Written evidence submitted by Dr Emma Hayward (RTR0028)
I am a GP and also a clinical teacher at the University of Leicester Medical School. I am submitting evidence because I have worked in the NHS and in undergraduate training for nearly two decades and have insight into the issues raised by the inquiry from personal experience. The views expressed below are my own and do not represent the views of the organisations I work for.
What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?
We need to train more healthcare professionals within the UK and particularly support training in underserved specialities. In order to recruit into primary care, students need to experience work in the community and general practice during their undergraduate studies.
An example of a short-term intervention would be to increase the weekly tariff paid to GP surgeries who host nursing and pharmacy students. At present, the tariff does not cover their costs which is a disincentive. Unlike nursing students in hospital, students within primary care cannot contribute independently to patient care and need supervision. This is not properly re-numerated and therefore there are very few placements for allied health professionals in primary care. This is a missed opportunity to inspire the next generation of primary healthcare professionals.
The tariff for medical students is better but needs review to ensure that the costs incurred by having medical students in the practice are properly covered, especially as the GP workforce is under particular pressure. Practices under pressure may withdraw from any work which is not vital to patient care so there needs to be a real incentive for them to continue educating medical students. At Leicester Medical School we have an excellent cohort of GP tutors who are very keen to host our medical students. Other medical schools are not so fortunate. I believe that one reason we have a good cohort of GPs willing to teach is that we have invested in their development as educators by hosting seminars and an annual conference. However, as university funding is squeezed it is harder to do this within existing budgets. I would like to see money allocated for universities to use to invest in their clinical teachers from primary and community care to increase capacity in this area. This will help in the medium term.
In the long term, increasing the capacity of medical schools to train more doctors will mean further investment in buildings (many of which are not physically big enough to accommodate larger student cohorts), teaching staff and also funding for administrative staff as the latter are often overlooked.
What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?
Recruiting healthcare staff from countries who have worse health outcomes than our own is ethically problematic. We should move towards reciprocal arrangements where both countries can benefit from mutual exchange of skills and expertise. Investing in programs which allow NHS doctors to have a sabbatical working or teaching in a different context would have benefits for the doctor, the NHS and the host country. These programs should also be open to staff working in primary care.
What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:
Could the training period for doctors be reduced? No. The training is intensive enough as it is. Developing expertise takes experience and experience takes time.
What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them? Workload and perceived lack of support.
As a doctor in primary care I face an overwhelming workload every day, which has adversely affected my own health and impacted on my family. However, the workload would be easier to tolerate if I did not also face the very real possibility of patient complaints, referrals to the GMC or even the courts – these may happen to any doctor, no matter how diligent. Despite the GMC reassuring the medical profession that current circumstances (Covid) will be taken into consideration if complaints are received, as a profession we remain apprehensive. Since the pandemic started there have been court cases where doctors were judged to have fallen short, despite working under unprecedented pressure. There needs to be some honesty about this: in a system where resources are stretched, occasionally some patients come to harm. Blaming the doctor who happened to be on duty adds immeasurably to the stress we feel each day at work. The case of Dr Bawa-Gaba illustrates how one doctor was singled out and endured years of investigation, instead of it being acknowledged that she was hampered by larger system failures. It is hard to describe how much this case has affected doctor morale; the feeling that we will be held to account for systems failures beyond our control. I cannot go into details due to patient confidentiality but it is not uncommon in general practice to be left with responsibility for cases that are beyond our remit and capacity e.g. patients with severe mental illness discharged from psychiatry, monitoring of patients with complex medical problems that are not within our contract and managing patients discharged form hospital with inadequate care. Even passing back responsibility to the right people takes much of our time. If we cannot get the patient back under the care of the right team, the responsibility inevitably remains with the GP and therefore also the blame if/when things go wrong. Moving from a blame culture to one of support and understanding would help to address this but this needs to be more than just platitudes in order to restore doctors’ confidence.
Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?
Primary Care and mental health, especially in deprived areas are of greatest concern. Increasing the percentage of NHS funds that is allocated to General Practice to 11% or more would help. Changing the weighting of deprivation payments to better reflect the actual cost of providing care in resource poor settings would also help. Ensuring that doctors do not face financial penalties for remaining in work (reviewing the pension tax) and also that a choice to work in primary care is as financially rewarding as a career in secondary care would also help retain GPs.
Consulting in general practice is a high level skill and best performed by a medically qualified doctor with appropriate higher training. Allied healthcare professionals can be employed to assist with certain aspects of care but require support due to the complexity of our case load. This creates an additional burden on GPs as we have to manage not just our own patients but also the cases other people are seeing. It is not uncommon to be interrupted multiple times in a single clinic which adds to the cognitive load for the GP and raises patient safety concerns (being interrupted makes mistakes more likely). This is not to say that allied healthcare professionals should not have a role within General Practice. If Physician Associates could be employed to manage some of the administrative tasks that are presented to GPs this would be enormously helpful.
Another valuable addition to the primary care team would be chaplains. The research for my Masters in Medical Education demonstrated that many GPs identified patients who presented with a spiritual aspect to their problem. However, unlike hospitals where chaplaincy is well established, there are only a few examples of chaplains in primary care. Those services which have been established have been highly effective for patient care and may also be able to provide support for the workforce. I am involved in the development of training material to help clergy gain confidence in supporting people with physical and mental health problems – support for schemes such as this could help diversify the workforce and alleviate some pressure in general practice.
What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?
A few years ago I developed a course in Integrated Care for fourth year medical students at the University of Leicester. This involved working with teams within two community healthcare trusts as well as the university hospital. What became apparent as we developed and ran this innovative course was that whilst Integrated Care teams had been established in places, their success in delivering truly integrated care was limited by lack of training in new ways of working. I developed a proposal to research the best ways of training diverse professionals to work in integrated care but despite approaching HEE, the Deanery and various other stakeholders I found that there was no money allocated for training for these teams. I believe that Integrated Care teams are the right way forward for healthcare over the next few decades but their success will be limited if they do not received adequate training in how to work effectively. Effective training methodologies for work in this setting have not yet been proven. There is an urgent need for the Department of Health to invest in research to establish how to train integrated care teams and support integrated working. I would happily discuss development of a research project to look into this question if funding can be found for it.