Written evidence submitted by the Association of British Neurologists (RTR0031)

Response to: Workforce: recruitment, training and retention in health and social care consultation

1. 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?

Incentivise medical careers as other professional programs have done. Relying on goodwill isn’t a long-term solution.

Short term: increase salaries. We have insufficient neurologists to cover the work required in the NHS and need to look at alternative models of working, expanding the workforce by upskilling physician associates, specialist nurses, pharmacists and other allied healthcare workers to enhance continuity of care and plug the gaps. We also need to work closely with areas such as stroke to effectively increase neurology numbers and co-develop pathways for acute neurology.

In the short term better support from HR (often a stumbling block that is delaying the process considerably), short to medium - more flexible arrangements regarding job plans if people want to work part time or across different sites. I’d put the pension question here both for recruitment but also for retention of more senior staff with experience. For health and social care long term recruitment it would be important to increase status of the profession to encourage more young people to pursue this career. How, I’m afraid I don’t know. Increasing pay will most likely help.

We need to address the issues in areas with persistent vacancies by exploring collaborative working across trusts, combining to bolster neurology expertise in those areas without neurology.

Medium term: offer career opportunities and set benefit plans; improve mentoring and learning experiences. we need to increase neurology numbers in training – we fully recruit to neurology trainee posts so if we need extra staff we need to increase the numbers trained. Attracting people to traditionally unpopular geographical areas will require changing the way we train to ensure equitable training across the country with appropriate access to specialist training regionally.

Long term: foster a collaborative culture where opinions are heard; bring research into routine setting to improve care. Needs to be ‘ground-up’ with more medical school places – this means increasing capacity within medical schools, especially within clinical years of study. A national mapping exercise is required to find out where there is the most capacity to support this – it is not sensible to simply increase numbers of students at already full institutions. Increased student numbers in the schools should be matched to an increase in available FY posts for the students who graduate.

Suggest using workforce information already available e.g. collected by the Royal Colleges regarding why people are leaving medical professions.

Incentivise e.g. tax system, pensions for people to increase rather than decrease their hours worked.

In addition to the obvious attraction of higher salaries, particularly for antisocial hours, there needs to be a continued emphasis on employee well-being, as we have seen develop during COVID. Employees need to feel as though they are thriving, personally and professionally, in the work place, if they are to be retained.

In the longer term the number of places available for training in the different disciplines of healthcare need to be increased to take in to account the increase in part-time working, portfolio careers and parental leave.

Day-to-day working experience need to be attractive including adequate administrative, support, junior staff, new post mentoring, peer to peer support & feeling part of a team & that you are contributing & valued.

There must be clear opportunity for equitable career progression (which will also help retention) as well as appropriate renumeration.

Building a networked approach to recruitment across a region, rather than individual trusts will enhance consistency across regions; aligning that to training will increase willingness to stay in that region.

It’s crucial to acknowledge that there are UK-specific recruitment issues which are different from anywhere else in the world. These UK-specific issues include:

1. Poor pay of UK doctors (and possibly other health care professionals) compared to EU, Australia, etc

2. Major retention issues, partially due to poor pay, but also pension changes, “shape of training” and generally poor succession planning

3. Many UK health professionals have elderly relatives abroad – a further reason for many to retire early or move back to their home country and more so than ever due to change in political climate in the UK, stricter visa rules etc.

As dementia moves up the agenda and there are realistic prospects for disease modifying therapies, the staff force available to accurately diagnose individuals using state of the art diagnostics needs to increase dramatically, as does the ability to deliver potentially radical treatments with possibly significant side-effects. The current fragmentation of dementia diagnostic services across the country needs to be urgently addressed with increase numbers of specialists and more close working between neurology, psychiatry and geriatrics. The issues regarding social care needs for patients with dementia have come to the fore through the Covid crisis, with fears that staffing of care facilities will become ever more difficult if the population ages, more people get dementia, and the workforce (including from overseas) diminishes

1.1 What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

Must include more digital health in training.

Ensure more seamless transition between placements and include locality as part of allocations.

Increase salaries and benefit plans.

Investigate reasons people may drop out:

e.g. family plans

possible penalisation/disincentive of tax systems to 'working too much'.

See whether remote working can assist areas finding it hard to recruit locally.

We need to promote dementia as a growing area for both clinical and research careers and incentivise individuals with appropriate skill sets to join the profession. Promoting closer working between neurologist, psychiatrist and geriatricians and considering different models of care with different expertise (diagnostic, drug delivery, ongoing care) directed appropriately

We must promote neurology as a common medical specialty and an area that integrates with all other medicine; we need to work closely with general and stroke physicians, care of the elderly, psychiatry and primary care to ensure attractive training programmes in neurology with special interest thrive – the challenges of Shape of Training will need to be framed as opportunities for greater integration – this will need to be kept under close review as the new programme starts, as it will have a knock on effect on trainee effective numbers initially, and will need trusts to plan for alternative workforce solutions to support.

It will be important to ensure research (delivery) training is incorporated into multi-professional training across health and social care which will hopefully aid retention as well as care quality (see also: Best Research for Best Health, The Future of UK Clinical Research Strategy).

Eliminate the gender pay gap.

Eliminate work-place sexism (BMJ report on this very troubling, RCS data highlight how much of a real issue this is.

There needs to be emphasis placed at medical school on broad transferable knowledge and skills so graduates are well equipped to develop into a broad range of specialisms. Clinical years medical students will need to spend time outside of large teaching hospitals to expose them to different models of care as well as to provide enough clinical placements for the larger numbers coming through.

Current UK workforce reflects previous models of working with general physicians attending to lower level specialist disease. With the drop in general physicians either more specialist workforce is required, or other medically trained professional groups need to pick up the work. This could include geriatricians taking a greater role in Parkinson’s disease in the elderly, epilepsy in the elderly or common scenarios such as gait problems in the elderly.

The training programme has to be more flexible to adapt to changing situations. For example, registrars should be able to continue to work as registrars after completing training if not enough consultant posts are available.

Although sub-specialisation is necessary in all of the disciplines of medicine and surgery if it can be done in a way that preserves the generic skills of those involved it will make the workforce more flexible and more easily redirected to other roles in healthcare to help individuals refresh their perspectives and gain – or preserve – other competencies.

From a medical training point, a lot of fact based teaching and training has given way for “softer” topics already. I also don’t think we should allow doctors to be pushed through training quicker to fill gaps. Increase number of students may help. It may also be possible to consider that some students will want a future career in science and less so in medical/clinical practice and it might be useful to allow students to take time to do research even if that would extend their training.

2. What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

There is no such a thing as a “correct” balance. Ideally most of the posts should be covered by domestic workforce. However, if there are shortages in staff, recruitment from other countries should be facilitated. For all posts, people from abroad should be allowed to apply and compete with domestic workforce on “equal” terms. Exchange of staff to improve skills (research) should also be encouraged not just to fill gaps but to enrich UK workforce and allow people to bring their skills to UK and subsequently bring their skills back to their country should they not wish to stay in UK

If suitable profession standing exists there should be no issue in international recruitment as well. But the need for more general skills in U.K. training pathways for secondary care as well as specialist in secondary care will preclude many European nations.

Recruitment of health care professions in England is very challenging at present, with many positions (nurses, radiographers) completely unfilled. International recruitment in the short term is a possible solution. However, more training posts, and improved conditions of training, should be considered if we want this situation to change in the medium and long term.

Although training numbers/student numbers have increased it does not reflect change in work patterns - increase in career breaks and part time working. This must be acknowledged in future workforce planning and domestic numbers training need to increase. We should not be in a position where we are overly reliant on international recruitment.

2.1 What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

It is vital and morally correct to get this right. A rich country should not be taking staff from developing countries with even greater problems with healthcare delivery than the UK. We can take staff in training or consultant staff for periods of working in the UK, to contribute to service but only if it is also part of their training. Visas should be short term so they aren’t sucked into working permanently in the UK. That isn’t to say that they couldn’t apply to live permanently in the UK and achieve British citizenship, but a balance is needed between UK healthcare delivery requirements, professional development for the individual and the needs of their domestic health economy.

Make sure that the fees for EU people attending training programmes is the same as UK trainees.

Look at financial assistance for settling, assistance for families and help with visa etc. Mentorship and links to communities to prevent isolation.

There should be schemes run for people from abroad, not just for language (very important in health care, particularly when caring for elderly) but also practical issues such as how wards and hospitals work. I attended a workshop by GMC where they pointed out that doctors recruited were often not aware of practicalities which then resulted in mistakes and miscommunications.

Ensure attractive visa packages with sufficient longevity for someone to become established; ensure the long term career prospects are equitable.

3. 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?

One could consider subsidising training for nursing, clinical physiologists. Reduce admin tasks to increase time HCA and nurses can spend with patients.

Increase salaries

The current fragmentation of services across multiple different specialties and lack of clear pathways has led to very variable delivery of dementia diagnostics and care across the country. This in turn makes it difficult to plan services, although it is clear that given the scale of the problem that dementia poses, the workforce is woefully under resourced

In particular:

3.1 To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

The RCP workforce unit has shared presentations from HEE on workforce projections up until 2040 based on demographic projections. HEE staff involved in that work have declined to make themselves available to discuss their findings with medical specialty organisations such as the Association of British Neurologists. As most service developments require medical staff, open conversations are required.

It is clearly difficult to acquire reliable data about the numbers clinically active in any professional group, their stage of career, their plans for retirement, and whether they are full or part time. This in turn makes it difficult to plan the numbers admitted to courses for basic training. I am not aware of a an adequate system that acquires and collates the required information.

It is important data to collect and also acknowledge that work patterns are changing with more people looking to work part time and take career breaks.

The impact of Shape of Training is beginning to be felt by those who started training Aug 2021 – This programme is detrimental and may turn out to be disadvantageous for neurology, as it is clearly a fix for poor historic workforce planning. Fewer neurologists will complete training because of this. We do not expect combined neurology and general internal medicine posts to be created. It is hoped that Shape of Training will be reviewed and changed if the predicted flaws are shown to be a problem for workforce. The stress on GIM rotas and wards has been massively amplified by COVID so trusts are very focussed on ways to increase GIM support. The emphasis on networks from the Neurology GIRFT report suggests a greater emphasis on neurology, so reducing the workforce through Shape of Training will increase difficulties.

More specialist nurses or AHPs. It does depend on how we spend our time as doctors or employ our disease area expertise - too often we underutilise the other professionals who could see patients and provide care under our supervision. This would mean a shift in role that may not be to everyone's tastes and training would need to really address this properly. Also need to consider quality vs utility in this respect.

AHPs require, training and supervision, and they increase the complexity of the work left for the senior clinicians. This requires integrated workforce planning.

From the Parkison’s Disease perspective, there is a specific need to deal with the globally increasing number of people with PD which will require a substantial increase in PD specialists/nurses/carers etc.

There is no reliable system in place. Survey performed of neurologists in the UK in 2019 confirmed that we have insufficient workforce, which will increase in coming years. For example, in neurology we have 1.1 neurologists per 100,000 population; WHO state that in high, and high middle-income countries, the number of neurologists per 100,000 population was 2.96 and 3.10 respectively. We rank 44th in 45 countries in the EU, with only Ireland being worse.

WTE workforce is poorly measured as much of the neurology workforce is part time clinical, part time academic so the figures of posts overestimate numbers.

Finally, more are looking for LTFTW which will exacerbate the deficit.

We do not have a good handle on patterns of demand in neurology as there is no coding of outpatient activity and neurology is 80% an out-patient activity – so we desperately need a mandated system of coding in place for outpatients to show what demand is across the specialties. This is very likely to be true of a range of other specialties. Without granular activity data precise management of services is impossible.

Effective out-patient coding will enable us to determine what type of neurologists are needed and where. We also need a system for measuring inpatient referral activity done by visiting neurologists which is completely hidden activity at the moment and yet makes up a significant proportion of a neurologist’s work. The ABN guidance in 2012 suggested we need daily neurology rounds in every trust. We are a long way from that and are hampered by lack of data.

3.2 Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

There is relatively little coverage of dementia in many training programs, risking a significant skill set deficit as and when new treatments come on stream.

More digital health training and more directly supervised objectives and outcomes with mentoring and more support. Maybe more objective testing too for skills.

An emphasis on broad and transferable knowledge and skills is needed in undergraduate medicine – standardising this across medical schools (ie with MLA) is a positive step. Careful assessment and analysis of the first few years of this exam will be needed to ensure it is achieving intended goals. It is unclear that the current MLA list of ‘presentations and conditions’ is fit for purpose and may reflect outdated notions of what medical students need to know.

Curricula for postgraduate medical training have been updated / are being updated currently as part of ‘shape of training’ – analysis of outcomes from this reform will be necessary to see if it meets its goals (providing more generalists) without unintended consequences (a relative lack of ‘specialists’). It will take a minimum of 5-10 years to assess this.

The curricula for training in the medical specialties have been updated following the Greenaway report (Shape of Training, Oct 2013) in order to put generic medical skills, particularly as they apply to our current population of older adults with frailty and multiple comorbidities, at the heart of training in all the medical specialties such as cardiology, neurology and gastroenterology. The new curricula began with stage ! of the new Internal Medicine Curriculum in August 2019 and from August 2022 all medical specialties will be following new curricula. These new curricula have the potential to make the medical workforce more readily redeployed to general medicine at times of future pandemics, or in other crises that require the workforce to focus on general rather than specialised medicine.

Training doctors curriculum is being updated at the moment and will increase cross working with general medicine and stroke. The concern here is that there will be less time spent on training in neurology so newly qualified consultants will be less experienced in their primary subject. They will have broader skills in Internal Medicine and stroke. With Shape of Training the risk is that they are pulled away from neurology, to internal medicine and stroke, when all have workforce issues.

The curriculae for other AHPs do need review to ensure as these models evolve, these staff have the right mix of skills. In particular, there is no clear job plan or curriculum for a speciliast nurse.

Allied professionals must be part of the mix but, we should not lose sight of the fact that these colleagues ‘add value’ differently from the way in which value is added by senior medical staff. Sometimes, they assist in identifying the problems rather than in solving them which increases demands on medical staff while improving quality of care.

Administrative support colleagues, such as secretaries and clerks are vital members of the medical team. Increased reliance on technology such as electronic patient records has weakened the role of the traditional medical secretary, though they remain key communicators with patients and vital to transferring clinical decisions into the electronic record. A substantial body of admin work has been created as an additional pressure on consultants’ working weeks.

3.3 Could the training period for doctors be reduced?

Undergraduate studies are typically 5-6 years and 5 seems to be the minimum required to achieve safe competency for FY practice. There is already concern that there is a lack of fact based teaching for undergraduate doctors which is only corrected in their post-graduate training.

“shape of training” for postgraduate medical training has only just been introduced so it is too early to judge if it is effective or not. It reorganises training but has not meaningfully shortened it. Without an analysis of whether this new system works it is impossible to say whether it could or should be changed to shorten it. There is a concern that Shape of Training is already increasing the breadth of training and therefore decreasing the depth of knowledge in a complex multisubspecialty areas.

Postgraduate training is long in the UK compared to any other European country –shortening of the pre-Specialist training would be the only training component that could be shortened but that might extend requirements of specialist training.

The complexities of diagnosing and treating complex conditions such as dementia is not trivial, and doctors need appropriate training. As and when they’re disease modifying therapies which require close supervision and monitoring, these needs will only increase. This emphasises the importance of subspecialist training. Traditionally this has been acquired from out of training periods as part of MD or PhD studies. Post CCT

3.4 Should the cap on the number of medical places offered to international and domestic students be removed?

International students, in particular from EU, have stopped coming to England as their training fees are now very high (the same as non-EU fees).

The cap should be removed given shortages and financially people should be incentivised to come especially in key gap areas.

Removing the cap does not in itself solve any problems – simply increasing medical student numbers is not effective. It only works if medical school capacity for students in clinical years increases. It only works if there is a commensurate increase in early years training posts that are appealing to junior doctors so that, having been trained in the UK system, they then stay in it

Possibly increase numbers but one still has to ensure quality of the training and current workforce has to be able to keep up with training the new students/junior doctors as well.

We were unclear as to the financial aspects of this question. UK Universities are a major income stream. Visa regulations and residency periods need to be considered. International students form very low income countries should be permitted to study and work in the UK, but if they are able to gain long-term residency that would disadvantage their home country. This is a complex area with the risk of adverse outcomes.

4. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

For medical staff, burnout, long hours with little recognition, increased admin and non-patient facing tasks, pay and conditions in non-healthcare sectors.

For other staff, likely similar but may be driven by low pay, low status, the work is also hard physically and mentally.

Too much focus on providing care rather than training.

Financially with pension and tax systems after a period of time the reward for working is not sufficiently incentivised. Pay, taxation and pensions have to be simplified and changed to avoid a situation where some people are underpaid and for others it does not pay to work.

For medical staff this is mainly bureaucracy and volume/pressure of work.

Junior doctors are not treated in a professional manner – they have little control over the hours they work and are subject to short-notice shift changes on a frequent basis. Service provision is often provided at the expense of training. When the trainee workforce feels valued it will perform better.

One of the main driving forces behind this is chronic under-resourcing meaning that rota gaps are ‘the norm’. It should be the case that hospitals run on rotas that are habitually ‘over-staffed’ in order to protect training time – this requires more training posts at every level.

For trainees, lack of known localities for the duration of training (up to 8 years) which are not attuned to personal lives. Particularly the inability for couples to apply to work in the same Deanery

Mandatory training has be streamlined and patient centred.

5. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

Geographical inequality is a major issue in rural areas. This is related to socio-economic policy as much as medical health policy. We should not underestimate the risk of paradoxically detrimental outcomes in small hospitals from centrally imposed solutions that involve cost but fail to generate any productivity. Strengthening hub-spoke systems based o specialist centres [particularly neuroscience centres] be a mechanism for avoiding single-handed Neurology ‘departments’ and all the attendant risks of failed recruitment, prolonged absence, and ‘going rogue’.

As with neurology services in general, there is a focus of neurology dementia services in and around major universities and conurbations. These services need to be equitably accessible.

There are historic different opportunities within the golden triangle, also considerably better overall infrastructure (transport etc). Doctors trained there do not want to move to more peripheral or rural sites, though doctors who train in provincial or semi-rural areas are much more likely to stay there for their working lives.

Acute Stroke services should be accessible from all parts of the country. They should be linked with acute neurology services with common facilities, radiology departments and possibly beds.

There are areas of the country where there have been historical issues with recruitment. These have been highlighted by the GIRFT report. In addition, there are some trusts where there are no neurologists at all – this has to be made a priority to resolve.

There is very good GIRFT data on the inequalities in the distribution of neurology consultant and trainees. This data should be core to examining these issues.

A significant barrier to recruitment is lack of confidence that a neurology service is robust enough to cope with workforce deficiencies. So service developments currently underway with NHSE must be coupled with workforce planning to be a success.

Improve links between remote hospitals and isolated, and larger hospitals with virtual MDTs to achieve equality of access to specialist services in all geographical areas.

6. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

Proactive workforce planning. All decisions on service need to be made in collaboration with workforce/HR teams. They’re disconnected at present so all ambitious talk about service developments lack resilience.

7. To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?

Pension issues affecting retention commented on elsewhere in this response.

Salaries do not seem to be competitive in the entire health sector.

The training contracts have to be more flexible to adapt to changing situations. For example, registrars should be able to continue to work as registrars after completing training if not enough consultant posts are available.

The employment of more specialist nurses or AHPs requires a shift in role to more supervision and training

8. 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?

Healthcare jobs need to be attractive so that people choose them, can excel in them, progress in and develop. ICSs need a mechanism for monitoring these factors. Currently, jobs are mapped to the requirements of the perceived needs of the employing organisations rather than being mapped to the health and social care needs of the population.

ICSs will need to collaborate for specialist service provision for equality of access to be achievable. ICSs are seen as independent units but that would fail for specialist services.

January 2022