Written evidence submitted by Professor Rachel Jenkins (RTR0052)

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?

NB This submission to the Consultation will largely focus on medical staff.

Expand/double UK medical training places immediately to develop a long term sustainable workforce

1. Introduction

I am Professor Rachel Jenkins, now semi-retired but was former Director of the WHO Collaborating Centre for Mental Health 1997-2012, Kings College London; before that I spent ten years as Principal Medical Officer for mental health, Department of Health 1988-96, and before that was consultant and senior lecturer at the Maudsley/Institute of Psychiatry (1981-4)and then at St Bartholomew’s Hospital and Medical School(1985-88) . Since 1997, I have been working on mental health policy, research and training in low and middle income countries(LMIC), so have had decades in which to see at first hand the damage that the UK and other OECD countries are doing to the health of populations in LMIC  by recruiting their doctors. I am therefore submitting this evidence in the hope that it will strengthen the case to greatly expand UK training of medical students so that the UK neither actively recruits from LMIC or acts as such a major  to passive recruitment from LMIC by having large numbers of unfilled posts in the UK.

With acknowledgements to the following for their inputs to this evidence.

Dr Julian Lob-Levyt, former chief health  advisor, DFID

Dr Elizabeth Goodburn, retired GP

Professor Ruth Mandel, Department of Anthropology, University College London.

The Covid crisis has highlighted the importance of resilience in health systems in all countries across the world. It is now widely accepted that the NHS is significantly understaffed compared to similar countries, and therefore needs to greatly increase the number of staff it trains-indeed double the number of medical student places.

The shortfall in UK trained staff is resulting in heavy recruitment from other countries , especially low and middle income countries (LMIC). Therefore this submission also analyses current UK strategies that are depleting  (LMIC) of their medical staff, leading to the weakening of their own health systems. To meet our international obligations to develop a self sustaining system of health workers that does not rely on recruitment from LMIC, this submission proposes the main steps that must be taken to recruit the extra staff that are needed across the UK health and social care sectors in the short, medium and long-term. The submission  then delves more deeply to suggest structural changes to more efficiently integrate and utilise those staff.

2. Summary

The problem

• The UK trains less than half the number of doctors it currently requires. The shortage is made up through ever increasing overseas recruitment. The UK response to workforce shortages and planning is ad hoc and, in the case of LMIC, unethical and deeply damaging to their health services.

• In 2019, 55% of new GMC registrations were from outside the UK, a rise from 44% in 2013. The UK has utterly failed to meet its obligations in WHO’s code of practice 2010, to which it is a signatory, to become self-sufficient in doctors training. Indeed, even by 2017, 30% of all UK doctors had been trained by other countries, compared to the OECD average of 18%.

• The proportion of doctors now working in the NHS who were trained by LMICs has risen from 25% (66,387) in 2019 to 28% (85,860) in Dec 2021. Whilst this problem is not only confined to the UK, amongst OECD countries it is one of the main offenders (5th worst out of 32 countries).
• Structural constraints between primary and secondary care, between different cadres of workers in health and social care and fragmented service delivery, all lead to system inefficiency and higher costs.

Solutions

• Set up a system of independent monitoring of workforce needs and planning, and mandate Secretary of State for Health and Social Care and Treasury to act on the findings.

• Expand medical student training to achieve a sustainable workforce, and continue the expansion of medical schools into new regions in the UK to encourage local retention

• Set clear goals including but not limited to a doubling in medical student training in the UK, and limiting future recruitment from LMIC's with demonstrable staff shortages to less than 10% of the UK workforce.

• Management Changes to increase Staff retention

• Quality of care. This submission uses the example of mental health care to highlight interdisciplinary and structural changes for improving quality of care. Detailed proposals are made, ranging from modified curricula among different cadres of staff, to better interdisciplinary and integrated working, to tackling social risk factors. However,r such changes are equally applicable across all other aspects of health care and prevention.

3. Body of response to consultation on Medical staffing.

Currently the UK is only training half the number of medical students it needs to achieve a self-sustaining medical workforce. This parlous situation has been developing for many decades and is getting worse, despite numerous warnings from the Todd report 1968 onwards, and despite clear GMC data. The UK is a signatory to the WHO Code of Practice 2010 which requires countries to become self-sustaining in its health workforce. However, at present, the UK shortfall is growing rapidly rather than reducing, and we are on track to worsen this disastrous situation unless rapid action is taken to double the number of medical student training places

In 2017, around 50,000 doctors had been trained elsewhere, but this more than doubled to 112,024 trained elsewhere by Dec 2021.

In 2018/2019, over half (55%) of new GMC registrations were by doctors trained outside the UK. which is an increase from the 44% joining the UK in 2012/2013.

The proportion of all doctors working in the UK who were trained by LMIC has increased from 25% in 2019 to 28% in 2021.

1. The immediate main step must be to double the number of medical student training places.

The problem is a government cap on the number of training places. There is no shortage of willing and suitable applicants of sixth formers to medical school. Many more people apply for medical training than can be accepted for training, due to the restriction of number of training places which each medical school is allowed to offer. The number of medical student places has indeed steadily increased from 7767 in 2017/18 and is now 10,403 (2020-21). But this figure still needs to double if we are to approach self-sufficiency in doctors, and adequately address the commonly reported lack of GPs, psychiatrists and other specialists in the UK without damaging the health systems of other countries.

The costs of medical student training are artificially inflated by SIFT  payments -see table below-which have long been absorbed into basic service provision, so it could not be readily removed for existing numbers of students without hardship to the NHS which has long been reliant on it....however, it could be greatly reduced for future expansion of student numbers . New medical schools could focus on a hybrid model of taking science graduates and putting them through a shortened course of 4 years instead of 6..ie one year for preclinical and 3 years as usual clinical. So it looks to me as if the SIFT  costs are artificial ways of getting more Treasury money into the NHS, attributed to medical students, who do not in fact cost this much.  There is no shortage of people wanting to study medicine. 

SFC – Scottish Funding Council – goes to the Universities

ACT – Associated Costs of Teaching. NHS Education Scotland (NES) distribute to health boards to support clinical placements and teaching

SAAS – Student Award Agency Scotland – flat rate payment for all Scottish students to this agency

Our team had a PQ on this recently and we provided the following tables. If you need anything further just let me know.

2. Increase support and funding for primary care.

Better support to primary care will result in reduced pressures on specialist services. If something goes wrong in primary care, there is often unleashed a cascade of unfortunate consequences that result in an otherwise avoidable hospital admission eg delayed treatment of urinary tract infection, chest infection of skin infection in older people, resulting in confusion, falls as well as more intractable infections.

Primary care in the UK is one of the most comprehensive and cost effective in the developed world, particularly so in the decade of 2000-2010, when funding was increased. Since 2010, funding has been progressively and significantly eroded. This has led to increased pressure on services and staffing.

While some forms of outsourcing have been helpful, the progressive contractual division between GP and other community services such as District Nursing has been seriously detrimental. At the same time there has been less and less funding for extra services based at GP premises such as psychological counselling, specialist clinical outreach clinics, ante-natal & child health, and social services. General Practice and the wider Primary Care services would benefit greatly from funding into these services being re-instated and from systems (including IT systems) that support co-ordination and joint working.

Furthermore, while primary care has been very effective in improving assessment and management of hypertension, diabetes and asthma within routine care, there could still be useful improvements in routine assessment and management of common mental disorders (1 in 6 of the general population and 1 in 3 of all GP attenders) which are closely entwined with physical health issues and social problems, and which have a considerable impact on the prognosis of physical conditions, and so need to be addressed within the primary care consultation as part of a multiaxial approach addressing physical, psychological and social needs simultaneously, especially as psychological symptoms can mimic physical illness and vice versa, leading to diagnostic confusion. This requires regular CPD for primary care staff on these conditions. This would improve the prognosis of physical conditions, lead to earlier intervention of mental conditions, and would result in a reduction in specialist care pressures. 

Such support needs to include

• A supportive environment for primary care-the recent abuse of GPs in the press needs to be stopped. GPs need much more support from government and the press, and the government needs to show leadership over this.
• Systematic dialogue between primary and secondary care (in the rural area in which I am living, both sides complain that the other is impossible to get hold of, and so more structured opportunities for dialogue need to be established),
• encourage co-ordination and co-location between different primary care sectors (social services, psychology counselling, social prescribing, district nursing, midwifery and children’s services, pharmacy)
• provide support for medical student training in primary care environments (this could also facilitate the expansion of medical student training places)
• better IT systems for primary care that communicate properly with the hospital systems, and that enable rapid review of previous history and risk factors to inform each consultation.
• Ensure systematic CPD on mental health skills for primary care. I understand there is a lot of CPD available, but it would be good if all staff had to do mental health CPD every 2 or 3 years as mental health is such a central part of the workload.
• longer appointment times (eg 15 mins at least) to enable multiaxial biopsychosocial care eg people with rheumatoid arthritis are often depressed and lonely because of their pain and lack of mobility, so a multiaxial approach is needed to address their physical, psychological and social needs simultaneously
• better intersectoral liaison eg with local social services, so patients can be readily signposted to help with common risk factors such as domestic violence, sexual abuse, unmanageable debt, housing problems etc; and to social prescribing including things like diet, exercise classes, group activities such as singing, gardening and painting.
• ensure all doctors incorporate health promotion and prevention into their routine consultations-especially physical exercise and mobility at all ages, and a more varied plant based diet. Lack of mobility and balance in older people is shocking and needs a systematic primary care focus to reduce the need for institutional care of older people

In my own field, psychiatry, while many GPs do in fact manage a considerable amount of depression, anxiety and assessment of suicidal risk, I am also aware that some GPs do not consider that they have the requisite skill set to be confident in assessment and management of common mental health problems such as depression, anxiety and suicidal risk. This is a result of too little policy attention to mental health in primary care over the last 20 years, accompanied by inadequate emphasis on these core skills in medical student training and in continuing professional development. The epidemiological situation in relation to common mental disorders such as depression and anxiety (1 in 6 adults in the general population at any one time, and 1 in 3 GP attenders) is such that most need to be seen as core business for primary care, not something to be routinely passed to a specialist waiting list.  If too many such cases are referred, the waiting period becomes too long. So, making sure that GPs, GP trainees and indeed all doctors have these competencies, and have the opportunities for systematic dialogue with psychiatrists, would improve overall mental health care, without simply assuming that the solution has to be an ever expanding supply of psychiatrists, at least until the UK is training enough medical students to support an expansion of psychiatrists.

3. It is not appropriate to actively recruit doctors from low and middle income countries (LMIC)

as this greatly damages their health systems, with clear effects on the health and premature mortality of their populations (see below). Since the start of the pandemic, OECD countries including the UK have expanded their recruitment of foreign health workers, and OECD (2020) has warned that

“While the international recruitment of foreign health workers has been considered as a quick fix to address skills shortages in some countries during the Covid-19 crisis, it cannot be seen as an efficient or equitable solution. First, it does not address more structural imbalances between the supply of and the demand for health professionals. Moreover, given the global nature of the pandemic, it deprives sending countries-often characterised by weak health systems-of essential health workers when facing a major epidemic.”

The recent emergence of the Omicron variant has demonstrated again the importance of having strong health systems in all countries, and the vulnerability of richer countries if poor countries do not also have strong health systems. The House of Commons 2021 report  on Covax and Global access to Covid-19 vaccines highlights (p20) the shortage of health workers in LMIC as an important limiting factor in vaccine roll out, as well as , of course, shortage of the vaccines themselves.

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?

1. DHSC needs to monitor the GMC database closely …this does not seem to be happening! I am astonished by the longstanding lack of policy attention to the shortfall in UK medical student numbers over decades. There needs to be a fit for purpose centre for workforce planning, which annually monitors the training numbers to ensure the UK has a self sustaining supply of doctors. Recruitment of adequate numbers of sixth-formers into medical training is not a problem; the problem is the shortage of training places. More medical schools will need to be built as well as expansion of existing medical schools.

2. Training medical students needs to equip them with the skill sets they will need in their future roles, to be able to deal with all common health problems.

3. training needs to emphasise a holistic biopsychosocial  model, since  physical illnesses, psychological illnesses and social problems are closely intertwined and each affects the other. 
4. The training also needs to provide intersectoral experience  across hospital, primary care, community, and institutional settings  (schools, prisons, care homes etc). A more intersectoral approach was being developed between 2000 and 2010 with medical students doing significant sections of their training in primary care. However, this does of course require additional funding and staffing and I imagine the progress has not been sustained in recent years.

5. Address retention by developing supportive working environments. The GMC database shows that the loss of licensed doctors in the UK due to early retirement from medicine across all age bands is very high. Over the last ten years, there has been a loss due to retirement of between 5,000 and 10,000 doctors for each of the five year age bands between 25 and 70.  Much more emphasis needs to be placed on developing supportive working environments, within both primary care and hospital care. It is likely that the current crop of health service managers are not fit for purpose in setting such supportive environments. Perhaps their pay and bonuses would be better linked to staff retention outcomes than to health service financial processes. Indeed, I am reminded of a conversation with Sir Roy Griffiths (a family friend) who told me about a conversation he had with his transport manager at Sainsburys at a time when Sainsburys was experiencing delivery delays to the shops. Roy asked the transport manager what he thought his job was, and the manager replied, “To manage the transport department”.

So Roy said “Wrong…your job is to get the goods to the shops on time.” Similarly the job of NHS bosses is not to manage the NHS..it is to get the patients better on time….otherwise, if we are not doing that, then tax payers’ money would be better spent elsewhere. Getting the patients better on time relies on NHS managers supporting skilled staff to work their best, which means emphasising staff support in health management training and appraisals, and it means more of a focus on health outcomes than on business processes.

It may be that the reduction in junior doctors’ working hours, following the “working time directive” , necessitating as it did the loss of the “firm” structure of medical and surgical teams, has inadvertently resulted in the loss of a supportive senior team around the junior staff. However, it has likely reduced the risk of junior doctor exhaustion and burn out from the very long hours that junior doctors had to work in the 1960s and 70s. We should certainly be conducting independent exit interviews with all staff who resign, to find out the reasons and what might have encouraged them to stay.

6. Recruit retired doctors back into the workforce…many would be keen and willing to return if the pension problems were  sorted out. Need a better system to recruit retired doctors …many of us were keen to work during the pandemic but were not facilitated to do so…instead we discovered that we were trying to converse by email with a not well programmed algorithm rather than with an intelligent human who could place us appropriately. Pension problems are certainly an issue, but not the only factor. The Appraisal system brought in for doctors including GPs (following the Shipman case) has had benefits (though unlikely to block serial murderers!). However, one of the components is the requirement to undertake an annual appraisal to retain a ‘Licence to Practice’. (This is different from GMC Registration but is overseen by the GMC). Regaining a Licence to Practice is currently a  tortuous process. Since the pandemic the GMC has been looking into how this can be modified but as far as I know they haven’t yet come up with anything substantial.

4. Social work staffing

Social staff (social workers and care workers) need to be trained to be alert to common health problems so they can refer rapidly and appropriately. This will be assisted by integration, co-working and co-location of social workers, GP primary care facilities, district nursing etc

• eg if an older person develops acute onset confusion, there is likely to be a physical health problem eg infection that needs urgent medical assessment and treatment
• Eg if an older person develops a skin infection, it needs rapid medical treatment before it progresses to infect the bones, which are far more difficult to treat.
• Half of all social work clients are clinically depressed so need assessment and treatment by their GP.
• there is a very high prevalence of mental disorders in children in care, so they need routine proactive assessment by their GP so they can be properly treated and so that they can function properly in school.

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

.

The problem

The work which international recruits do for the NHS is invaluable, the NHS is highly reliant on them, and currently the NHS would be sunk without them. But the point here is not about their immense value to the UK but rather about the scale of their lost value to the countries that trained them and to the populations in those countries that need health services at least as much if not more than we do. There has been an extensive literature for some decades documenting medical brain drain from low and middle income countries (LMIC) that demonstrates the damage to the health services in those countries.  These LMIC that lose their home-trained doctors to rich countries have therefore been unable to increase their own doctor/population ratios, and have indeed, especially in Africa, often seen these ratios fall, despite decades of medical training in their universities.

In the early decades of the NHS, certainly a small proportion of internationally trained staff did return to their source countries. I am personally familiar with a few who, after a period in the UK in the 1960s and 70s, have done sterling work after their return to their source countries, setting up academic training in university departments, as well as leading clinical services.  Such returnees from that era have often been my colleagues and project partners in my own decades of overseas policy, training and research work. However, the proportion of overseas doctors who permanently return to their source countries is now vanishingly small (a total of 175 in the last 5 years).

Furthermore, the UK reliance on internationally trained staff is increasing rather than decreasing. The GMC has reported a dramatic increase in overseas trained doctors, known as international medical graduates (IMGs) In 2019 more doctors joined the workforce from outside the UK than were UK-trained, a ratio never before seen. The figure of 112,024 IMGs in Dec 2021 has increased from around 50,000 in 2017, thus more than doubled in the last four years.

But even more worrying, UK reliance on doctors from LMIC in particular is also increasing rather than decreasing. Data extracted from the GMC database indicate that by Dec 2021, the UK has 306,283 licensed doctors, and of these 36% were overseas trained , and 28% were trained by LMIC. The numbers trained by LMIC who are now working in the UK have dramatically increased over the last two years from a total of 66,387 in 2019 to 85,860 in Dec 2021.

The UK is of course not alone in relying on overseas doctors, but it has long been a main destination country. Even by 2006, half of all doctors trained in Africa, who were then working in developed countries, were working in the UK (Kirigia et al 2006); and by 2017, 30% of UK doctors had trained in other countries compared to 18% in OECD countries as a whole and, of these overseas trained doctors, 62% were from LMIC. 

The number of migrant doctors and nurses from LMIC working in OECD countries has increased by 70% between 2000 and 2019 (OECD 2021), so that across the OECD, nearly one quarter of doctors are born abroad and nearly one fifth are medically trained abroad; while, mong nurses, 16% are foreign born and 7% are foreign trained. It is clear that the losses incurred by LMIC due to their doctors coming to the UK are compounded by their losses to other OECD countries. The UK therefore needs to develop its own sustainable health workforce, and encourage other OECD countries to do the same. 

Brexit is resulting in the loss of European staff from the NHS and disincentives for new applicants. In addition the loss of the Erasmus scheme has led to the collapse of junior staff exchanges.

Since the start of the pandemic, OECD countries including the UK have expanded their recruitment of foreign health workers from LMIC still further, and OECD (2020) has warned: 

“While the international recruitment of foreign health workers has been considered as a quick fix to address skills shortages in some countries during the Covid-19 crisis, it cannot be seen as an efficient or equitable solution. First, it does not address more structural imbalances between the supply of and the demand for health professionals. Moreover, given the global nature of the pandemic, it deprives sending countries-often characterised by weak health systems-of essential health workers when facing a major epidemic.”

The pandemic and the recent emergence of the Omicron variant have demonstrated yet again both the importance of having strong health systems in all countries, and indeed of the vulnerability of richer countries if LMIC   do not also have strong health systems.

In relation to the home grown supply of doctors, the expansion in UK medical student numbers is far less than the expansion in recruitment of international trained doctors, so that both the proportion and number of internationally trained doctors is increasing rather than decreasing. The GMC reports that while, from 2012 to 2016, there was a 10% decline in the number of licensed IMG doctors, there was a complete reversal of this between 2016 and 2019, when there was an increase of 16%. This was particularly evident between 2018 and 2019 when the number of licensed IMG doctors grew by 8.3% in a single year. More than half (55%) of doctors who joined the workforce between June 30th2018 and June 30th 2019 had qualified outside the UK, which is an increase from the 44% joining between the June 30th snapshot dates in 2012 and 2013. Over the last 18 months, we have acquired a further 14,000 doctors from outside the EEA,  and the proportion of IMGs trained by LMIC has increased from 25% to  28% in Dec 2021.

In that period, the number of medical student places has indeed steadily increased from 7767 in 2017/18 and is now 10,403 (2020-21). But this figure still needs to double if we are to approach self-sufficiency in doctors, and adequately address the commonly reported lack of GPs, psychiatrists, and other specialists in the UK without damaging the health systems of LMIC, with much lower doctor/population ratios and far worse health indices than we have.

The losses incurred by source countries when their doctors are recruited to the UK include not only the cost of educating the doctor and the loss of that financial investment for 35 years,  but also  the losses incurred by the health service due to lost health promotion, prevention, treatment and rehabilitation; the loss of supervisors, mentors, and role models; the loss of functionality of the referral system; the loss of public health researchers; the loss of custodians of human rights especially in rural areas; loss of savings and entrepreneurs; loss of employment opportunities for ancillary staff; loss of tax revenue; and disruption of families.

Mills et al 2011 examined 9 sub-Saharan African countries and found that the overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn, while the benefit to the destination countries of recruiting trained doctors was the largest for the UK ($2.7bn) and for the US ($846 million).

Besides the lost investment from the education and training cost, interpreting doctors as human capital, there is also a loss from the subsequent productive function of the doctors, which includes an impact on mortality in the source countries. Saluja et al (2020) estimated the economic cost for LMICs due to excess maternal mortality and under age 5 mortality associated with migration of doctors, and the authors found that LMICs lose $15.86 billion annually due to physician migration to HICs. These figures are therefore many times higher than those of previous models on the costs of brain drain. Saluja et al. (2020) estimate the Africa region bears a cost of $6.4 billion annually due to the excess mortality associated with the brain drain of its doctors, reflecting the fact that brain drain does not simply result in a one- time capital loss but rather continues to affect LMIC each year that their doctors are out of the country. When these costs are considered as a percentage of gross national income, the cost is greatest in the WHO African region and in low-income countries.

This skills-drain is clearly an enormous opportunity cost for LMICs and is an unjustifiable subsidy to the UK. The flow of resources from users of poor-country healthcare systems to users of rich-country systems subsidises the latter because the migrating professionals were trained in the LMIC, with their training typically highly  subsidised by their governments. The UK’s National Health Service is using resources from LMIC that it has not developed or earned through investment. The subsidy is perverse and unjust because it worsens global inequity in access to healthcare.

The solutions

1. Aim for at least 90% domestic recruitment and less than 10% international recruitment, because every doctor we take from LMIC damages the health of that country for each subsequent year that they do not work in their source country (see Annex 1,2 and 3 ).
2. We should give adequate compensation each year to LMIC for those IMGs we already employ (see Saluja et al 2020 which quantifies the annual loss to LMIC from its lost doctors),
3. and we need to plan adequate financial support in advance for resettlement into long term posts back in the source countries for those we recruit on supposedly short term training visas.

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:

• 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?
• Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?
• Could the training period for doctors be reduced?
• Should the cap on the number of medical places offered to international and domestic students be removed?

1. Numbers

There is not an adequate system. The GMC has an excellent recording system but no-one seems to be paying attention!

1. An annual watch should be kept on new GMC registrations to ensure that medical student numbers are planned to meet UK needs and  enable all active NHS recruitment from LMIC to be stopped..
2. The cost of training adequate numbers of doctors and nurses should be top sliced from the NHS budget to ensure it has priority.

2. Curricula

The initial and ongoing training of staff in the health care sector should include

1. a multiaxial approach is needed to address patients’ physical, psychological and social needs simultaneously
2. better intersectoral liaison eg with local social services, so patients can be readily signposted to help with the common social risk factors for health problems eg domestic violence, sexual abuse, unmanageable debt, housing problems etc
3. ensure all doctors incorporate health promotion and prevention into their routine consultations-especially physical exercise and mobility at all ages, and a more varied and more plant based diet(especially in view of climate change) . Lack of mobility and balance in older people is shocking and needs a systematic primary care focus to reduce the need for social and institutional care of older people.
4. epidemiology so that all doctors know the prevalence and risk factors of the common  conditions, and can plan accordingly to meet the health needs of their respective populations
5. much more on mental health and mental illness and on the common comorbidity with physical illnesses. All doctors need some regular and systematic CPD on common mental health problems to ensure they have the skills they need to address them without the need to refer to a specialist, since 1 in 3 GP attenders has an identifiable mental health problem, and 1 in 2 general outpatient attenders has an identifiable mental health problem, and these mental health problems worsen physical health outcomes if left untreated. Mental illness is far too common for it to be regarded as a wholly specialist area…there needs to be competent assessment and management at primary care level in the same way that there is for asthma, diabetes, hypertension etc.
6. more on their own mental health promotion, prevention and care. Staff cannot work well when their own mental health needs have not been met.

3. The cap on medical places for domestic students should be removed.  A cap on international students could usefully remain, as domestic students are more likely to stay in the UK afterwards.
4. The training period should not be reduced, but final year clinical students could be made more use of by their respective clinical teams to which they are attached. In my own field, psychiatry, more not less training time is needed, and I expect that all specialties feel the same way.
5. Establish medical schools in every region of the country so that students undergo local clinical placements and are more likely to settle in those areas.

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

1. Burn out-ensure adequate rest , holidays and exercise
2. Lack of supportive supervision-ensure constructive appraisals and reinstate “firm” team structure.
3. Onerous administrative burdens-review and reduce
4. Bullying environments-zero tolerance approach.
5. Poor management that is not fit for purpose ie managers are mistakenly perceiving their role as “managing the NHS” rather than as “delivering improved health and social outcomes on time, across the relevant sectors”.

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?

1. A ten year plan to have a sustainable UK workforce trained in adequate numbers to ensure that the NHS stops all active recruitment from LMIC.
2. Any NHS active recruitment to training schemes for people from LMIC should only be approved if they are accompanied by individual tailored resettlement packages arranged and agreed beforehand, so that trained staff do indeed successfully return to work long term in their source countries. At present, there is no evidence that the UK can achieve this.

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?

1. Need a more supportive environment
2. Regular CPD and access to life long learning opportunities
3. Managers who focus on improvement of health outcomes for their populations.

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?

1. build enough resilience in the system to ensure that it is not running at over 100% capacity all the time
2. better planning for bed numbers and range so that acute beds are not blocked by people needing convalescence and rehabilitation rather than medical care
3. when I was Principal Medical Officer in the Mental Health Division 1988-96, and we were working on the closure of the old asylums (around 120,000 asylum beds) and on the development of local comprehensive psychiatric services including local inpatient beds, as I recall, we estimated a need for around 40-50,000 local psychiatric beds…but there are now only 17,000. I accept we may have over-estimated, but not by that much!! This explains why there is such pressure on local inpatient psychiatric services, why there are so many out of area placements, and why it is so difficult for GPs to be able to arrange admission for acutely suicidal people who need round the clock nursing supervision until no longer actively suicidal.
4. skill mix needs to be informed by the epidemiology of the various conditions…eg mental illness is so common that it is a no-brainer that all doctors need some mental health skills.
5. It is not enough to attract people with the right skills; they also have to be supported with appropriate CPD for the specific role they are in.
6. Retention will be helped by supportive management (see above).
7. Integrated care systems require staff to have good experience in cross sectoral working and coordination, and understanding of information sharing systems

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

Establish medical schools in every region of the country so that students undergo local clinical placements and are more likely to settle in those areas.

Professor Rachel Jenkins, former Director of WHO Collaborating Centre, Kings College, London

With acknowledgements to the following for their inputs.

Dr Julian Lob-Levyt, former chief health  advisor, DFID

Dr Elizabeth Goodburn, retired GP

Professor Ruth Mandel, Department of Anthropology, University College London.

January 2022