
Trainees are dragged into providing service with less time for
education and training, and, at times, consultants have to fill in
this rota, decreasing morale among the consultant workforce, as
well as their service during the day time being impacted.
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[162] Dawn
Bowden: Okay. Because you talked about in your evidence,
didn’t you, that possibly the increased production of local
trainees would be a longer-term solution—
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[163] Dr
Kunnath: It is a solution we can look for—
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[164] Dawn
Bowden: —but it’s several years we’re talking
about, isn’t it?
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[165] Dr
Kunnath: Probably a decade, to reach that middle-grade
level.
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[166] Dawn
Bowden: Yes, to reach that. So, what would be the kind of
immediate-to-short-term solution, in your view?
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[167] Dr
Kunnath: The royal college has embarked on a few strategies.
Now the royal college is managing the ST1—not, as such,
recruitment, but the management of interviews in regional clusters.
That means that a candidate doesn’t have to apply to each
deanery and they need to attend a few interviews in a few clusters.
So, that should improve ST intake.
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[168] It has actually
done some improvement, but I was told that, lately, in the last two
years, ST1 application has gone down and, this year, there
weren’t enough candidates to fill all the seats, so they had
to re-advertise for ST1. In an attempt to mitigate the situation,
the royal college also has embarked on a programme called a medical
training initiative. This is to bring overseas doctors on a
two-year contract on a tier 5 visa. I’m not sure how much
impact this has made, but there have been problems with that as
well. Two of my colleagues in Glan Clwyd Hospital had recently
visited India and they reported that the response was less than
satisfactory. Anecdotally, one of the reasons for that is that (1)
it’s a limited contract, and, second, the incentives are now
fading. Decades back, there were a lot of financial incentives and
training incentives. Now the situation in those countries has
changed, the financial incentives are much less, and the training
opportunities have increased a lot. High-tech hospitals have sprung
up everywhere, so there is less incentive for people to come to the
UK now.
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[169] Dawn
Bowden: Yes, sure. Okay. Can I ask you—
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[170] Dai
Lloyd: The psychiatrists?
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[171] Dawn
Bowden: Yes, the psychiatrists.
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[172] Professor
Lloyd: So, the Royal College of Psychiatrists is the
professional and educational body that trains and support
psychiatrists in Wales and the UK. We aim to do four main things,
which are: improve standards of care, improve outcomes for people
with mental health problems, promote understanding about mental
health issues, and promote parity of esteem. That’s very
important and I’ll come back to that later.
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[173] There are about
250 consultant psychiatrists in Wales at the moment and about 590
people in training and non-consultant career grades. We have issues
both with recruitment and retention, but are doing a number of
things to try and address that. So, the specific issues that we
have with recruitment are that the fill rate for our training
slots—. So, every year, we advertise training slots in the
different sub-specialties within psychiatry and the fill rate for
those—the number of people who we actually manage to appoint
into the scheme—is about 60 per cent. So, of the jobs that
are available in Wales, about 60 per cent get filled. That’s
slightly below the UK average. This year, about two weeks ago, my
colleagues in the deanery interviewed for what are called core
trainee slots in psychiatry. Those are the jobs that you do after
you’ve done your initial two years of hospital posts. There
were 18 slots available, for which there were eight applicants. So,
once you get through the training scheme in psychiatry and you
become a consultant psychiatrist, people tend to be retained
reasonably well in Wales and they tend to have high job
satisfaction. The difficulty is getting the front end in. Now,
I’m back here in a couple of weeks to talk to you about
medical schools, but I think there’s an important aspect
for—. If you want to address shortage in certain specialties
across Wales, you have to address the whole pipeline, from outreach
to schools, through to how different subjects are represented in
the curriculum, through to a variety of initiatives and incentives
to help retain people once they qualify and start to work here. And
there are a number of things that we’re doing to try and
address that.
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[174] Dawn
Bowden: Because you talk in your evidence, don’t you,
about the profession of psychiatry actually having a stigma
attached to it—you know, that it’s not the most
attractive of the specialties to go into, or perceived as not the
most attractive?
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[175] Professor
Lloyd: I don’t think so. [Laughter.]
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[176] Dawn
Bowden: No, no—I was just referring to what was said in
your evidence about the perception of the profession.
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[177] Professor
Lloyd: Yes, I mean, psychiatry and mental health—. Well,
it’s broader than professional psychiatry—it’s to
do with the public perception of mental health and mental illness.
We’re roughly where cancer was 25 years ago. It’s
becoming easier to talk about mental health problems. One in four
of us at any one time, in any one year, will have one. So, you
know, we all know somebody who’s been affected by mental
health problems. For us, the issue is addressing that at student
level. For my own medical school in Swansea, we actually have a
higher proportion of people going into psychiatry than almost any
other medical school in the UK, and that’s because of the
excellent people who are role models—my colleagues who do
most of the teaching for that. So, the way you address that kind of
stigma is by having good role models and people who want to show
what an interesting career it is.
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[178] My colleague
here is a community paediatrician; I’m a community
psychiatrist. The nature of medical practice is going to change.
Psychiatry went through a process of deinstitutionalisation in the
last century. Care in the community often didn’t mean care by
the community, but nonetheless we moved out of large hospitals.
We’re going to see the same thing happening with all medical
specialties in the future. We’re going to move away from a
traditional twentieth century DGH-based model of care, I think, and
psychiatry is particularly well placed to benefit from that, having
gone through that process already, and that needs to be reflected
in what training has to offer.
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[179] Dawn
Bowden: Okay. Thank you for that. So, can I just ask you both
whether you feel that doctors and LHBs have the information
available to them to identify the factors that influence where
doctors want to work, for instance?
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[180] Professor
Lloyd: So, there is a—if I just finish that one off, if I
may—national campaign working around recruitment and
retention at the moment, and it’s excellent. What it does is
it says, ‘Wales is an excellent place to come and work
because there are lots of fantastic things to do when you’re
not working’, which is true. That’s absolutely
true—I couldn’t disagree with that—but it
doesn’t promote the positive aspects of working in an NHS
that’s actually better than the NHS in England. We know that
last year more junior doctors came to work in Wales into foundation
posts from England than in previous years, and that’s
a—
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[181] Dawn
Bowden: And is that also true of training and study in terms of
getting people to study and train here as well?
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[182] Professor
Lloyd: One of the problems for trainees at the moment is that
because of the financial difficulties that many of the health
boards face, study leave budgets are being curtailed. So, that
makes it slightly harder for the trainees to undertake the kind of
study leave that they need, and I’m sure my colleague would
echo that. So, yes, the health boards do have the information they
need. For psychiatry it’s interesting, because about 10 per
cent of each health board’s budget is spent on mental health
and learning disability services. About 1 per cent of the
board’s time is taken up with talking about it. So, maybe
they don’t—. You know, if you’re having to fill
the front end of the rota for emergency departments and things,
you’re going to pay less attention to things that appear less
urgent, such as psychiatry, although there has been significant
investment in some areas of psychiatry, like liaison, which does
have a direct impact on bed utilisation in general hospitals and
things. But more could be done around training, and that’s
where the college is taking an active role in trying to promote it
as an attractive career.
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[183] Dawn
Bowden: Okay, thank you for that.
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[184] Dr
Kunnath: My colleague mentioned the study leave, but I
don’t think that is any better in England, so there
shouldn’t be much difference. There are a lot of positives to
working in Wales, in job satisfaction and all, because here you
find a true public sector service, but there’s no dichotomy
between primary, secondary and tertiary care and there’s no
competition. So, that should add to positive things, but, somehow,
that doesn’t produce any results. That’s why I’m
a bit perplexed. That is because, probably, people outside
Wales—I was trained in England, so until I came to Wales, I
did not know all this. So, there’s a large information gap. I
don’t know how this can—
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[185] Dawn
Bowden: So, you think, in terms of selling Wales as a place to
work, as opposed to just a place to live, actually, NHS Wales
should be talking more about what the Welsh NHS is like, what it
looks like and how it feels—
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[186] Dr
Kunnath: Yes, and what the difference is like.
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[187] Dawn
Bowden: What the differences are and what it feels like to work
in a true public service organisation, yes.
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[188] Dr
Kunnath: So, there are many people who are
frustrated—
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[189] Dawn
Bowden: I think that’s a fair point, yes.
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[190] Dr
Kunnath: —about this money flowing, patients and all that
kind of stuff that is not here, but that’s not well
advertised. The other thing I find is a bit of connection and
anxiety about children and education and all those things, because
I know two of my colleagues—their families are in England and
they commute in the week, and I do myself. So, those things are
there, especially those people who are coming into higher posts,
who are past their 30 to 35 years, with families. These are
anecdotal things; I don’t think there’s any study that
has been done about satisfaction of work-life balance.
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[191] Professor
Lloyd: If I may just come in on that—I’d absolutely
echo what you said that more needs to be done on this being a good
place to work and the virtues of the Welsh NHS. We saw that around
the stuff around ambulance wait times and so on. We seem very
reluctant to say what’s good about working in Wales.
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[192] Dawn
Bowden: That’s great, thank you.
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[193] Dai
Lloyd: Moving on, Jayne, you’ve got the next
question.
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[194] Jayne
Bryant: Thank you. I think, Professor Lloyd, you put it very
eloquently, because we’ve heard lots of witnesses saying
things about the importance of a work-life balance, and I think
we’re realising we’re perhaps concentrating on the life
stuff, as Dawn has said. First of all, we’ve heard also more
evidence around the benefits for more consultant involvement and
ownership of the recruitment process. Do you think that’s
happening at the moment?
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[195] Professor
Lloyd: So, there’s an opportunity to try and address that
through health education Wales in the future. At the moment, I
think there’s a disconnect, certainly in our specialty,
between training and service provision, which leads to overemphasis
on the training aspect to the detriment of service provision. So,
the way in which medical training, and certainly in our specialty,
is organised, is it’s quite hard—you don’t have
as much contact with trainees as you used to. There are
opportunities to do that differently. So, the answer to your
question is ‘yes’.
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[196] In south-west
Wales, we have a thing called ARCH, which is A Regional
Collaboration for Health, which is looking at different ways of
delivering healthcare, and there’s an argument about how much
commissioning of training posts should be done nationally and how
much should be done locally. I think, on balance, I’m in
favour of doing it on a national basis, but there are problems if
you’re a trainee in south Wales, having to move to north
Wales, or vice versa. It’s very difficult, once you’ve
settled and you have family, to be expected to move around the
country for training slots, which, in some specialties, is
necessary, because of the subspecialisms, but probably isn’t
for ours.
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[197] Jayne
Bryant: So, do you think doctors could be more involved in the
process then and, perhaps—?
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11:00
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[198] Professor
Lloyd: The deanery fills that role at the moment, and my
colleague Ian Collings is the head of the school of psychiatry in
the deanery, and he’s very much involved with the selection
processes. So, where the disconnect is between the local service
needs and the training—let me give you an example. It’s
quite hard to fill the training slot in psychiatry the further west
you go in Wales. I’ll speak about the parts I know best. Sort
of west of Swansea it’s harder to fill the training
slots—yet, you’ll hear that from other specialties as
well. Yet, if we want to promote people to work in those areas we
need to actually make them more attractive places to work and,
actually, rather than take—. There’s a balance: you
can’t have juniors working unsupervised, so the response is
to take them away from the places where there aren’t the
consultants, which sets up a vicious cycle and makes it worse in
the long term. We need a solution to that, which I think we can
offer.
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[199] Jayne
Bryant: Brilliant, thank you. Talking about the need for a
national approach, do you think there should be that national
approach to workforce planning and recruitment, or do you think it
should be done at a more—?
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[200] Professor
Lloyd: Well, workforce planning and recruitment should be
done—. There’s a national element to it because the
workforce needs to be planned nationally. There are some things
that can be done locally. I think the key thing is not to
disconnect training and service provision, and to look at it across
the different professions. Because if we’re following the
principles of prudent healthcare, then my colleague and I should
only do the things that he and I can do best. If there are things
that other people can do, who cost much less than we do, then they
should do it. So, if you have an approach that is national, that is
informed by both service provision and by training, and has
everyone working at the top of their licence during their training
and subsequently, it would be better.
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[201] Jayne
Bryant: Okay. Dr Kunnath, do you have any—?
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[202] Dr
Kunnath: Yes, I think the strategic planning should be at the
national level, but there should be a lot of local involvement
because the availability of service provision and the availability
of the trainees and doctors is variable in areas—especially
in north Wales, where geography is widespread. One of the problems,
especially in north Wales, is the geography itself. Sometimes,
doctors will have to travel between places that are far away. We
have had a vacancy in paediatric audiology for a long time and we
couldn’t get that filled. The person who was assigned has to
travel almost 60 miles, and that is unsustainable and that person
has to withdraw. So, it may impact upon people who want to come
into Wales as well. So, I don’t know what the solution can be
because the population is dispersed. It’s not concentrated in
one place, and you have to provide a service in the community;
otherwise patients have to travel. I don’t know whether there
are any quick fixes for that.
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[203] Jayne
Bryant: Okay, thank you.
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[204]
Dai Lloyd: Rhun, mae’r cwestiynau nesaf gennyt
ti.
|
Dai Lloyd: Rhun, the next questions are
yours.
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[205]
Rhun ap
Iorwerth: Diolch yn fawr iawn. Jest i fynd ychydig bach yn ddyfnach i
mewn i gwpl o faterion sydd wedi cael eu codi yn barod, mi sonioch
chi, Athro Lloyd, ynglŷn ag initiatives and incentives.
Pa fath o initiatives ydych chi’n meddwl y gellid
edrych arnyn nhw’n agosach? Rhai ariannol? Rhai datblygu
arbenigedd? Beth?
|
Rhun ap
Iorwerth: Thank you very much.
If I could just dig a little deeper into some of the issues that
have already been raised, Professor Lloyd, you mentioned
initiatives and incentives, but what sort of initiatives do you
think could be put in place or could be studied more closely? Are
they financial incentives? The development of expertise? What are
they?
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[206]
Yr Athro Lloyd:
Nid wyf yn siarad Cymraeg
da.
|
Professor Lloyd: My Welsh isn’t
particularly good.
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[207] So, I’ll
reply in English if that’s okay.
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[208]
Rhun ap
Iorwerth: Wrth gwrs.
|
Rhun ap
Iorwerth: Certainly.
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[209] Professor
Lloyd: Okay. So, what types of initiatives could be put in
place? The Royal College of Psychiatrists is working with the
National Centre for Mental Health, which is Wales’s first
biomedical research centre. It’s one of the premier places
for psychiatric research in the UK, if not the world. It’s
based in Cardiff and has links with both Bangor and Swansea.
We’re planning a number of educational initiatives with
them—conferences and training events—aimed at making a
vibrant community for trainees to feel engaged with. The location
of training is important, as a second thing. There is an argument
for, as I say, probably having a north Wales training scheme and a
south Wales training scheme that are merged, so you just have one
large scheme in the north and two in the south, probably—one
covering south-east Wales and one covering south-west Wales. That
would mean that people felt more part of their local community.
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[210] We have found,
from our medical school, that people are more likely to go into
psychiatry if they had positive role models. So, we’re doing
a lot of work with schools. People are going into schools to talk
about mental health, which has other benefits, and they’re
doing things with school leaders about psychiatry as a career,
explaining what it is. People don’t understand that
it’s a medical specialty. I guess the other issue is that
people ask questions about whether there are things that should be
done with the pay structure. So, probably not. At consultant level,
I don’t think it’s pay incentives that make a
difference to people. There’s parity at the moment between
Wales and England, pretty much, on pay. The Welsh system of
commitment awards is better than the English system for
consultants. So, that’s an incentive to retain people. But,
essentially, you said, ‘What sort of things are we
doing?’ It’s about creating an environment where people
feel engaged with the profession, passionate about it and are
adequately supported.
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[211] Rhun ap
Iorwerth: And how could that be done in a way
that—because, presumably, they’re trying to do this in
England as well.
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[212] Professor
Lloyd: Yes.
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[213] Rhun ap Iorwerth: Everybody’s in competition, in healthy
competition, so how do you make Wales stand out? What are the
tweaks that could be introduced, possibly, that could make Wales
particularly attractive in these areas?
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[214] Professor
Lloyd: The bit missing from the recruitment campaign is that
it’s also a very good place to work because there are
fantastic clinical services in some areas and there’s very
good research going on. You know, it’s how we add that
element to it really, I think, which is missing at the moment;
celebrating work as opposed to leisure, which is also
important.
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[215] Rhun ap
Iorwerth: Yes, and I’ll give you a chance to answer in a
second as well. Financial incentives, in addition to salary, things
like paying training fees that are—. You know, it is a burden
on trainees [Inaudible.]
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[216] Professor
Lloyd: I think the solution is actually earlier in the
pipeline, if ‘pipeline’ is the right word; it suggests
something industrial, and it’s not what I mean. But if you
increase the proportion of Welsh graduates, or Welsh school
leavers, going into Welsh medical schools and encourage them going
into certain professions, then you have feeder courses for, say,
graduate-entry medicine for the people who haven’t got in the
first time round. They’re going to stick around, and
they’re more likely to put that—. You know, if they
haven’t got roots already, they’ll put them down. You
have to make the professions attractive for them to go into. So, if
there’s anything to be done about pay structures, it’s
early on, around the time after people have just qualified, I
think, because by the time they’ve decided on their
specialty, they’ve made their choice.
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[217] Rhun ap
Iorwerth: Yes, but increasing the pool of undergraduates is key
to that as well, because the more you have there—
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[218] Professor
Lloyd: Yes, and looking at ways—. You know, there are
differences between the medical schools in terms of the proportion
of people who stay in Wales or go to England, Australia or
wherever, and all that needs to be taken into account.
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[219] Rhun ap
Iorwerth: Thank you. Some blue sky thinking from you as
well.
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[220] Dr
Kunnath: Yes. The royal college have done some studies, for
which they don’t have the figures yet, but there’s been
quite a bit of a drop-out after graduation, and they don’t
know where they’re going. So, what the Royal College of
Paediatrics and Child Health have done is to engage with medical
students. So, they are doing a lot of engagement work with medical
students and foundation trainees to attract them into paediatrics,
but that’s in general, UK-wide, though. As far as Wales is
concerned, there are a lot of positives for consultants to retain
their jobs—job satisfaction, and for the trainees to come in
as well, because, with the new contract in England, it will be more
attractive for them to come to Wales. That has not had any results
yet, but that’s maybe something we can embark on.
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[221] Rhun ap
Iorwerth: It strikes me, from listening to you and from our
earlier witnesses this morning, that the different specialisms have
different issues they need to address. Attracting more people into
your specialism is a particular issue. With emergency medicine, we
were hearing this morning, ‘No problem; it’s the number
of training places to meet the demand that there is out
there’. What about the ways that the issues are cross-cutting
and where there could be a Wales-wide strategy for increasing
people right across the profession who either want to be recruited
to come into Wales, or who want to come in to train in Wales? What
are the things that are in common between you, where there could be
co-operation?
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[222] Dr
Kunnath: I can’t think of anything right now.
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[223] Professor
Lloyd: The recruitment campaign is absolutely spot on as far as
it goes about Wales being a great place to live. Let’s
celebrate the working environment as well.
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[224] Rhun ap
Iorwerth: And we have an NHS that has a different attitude to
Jeremy Hunt’s junior doctors, and what have you.
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[225] Dr
Kunnath: That needs to be promoted and advertised.
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[226] Rhun ap
Iorwerth: What about—and this is something we explored
this morning as well—if we had an NHS in Wales that had a
clear strategy on increasing the number of undergraduates,
increasing training places, as well as developing excellence? Okay,
that wouldn’t deliver the people maybe for some years,
because it takes time to train a doctor, but would the existence of
that strategy in itself help you today to attract people here?
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[227] Professor
Lloyd: Yes. Yes, it does. People find that having a medical
school, being linked to one, being involved in teaching and
training, helps recruitment, retention and so on. My colleague Dean
Williams, from north Wales, gave evidence here a couple of weeks
ago, and he made that point about the value of having a centre of
academic excellence, which actually does act as a focus for those
kinds of training activities in a region. So, that is
important.
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[228] Rhun ap Iorwerth: Okay. And your
thoughts?
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[229] Dr
Kunnath: My training colleagues have previously mentioned that
having to go outside for tertiary specialist training might impact
on them coming back. So, if those kinds of facilities are there,
available locally, then more people could be retained.
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[230]
Rhun ap Iorwerth:
Okay.
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[231] Professor
Lloyd: I can give you an illustration of that. I have a trainee
at the moment who comes from west Wales. He is Welsh speaking.
He’s an excellent trainee. He went out to England to do his
medical training and he’s come back. He’s applying for
a consultant job in west Wales and they are very keen to appoint
him there. I hope he’ll be successful. If we had more people
like that coming through the system, that would help as well. So,
there’s both a long-term gain and a short-term gain from the
vibrancy of having those kinds of centres.
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[232] Dai
Lloyd: Okay. Caroline, you’ve touched on some of this
issue with regard to people having to go for higher training in
England, and possibly not coming back—have a go.
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[233] Caroline
Jones: Yes. There’s concern at the moment that some
trainees have to move to England for specialty
training—neonatology, for example—and the concern is
that once these people have gone, the chances are they may not come
back. So, really, we need the training to take place in Wales.
Could you tell me what your views are on this?
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[234] Dr
Kunnath: At the moment, there is provision for developing the
neonatal service in north Wales, but most of our trainees rotating
in north Wales have to have tertiary hospital experience in Alder
Hey hospital. Those kinds of facilities are not available in north
Wales. Equivalent services are available only in south Wales, but
the rotation is different now. I don’t know whether it is
feasible to develop those kinds of services in north Wales.
Depending on the population, I’m not sure, because you need
to have that kind of population and case load.
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[235] Caroline
Jones: Yes, but anywhere in Wales?
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[236] Dr
Kunnath: Yes, but the problem is—
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[237] Caroline
Jones: Central.
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[238] Dr
Kunnath: Yes. Travel between south and north, which the
trainees did not like very much, was the reason for developing a
north Wales rotation with Mersey Deanery, and that was running
successfully, and we are getting trainees from Mersey as well.
Sometimes, Mersey trainees, if they can get good experience here,
may choose to come here and take up the jobs.
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[239] Caroline
Jones: Yes. So, you think that it’s a two-way sort of
situation, really. But obviously we’d be in a much better and
win-win situation if we did have those services because we could
attract more people here, as well as retaining our people who would
normally go to England for this specialty training. We’d have
a sort of nucleus, then, of people from away, and retain our people
here.
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[240] Professor
Lloyd: If I may—
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[241] Caroline
Jones: Yes, certainly.
|
|
[242] Professor
Lloyd: We have some specialties that we can’t provide in
Wales at the moment for psychiatry. So, we don’t have
in-patient provision for eating disorders.
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11:15
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[243] We lack training
in medical psychotherapy, and there are a couple of aspects of
forensic training where people need high-secure psychiatric
exposure, where they have to go out of the country. For psychiatry,
it’s probably not important for training purposes to provide
all of those. But for eating disorders, medical psychotherapy and
for perinatal psychiatry, it’s important to provide those
locally from a service point of view, which is a different
point.
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[244] Caroline
Jones: Okay, thank you.
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|
[245] Dai
Lloyd: Julie, you’re back on paediatrics.
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[246] Julie
Morgan: Just following that one point for a moment, what
provision is there for mothers and babies to receive treatment?
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[247] Professor
Lloyd: The challenge for the mother and baby perinatal
psychiatry services is the on-off demand nature of them. So,
it’s difficult to provide a—you need a very large
population base to have a permanently used facility. There are
services in Wales for mothers and babies, but not in-patient
provision at the moment.
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[248] Julie
Morgan: Do you think that’s something that will happen,
because there used to be, didn’t there?
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[249] Professor
Lloyd: There used to be; there were in Cardiff, yes. There is
provision, but not beds at the moment. I think it’s actually
very important that mothers and babies receive the right kind of
care because it’s really important from the point of view of
bonding and so on. Ideally, we would have those services. It comes
down to cost, I think.
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[250] Julie
Morgan: Right, because I’ve been approached by
constituents about this issue. Thank you very much.
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[251] I wanted to ask
some questions about paediatrics, and I know the royal college is
concerned about the staffing levels. We had a submission from
Bliss, which says that over half of the neonatal units in Wales
don’t have enough staff to meet the minimum standards for
quality and safety. And I was very pleased, with another member of
the committee, Lynne Neagle, to visit the neonatal unit in the
Heath earlier this week. I wonder if you could clarify whether
it’s a shortage of staff being there to be employed, or who
could be recruited, in terms of both doctors and specialist nurses,
or whether it’s the absence of funding for those jobs that
causes the issue, because that seemed to be one of the crucial
issues.
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[252] Dr
Kunnath: A sub-regional neonatal unit is in the process of
being established in Glan Clwyd Hospital. Staffing has been
progressing, but there is also, of course, the number of minimum
cases they need to have to retain the expertise level. So, I think
that was the impediment in developing a tertiary neonatal centre.
So, at the moment, we are collaborating with the tertiary neonatal
set-up in England. How much staffing has been a problem, I’m
not sure.
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[253] Julie
Morgan: Could you tell me about the Heath, for example? You
don’t know about the staffing there.
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[254] Dr
Kunnath: No, I don’t.
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[255] Julie Morgan: No, because I was not clear,
after the visit, whether it was a lack of staff or a lack of
funding for posts that was the issue.
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|
[256] Dr
Kunnath: In the Glan Clwyd sub-regional unit, I think that
funding is available.
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[257] Julie
Morgan: Funding is available, right.
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|
[258] Dr
Kunnath: Yes. I can’t be quoted, because that’s
what my impression is, because they are trying to staff—.
But, from the nursing level, there has been a problem in
finding—
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|
[259] Julie
Morgan: Nursing level?
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|
[260] Dr
Kunnath: Yes.
|
|
[261] Julie Morgan: So, in terms of attracting
nurses to work in neonatal units, is that difficult to do,
then?
|
|
[262] Dr
Kunnath: It’s beyond my knowledge. I wouldn’t be
able to answer that.
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|
[263] Julie
Morgan: Right. Thank you very much.
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|
[264] Dai
Lloyd: Just following on from that, isn’t there an
element, as well, of mismatch of where the cots are? Just to be
sort of bold about it, it’s not just staffing or medical
recruitment, or nursing recruitment; it’s actually the
physical presence of cots. And, whether they’re paediatric
intensive care cots or special care cots, it’s the same cot;
it just depends how many nurses are around to staff it.
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[265] Dr
Kunnath: Yes, but there is an element of the number of the
high-risk deliveries to become class 1, because, to maintain a
minimum expertise level, you need a minimum number of high-risk
babies to be delivered in the unit. So, I don’t know if that
has been established or not—at the moment, the tertiary
centre is in Chester and there’s a sub-regional
unit—but this can be developed. And, even while developing
that, there is a debate, actually, that the high-risk deliveries in
Bangor have to be stopped and they have to be transported all the
way to Glan Clwyd Hospital. That was close enough for—. The
debate has been going on for some time but, at the moment, it has
established. Hopefully, it will flourish.
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[266] Dai
Lloyd: Okay. Jayne, you’ve got the last question.
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[267] Jayne
Bryant: Thank you, Chair. Do you think the shape of the
healthcare services should change to ensure there are sufficient
doctors to staff current and future hospital doctor rotas? I think
the RCPCH has made the case for whole-system change in paediatrics
with fewer and larger in-patient units providing
consultant-delivered care. Do you want to expand a bit on that and
perhaps Professor Lloyd could also come in?
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[268] Dr
Kunnath: That actually is a royal college policy, because,
especially for tertiary-level, high-quality care, that level of
concentration is needed. But translating that into the Welsh
context is a bit difficult because the population density is
dispersed. But, without that concentration, the expertise will not
be attained and that will impact the quality of care. But that will
be at the cost of the population needing to transfer, arranging
transport and so on. There should be a balance.
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[269] Jayne
Bryant: Yes, okay. Professor Lloyd.
|
|
[270] Professor
Lloyd: It’s an issue across all specialities, I think.
The current models of care are unsustainable and, from primary care
right through to tertiary and quaternary care, we need to have
different models of care. The settings in which it’s provided
and training need to alter to reflect that so we’re training
the people who can work in the community more. Hospitals are
generally best avoided if you can possibly do it. We will
need—the most difficult and complex care will need to
continue to be delivered in hospitals, but a lot should be
delivered in the community and home settings, but we need the
workforce in the right place with the right skills to do that.
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[271] Jayne
Bryant: Thank you.
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|
[272]
Dai Lloyd: Ocê, hapus? Unrhyw gwestiynau eraill? Na.
Pawb yn hapus. Felly, diolch yn fawr iawn ichi. Dyna ddiwedd y
sesiwn. Diolch am eich cyfraniadau ac am ateb y cwestiynau mewn
modd mor raenus ac mor aeddfed. Hefyd, diolch am y papurau y
gwnaethoch chi eu cyflwyno cyn y cyfarfod. Diolch yn fawr iawn am
hynny. Fe allaf bellach hefyd gyhoeddi y byddwch chi’n derbyn
trawsgrifiad o’r sesiwn yma jest i wirio fod popeth yn iawn.
Ond, gyda hynny, fe allaf gyhoeddi bod y sesiwn yma ar ben ac fe
allaf gyhoeddi i fy nghyd-Aelodau y cawn ni nawr egwyl am chwarter
awr. Felly, diolch yn fawr iawn i chi i gyd.
|
Dai Lloyd: Okay, happy? Any further
questions? No, everyone seems content. So, thank you very much.
That brings our session to a close. Thank you for your
contributions and for answering the questions in such a polished
and mature manner. Also, thank you for the papers that you prior to
the meeting. Thank you very much for that. May I also inform you
that you will receive a transcript of this session so you can check
it for accuracy? But, with those few words, can I announce that
this session is now at an end and tell my fellow Members that
we’ll take a quarter of an hour’s break? So, thank you
all very much.
|
|
[273]
Professor Lloyd:
Diolch yn fawr.
|
Professor Lloyd: Thank you very
much.
|
|
[274] Dr
Kunnath: Thank you.
|
|
Gohiriwyd y cyfarfod rhwng 11:23 a
11:41.
The meeting adjourned between 11:23 and 11:41.
|
|
Ymchwiliad i Recriwtio
Meddygol—Sesiwn Dystiolaeth 8—Byrddau Iechyd
Lleol
Inquiry into Medical Recruitment—Evidence
Session 8—Local Health Boards
|
|
[275]
Dai Lloyd: Croeso yn ôl i sesiwn ddiweddaraf Pwyllgor
Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad. O dan
eitem 4 ar ein hagenda'r bore yma, rydym ni’n parhau
efo’n hymchwiliad i recriwtio meddygol, a sesiwn dystiolaeth
rhif 8 y bore yma. O’n blaenau nawr, mae rhes o’r
tystion diweddaraf, sef cynrychiolwyr o fyrddau iechyd lleol.
Croeso i’r pump ohonoch chi.
|
Dai Lloyd: Welcome back to this latest
session of the Health, Social Care and Sport Committee here at the
National Assembly. Under item 4 of our agenda this morning, we
continue with our inquiry into medical recruitment. We move to
evidence session No. 8. Joining us now are our latest witnesses,
who are representatives of the local health boards. So, welcome to
all five of you.
|
|
[276]
Rydym ni wedi derbyn tystiolaeth
ysgrifenedig ymlaen llaw a diolch am hynny. Mae yna nifer o
gwestiynau wedi cael eu paratoi gerbron yn seiliedig ar y
dystiolaeth rydym ni wedi’i derbyn. Peidiwch â theimlo
o reidrwydd bod yn rhaid i bob un ohonoch ateb pob cwestiwn, ond,
wedi dweud hynny, a gaf i groesawu’n ffurfiol felly yr Athro
Peter Barrett-Lee, Ymddiriedolaeth GIG Felindre, Sharon Vickery,
Bwrdd Iechyd Lleol Prifysgol Abertawe Bro Morgannwg, Martin Jones,
Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr, Dr Evan Moore, Bwrdd
Iechyd Lleol Prifysgol Betsi Cadwaladr hefyd, a Dr Philip Kloer,
Bwrdd Iechyd Lleol Hywel Dda. Croeso i bob un ohonoch chi ac,
wedyn, heb fynd ymlaen ymhellach, awn ni’n syth i mewn i
gwestiynau, ac mae gan Julie Morgan y ddau gwestiwn
gyntaf.
|
We’ve received your written evidence and
I’d like to thank you for that. We have a number of questions
that have been based upon the evidence that we’ve received
from you. Don’t feel that each and every one of you has to
respond to every question, but, having said that, may I formally
welcome Professor Peter Barrett-Lee, Velindre NHS Trust, Sharon
Vickery, Abertawe Bro Morgannwg University Local Health Board,
Martin Jones, Betsi Cadwaladr University Health Board, Dr Evan
Moore, again, Betsi Cadwaladr University Local Health Board, and Dr
Philip Kloer, Hywel Dda Local Health Board? Welcome to all five of
you and, without further ado, we’ll move immediately to
questions, and Julie Morgan has the first questions.
|
|
[277]
Julie Morgan: Bore da. Really, it’s a general question to
start off with. How effective do you think the LHBs and the deanery
are in recruitment? Could you tell us if there is more flexibility
being used in planning jobs? Are consultants being more involved in
recruitment? What targeting is taking place about the way posts are
advertised? Is there collaboration between you as LHBs and trusts
to ensure that you make maximum use of those who are recruited? So,
that’s a whole range of things. Perhaps you could make a
comment about part of it.
|
|
[278]
Dai Lloyd: Whoever feels inspired to kick off.
|
|
[279]
Julie Morgan: Yes.
|
|
[280]
Mr Jones: I’ll start. It’s Martin Jones, director
of workforce from BCU. In terms of the effectiveness, I think
actually there’s a lot of close working between the deanery
and the health boards. I think there’s a joint interest to
ensure recruiting people through the training means, but there are
also, actually, issues about non-training doctors as well—so
the specialist doctors that are required for service work.
There’s a lot of work going on with the ‘Train. Work.
Live’ campaign to try to actually promote Wales as a unified
brand in terms of recruiting doctors and, in terms of collaborative
working with our consultants, there are many examples of
consultants actually bringing forward innovative ideas about
mountain medicine or the creation of year 3 foundation programmes
to try to actually encourage doctors to stay in Wales.
|
|
[281]
Julie Morgan: Thank you.
|
|
[282]
Dr Kloer: I’ll make a comment. Dr Phil Kloer, Hywel Dda
medical director. I think there is a very close working
relationship between the deanery and the health boards. The area
that I think ourselves and the deanery are exploring at the moment
is around rural health training, because many of the trainees tend
to spend most of their time in specialist centres, which means that
there’s less footfall of trainees in more rural hospitals
and, when trainees are in rural hospitals, they’re more
likely to stay there or come back in the future if they’ve
experienced that environment.
|
|
11:45
|
|
[283] Experience in the highlands has suggested that about
10 per cent of trainees, when asked, would like to
experience their career in the future in a rural environment, and
it’s important I think that we give that 10 per cent of
trainees that experience so that it captures their imagination and
inspires them to come back and work in that rural environment.
It’s important, though, that we’re able to provide the
level of training that they require, so we wouldn’t want to
reduce the quality of their training just by putting them in a
rural environment. So, it’s a conundrum for us, but I do
think we can make some steps on that in the future.
|
|
[284] Ms
Vickery: I think, from a structural perspective, we have an
all-Wales strategic medical workforce group, and there are a number
of representatives from the health boards, but also the deanery sit
on that group, and it’s looking at the strategic medical
workforce issues for Wales. So, the deanery is working hand in
glove with us, really. There’s a subgroup looking at
psychiatry, a subgroup looking at surgical services, a subgroup
looking at primary care. So, really, we’ve never worked so
closely most probably with the deanery on specific areas where we
know that we have problems.
|
|
[285] Dai
Lloyd: And Peter. You don’t have to touch the mike.
|
|
[286] Professor
Barrett-Lee: Thank you. Just to talk from the Velindre
perspective, particularly the cancer centre, I think it’s
really important to emphasise what trainee doctors are looking for.
They’re looking for a supportive environment and an
educational environment. Of course, they want to look after
patients and experience the service side, but I have a son
who’s a junior doctor and I know their main priority is a
supportive environment and their education. There’s a lot of
pressure on them to get a lot of things done in their training. So,
I think that’s why we have to work very closely with the
deanery and with our trainees, so that we understand exactly what
their needs are. We know what our needs are—they’re
both educating them and running a safe, reliable and excellent
service. We must understand that their main priority is their own
education. The deanery can help in always keeping that balance for
us. If you have excellent support and education for your trainees,
you will attract more, because the internet and their groups will
echo that message around. If you don’t, then that message
will be, ‘Be careful of this place; it’s not a
supportive environment’.
|
|
[287]
Julie Morgan: But you feel that closeness with the deanery. You
feel the closeness with deanery is there.
|
|
[288]
Professor Barrett-Lee:
I think it’s really helpful, and it
is there, and I echo what Sharon said, we’ve never worked so
closely together. We should have done earlier, but we are doing it
now and have been for several years.
|
|
[289]
Julie Morgan: Thank you. Dr Moore, any comments at all?
|
|
[290]
Dr Moore: From a Betsi point of view, we have an excellent
relationship with the deanery and work very hard with them to
understand what our essentially Cardiff-based students would need
in order to spend time in north Wales. And, when they come up to
us, the feedback that we get from them is absolutely excellent,
both directly and through the deanery. So, they recognise the good
training that we give. We’re working hard with them to make
that as attractive as possible for the junior doctors who come to
us, and we’re having good results with that and are pleased
with the relationship.
|
|
[291]
Julie Morgan: Thank you. There does appear to be a lack of clear
and accessible data on medical vacancies available in one place.
How do you think that can be addressed? Anybody got any
ideas?
|
|
[292]
Dr Moore: We certainly would know what vacancies we have, so
I’m not sure that I understand the question.
|
|
[293]
Julie Morgan: You don’t think that that is true, that
there’s not available in one place all the medical vacancies
that there are.
|
|
[294]
Dai Lloyd: We’ve had evidence that says that, basically,
it’d be nice to know all-Wales figures for the different
specialties of what the vacancies are and where they are. They may
well be collected on an individual health board basis, but where is
the all-Wales situation? I think that is the basic tenet; I
don’t know. Peter.
|
|
[295] Professor Barrett-Lee: We do receive regular updates at the medical
directors’ meeting from the deanery who come and produce
spreadsheets, both on where the vacancies are and where they may be
expected to be, so there’s always a projection as well,
because there’s a continual round every year, several times
every year, of recruitment. So, we do, I think—. And
then, individually, in our own organisations, of course, we know
exactly where those gaps are every day in real, live time.
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[296] Julie
Morgan: So, you don’t think this is much of an issue,
really.
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[297] Professor
Barrett-Lee: I don’t think the extent of the
problem, and knowing about it, is an issue. I think we know where
the problems are; it’s how we address them, I think.
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[298] Julie
Morgan: Thank you. Do you think enough effort is being made to
ensure that we have more students who live in Wales applying and
being admitted to Welsh medical schools?
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[299] Ms
Vickery: Most probably, the answer to that currently is
‘no.’ We know, from looking at statistics, that a few
years ago there were about 30 per cent Welsh-domiciled students,
but that’s fallen to about 10 per cent recently, and that
doesn’t compare well to some of the other UK countries. We
know that the evidence suggests that if they train in Wales, they
stay in Wales, and so, if you just go back to the structure that I
talked about earlier, the all-Wales strategic medical workforce
group, it’s just setting up another sub-group. It’s
another area that we want to explore around access and medical
sustainability, and that will very much be looking at how do we
work with schools to attract schoolchildren and school students to
be interested in medicine, to see it as a viable career, to prepare
them for entry into the medical schools, potentially working with
universities in Wales, as well. I think that group will toy with
the concept of can they set quotas and will that possibly breach
some elements of employment legislation. There’s all of that
work, then, to work through, but I think for you to take some
assurance, it’s on our agenda. It’s going to be
addressed, and I think it’s an important issue for us to
address.
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[300] Julie
Morgan: Why do you think the numbers have dropped?
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[301] Ms
Vickery: I don’t know whether—. Anecdotally,
I’ve heard that the entry criteria in some of the local
schools can be quite stiff, and people apply to study in Wales, but
perhaps they don’t get places and then they go abroad. Peter
was just talking earlier—his son applied for one university,
didn’t get in and then went to Southampton and has stayed in
England ever since. So, clearly, it’s something that we need
to grab hold of, and it’s going to be a fairly major plank of
work now, going forward.
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[302] Julie
Morgan: Because we’ve been given examples of outstanding
students who have been refused in Wales and then they’ve got
places in Cambridge—
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[303] Ms
Vickery: We need to unpick all of that.
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[304] Julie
Morgan: So, you’re going to look at all that?
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[305] Ms
Vickery: Yes, definitely.
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[306] Julie
Morgan: Thank you.
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[307] Dai
Lloyd: Philip and then Martin.
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[308] Dr Kloer:
I think this is a really critical point for us when thinking about
recruitment in Wales. I think there’s a question, certainly,
about the disparity between people with a Welsh postcode going to
our universities compared with the numbers in, say, Scotland and
England. We have very low numbers, as you’ve heard in
evidence before and in our submission. I think there would be a
variety of ways we could change that to help our residents get into
medical school. I think it would have a really big impact on the
likelihood of us being able to recruit to posts in the future.
There are thousands of applicants to our medical schools. The
bottleneck is clearly at the medical school level. As you go
further up the scale as medical doctors, there are fewer and fewer
applicants for posts until you get to consultants, where there
sometimes aren’t any applicants for a post. So, we know that
there’s an issue at the bottleneck at medical school.
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[309] I think
there’s a second question as to whether we’ve got the
number—which is related to the medical students—right
in Wales, and whether we’re actually training enough, because
to train fewer medical students than we actually need is an issue.
We know that medical students do leave Wales and we know there is a
small drop-out rate as well. So, it is inevitable that we will have
a medical workforce shortage unless we’re drawing in huge
numbers from other countries.
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[310] I think, also
related to this is how we attract people, not only into medicine,
but into all health and social care professions in our schools.
We’re the biggest employer, and do we raise the profile
enough of that in our schools and the fact that this is a really
worthwhile occupation to go into? Across the spectrum, we need
healthcare support workers, carers in the community, district
nurses—all of whom will be important, because whilst we need
doctors, we do need the whole team. So, I think there’s a lot
to this, but trying to somehow ensure that we get more
Welsh-domiciled students into medical school, I think, would be
quite a quick win for us.
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[311] Dai
Lloyd: Okay. Martin.
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[312] Mr Jones:
I just wanted to share some of the work that’s going on in
BCU through the undergraduate medical departments and through
consultants on their own initiative. I think there’s a range
of work going on, engaging with schools, particularly around the
medical agenda. There were four things that were shared with me by
the undergraduate department in Bangor: they’ve got work
going on with very young children about desensitising their
attitude towards hospital and healthcare; they’ve got school
roadshows going on in respect of people before they take their GCSE
examinations so that they’re choosing the right type of GCSEs
to support their journey onwards; they’re working with
Communities First groups to help people in particular communities
to see medicine as a particular career; they’ve got study
days that are going on for year 9 to year 13 pupils, including the
use of skills simulators; and they’ve got the Seren network
where they’re working with post-16 children—and
I’ve got examples from both Bangor and from Glan Clwyd where
they’re working with students to give them some exposure to
medicine and to have lectures on biological subjects that may help
them with their A-level examinations. They’re introducing
them to medical students already in the system so that they can
understand the application processes and how they can sharpen their
skills and presentation processes; and they’ve had sessions
with the coroner. So, I think there’s a lot of work going on.
I think the big investment there is the health service reaching out
into communities and into educational establishments to try to
ensure that pupils have got the best opportunity and the best
platform to compete in a competitive process of gaining a place in
medical school. One of the statistics that they particularly shared
with me, which I thought was interesting, is that 33 per cent of
applicants may actually get accepted for medicine, but of the
cohort who had been working with Bangor—in the 2015
cohort—68 per cent of those had been successful. So, I think
it shows—. There’s been a tremendous amount of energy,
enthusiasm and voluntary time given by clinicians to actually
support that programme.
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[313] Dai
Lloyd: Great. Julie, did you want to come back?
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[314] Julie
Morgan: Thank you. A final question: how much do you think
external factors will influence recruitment and doctors wanting to
come to Wales, such as the junior doctor contract in England and
Brexit?
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[315] Dai
Lloyd: Who wants to take on Brexit? There we
are—Sharon.
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[316] Ms
Vickery: [Inaudible.]—junior doctor contracts.
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[317] Dai
Lloyd: Oh, junior doctor contracts. There we are; another big
issue.
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[318] Ms
Vickery: In Wales we haven’t been completely idle in
terms of looking at the different contractual situation. Certainly
for the last 12 to 18 months we’ve been working with our
English counterparts whilst they’ve been going through their
fairly tortuous journey. We listened carefully. We’ve learned
a lot about the contract that’s in operation in England. They
advised us very strongly to sit and watch and learn whilst they
went through their journey. So, we know a lot about the contract.
We know a lot about the advantages and the disadvantages of that
particular contract. Certainly over the last 12 months
there’s been a lot of fairly detailed modelling that’s
been going on behind the scenes, working with some of the
intelligence that’s been given to us by England. Obviously,
I’m not a member of the Welsh Government, but I know that
I’m working with my Welsh Government colleagues, and
it’s fair to say that there’s a lot of consideration
going on currently in terms of what we do in Wales. I think
there’s a sense that we need to do something in Wales, but we
haven’t yet made any of those decisions. I think, in terms of
some of the intelligence that we picked up, that certain
specialties—because some of the premium that they pay in
England, and depending on the grade of the doctor—may be
better off than some of the doctors here; but that’s not
absolutely across the board. I think, for you to take some
assurance, that we’ve been looking, we’ve been learning
and there’s recognition that we need to be making some
decisions about what we’re doing in Wales.
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[319] Julie
Morgan: And do you think the lack of confrontation in Wales,
basically, has been a plus in terms of—?
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[320] Ms
Vickery: Definitely. We’ve heard from our junior doctor
colleagues, and from the BMA, that they were very pleased that the
Welsh Government didn’t decide to impose the contract as they
did in England. I think that’s a major selling point. Because
one of the major lessons that we were taught by England was that,
if Wales decides to implement that contract in that current format,
the only way that it will be implemented successfully is to have
positive junior doctor engagement. Without it, we would really,
really struggle to operate that contract. So, it is a big plus for
Wales.
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12:00
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[321] Dai
Lloyd: Okay, Martin, you had a—
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[322] Mr Jones:
It was on the question about the external factors and the
issue—. I mean, Brexit is one issue, but I think the big
question is that medical degrees are an international passport to
work anywhere across the world, and British doctors are in demand,
as are many other clinical specialties. Certainly, in some of the
analysis we’ve done, we have doctors from 55 different
countries working in the health board and they make up about 40 per
cent of our total medical workforce. About 8 per cent to 10 per
cent of that will be from Europe, with Ireland, Poland and Germany
being countries that are particularly represented there, but many
countries—Hungary. There are a lot from European countries
and very large numbers of individuals from India and Pakistan, and
they have served, actually, the Welsh health service enormously
well over many, many years. So, the real issue is actually about
how we ensure that the ongoing debate about what the position of
the UK may be in terms of immigration does not destabilise the
commitment of those people who have given many years’ service
to the health board. Certainly, I’ve been approached by
individuals to ask for assurance and we’re trying to provide
whatever assurance we can in a climate where we don’t yet
know the full details. What we do know is, actually, that we are
privileged to have doctors from all across the world providing
high-quality services to the patients and population that we serve,
and it’s important that we actually keep those people content
and work and support them properly.
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[323] Julie
Morgan: Would that be true of the other health boards and
trusts, that staff have needed reassurances, as far as
possible?
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[324] Dr Kloer:
Yes. Certainly, in Hywel Dda, I’ve had a number of EU doctors
asking me for similar reassurance. I suppose it’s in that
period where we’re unsure what the terms will be. It depends
on those terms. If the terms were that those doctors were no longer
able to work in our NHS, then that would be about 8 per cent to 10
per cent of our workforce that wouldn’t be there, and that
would give us an even greater problem. But, as has been stated,
it’s not just EU doctors; there are a lot of countries around
the world whose—. We have multinationals making up a large
proportion of our workforce. One of the factors that is important,
sometimes, is the delay in obtaining visas. That has had a
significant impact on us at times because there are a number of
steps to go through. So, anything that could be done to speed up
that process would be helpful. I think as part of Brexit also, our
regulators, such as the GMC and others, are going to have to work
out what their policies would be to EU nationals coming into our
country.
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[325] Dai
Lloyd: Okay. Rhun on this.
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[326] Rhun ap
Iorwerth: Yes, just on that point in particular, obviously, 10
years from now we’ll know what the implications are of
leaving the EU. The question is that we need doctors now and we
need doctors from the EU who are here now to stay and we need more
to come. Is that insecurity something short term that is of real
concern to you?
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[327] Dr Kloer:
I think the doctors that I’ve spoken to who currently work in
Wales are—. My interpretation of what they’ve said is
that they would be unlikely to leave. I think, as it stands at the
moment, the concern for me is that it’s difficult for them to
persuade their colleagues to now come. I think that’s the
issue with the uncertainty.
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[328] Ms
Vickery: Just to say that in ABM there has been some extensive
international recruitment over the last 18 months. We started with
Europe—so that’s just one thing to bear in
mind—and we’ve now got, probably, more EU doctors than
we would have had previously. So, that increases the risks for us.
But what we’ve now done, because of the uncertainty around
Brexit, is that we’ve moved our focus from Europe and
we’ve been to Dubai and to India.
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[329] Dai
Lloyd: Any excuse. [Laughter.]
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[330] Ms
Vickery: It’s fair to say that the quality of the Indian
doctors—. There’s been a recent initiative called
BAPIO where we’ve
worked with the royal colleges and gone out and we’ve—.
That’s another example of collaborative working. We went out
as Wales—as opposed to individual health boards—and we
were successful in recruiting 58 doctors. We could have recruited
more, had we had more vacancies in the right specialties. We had 93
who were eligible to be employed. So, the quality of doctors in
India was really, really, really good. But, just for you to be
aware, I suppose we are, almost implicitly, taking some of the
uncertainty around Brexit in order to drive some of our policy
around international recruitment.
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[331] Dai
Lloyd: Moving on: Caroline, you’ve got a couple of
questions now.
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[332] Caroline
Jones: Diolch, Chair. Yes. The committee has evidence about the
length of time it takes to recruit and appoint medical staff. What
do you think can be done to get more clinical ownership and
involvement in the recruitment process to help address this,
really?
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[333] Professor
Barrett-Lee: I’m not sure exactly if you mean the
process—the recruitment procedure—or if it’s more
about how we attract. I can answer both. One thing that I think
we’re all becoming more aware of, that we have a role—.
All of us who are medically qualified, but also anybody, really,
who works in the NHS, has a role in promoting Wales and the Wales
NHS when they’re outside of work. We think there may be some
negative messages out there, and we could counteract those in our
social interactions, probably, more—be more of a champion.
So, that’s one area.
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[334] I think the
other one is: there have been improvements to the actual
recruitment system lately, and that hopefully will help. It really
plays into what we’ve just heard from Phil. Because of safety
issues, and because of getting the right people and making sure
that all the things are done correctly, there are a lot of steps in
recruiting people. And we also have to remember that the recruitees
have a lot of choice nowadays, and we often find that we are let
down at the last minute by people withdrawing. I would say it is
quite an onerous task, to be involved in recruiting new members of
staff, and anything, again, anything we can do to streamline
it—. I do think medical engagement is important, because we
can keep that pressure on and say, ‘This is not just a
recruitment process; we actually need this person desperately, so
anything you can do to speed it up would help.’
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[335] Caroline
Jones: With regard to what you said about people withdrawing,
have you any idea what percentage of people withdraw, and do you
have an audit trail as to why?
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[336] Professor
Barrett-Lee: So, we are a small organisation compared to the
local health boards, and we haven’t kept, in the past,
detailed statistics on this. But I looked at the last two posts
that we were recruiting to, and some of the posts weren’t
completely permanent, and one aspect was the uncertainty over what
the contract meant, and it was aligned to getting mortgages. So, I
think that’s something we need to look at. Again, why
can’t we work, perhaps, with mortgage companies? Why
can’t the Welsh NHS engage with the financial sector and say,
‘Look; come on. You need to help us too’? And there
were a number, I know—. Sometimes it’s just simply that
they get another offer somewhere else. So, we haven’t done a
detailed analysis of that, and that may be something that’s
important as well.
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[337] Caroline
Jones: Okay. Thank you.
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[338] Dai
Lloyd: Martin, did you want to come in here?
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[339] Mr Jones:
I would comment on a number of those. Certainly, one thing the
health service did some time ago was to actually move to a shared
services partnership with back-office functions. That has tended to
mainly work for non-medical staff rather than for medical staff,
with the medical staffing function being quite a specialist area of
employment, but increasingly, there is work being done, more, on a
national basis on things like the GP trainee contracts. The GP
trainees are now actually hosted by one employer, rather than
actually multiple employers. Things like the DBS—the
Disclosure and Barring Service. Checks for doctors are now being
done through shared services, and shared services do have,
actually, quite an ability to analyse every step in the recruitment
process, and there’s ongoing work to try to actually reduce
the amount of time. I think the one thing—just thinking about
it as we were speaking—that is different is that, clearly,
across the UK there are different types of health organisations,
and in the English system with foundation trusts, they don’t
seem to be actually dependent on the same rules of, for example,
royal college advisers, and the amount of time it takes perhaps to
actually organise interview panels. So, I suppose that’s one
thing that we could continue to enter into debate with Welsh
Government on, about the regulations that we employ for consultant
appointment panels, for the advisory consultant panels, and whether
there’s anything that could be done to actually make them
easier to convene so that time isn’t lost relative to other
organisations that have less onerous arrangements for actually
putting panels together.
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[340] Dr Moore:
We certainly would have examples, especially at consultant level,
of people who—. So, when you come to the end of your
training, you have a certain period of time during which you need
to find a consultant post, and at the end of that you won’t
have a job. Obviously, there’s a pressure on people at that
point in their careers to get a job. And we certainly would be
aware of people who we were hoping to appoint and lining up panels
for, but due to various delays haven’t been nimble enough,
whilst more nimble organisations—. Some of the responsibility
for that obviously lies within the health board and they have been
able to appoint the person, and once they’re appointed,
they’re appointed often.
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[341] Dai
Lloyd: Sharon.
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[342] Ms
Vickery: Just really to be clear that, when we talk about
recruitment for doctors in training, then, obviously, the deanery
manage the recruitment there. So we don’t have a huge amount
of influence over that process except to say that we are looking.
Martin just talked about the Disclosure and Barring Service. There
is portability now with those checks, but it’s over a
three-year period, and we are looking now at extending the
portability of other pre-employment checks because junior doctors
find it really irksome that, when they rotate within
Wales—different employers—they’ve got to go back
through occupational health and those sorts of things. As Martin
and Peter said, there have even been some introductions of
different software and track systems; that’s helping to speed
the process up as well.
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[343] Dai
Lloyd: Good.
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[344] Caroline
Jones: And could you tell me if you think the health boards
have a clear idea of what the future medical workforce requirements
are, and what the target numbers for training places should be?
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[345] Dai
Lloyd: There we are. A starter for 10. [Laughter.]
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[346] Caroline
Jones: Don’t all rush at once.
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[347] Mr Jones:
I think that there are a number of things there. The strategic
medical workforce planning group has been doing work and has
commissioned external work to look at the number of doctors in
training, how the demography is changing in Wales, and how the need
for different specialties may change. So that work is going on. I
think the one thing that is often highlighted is that, with a
five-year undergraduate degree and then possibly nine to 12 years
for someone to qualify as a consultant, a lot of things can change
in that time. So there is work now going on to actually try to
bring the non-medical and the medical workforce planning into
closer alignment, and that will actually take place in forthcoming
years, because it is a multi-disciplinary team effort. There are
many different clinical specialties that are working alongside
doctors; there’s the development of physician associate
programmes, and actually how those contribute. So I think
it’s a continuing challenge. People are looking very
carefully at how society is changing, they’re looking at the
age profile of the workforce we have and what the attrition rates
are, but one thing I’m sure about is that, in 15 years’
time, things like the extent to which genomics and gene therapy and
that are going to be used will be different to what we can imagine.
We are endeavouring to plan based on what information we know, but
that is an imprecise science.
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[348] Dai
Lloyd: Thank you. Philip and then Peter.
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[349] Dr Kloer:
I would say that that’s quite a difficult question, I think.
And it depends how far into the future you look because we’ve
done some workforce modelling based on our current service models
in the all-Wales group, but, clearly, looking at the demographic of
the future, the over-85-year-olds, the amount of chronic disease,
dementia, frailty and end-of-life issues that we’re going to
have, and the fact that it’s all going to have to be very
much community facing, the fact that, in our area, if we continue
with the same model in primary care, we would need to recruit an
additional 82 GPs over the next few years because of retirements.
Clearly, it’s not going to be based all on medical doctors;
there’s going to be a multi-professional workforce. I think,
also, due to the advent of technology, at some stage we will have
an electronic clinical record. At some stage, our public will
increasingly have more access to their own records, and be able to
make many more decisions about their care. And the future
generation will not be happy to wait for ages; they will want to
get their information on their phones. So, I suppose, to actually
pinpoint exactly what the workforce model and the service model
will be is difficult, but I think we can make enough assumptions
that we do need to major on recruitment of a range of
specialities.
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12:15
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[350] We’re
clearly not recruiting—. There’s not enough supply of
doctors. Even for the future workforce, even with all those
changes, we will need more doctors, nurses and therapists in the
future.
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[351] Dai
Lloyd: Okay. Peter.
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[352] Professor
Barrett-Lee: Just really to echo those points but to add
another one. We’ve been looking at this with external
consultants with regard to transforming cancer services in
south-east Wales and the building of a new cancer centre.
It’s quite easy—relatively easy—to model the
workforce requirements in the future based on what we do now or
what we have done in the last few years, because we know what we do
now and we’ve got some figures. The big issue is: how do you
predict what healthcare looks like, say, in oncology, which is one
of the fastest moving fields? We’ve heard about genomics, but
there are lots of other developments as well. How do we predict
what it looks like in 10 years? I think that is difficult, but we
have to try and make a best guess because otherwise we become
paralysed, we can’t do it, we can’t think what’s
going to happen in the future, and then we do nothing. So, we have
to, I think, accept that it may not even be a science, really,
workforce planning; it may be an art. We just have to accept that
and do our best and get the best information we can, but accept
there are huge uncertainties.
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[353] Dai
Lloyd: Yes, good point. Moving on, Rhun, some of the issues
have been covered, I think.
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[354]
Rhun ap
Iorwerth: Mae ychydig o gwestiynau penodol gennyf i. Rwy’n meddwl
bod yna gytundeb yma ein bod ni eisiau gweld rhagor o israddedigion
yng Nghymru. Rydych chi wedi gwneud y pwynt hwnnw’n dda iawn.
A gaf i ofyn i’r tystion o’r gogledd—rwy’n
cymryd eich bod chi’n gefnogol iawn i ddatblygu addysg
feddygol yn y gogledd, ym Mangor, mwy na thebyg—beth yw eich
barn chi ynglŷn â’r tebygrwydd y gallwn ni symud
ymlaen efo hynny yn gyflym? Pa gryfhau a fydd angen ei wneud yn y
gogledd yn Ysbyty Gwynedd, er enghraifft, fel ysbyty dysgu, er mwyn
i hynny ddigwydd?
|
Rhun ap Iorwerth: Just afew specific questions
from me. I think there’s agreement here that we want to see
more undergraduates in Wales. You’ve made that point very
strongly. May I ask the witnesses from north Wales—I assume
that you’re supportive of the development of medical
education in north Wales, in Bangor, more than likely—what is
your view on the likelihood that we’ll be able to proceed
with that swiftly? What will need to be done in north Wales, in
Ysbyty Gwynedd, for example, as a teaching hospital, for that to
happen?
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[355] Dr Moore:
I very much welcome that question. I think that, if we look at the
issues that we have, and accepting that we don’t have enough
doctors in the UK, or in Wales for that matter, there really are
only two things that we can do to tackle that: one is to attract
more doctors in who’ve been trained elsewhere or, secondly,
to train more doctors ourselves.
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[356] One of the
points I wanted to make in the last question is that no matter how
many doctors we think we will need in 10 years’ time, to some
degree, the number that we will train for the next 10 years is
already set. So, the number of medical students that will churn out
over the next five years has already started and is already done
and is unalterable. The number of consultants or GPs that will
create is now set for the next 10 years. That’s done. I think
that’s a very important point to remember in all of this.
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[357] In terms of a
medical school in Bangor, which is the question that you asked us,
I think we would be very supportive of anything that increases the
supply of doctors to north Wales. There are a number of ways that
that could be achieved, and certainly a medical school in Bangor is
one of them.
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[358]
Rhun ap Iorwerth:
Can I just stop you before you carry on?
I chose my words fairly carefully in terms of developing medical
training in Bangor. I think a full-blown medical school is
something that we should have an eye on and we should aspire to,
but there are things that we could do far sooner than that in
having undergraduates in Bangor as part of a new community medical
training scheme over there.
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[359]
Dr Moore: Okay, so we’re very proud of the training that
we currently give at Gwynedd hospital. It’s received several
awards and has good outcomes. We have a good relationship with
Bangor University and some of the education that goes on there
we’re heavily involved with. Professor Williams, for example,
is an employee of ours and of the university—I know he was
here earlier in the week. We work very closely with them, offering
placements, offering education, offering what training we can. Is
that the sort of thing you’re asking me or am I missing the
point?
|
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[360]
Rhun ap Iorwerth:
Yes, but that’s already
happening.
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[361]
Dr Moore: It is.
|
|
[362]
Rhun ap Iorwerth:
What we need to do is move forward and
have undergraduates training and being Bangor-based medical
students.
|
|
[363] Mr Jones: Just
to clarify, we do have undergraduates in Bangor. They have tended
to be from year 4 of the training onwards—there have been,
actually, some expansions: we have people at year 3. I think the
aspiration that many people have is to ensure that we have more
people drawn into the Welsh medical education system from north
Wales. The numbers from Wales are relatively small. I think,
recognising that it’s an international currency and that
people can work out of anywhere in the world, if you’re
starting off with students who have a strong compass about working
in the communities from whence they came, even if they don’t
in the future—it’s a lot for 17-year-olds and
18-year-olds to plan their career all the way forward—and if
you’re starting with a greater number of people who are
predisposed to the idea of working within their local communities,
then the likelihood of people coming forward must be higher. So, I
think one of the big things must be about increasing the proportion
of people who are going through a Welsh medical education, who are
domiciled in Wales and who are Welsh-speaking, because to fulfil
that need as well—that’s going to be really, really
important.
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|
[364] I think,
actually, one of the things we’ve often found is a concern
that, if people start their medical education in different parts of
Wales and start building relationships and start actually getting
settled in communities, it’s always seen as a negative factor
in terms of people coming back to north Wales. So, we would be
really encouraged with anything that helps us increase the
proportion of Welsh medical students, who are drawn from Wales and
drawn from north Wales, who can have as much of their medical
education within north Wales at local hospitals and can maintain
the links with the community and can maintain their aspirations and
dreams for the future by working as a medical practitioner within
the communities from whence they came.
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|
[365]
Rhun ap Iorwerth:
Which is why it’s rather
frustrating when we hear of A-grade students failing to be given an
interview even for medical colleges in Wales—it’s a
story that we hear far too often. As a ‘yes’ or a
‘no’ or a nod or a shake of the head, or whatever, do
you think that any student in Wales who wants to study medicine in
Wales—any 16-year-old, 17-year-old or 18-year-old in
Wales—should expect to be able to be offered a place in
Wales?
|
|
[366]
Mr Jones: Rather than actually guarantee, I think what I would
like to see is a trajectory that shows an increasing proportion of
Welsh undergraduates who are drawn from Wales because I think it is
really important. It’s quite clear that the proportion of
people drawn from Wales are lower than other UK countries. We need
to address that. There are bilingual and linguistic skills that we
need to have and the cultural awareness, and I think increasing the
proportion of Welsh-domiciled students would help in those
respects.
|
|
[367]
Rhun ap Iorwerth:
Who’s going to go further than
that? [Laughter.]
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|
[368]
Caroline Jones:
Two. [Laughter.]
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|
[369]
Mr Lee: I’ll go a bit further. I’ll go further
and say that it would be good to see them actually get through to
the interview stage because I think to give them a chance to talk
about their experience of living and being born and brought up, or
whatever, in Wales and what they can bring to that local medical
school, because many of them—. I understand the
university’s problem; they get—. Medicine is a popular
choice and there are lots of applications. They have a screening
process, which is probably just based on academic achievement and a
school report. What if they were to build in the postcode as part
of that, and give those people a chance, at least at interview? I
don’t think we could guarantee someone a place, but we could
perhaps say that we would have a very low threshold or high
threshold, whichever way you put it, to interview Welsh
students.
|
|
[370]
Rhun ap Iorwerth:
It would be good if that was a
recommendation of this committee, I think.
|
|
[371]
Dr Kloer: I would just very, very strongly support that. I
think, yes, it’s not just academic achievement, of course,
that will get you into doing medicine, but I really strongly
support the fact that we get people to interview who have the right
grades and who have a Welsh postcode.
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|
[372]
Rhun ap Iorwerth:
And that’s an important thing to
remember—nobody is thinking of letting people in with lower
grades because you need people with high grades to be
doctors.
|
|
[373]
Moving on from that, the consensus on the
need to have more graduates coming through the system in
Wales—on recruiting people to then train in Wales, I know you
say that it’s the deanery and not yourselves directly, but
also on attracting people to work in Wales, who’ve already
trained, give us some ideas of the incentives that you think should
be explored more on a Wales-wide level—financial incentives,
paying training fees, or whatever it might be. I’ll invite
you to be as innovative as you like.
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|
[374] Dr Moore: I’m not sure that financial incentives
are the most important thing or even where you’d want to
focus your efforts. I think the efforts where we’ve certainly
seen results, certainly at Ysbyty Gwynedd, are around providing
training schemes that give the training that junior doctors
want—that give the breadth and touch their interests, as well
as making them feel at the end of it that they will actually be
prepared for the job that they want; some confidence in them
perhaps that there will actually be a job at the end of that that
won’t require another relocation of spouse and family around
the country; security around tenure of employment and the mortgage
implications that that has, and security of finances in doing that;
things that make the rotation easier to do, whether that be
geographical, so you’re not moving around quite so much, or
you’re in a modest area of movement for a period of time;
good support whilst you do the training; good access to trainers
and resources for those courses that are laid on; and time off work
or time off duties to attend those courses and to sit your exams,
and to study for those exams. So, I think it’s all those
things. And those are the things that we have had some successes
with and are proud of, and are trying very hard to do more
with.
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|
[375] Rhun ap
Iorwerth: Any of those that you mentioned there are things
that—I’ll give you an opportunity in a second. Are any
of those things that you mentioned there things that can be
developed in Wales to make Wales stand apart from other parts of
the UK that are also trying to recruit more people?
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|
[376] Dr Moore:
I don’t think developing those things in Wales is a new thing
or something that hasn’t been happening or isn’t
ongoing. I can think of the Train Work Live scheme or work where
you’d love to live—all those sorts of things have been
doing that, and we’ve been having good success with that in
the deanery. So, for example, being at all the BMJ fairs and
conventions, and representing Wales in a positive light has
achieved a lot of that. But it is the sort of thing that when you
get success with it, it’s worth redoubling your efforts and
putting more effort into it, because you know you’ll get the
dividend. Do you want to add anything to that, Martin?
|
|
[377] Mr Jones:
There is some work going on with incentives already, isn’t
there? Recently, Welsh Government have announced support for GP
trainees in areas where there’s a low percentage of take-up.
So, all areas in north Wales have been designated as falling within
that scheme, so that will then give people £2,000 towards
some skills training and give them £20,000 if they fulfil
their training in Wales and then stay for a year after.
You’ve got the nurse bursary, again, which is providing some
linkage for people to remain within Wales.
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|
[378] We’re
trying to promote the work environment, and it goes with the Train
Work Live. North Wales was identified in the top four in terms of
Lonely Planet’s interesting places to visit. So, we’re
trying to use and develop websites and materials that convey that
not only is it a good place to work, it’s also a good place
to live and bring up children and spend your life. So, we’re
working hard on that, and we’re just on the cusp now of
developing some websites that will carry that material and carry
that branding in north Wales, because it’s really
important.
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|
[379]
Rhun ap Iorwerth:
One of the problems identified by an
earlier witness today was that perhaps ‘good place to
live’ is an easy one to sell because of the natural
environment and what have you. The ‘good place to work’
is the one where we have a challenge, and the incentive there
surely is having that good-quality training—
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|
[380]
Mr Jones: I think particularly, though, it’s not uncommon
for professional individuals to be married or have partnerships
with other professional individuals. We’ve certainly been
able to recruit partners to north Wales, and creating that
opportunity for people to relocate as a family has been important.
We’re having discussions with the universities about what
opportunities there might be there, but I think there’s a
wider issue about the availability of quality jobs right across the
sectors, because people will not just come as a health
unit—they will have family members who will be working in
different parts of society as well. So, making sure that the
ambition that we all have for all parts of Wales—that we have
vibrant economies and vibrant opportunities for employment—is
important in terms of how we make ourselves attractive, because
people don’t locate as individuals—they quite often
relocate as family members.
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|
[381]
Dai Lloyd: Amser symud ymlaen, a’r
cwestiwn nesaf—
|
Dai
Lloyd: It is time to move on,
and the next question—
|
|
[382]
Rhun ap Iorwerth:
Roedd Peter
eisiau dod i mewn yn fanna.
|
Rhun ap
Iorwerth: Peter wanted to come
in there.
|
|
[383]
Dai Lloyd: Peter, sorry.
|
|
[384] Professor Barrett-Lee: I’ll be very quick. If you are known as a
department for having a low pass rate, then that’s a very big
disincentive for junior doctors. So, if you’ve got a high
pass rate, it’s a big incentive for them to come to
you. So, it’s really important to get your educational
support right, but that word gets out there as well, so everybody
will know what your pass rate is.
|
|
12:30
|
|
[385] Dai
Lloyd: Good point. Dawn.
|
|
[386] Dawn
Bowden: Thank you, Chair. I just wanted to pick up, really, on
the confed’s evidence around the changing shape of services,
and I know it’s something that’s been talked about for
a long time. The confed’s evidence talks about—
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|
[387] ‘it has
become increasingly clear that a transformation in the way
treatment is delivered is required’
|
|
[388] and it talks
about—
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|
[389] ‘A
sea-change in the way services are designed is vital’.
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|
[390] Can I see from
any of you, really, whether you think that we do need that sort of
change in the health service now in Wales, including, possibly,
service reconfiguration, which we’ve started and which has
stumbled in some areas? But would that in itself be sufficient to
deliver the additional numbers of medical staff that we need, or
are the two processes actually not connected?
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|
[391] Dr Kloer:
I think they’re definitely connected, and they will be one
really key factor. Going back to what I said earlier, looking at
the challenges that we’ll have in looking after the future
population, our services aren’t, at the moment, configured to
deal with the future demographic, the fact that we have higher
obesity rates, the fact that we will need to focus a lot more on
preventative and proactive care in communities and, certainly, our
GP practice, given the fact that it’s unlikely we’ll be
able to recruit, as it stands, as many GPs as we need with the
current model. As Evan said earlier, we’ve already fixed how
many medical staff will come out of medical schools. We will have
to have a multiprofessional model, and, in pockets, we can see
those models developing. In Kidwelly, we’ve completely
changed the model, where it isn’t so traditional, where you
go in and you’d see the GP first. Actually, you’re
rerouted to the physio when you have an issue, actually, that the
physio’s the best to deal with, or an advanced nurse
practitioner, or pharmacist or paramedic. Every professional has a
really key role to play. The doctor has, then, other roles. My
feeling would be, hopefully, certainly in primary care, instead of
us having the routine seven-to-10 minute appointment for every
single sort of circumstance when somebody comes to the GP practice,
actually, we have a longer time for the GP to spend with patients,
even though we may have fewer GPs, because the multiprofessional
team will be around them. But that does mean we need to be able to
recruit all those other multiprofessional staff. So, I think we can
see the future emerging in primary care.
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|
[392] I think in our
hospitals, trying to get access to specialist opinion, where
consultants are becoming more and more specialist, it’s
difficult for them to be in every single hospital across Wales. I
suspect that the future will make much better use of telehealth.
When you look at Kaiser Permanente, they have a default position
where nearly all their specialist opinion is undertaken via
telemedicine. If you have the right professional, not necessarily a
doctor, sitting next to the patient, they can access that
specialist opinion remotely, rather than taking a four-hour drive
to see a specialist for a relatively short period of time. I think
that will help us with our medical recruitment issues and reduce,
perhaps, or, for a time, help us with the shortfall of doctors that
we’ve got. But I don’t think it will be the only thing;
I think all the other factors are also important.
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|
[393] Dai
Lloyd: Martin.
|
|
[394] Mr Jones:
I just wanted to add to that and include the—obviously, your
interest today is actually around medical recruitment, but medics
make up just over 8 per cent of our workforce, so there is a huge
array of other clinical specialists. People who are looking to join
us in the future will have their mind’s eye on what their
work experience will be, what it’s going to be like working
for an organisation. Critically, that does actually reflect how
many peers and colleagues they have and, actually, how sustainable
the service is, so the question of sustainability and the question
of the extent to which we have robust medical teams, but also
robust multidisciplinary teams so that people can understand how
they can make a contribution, but in a sustainable way, so that
they’re not burnt-out, is really important.
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|
[395] So, that change
is—the NHS is littered with examples of where people are
pushing the boundaries and developing new skills. That goes all the
way up from healthcare support workers who are developing
additional roles all the way through the professional
groupings.
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|
[396] Dawn
Bowden: Can I just follow up on that? We hear quite a lot,
actually, about pockets of good practice where these things are
happening. To what extent are health boards actually sharing good
practice? I know one size doesn’t fit all—I understand
that—but if something is working really well in one area, we
don’t seem to see that replicated as a matter of course in
other areas. It seems like everybody has to go through the same
process of identifying their little pilots and pockets of good
practice.
|
|
[397] Mr Jones:
I think that there are a number of contributions trying to change
that. There are Bevan exemplars, there are staff achievement
awards, there are union achievement awards, which are celebrating
success. I think some of that is about promoting what’s going
on and sharing it. We’ve recently introduced a new award in
Betsi Cadwaladr University Local Health Board, the Seren Betsi
Star, which is about celebrating individual contributions, where
peers have nominated people. So, I think it’s about creating
a virtuous circle and promoting examples of good-news stories.
There are a lot of good things going on.
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|
[398] Dai
Lloyd: Okay. Philip.
|
|
[399] Dr Kloer:
Yes. I think there are a number of ways that we do share our
practice. I think the question could be, ‘Why haven’t
we implemented that model across our own health board, where
we’re very aware of it?’ There is some winning of
hearts and minds, because the clinicians are trying to get used to
the fact of a different way of working, where patients are routed
directly to physiotherapy or a pharmacist, and understanding that,
and also for our public to get used to the fact that, actually,
you’ve had a really valuable opinion if you haven’t
seen the medical practitioner. In fact, sometimes, actually that
person was much better for the situation that you’ve come to
the surgery for. So, there’s winning hearts and minds, both
in our staff and in the public, that we need to do over the next
few years.
|
|
[400] Dawn
Bowden: And that’s not easy to do.
|
|
[401] Dr Kloer:
No.
|
|
[402] Dawn
Bowden: All right. Thank you very much.
|
|
[403] Dai
Lloyd: Okay. Turning to primary care—Jayne.
|
|
[404] Jayne
Bryant: Yes, thank you, Chair. I was going to focus on primary
care. You’ve given some examples, but perhaps you can expand
on what role health boards play in trying to attract more doctors
to work in primary care.
|
|
[405] Dai
Lloyd: Martin.
|
|
[406] Mr Jones:
I’ll give this as an example. Obviously, it’s becoming
a mixed economy in the sense that we still have general
practitioners working under the GMS contract. We actually celebrate
that. We are certainly not looking to move away from that model. We
have had some examples, though, where the health board has actually
introduced managed practices where we employ the staff ourselves.
We’ve got schemes in north Wales now—the outstanding GP
programme—where we know that general practitioners who are
completing their training don’t always feel confident about
making that step into practising fully. We have been running a
programme for a number of years now, where we’re actually
providing some additional support to people at the end of their
training with a view to try to encourage people to come to north
Wales. But, again, the same question there is that, actually,
it’s not just about the medical practitioners and that model;
it’s about creating a whole range of different healthcare
professionals that can contribute. So, in Prestatyn, for example,
we’ve recently taken on the responsibility for GP services as
an employed model, where we’re engaging a whole range of
different clinicians and supporting that.
|
|
[407] Jayne
Bryant: And that’s been successful so far.
|
|
[408] Mr Jones:
It has been successful. There are still some challenges. There are
some differences in the way that we’re currently exploring
the differences between the rates of remuneration for a salaried GP
as opposed to a consultant or somebody else in the normal
workforce, because there is a discrepancy between the two. It
appears that there are a number of clinicians who are content
working as locums as opposed to in full-time positions. It’s
a career choice for some individuals at the moment. So, I think
there are a number of things we’re trying to do in terms of
pay rates, opportunities and training opportunities. There are
changes coming through in terms of taxation, with the IR35
that’s coming through about the status of people to actually
work as limited companies now. That may change things again to the
future. So, we’re working continuously to try to ensure that
we have creative models and welcome people into primary care within
north Wales.
|
|
[409] Jayne
Bryant: You were saying that there are creative models. Is
everybody else aware of those throughout Wales, or do you know much
about other good examples?
|
|
[410] Mr Jones:
I think there are a number of forums that exist. Each of the
directors of the health boards has peer groups. So, there are those
opportunities where people do exchange information. I think there
can always be improvements in terms of the extent to which people
are sharing, actually, what’s going on on the ground. But
again, I think it’s actually getting back to what I mentioned
earlier—it’s about creating those opportunities to
celebrate success and actually positively promote what NHS Wales is
achieving.
|
|
[411] Jayne
Bryant: And what are your views about opening up more GP work
opportunities for post-foundation-year doctors? Does anyone else
have any opinions?
|
|
[412] Dai
Lloyd: Philip.
|
|
[413] Dr Kloer:
I think there’s no doubt that increased footfall in general
practices is likely to increase the number of doctors who’d
think of a career in primary care, in the same way that increased
footfall in Hywel Dda university health board will increase the
likelihood that we’ll get people coming to work with us. So,
I think it’s important to make sure that, where we’ve
got practices, or areas where we’ve got difficulties in GP
recruitment, that we do get doctors in at a relatively early stage
in their career to come and experience those GP practice areas. So,
I would certainly support that. Just going back to your other
point, I think the future of GPs—. We have to recognise that
the GPs coming out of training now are less likely to want to take
on a partnership, they’re nervous about that in the current
climate for all sorts of reasons, and we have to look at other
options for them. So, we’re looking at portfolio careers,
where GPs can do some GP work but can do some other work with us,
either in the community or in the hospital, because there’s
plenty of value that they can give in those areas as well.
|
|
[414] Jayne
Bryant: Great, thank you. We’ve had some conflicting
issues around a sort of indemnity. Do you think it’s
impacting on the ability to recruit new doctors into primary
care?
|
|
[415] Dai
Lloyd: The cost of indemnity.
|
|
[416] Jayne
Bryant: The cost of indemnity, yes.
|
|
[417] Dr Kloer:
It’s certainly something that gets raised with me very
regularly, the high cost of primary care GP indemnity. Certainly,
the indemnity to work in primary care is much more than for a
hospital doctor, from what I’ve been quoted. So, I do think
it’s a real issue. I think it’s actually sometimes an
issue at the end of people’s careers, because people think at
a certain point in their career, ‘Is there any point in
paying that much indemnity for the money I’m getting?’,
because it’s eroding into their salary. So, I think
it’s more of a factor, actually, at that end of the
career.
|
|
[418] Jayne
Bryant: Thank you.
|
|
[419] Ms
Vickery: I suppose just a few statistics, really, from me. In
preparation for today—structurally within ABM we actually
created a whole delivery unit just looking at primary and community
services—I spoke to our unit medical director for primary
care. He said that his wish list really—he’s fairly new
in post—would be to have an appropriate range of incentives,
and he was definitely very clear about having indemnity paid for
all the people working within primary care. I don’t know
whether you’re aware, but currently all GP trainees, in terms
of these cohorts, during their training have their indemnity paid
as part of their incentives. Again, just picking up on some of the
things that have been mentioned, in the BMJ careers fair last
October the emphasis was on GP recruitment from Welsh Government.
Now, it’s almost impossible to prove a causal relationship
between incentives and the increase in the number of applicants,
but, after round one, there is a 19 per cent increase in the number
of doctors now applying for GP training in Wales. So, just a few
statistics for you to think about there, okay.
|
|
[420] Dai
Lloyd: Okay, good. Time for the last question, and it’s
Dawn.
|
|
[421] Dawn
Bowden: Yes, it’s just to follow on from that, really,
still on GPs. It’s just a quick question about whether local
health boards can clarify how the Welsh Government funding provided
for GP clusters has been spent, and what impact that’s
had.
|
|
[422] Dai
Lloyd: GP clusters—early days, not enough dosh.
|
|
[423] Dawn
Bowden: Too early to tell?
|
|
[424] Dai
Lloyd: Philip, or Mark.
|
|
[425] Mr Jones:
I can’t clarify the issue about the funding arrangements. I
don’t have the have the details to do that; we’d have
to actually submit something outside, I think, if there was a
specific question on that.
|
|
[426] Dawn
Bowden: That’s fine.
|
|
[427] Dai
Lloyd: Okay. Philip.
|
|
[428] Dr Kloer:
I think it’s early days, but it’s been really helpful
to have GP leaders who have money that they can prioritise for the
needs of their local population, because, when you look across the
world, the general feeling from the King’s Fund is that you
should consider need based on about 30,000 to 60,000
population.
|
|
12:45
|
|
[429] Two of our
clusters, just to mention them—one of them is looking at
pre-diabetic care. It’s early days to see the full evaluation
on that, but the feeling is that we’ve been able to target
things that we wouldn’t ordinarily have previously targeted.
Another area is to invest in some software that allows us to risk
stratify our population in Carmarthenshire, where we have 700 Stay
Well plans for those people in the population who are likely to
become unwell at some stage, and then there’s a really clear
escalation plan for when they do become unwell. So, it has allowed
us, I think, to do that sort of innovation in our clusters, which,
for the local population, is really important. But yes, it’s
a relatively small amount of money, and it’s early days.
|
|
[430] Dai
Lloyd: Julie, you had a question, to finish off.
|
|
[431] Julie
Morgan: I just wanted to ask for a bit information, going back
to the discussion. The BAPIO initiative seems a tremendous
initiative. How long do the doctors stay here, and what are the
arrangements?
|
|
[432] Ms
Vickery: They come in at tier 5, and so there has to be
liaison—an agreement with the royal college and the deanery.
They had all of that all sorted. They can only stay with us for two
years. If you go back to the all-Wales strategic workforce group,
there is a medical training initiative/BAPIO sub-group actually
reporting into that group, so they were the people who planned the
event, and, as I say, it’s collaborative across
Wales—we all work together. I think I alluded to it earlier
that a number of our consultants, obviously, went out to interview,
and they were staggered by the quality of the candidates out
there.
|
|
[433] What we’ve
been very clear about with all of the health boards—and the
BAPIO sub-group is continuing to do a piece of work around this,
and around evaluation, in terms of this particular trip—is
that if we get this right, it could establish a new training
pipeline for Wales, and, anecdotally, some of the consultants
actually said if we got this right, we could solve some of the
recruitment problems for Wales, or we could solve the recruitment
problem for Wales. So, how we treat those doctors, how we plan
their training, their experience with us, is absolutely critical.
And I think, in terms of the employers confederation evidence, it
sort of alludes to the fact that, actually, increasingly, there are
different generational issues here coming into play, and how we
treat doctors, how they’re valued, some of the values and
behaviours that they see in organisations, sometimes play out in
the GMC survey. And increasingly, if we don’t treat those
doctors properly and they don’t feel they’ve had a good
experience, then clearly they’re not going to tell their
colleagues then to come, and that pipeline will dry up. And that is
absolutely key to taking to the BAPIO scheme forward.
|
|
[434] Dai
Lloyd: Grêt. Diolch yn
fawr. Mae amser y sesiwn ar ben. Diolch yn fawr iawn i chi am eich
atebion dwys, manwl, doeth—a phob ansoddair arall: aeddfed,
graenus. Diolch yn fawr iawn i chi. Gallaf i bellach gyhoeddi y
bydd yna drawsgrifiad o’r sesiwn yma yn cael ei gyflwyno i
chi er mwyn i chi ei wirio fe, fel ei fod yn ffeithiol gywir. Ond
gyda hynny o eiriau, a allaf i ddiolch unwaith eto i chi am eich
presenoldeb? Diolch yn fawr iawn i chi. Ac fe allaf i gyhoeddi
i’m cyd-Aelodau fod yna doriad am ychydig ginio nawr, ac fe
fyddwn ni nôl yn brydlon am 13:30. Diolch yn fawr.
|
Dai Lloyd: Great. Thank you very much.
Our time is up. Thank you very much for your comprehensive,
detailed and wise answers—and many other adjectives that
apply: mature, polished. Thank you very much. May I now just inform
you that there will be a transcript of this session sent to you so
that you can check it for factual accuracy? But with those few
words, may I thank you once again for your attendance? Thank you.
And may I just inform fellow Members that we will now break for
lunch, and we will return at 13:30? Thank you.
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|
Gohiriwyd y cyfarfod rhwng 12:48 a
13:31.
The
meeting adjourned between 12:48 and 13:31.
|
|
Ymchwiliad i Recriwtio
Meddygol—Sesiwn Dystiolaeth 9—Deoniaeth
Cymru
Inquiry into Medical Recruitment—Evidence Session
9—Wales Deanery
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|
[435]
Dai Lloyd: Croeso i sesiwn prynhawn y Pwyllgor Iechyd,
Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol
Cymru. Rydym ni’n symud ymlaen rŵan i eitem 5, â
pharhad i’n hymchwiliad ni i recriwtio meddygol. Hon ydy
sesiwn dystiolaeth rhif 9.
|
Dai Lloyd: Welcome to this
afternoon’s session of the Health, Social Care and Sports
Committee here at the National Assembly for Wales. We’re
moving on to item 5 and the continuation of our inquiry into
medical recruitment. This is the ninth evidence session.
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|
[436]
O’n blaenau ni’r prynhawn
yma mae cynrychiolaeth o Ddeoniaeth Cymru. Croeso i’r tri
ohonoch chi. Fel rydw i wedi ei ddweud eisoes, rydym ni wedi cael
tair sesiwn eisoes y bore yma ar yr un pwnc. Hon ydy’r nawfed
sesiwn dystiolaeth, i gyd ar recriwtio meddygol.
|
Before us today we have representatives from
the Wales Deanery. Welcome to the three of you. As I’ve
already said, we have had three sessions already today as part of
the same inquiry. This is the ninth evidence session on medical
recruitment.
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|
[437]
Felly, o’n blaenau ni
mae’r Athro Peter Donnelly, deon astudio ôl-raddedig
dros dro, Dr Phil Matthews, dirprwy gyfarwyddwr meddygaeth teulu a
phennaeth yr ysgol hyfforddiant arbenigol ar gyfer meddygaeth
teulu, a hefyd Dr Helen Baker, cyfarwyddwr cyswllt gofal
eilaidd.
|
So, we have Professor Peter Donnelly, interim
postgraduate dean, Dr Phil Matthews, deputy director of general
practice and head of the specialty training school for general
practice, and also Dr Helen Baker, associate director for secondary
care.
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|
[438]
Rydym ni wedi derbyn tystiolaeth
ysgrifenedig ac, yn naturiol, mae fy nghyd-Aelodau wedi darllen pob
gair mewn manylder aruthrol ac mae gyda ni gwestiynau wedi’u
seilio ar hynny i gyd. Felly, gyda’ch caniatâd, fe awn
ni’n syth i mewn i gwestiynau, felly. Mae’r ddau
gwestiwn cyntaf o dan ofal Dawn Bowden.
|
We have received written evidence and,
naturally, my fellow Members will have read every word of that in
great detail and we have questions based on that evidence. So, with
your permission, we’ll go straight to questions. The first
two questions come from Dawn Bowden.
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|
[439] Dawn
Bowden: Thank you, Chair. Good afternoon. For the purpose of
the record, as much as anything else, and for my benefit, can you
just explain in a bit more detail what the deanery’s role is,
especially in supporting effective medical recruitment and
retention?
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|
[440] Professor
Donnelly: Yes. Perhaps if I—. If it would help if I
described the role of the deanery and the constructs around it and
some of our activities and responsibilities—so, the Wales
Deanery is a single deanery for the whole of Wales. We are directly
commissioned by Welsh Government and our remit is around medical
and dental training. So, it is a narrow remit, but that is it.
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|
[441] In essence,
there are a number of obligations that we’re given each year
by Welsh Government. Central to our activities and our deliverables
is the quality management of training programmes across all
specialties in Wales. That is dictated by, and we’re
accountable to, the regulators. Primarily, that’s the GMC,
the General Medical Council, who have set standards for medical
undergrad and postgrad training across the UK, but also the GDC,
for dental training.
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[442] In addition to
that, one of our responsibilities is the management of those
training programmes as well as the commission and allocation of
training posts across Wales. Now we do an awful lot more—what
we describe kind of around that—in terms of support,
including recruitment and, I think, importantly, retention. I think
that’s been a focus for us: what’s the product that
Wales is offering in terms of medical and dental training?
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[443] We can recruit
and have—the recruitment campaign that we’ve been
involved with recently is very positive. But, actually, it’s
about retention and what is the experience within each of those
health boards, within each department, within each general
practice, and this generation of trainees has a very precise
specification in terms of requiring high levels—and they
should require this—of supervision, a positive learning
experience, as well as more of a focus on work/life balance, which
I think we all recognise within this generation. So, that’s a
kind of summary of where our roles are.
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[444] Dawn
Bowden: And what would your assessment be of, in general terms,
how effective you’ve been as an organisation in achieving
those aims?
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[445] Professor
Donnelly: If I perhaps focus on the quality management, because
that is a core activity, our quality management process is
regulated, in essence, by the GMC, and I think the feedback
we’ve had from the GMC over a number of years is that we are
described as an exemplar in terms of risk-based escalation process,
which, essentially, means that we triangulate data from various
sources, including the trainee GMC survey, plus health boards, and
then work with health boards. So, a lot of our work is working with
health boards and general practices to address any training issues
that arise so that we can nip those in the bud and we can move on
very quickly so that trainees get a positive experience.
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|
[446] In terms of
recruitment, we’re part of that all-Wales recruitment process
and have been for a number of years. A number of things that
we’ve introduced, I think, have helped. One in particular is
the education contract, which is a contract between the
trainee—each trainee in Wales—the local education
provider, which, in Wales, is the health board trust, the medical
director and clinical director level, and ourselves. So, it’s
a kind of tripartite education agreement. What that means for
trainees is that they are empowered to feed into us on a live
basis, if there are any issues around training, which we can work
on quickly with the health boards and practices to rectify so that
the trainees see that we’re actually managing that, and
actively managing it.
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|
[447] Dawn
Bowden: Okay. In terms of the recruitment processes themselves,
do you have a view on whether the LHBs perhaps try to take on too
much themselves locally and whether maybe it’d be better if
there were more of a national approach to that. What’s your
view on that?
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[448] Professor
Donnelly: I guess you do need to separate, or we need to
separate out, recruitment of trainees, which, typically, is
administered by royal colleges centrally, so, there’s
national recruitment, as opposed to the recruitment of
so-called—so-called—non-training grades within health
boards, which each health board will do individually. I think there
is an argument and we’ve had many conversations—. In
fact, we’ve just come from a conversation with a health
board, where, clearly, if there was a more co-ordinated approach
across those health boards in terms of recruitment to non-training,
i.e., there was less of a feel of competition between the health
boards, then Wales would be better served and I think a flow of
service provision—. I guess that—
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[449] Dawn
Bowden: A more joined-up approach, really.
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[450] Professor
Donnelly: Yes, I think that more collaborative approach,
yes.
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|
[451] Dawn
Bowden: Just one final question, Chair, if I may: do you have
any clear idea of the factors that might make doctors want to stay
and train and work in Wales—what might be the factors that
would keep them here?
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[452] Professor
Donnelly: Helen, if you perhaps would want to talk on that.
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|
[453] Dr Baker:
We know from various evidence sources that geography, and trainees
who have built roots and established roots in a particular area, is
one of the key factors to their decision making in terms of their
recruitment. We’ve recently—because we’re in the
middle of our recruitment round at the moment—run a survey of
all of those trainees coming to interview with us to find out
exactly what are those key factors, and the vast majority have
indicated that it’s important that they’ve got
somewhere where their friends are, their family is, and it’s
a geographical location that is known to them.
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|
[454] Second to that,
then, is the quality of training that is on offer and that is the
second factor that they will look at. They’re also looking
for opportunities to enhance their training and enhance their
knowledge and understanding. So, a lot of trainees want experience
of research opportunities, which we deliver within the Welsh
Deanery through our Welsh clinical academic track programme and
other programmes that we’ve got.
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|
[455] They also want
increased opportunities to undertake and gain teaching
qualifications. We’ve got a number of fellowship programmes
that are run with the health boards in terms of delivering that,
but that is something that we’re working on at the moment,
and we want to develop further. So, those are additional incentives
and areas that they’d like us to focus on in their
training.
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|
[456] Dawn
Bowden: Did you find—is it generally families or people
that are in relationships, partnerships, that tend to want to stay
here and stay together? Because I was explaining to the Chair
earlier on that I was talking to a number of students thinking of
going into medicine recently in my constituency. They were all
young single men and women, 18, 19 years old, who couldn’t
wait to get out. They’d spent their whole lives in Merthyr
Tydfil. They wanted to go and see the big, wide world. So,
it’s that kind of wanting to keep people here, but
there’s an incentive for them to go out and see the big, wide
world, isn’t there?
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|
[457] Professor
Donnelly: Yes, perhaps—[Inaudible.]—I had
the same conversation with some medical students in Cardiff uni
just last week, really, where there were some Welsh-domiciled, who
said, ‘I’ve been here all of my life; I want to go
somewhere else’. And, of course, I was saying, ‘And
you’re going to come back, aren’t you?’ And I
think that’s where we need to set the conditions, whereby we
want them to go out, actually, because that cross-fertilisation is
so important within health. We’re talking about medicine
here, but, actually, it’s important across health. So, I do
think that, as Helen was saying, there’s a whole range of
issues in terms of Welsh-domiciled and Welsh people going to
medical schools, but really it’s a numbers game in part, but
it’s also about the quality of training, the quality of
lifestyle. But then we have to remember that if you’re a
school-leaver medical student, when you qualify you’re 23,
24, and they are a different generation, they do have different
expectations, and that work-life balance, which is real. As someone
who trained in Powys for three years—and they had to prise me
out of Powys, because I would have stayed there—I would go,
‘Well, why wouldn’t you want to work there?’, but
I’m of a different generation. So, I think it’s in
Wales—across the UK this is in an issue, but I think, in
Wales, the trick for us is marketing, marketing the product but
making sure that that product is as fit for purpose, in fact,
fitter for purpose, i.e. that we provide what we call the
‘curriculum plus’. We have the curriculum, which is
very clinically orientated, but we need to wrap around that those
other experiences to make them fit for purpose to be a GP or a
consultant, or—. And I think that’s the trick for us to
get that, because we are—I use the words ‘in
competition’ with England, but what I mean by that is that
our general flow, if we lose trainees at whatever level, it’s
into England. There’s fewer to Scotland and fewer to Northern
Ireland, and we are losing some abroad, et cetera, or to career
breaks, but it’s generally that flow. So, I think it’s
us positioning ourselves so that we’re able to maximise the
opportunities. And I think that will require a cultural shift in
terms of just the interaction of the education providers, the
health boards and, say, ourselves and the GMC. It’s about
that prioritisation of training as a solution for wider
recruitment. If we can get the training right and that positive
experience, it’s such a positive benefit across the piste,
really.
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|
[458] Dawn
Bowden: Thank you. Thank you, Chair.
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[459]
Dai Lloyd: Y cwestiynau nesaf gan Julie Morgan.
|
Dai Lloyd: The next questions are from
Julie Morgan.
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[460]
Julie Morgan: To carry on with the issue about the Welsh-domiciled
students and the fact that we understand that the number at medical
school in Wales has actually fallen, I don’t know if you
could give us any reason for that.
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[461]
Professor Donnelly:
Obviously, our remit is outside of the
medical school remit, but I guess we would have a view. I do think
this is quite a complex issue, and I think you probably have to
start with the pathway of individuals from schools, and the
approach of careers advisers in schools and the approach of
teachers, and that kind of expectation. And, actually, I think it
is about understanding of the health agenda. I’m aware of
individuals, family members, who have been in school in Wales who
ask me advice about medicine, and they clearly haven’t been
given perhaps the most accurate advice. So, I think there is an
opportunity, if we think of this pathway, of us, of
Wales—when I say ‘us’, I mean Wales—having
a co-ordinated approach to informing schools, both the teachers,
the headteachers, careers advisers and the students, about careers
in health, not just medicine.
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|
13:45
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|
[462] We have had conversations recently about—.
Well, we have a whole range of simulated health facilities across
Wales, some superb simulated hospitals, and, of course,
through August, the real, unsimulated hospitals are quieter and
there would be an opportunity for us not to just do roadshows, but
to get schoolchildren in to rehearse, practice and
play—because learning through play is very important, within,
sort of, summer schools, for example. So, a health NHS Wales summer
school for schoolchildren and for the teachers, et cetera, to pull
in.
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[463] I think if you
then move to the selection process for medical schools, and I think
we’d be the first to say we’re not directly involved
and wouldn’t understand that completely, there has been a
move in both medical schools to, for example, increase the
opportunity for learning a range of modules in Welsh, and I think
that’s been a very positive step. I think the next step is to
look at the selection entry criteria and how we can steer that
target or whatever, but steer that towards enabling Welsh-domiciled
students and Welsh speakers to come in.
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[464] Having said
that, I think there’s almost a leap of faith with this. I
think our view—actually, I’m speaking for myself now,
so my personal view would be we do need to do that. It’s very
difficult with a multifactorial environment for us to test that in
a controlled sense, but it does seem intuitively the right thing to
do. But, having said that, a medical student said to me this week,
‘I’ve been here all my life, I want to leave and come
back.’ So, it’s complex, but I think it would be a step
in the right direction.
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[465] Julie
Morgan: We do hear a lot of examples—they are anecdotal,
but a lot of anecdotal evidence—of Welsh students who want to
go to medical school here and seem to have outstanding grades and
who may be living in places where, say, coming to Cardiff would be
a great move forward in the great wide world, and who don’t
get in. As we said, the percentage of those students seems to be
shrinking in the medical schools. So, it does seem that you are
saying, really, that perhaps we ought to look at some form of
mechanism to ensure that there is sort of a group where the issues
of Welsh speaking or Welsh domiciled could be considered.
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[466] Professor
Donnelly: Yes. I think the anecdote is repeated, and it
isn’t a criticism of the medical schools where—in fact,
anything we’re saying isn’t really criticism;
it’s more observation. But I would be aware that there are
very—well, actually, I’m not aware of any schools
within Wales—I don’t know every school,
clearly—that would provide coaching, for want of a better
word, to practice the selection process into medical school. So,
just having the grades isn’t enough. There is a quite complex
selection process, and I think the interview process, and a number
of us have been involved in both schools, does require—or
your performance is likely to be better if you’ve practised
or rehearsed with folk who understand the system.
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[467] Dai
Lloyd: On that point, Rhun.
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[468]
Rhun ap Iorwerth:
Should the grades be enough for a
Welsh-domiciled student who wants to study in Wales to actually get
an interview? I understand that the selection process is much more
complex than that, but if you actually live in Wales, you should
get to the interview stage if you have the right grades, no matter
how badly you’d filled in your application form.
[Laughter.]
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[469] Professor Donnelly: It’s an
interesting question. I think, because of your caveat at the end, I
would argue in terms of any standardised selection process that,
really, for a level of fairness, then, I guess all of the medical
schools across the UK would say what they will try and do is be
fair, but what they are looking for are certain criteria that they
would argue provide evidence for the individual being able to
progress through what is one of the most difficult undergrad
programmes—very intense, particularly once you hit the
clinical arena. It’s a particular skill set. So, in fact, as
I’m thinking through it, the clinician in me would argue,
‘Actually, the grades themselves aren’t
just—’
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[470]
Rhun ap Iorwerth:
I appreciate that, but should there be an
effort to prod that young person a bit further to see,
‘Actually, we need to make sure that you are not suitable to
come to medical school’?
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[471] Professor Donnelly: Definitely, and I do think that’s where you go
further down the pipeline, and for us to be able to identify those
individuals and support them, if in fact we think they’ve got
the skills and aptitude, because aptitude is a key element to all
of this, and those kinds of social skills.
Medicine—I’m generalising—is a kind of social
interaction, generally. So, yes, I think there are nuances around
this, but we’d agree the principle that we need to set
mechanisms in place where we increase the opportunity for those
Welsh domiciles.
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[472] Julie
Morgan: I’m interested to hear you say that, as far as
you know, there is no sort of coaching or training to deal with
interviews—in Wales, did you say?
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[473] Professor
Donnelly: I’m not aware of any schools that do that.
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[474]
Julie Morgan: You’re not aware of any.
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[475] Professor
Donnelly: So, that’s completely anecdotal from my
perspective. So, it is just that. But I guess, behind that is: is
that something we should be doing? If we’ve got high-calibre
individuals in Wales who can attain at that academic level, and who
possibly have the skills, should we not then provide what is
provided elsewhere in the UK, which would be that kind of coaching
to get through—
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[476] Julie
Morgan: And is that in state schools in England?
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[477] Professor
Donnelly: I think it’s across the piste, actually. I
think certain—. Obviously, private schools will target it,
but—
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[478] Julie
Morgan: They’ve always done that sort of thing.
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[479] Professor
Donnelly: Yes, sure. I think, in certain schools in England I
am aware of, where, in fact, they would have that approach because
they have, if you like, a history of feeding into medicine.
There’s a tradition of it. I think that’s what we need
to get over perhaps.
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[480] Dai
Lloyd: Rhun, on this point.
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[481]
Rhun ap Iorwerth:
Who should do that? You mentioned that
you’re not aware of the medical schools in Wales doing it,
but should it be the deanery doing that?
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[482] Professor
Donnelly: Well, in terms of intake to medical school, I think
NHS Wales should be doing that, with the universities and with
ourselves. I think this is a Wales responsibility. I think we have
to, again, set the conditions whereby any schoolchild sees it as an
option and if they don’t make the grades for medicine, they
then think, ‘Well, actually, nursing, health or science in
health’, because we need to push science as well. So,
it’s broader, I think, than just the medicine.
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[483] Rhun ap Iorwerth: On that note, would you
support a significant investment in a roadshow-type thing that goes
around Wales selling the NHS? It could actually be selling good
health as it does so. I know the Food Standards Agency had
this—had the lorry. It travelled Wales, and why not? But
actually, this is something that is very current and needs to
be—
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[484] Professor
Donnelly: Definitely. I think that sounds like a really good
idea in terms of one strand. I mentioned earlier about a kind of
summer school as well. I do think that we could be very innovative
around this and expose schoolchildren to a whole range of
scientific experiences that just trigger that thought: ‘Oh,
right; health might be for me.’ It might be physiotherapy,
and that’s great because we need physiotherapists. It
actually doesn’t matter. It’s about seeing health as an
option in terms of a career option.
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[485] Dai
Lloyd: Yes. Good. Julie, back to you.
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[486] Julie
Morgan: Yes. Thank you. We’ve heard about the possible
need for some trainees to move to England for sub-speciality
training. What effect does that have on recruitment?
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[487] Professor
Donnelly: Helen, I don’t know if you want to pick that up
around—
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[488] Dr Baker:
Yes.
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[489] Professor
Donnelly: We do have a number of training schemes that
straddle, particularly in north Wales, with Betsi Cadwaladr
University Local Health Board and into Mersey Care NHS Foundation
Trust. I guess the theme there for us is, over the last number of
years, what we’ve been trying to do is to make those training
programmes sustainable and self-sustainable in the north. So, I
guess there are risks around this, and we have talked about this
recently, in that if we have trainees who want to work in the
north, for example, and then we rotate them into Mersey, it’s
back to that, ‘If they’re aged 25, there is a risk
inherent in that.’ So, we are mitigating the risk of them not
getting all of their training in north Wales by abutting into
England, but actually, they may be attracted into the Mersey area,
into England. So, I think there’s a kind of risk. I’m
not sure whether we have any data on that per se at this stage.
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[490] Dr Baker:
The programmes where we’ve done this and we’ve
introduced a Mersey-Manchester component are very new.
They’re programmes that we’ve established in the last
sort of few years. So, at the moment we don’t have any
evidence around the trainees completing their training and then
deciding where to take up their consultant posts. But, as
Peter’s indicated, we are aware that, by mitigating the risks
associated with the trainees not having to rotate between the north
and the south, which was what was previously the case and why
we’ve established those links with the north-west and Mersey,
by doing so we’ve potentially created a different risk, which
is them having access and having a peer set that they regularly
interact with that is then in the north-west and Mersey, and they
may take up consultant posts if they’re advertised at a
better point in time in the trainees’ experience.
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[491] Dr
Matthews: Sorry, could I just add? In addition to the
risk—perhaps you’d agree Helen—there’s also
the potential benefit that people who are rotating in from
Liverpool might want to stay in Dyffryn Clwyd or Wrexham or Bangor,
when they’re coming across and doing their sessions in the
smaller district general hospitals as well. I think there probably
is a little bit of balance there.
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[492] Julie
Morgan: Thank you.
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[493] Dai
Lloyd: Okay. Rhun.
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[494] Rhun ap
Iorwerth: We had some witnesses this morning—in that
particular session it was emergency session and oncology—
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[495] Dai
Lloyd: And radiology.
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[496] Rhun ap
Iorwerth: And radiology. And they were of the firm opinion that
we have the capacity to significantly increase training places in
Wales. Do you agree with that, first of all? And if you do, why are
we not increasing the number of training places?
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[497] Professor
Donnelly: Perhaps if I start off, and I might hand over to
Helen half way through. I think the specialties you’ve
identified have been recognised by the all-Wales medical workforce
group as—. Based on the supply-and-demand data that
we’ve pulled together, there is a requirement for an increase
in the numbers in that workforce pipeline. And, in fact, through
the interim process that we agreed with Welsh Government last year,
there is an agreement and it’s been confirmed there will be
an increase in the clinical radiology intake for this August. Now,
it’s still not at the level, I think, that would meet the
supply demand, but it’s a significant step towards that. It
still doesn’t meet the requirements of what we’ve
articulated in the business case for the national imaging academy,
which is a yearly intake of 20, which would, I think, meet the
workforce demand. So that you’re aware, through that interim
process, there has been an agreement to increase other
specialities, including geriatrics, which clearly maps to the shape
of training and the demographic that we have, and general
pathology, which, again, the workforce data showed that, and we had
agreed then for this cycle to look at those other specialties that
you mentioned. So I don’t know if you want to add anything to
that, Helen.
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[498] Dr Baker:
I think, in addition to that, we need to be mindful that, if we
create additional posts at a speciality level, at the moment we
don’t have enough foundation trainees or medical students
coming through the pipeline to be able to do, and fulfil, those
posts. At the moment, the number of core entry-level posts that we
advertise already exceeds the number of foundation trainees
completing foundation by about 60 or 70 trainees. So, at the
moment, if we want to fill our posts, we are relying on the need to
import trainees from England or elsewhere. If we increase this
without increasing our pipeline through medical schools and through
foundation, then actually all we will be doing is battling against
England and other countries in order to get trainees. And by doing
that, we need to make sure that we’ve got a very strong
product that we want to sell in order to attract those trainees
across.
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|
[499]
Rhun ap
Iorwerth: Okay. Maybe if we
focus on that for a short while: speaking with Cardiff University
medical school, I think, there is an ambition to grow significantly
the number of medicine undergraduates that we have in Wales,
hopefully through the development of links in north-west Wales, and
the development of medical training there. What is your calculation
on the prospect, in terms of numbers, of increasing the number of
medical graduates in Wales annually, if we start from next year,
the year after?
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[500] Professor
Donnelly: I think the first thing to say is that, as Wales
Deanery, we would very much welcome an increase in medical student
numbers and intake in both medical schools and/or further
developments in north Wales. As Helen mentions there, and just to
drill down to some of the numbers again, the combined output from
Swansea graduate entry and Cardiff University runs at about 370 per
year. The number of F1 posts, which is their next stop into
foundation, is 339, so we already have a gap of 30.
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14:00
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|
[501] Whenever we get
to F2, we hold onto—we retain—about 60 per cent; and
we’ve always retained 60 per cent. Even pre Swansea medical
school, we retained. So, it fluctuates, but we’re around 60
per cent.
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|
[502] If you just see
this as a simple mathematical equation—I know it
isn’t—but if you increase the input and you keep those
percentage retentions the same, we’re going to keep more. I
think that’s put too simply, but that’s the basis upon
which we would very much welcome that. We think it’s about:
if we were to increase, where’s the trick here? How can we be
clever about that increase? I know there have been conversations
around if there was an increase of x—and I know a number of
200 has been floating, which is fine—let’s be
innovative around that because, clearly, if we look at all of the
workforce data that we have, and NHS Wales’s intention of
moving to a more integrated approach to the delivery of healthcare,
just as a general principle, that will mean, in some shape or form,
more community-based clinicians. Again, that’s
oversimplifying it—but more community-based clinicians. I do
think that the trick is for us to run a parallel curriculum with
either Cardiff or Swansea, or both, combined with north Wales,
around a kind of community curriculum; i.e. where the learning is
in the community but also in secondary care and
also—wherever. So, actually, they’d be more flexible
around those medical student placements. For that to be north and
west—
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|
[503]
Rhun ap Iorwerth:
And the west as well, yes.
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|
[504] Professor
Donnelly: Because the evidence is: if you have exposure
anywhere—actually, this is across all professions—but
within medicine, if you have any exposure, even if it’s
negative, you’re more likely to consider it. If you have
exposure and it’s positive, you’re even significantly
more likely to consider it. So, I think that increase in numbers we
would welcome. There still would be a question or a
call—it’s a policy position, I guess—in terms of
increasing the F1 and F2 places; otherwise the equation
doesn’t work.
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|
[505]
Rhun ap Iorwerth:
Yes, they need somewhere to
go.
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|
[506] Professor
Donnelly: Yes. And again, thinking of specialty, depending on
the scope of the increase as it works through the pipeline,
we’d need to look at the number of core—the entry
level—depending on the total increase.
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|
[507] Rhun ap
Iorwerth: Okay. There’s scope there as well, through
community medicine, to develop a specialism in rural medicine in
Wales. Would that be a direction you’d like us
to—]?
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|
[508] Professor
Donnelly: Again, I think it’s a very pertinent question.
With our stakeholders over the last few years—the health
boards, colleges, the GMC and the Welsh Government—we have
been talking about a kind of rural health curriculum. So, recent
conversations that the deanery has had with a number of key
stakeholders, including the medical director in Hywel Dda and the
GMC more recently, is that there is an option for us, for Wales, I
think, to get on the front foot with this. There isn’t a
rural health curriculum out there in the UK. What the GMC have
introduced recently is what they call credentials. So, it’s a
process whereby a certain skill set can be credentialed by the GMC,
and therefore I have a badge attached to me—but not just a
badge; I have a set of skills. So, we have a view that there is an
opportunity in Wales for us to look at a rural health credential
and work on that, over the next six to nine months, and for that to
then steer the rest of the UK. I think that would particularly
help, because I think that would act as a vehicle for clinicians to
land. This is more than medicine, because I do see it as a rural
health curriculum. You could visualise the curriculum itself.
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|
[509] Rhun ap Iorwerth: And combining
that—a real specialism—with anchoring students as
Bangor medical students, or Haverfordwest or wherever you might be,
would be a way to give us a better chance to retain our medically
trained professionals in those rural areas.
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|
[510] Professor
Donnelly: Yes, definitely. Again, I think we have to be clever
around that because the curriculum requirements will be at the same
level as every other curriculum. I think it’s not without our
gift to lead on that and actually implement it. It’s an idea
at this stage, but I think we’re starting to firm it up by
having those real conversations; i.e. let’s get a curriculum
team together. That’s the conversation I’ve had
recently. Let’s stop talking about it; let’s get a
curriculum team together and start to draft it. Then, as we go
through this, just check with the GMC in terms of: is this viable,
is this feasible et cetera. So, I think it’s a huge
opportunity for us to move on that.
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|
[511]
Rhun ap Iorwerth:
We’ve come a long way round;
we’ve come back to where we were before. So, you’re in
a position where we have 200 more graduates per year, say. Where
does that leave you in terms of the need to set firm and ambitious
targets for increasing training places and your ability to fulfil
those targets?
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|
[512]
Professor Donnelly:
It’s a challenge. If there
was—. Obviously, we would have the time period to do this
because of just working through med school. If we were to match the
numbers—so we just have that as a concept. If we match the
numbers, we would be looking then, in this case, in this example
scenario, at 200 additional F1 and then 200 additional F2. We do
have capacity issues and I think we would have to look cleverly at
that.
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|
[513]
But, having said that, if in fact that is
a community strand, I think there’s possibly more emphasis on
us attaching those F1 and F2s within primary care, and I
don’t mean GP, but within the primary care setting.
That’s not without its challenges, I guess, as well, in terms
of capacity, because each of those, particularly the F1s—. If
foundation remains in the current form that it is—. F1s are
pre-registration, so they are limited in terms of what they can do
clinically on a day-to-day basis. When they’re
post-registration, into F2, they have slightly more autonomy. So,
actually, community placements—the trainees get more out of
community placements if they’re post-registration because
they are able to get hands on, for want of a better
term.
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|
[514]
So, I would say it’s doable. Now,
this is six or seven years in the future. We don’t know what
the foundation might look like. We also don’t know if the
point of registration for medics in the UK will
change—currently it’s the end of F1. It’s under
discussion about moving the point of registration to the point of
qualification from medical school and possibly the introduction of
a medical licensing assessment across the UK. They’re going
to consultation around that fairly soon and they’re having
workshops in Wales actually around that. So, I think the
opportunity would be, if those 200 are community focused, for us to
look at where we would place them, with capacity issues. I
don’t know if Phil has—
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|
[515]
Dr Matthews: There’s certainly a willingness and capacity in
terms of manpower in general practice to do a lot more teaching,
both at undergraduate and foundation level. We already have a very
committed trainer base, especially for training for general
practice. Some of my colleagues might say the infrastructure in
terms of premises might need some attention, but there’s the
ability, there’s the willingness, and a number of people who
want to do this out there to feed into the rural strands that
Peter’s been talking about. Also, there’s more GP
exposure in both foundation and at undergraduate level, which we
know—if I can just blow that side of the trumpet—at the
moment feeds into the ability to grow your own GPs and for people
to work in more remote situations.
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|
[516]
Dr Baker: In addition, we also don’t know what the
landscape will look like fully for specialty training. With the
‘Shape of Training’ review that took place a number of
years ago, medicine programmes are likely to change over the next
few years, as we’re embarking on the pilot for that and also
plans for a pilot for surgical training. So, all of that could look
very different in the next four to five years and so that would
also impact upon the capacity.
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|
[517]
Dai Lloyd: Okay. Dawn, some of your issues have already been
answered.
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|
[518]
Dawn Bowden: They have been, to an extent. Can I just pick
up—? In relation to GPs, can I just pick up—? In your
evidence, you talk about whether we ought to consider the case for
setting targets for GPs, which has been done in the other nations.
Can you perhaps just expand a little bit more on that?
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|
[519] Dr Matthews: Yes, I think that paragraph in the evidence shows
that the ratio, for instance, in Scotland, of the number of places
to population is far higher than it is in Wales. Obviously, they
had a different starting point in that they’ve got more
medical schools and all that sort of thing. But I think we do need
to show some ambition in terms of recruiting to general practice.
One of the restrains, if you like, is that we’ve had this
target for over 10 years now—136 places a year. Because of
that constraint, each area, each of the 12 schemes in Wales, out of
necessity, has a quota, because you need to have, because of the
programme structure, a certain number of hospital jobs and
you need to have a certain number of trainers in that area. But I
think, if Welsh Government wished to increase the number of posts,
that we could, perhaps, try and fill flexibly in places like
Wrexham, where you might get a field effect where you might get
some more people being trained in Wrexham, for instance, and then
perhaps drifting out into other areas because their training had
been in north Powys or other parts of the Betsi Cadwaladr trust. I
think the same probably applies to Gwent; we could certainly get a
lot more people going to Gwent, and once we’ve got them in
Wales, people put down roots there, their partners put down roots,
and I think the—. Certainly, we need to focus on places like
west Wales, which are the hardest hit by the recruitment crisis,
along with north Wales. But if we can get more trainee
practitioners and then practitioners into Wales, surely more of
them will stay because they’ve put down roots and their
partners have got jobs, and that sort of thing.
|
|
[520] Dawn
Bowden: What sort of numbers do you think—? Because, I
mean, you were talking about Scotland, which has increased to 400,
hasn’t it? They’ve got kind of double the population of
Wales. What sort of numbers do you think we ought to be looking
at?
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|
[521] Dr
Matthews: Well, they’ve got 400 for a 5 million
population, and we’ve got 136 for a 3 million population. So,
by that, we should be talking somewhere around the order of
200.
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|
[522] Dr
Matthews: An oft-quoted figure you’ve probably heard from
elsewhere, from the GPC, is 180 to 190. Certainly, that would put
us on a par with England, where the ratio—. Scotland have
been a bit more ambitious and they are having trouble getting to
that 400 figure, but they’re over 300 now.
|
|
[523] Dawn
Bowden: Yes, okay. And just one quick question then, if I may,
Chair. I just wanted to move towards how the deanery works with
LHBs, in particular in ensuring that service needs are met. How do
you work that relationship to work that through?
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|
[524] Professor
Donnelly: Across the UK, this is possibly one of the most
complex issues in terms of marrying the curriculum requirement for
that trainee that year and the service pressure.
|
|
[525] This isn’t
a dichotomy; I think this is along a continuum. Where we get that
right—. Actually, emergency medicine is quite interesting.
So, on the GMC trainee survey, emergency medicine comes—. The
trainees in Wales are saying that they’re quite dissatisfied
with the workload; i.e. they’re saying they’re busy.
But then, at the other side, we’ve got the highest score for
satisfaction in EM training in the UK. So, there’s a kind of
formula there, isn’t there? What we’ve expressed a
number of times is that possibly the best training is where the
trainee is busy—not too busy where they get stressed and
their performance drops—but busy doing what the LHBs and the
population need. So, not too busy, but it maps to the curriculum
requirement that year, because each year will be different. If
I’m an emergency medicine ST4, I will have specific
requirements. The next year I will have different requirements. So,
the trick is marrying that and making sure that even though our EM
departments are extremely busy, as you’ll be aware, and
extremely pressured, that the trainees feel supported, because we
have the supervisors there and we have high-calibre trainers who
are supporting them. So, that’s an example of where
we’re getting it right.
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|
[526] I guess I would
go back to our quality management framework and how we work with
health boards, because frequently, if a quality of training issue
is flagged—and it can be flagged through a whole range of
sources: the trainees themselves, through their annual review of
progression; through the GMC survey; through our educational
contract—a theme is that the trainee’s not getting to
their curriculum requirements because of service pressure, and
that’s something we just work on constantly with the health
boards in terms of suggesting rota changes and just suggesting a
whole range of things and innovations about how we can free them up
and whether we can use other staff to free them up and then have an
agreement. So, I think it is an ongoing challenge for us. I think
in general in Wales we get that right. So again, the high-level
figure from the GMC trainee survey, which is a UK survey—for
the last four years we have been the best in the UK in terms of
overall satisfaction, and for each of the five years for which the
data is there, our score has gone up incrementally.
|
|
14:15
|
|
[527] Now, if you look
statistically, I think the four countries are fairly close
together, but in terms of overall satisfaction, we have the best
score, which is a positive. It is a constant balance, really. The
trainees are professionals, and if an emergency arises, they will
deal with the emergency elsewhere perhaps that doesn’t map to
the curriculum. If that happens too regularly, they may get to
their annual review of progression, which is a kind of panel
appraisal, and then we say to them, ‘You’re not
progressing’, but it’s a systems issue because of that
pressure. So, it’s constantly working with the health boards
to say, ‘Look, if we get this right—the quality of
learning—we improve the retention recruitment, the rotas are
more sustainable, your medical locum bill goes down, and
we’re in a positive spiral’, but it’s that kind
of medium to long-term approach.
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|
[528] I would have to
say that, in general, the health boards are very amenable to this
conversation. We have to say that very upfront. I think all of the
medical directors and particularly who we interface with—and
they’re related to associate medical directors for
education—do take this very seriously and work very closely
with us.
|
|
[529] Dawn
Bowden: Okay, fine. Thank you very much.
|
|
[530] Dai
Lloyd: And Julie to wrap up the last couple of questions.
|
|
[531] Julie
Morgan: I was interested in what you said to Dawn about
Scotland putting up its targets for GPs. Do you have any knowledge
of Scottish retention of doctors who have trained in Scotland?
|
|
[532] Professor
Donnelly: Sorry, Phil—that’s for you.
|
|
[533] Dr
Matthews: There is some evidence with their rural practice
programme, where they’ve made great strides in trying to
place and support people not just in training but afterwards in
rural areas. Their retention rates are pretty good, really. I think
the last document I read—they were retaining in the order of
60 per cent of people who were being trained in the highlands and
islands in fairly remote—not always in the highlands and
islands, but fairly remote parts of Scotland. So, there is some
good evidence that it works. The World Health Organization has
produced a document on what’s evidential in terms of getting
recruitment and retention into remote areas, and they stress the
need for support and placement in remote areas from an early stage
in medical training, both at undergraduate level, foundation and
afterwards, and not just in medicine but for all healthcare
workers. We need to expose people to community placements, rural
tracks—all those sorts of things.
|
|
[534] Julie
Morgan: So, that is something we could possibly follow in
Wales.
|
|
[535] Dr
Matthews: As Peter said, there have been some ongoing
discussions, and we very much support that.
|
|
[536] Julie
Morgan: Yes, but we could learn from what’s been done in
Scotland.
|
|
[537] Professor
Donnelly: Definitely. I think Scotland is an example. In fact,
there are very rural areas in north England that kind of—.
Because ‘rural’—we can have a long debate about
the definition of that—is, in essence, about access, I think,
to a whole range of things. So, I think there are lessons to be
learned, and we do have huge opportunities within the kind of rural
health that we—I mean Wales—are possibly not using, but
I think some of the conditions will need to change for us to be
able to do that.
|
|
[538] Julie
Morgan: Right, thank you. We’ve been discussing the
structure and the content of the training as we’ve been going
along. Is there any sort of one thing that you think should be
changed in order to improve recruitment and retention?
|
|
[539] Professor
Donnelly: Again, that’s a very valid question and I guess
I would reflect on the conversation we just had earlier with the
health board. One of the key elements—not without its
risks—or one of the key places we need to get to is where we
have a process in place whereby we have a certain level of agility
and flexibility to move trainees around to maximise their learning
opportunity. So, the kind of pattern at the minute—and
I’m overgeneralising—is they will be placed in hospital
X for six months. Because of their employment model, they will be
employed by that health board, and because of the funding model,
which is a very traditional 50/50 per cent—so, the health
board provides 50 per cent; we provide, as a deanery, 50 per
cent—all of that builds in flexibility. So, if we say to the
trainee, ‘Look, we’ve got a really good opportunity to
go to’—random hospital—‘the Royal Glamorgan
Hospital because they have got a paediatrician with a particular
interest in X. That would add to your curriculum. We’re going
to send you there for a month’—the process that we
currently have doesn’t allow that flexibility and agility.
And I think that is a barrier to us as a deanery being able to
innovate in terms of allocation of trainees in a flexible manner.
We are very cognisant of, if we move a trainee from hospital X to
hospital Y in another health board, the rota won’t be manned
there. So, I think it is about us looking innovatively at that
funding model to build flexibility and agility. So, if there was
that—or to at least revise that—. We have done that in
terms of employment. The shared services through Velindre are the
single employer for GP trainees. I think that standardised process
and mitigated risk have been seen by the trainees as extremely
positive, because every time they rotate, they’re not waiting
for another contract to be issued and they don’t have to go
through induction again and they don’t have to go through
various processes.
|
|
[540] So, I think
having that agility and flexibility around the employment/funding
model would allow us to be more innovative with training, and it
maps to the community. If we place trainees in the community, they
are going to be less likely to be available for the rota in the
hospital setting and then we come into the model again and we get
into a circle.
|
|
[541]
Julie Morgan: Thank you.
|
|
[542]
Dai Lloyd: Just a follow on on that agility—obviously,
we’ve had a couple of lively discussions with various junior
doctors over the last couple of weeks. In terms of that agility,
there was mention of allowing or having the capacity to allow F2s
to, say, do locums in general practice. Now, obviously, they are
fully qualified and registered, but they cannot, for a whole
variety of reasons, not least indemnity and contractual
obligations. Would your ability to be agile be looking at that sort
of stuff?
|
|
[543]
The other issue that was perplexing our
juniors was the performers list—you know, different
performers lists—and sometimes, when you’ve been
abroad, trying to get back into Wales and gaining access to that GP
performers list can be an issue. I don’t know if you want to
develop your agility argument.
|
|
[544]
Dr Matthews: Just taking them in reverse order, if I may, the
performers list issue is high on the BMA’s agenda, obviously,
because of the cross-border issues. I think there’s a general
view that, if there were a way of being on a performers list in
England and qualifying for Wales and vice versa, that would be
useful. I know there are lots of legal issues around that and
there’d need to be agreement between Governments for all
sorts of things. Can you just restate the other part of your
question again?
|
|
[545]
Dai Lloyd: Just allowing F2s to be able to do locums in general
practice. I know there are issues about that as well.
|
|
[546]
Dr Matthews: Yes, obviously, there are matters in statute that
would prevent it at the moment. I think one of the views put
forward in the transcript I read from one of your previous
contributors was advocating an F3 year, which, again, would need
statutory changes. We’re not able to do that at the moment.
You can only work in general practice if you are either a
foundation doctor or doing GP specialty training or actually on the
performers list or on the GMC register. So, there are all sorts of
technical reasons why that would be difficult. I think hanging it
on the term F3 is one way of looking at it. I think, personally,
that we need to improve community exposure at all levels of medical
education, as I’ve said before.
|
|
[547]
If I might make another point? Going back
to what Rhun said earlier, if there were some parameter at an early
stage of entry to medical school that could favour home-grown
applicants, again, there’s good evidence that, if you grow
your own medical students, the value of increasing the number
overall is synergised, for want of a better way of putting it. So,
I think we’d support that as well.
|
|
[548]
Dai Lloyd: Great. Thanks very much.
|
|
[549]
Unrhyw gwestiynau? Rhun.
|
Any questions? Rhun.
|
|
[550]
Rhun ap Iorwerth:
One last question, on the suggestions
from some that there should be a withdrawal from national selection
processes for training, at least in some areas, and that it is a
system designed for the NHS in England, basically—the health
education. What do you think?
|
|
[551] Professor Donnelly: I think, up to this point, we would feel that we have
a level of influence over those recruitment processes that place us
in a position where we can’t, for want of a better word,
protect the interests of Wales. The advantages I think at this
stage outweigh any disadvantages. The risk, if we did separate, is
that we would have a different selection process, and
especially training, which means trainees would not be able to flow
across. So, the national process, even though I understand some of
the arguments against, and possibly some of them are anecdotal,
because we have national recruitment, means that trainees, if
they’re above the bar through that recruitment, are eligible
to get a job anywhere and can move across through inter-deanery
transfers et cetera. I think it’s that standardised
approach—you know, if I flick back 10 years, the selection
process wasn’t robust, it wasn’t standardised, it
wasn’t as far as it should have been. We now have very clear
and, I think, an increasingly competency-based selection process
under recruitment, which is what it should be in terms of assessing
skills. So, it isn’t just an interview as such. You know,
it’s multi-stations assessing clinical aspects. So, for
surgery, for example, clinical skills are assessed.
|
|
[552] So, I think at
this stage our view is that being in a UK national
selection—the advantages outweigh any disadvantages. I think
we’re constantly keeping that under review in terms of if
that position changes, in terms of our level of influence, I think
particularly with Health Education England.
|
|
[553] Rhun ap
Iorwerth: One of the examples that we heard recently was from
dermatologists who saw excellent training places in Wales being
taken up by, perhaps, students who had qualified and had more
experience in dermatology in teaching hospitals in London that made
them better choices for those training schemes in Wales than
students taught in Wales. But, actually, they had no intention of
staying in Wales. They come here, get the training, and then go
back. Is that an issue?
|
|
[554] Professor
Donnelly: I’m sure that happens, and will happen in such
a complex system. I guess I would go back to: their stated
intention may be to go back to wherever, but again, if we can
ensure that they get a positive experience—a more positive
experience—here than the place they’ve just come from,
then we’re going to increase the likelihood, whatever the
specialty, of them saying, ‘Actually, the work-life balance,
the service experience, the perception of the quality training and
the quality of training is better here.’ So, I think there
will always be that flow, and I guess that medical recruitment is
very complex in terms of that flow across. I would also say that
those trainees coming into Wales is a very positive thing, coming
from elsewhere.
|
|
[555] Rhun ap
Iorwerth: Of course, yes.
|
|
[556] Professor
Donnelly: So, yes, we would accept that what we need to do is
make sure they get a positive experience and increase the chances
of retaining them, because I think our mantra has been that
it’s about retention. Recruitment’s fine, but actually
it’s about retention. What are we currently doing and what
else do we need to be doing?
|
|
[557] Dr Baker:
I would also add to that: we already know from trainees and
anecdotal evidence that there is a perception that Wales is
different—Wales has a different healthcare setting and
environment. Training, potentially, could be different in Wales. If
we then move our recruitment system, and run a different
recruitment system, we increase the perception that Wales is doing
something different. Trainees are in a competitive market, and they
do want to move around the whole of the UK and overseas, so if we
were to go alone and hold a Welsh recruitment process, we’d
increase that perception to trainees.
|
|
[558] Dai
Lloyd: Okay. Phil.
|
|
[559] Dr
Matthews: Just one final point: one common misconception is
that people don’t end up where they want to be, particularly
in the larger specialties. We hear that anecdote from time to time.
The fact of the matter is that what happens is people, basically,
get their first or second preference, not just by country but
within 50 miles of where they want to be. We’ve got good
evidence to that effect as well.
|
|
[560] Dai
Lloyd: Great.
|
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[561]
Diolch yn fawr iawn i chi. Dyna
ddiwedd y cwestiynu, ac felly diwedd y sesiwn. A allaf i longyfarch
ein tystion ar safon y wybodaeth, a diolch iddyn nhw’n fawr
am eu presenoldeb? Diolch yn fawr iawn i chi.
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Thank you very much. That brings us to the end
of the questions, and therefore the end of the session. May I
congratulate our witnesses on the quality of their evidence and
thank them very much for their presence? Thank you very much.
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14:29
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Cynnig o dan Reol
Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd
Motion
under Standing Order 17.42 to Resolve to Exclude the Public
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Cynnig:
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Motion:
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bod y pwyllgor yn penderfynu gwahardd y cyhoedd o
weddill y cyfarfod ac o’r cyfarfod ar 1 Mawrth 2017 yn unol
â Rheol Sefydlog 17.42.
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that the committee
resolves to exclude the public from the remainder of the meeting
and for the meeting of 1 March 2017 in accordance with Standing
Order 17.42.
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Cynigiwyd y cynnig.
Motion
moved.
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[562]
Dai Lloyd: Symudwn ymlaen nawr fel pwyllgor i eitem 6,
a’r cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y
cyhoedd o weddill y cyfarfod heddiw, ac o’r cyfarfod ar 1
Mawrth hefyd. A yw pawb yn cytuno? Pawb yn cytuno. Diolch yn
fawr.
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Dai Lloyd: The committee will now move
on to item 6, and the motion under Standing Order 17.42 to resolve
to exclude the public from the remainder of today’s meeting,
and from the meeting on 1 March. Is everyone content? I see that
everyone agrees. Thank you very much.
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Derbyniwyd y cynnig.
Motion
agreed.
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Daeth rhan gyhoeddus y cyfarfod i ben am
14:29.
The public part of the meeting ended at 14:29.
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