Written evidence submitted by the Academy Trainee Doctors’ Group (RTR0056)
The Academy Trainee Doctors’ Group (ATDG) is a forum for trainee representatives from the medical royal colleges and faculties to come together. It provides an informed and balanced view on cross-specialty issues relevant to college-registered trainees.
Recruitment, training and retention are the fundamental pillars which support a healthy NHS workforce. In light of growing concerns regarding the numbers of doctors in training and projected workforce figures, exacerbated by the COVID-19 pandemic, the ATDG welcomes the Committee’s inquiry. Our response focuses on issues which are pertinent to trainee doctors across the four nations, including those in both patient-facing and non-patient-facing roles, but which may be applicable to other staff groups within the NHS as well.
Doctors in training form a significant part of the medical workforce, making up almost one-fifth of registered doctors. Our submission highlights the following important considerations for the recruitment, training and retention of trainees across specialties and across the four nations:
a) Training resources
The pandemic has highlighted significant concerns across specialties regarding limited training resources. Challenges include the pressing need for improved IT and digital resources, training inequalities across different geographies, and variable accessibility of study leave and budgets.
Focus is needed on wellbeing and support, including the provision of resources equitably across the four nations, and in terms of removing barriers to trainees seeking help including stigma, guilt of burdening others, concerns about impact on careers, and job loss anxieties. Trainees derive inspiration from those who lead and train them; excellent clinical knowledge and skills are admired but so is the ability to talk openly about difficulties. Fostering an open and honest environment to discuss experiences will help change the current culture, show trainees that they are not alone in challenges they face, and encourage engagement with available resources.
The working environment of trainee doctors should be reviewed by individual Trusts and practices. Providing adequate areas for rest and recuperation and the availability of a balanced diet 24 hours a day 7 days a week will help trainees face current and future pressures.
b) Trainees seeking to re-enter training
Trainees who have taken significant time out of training (due to family or academic commitments etc) and attempt to re-enter training face logistical challenges. Many are expected to provide evidence of their foundation capabilities, which expires after 3.5 years. Trainees arrange placements for these skills to be reviewed and signed off by supervising consultants. To support doctors returning to training, attention should be given to individually tailored gap analyses which adequately capture skills gained while outside of training.
c) Diversity and inclusion
Any person, no matter their gender, ethnicity, religion, sexuality or other protected characteristic, should feel that they can train as a doctor without fear of discrimination or prejudice. This includes trainees with chronic health conditions and from widening participation backgrounds. Many colleges are exploring the inclusiveness of their specialties, and reflecting this in their leadership. Diversity and inclusion should be encouraged and any barriers need to be monitored continually and transparently acknowledged and addressed.
d) International trainees
It is very important for trainee doctors from other countries to be able to work in the UK if they wish to do so. There are many talented doctors who bring experience and knowledge for the benefit of patients, the profession and the health service. This can also work in reverse so that trainees from lower- and middle-income countries can take knowledge and experience derived from the UK back to their institutions. This is one of the intended benefits of the Medical Training Initiative, which is discussed in the Academy of Medical Royal Colleges’ submission to this inquiry. The ability for UK trainees to seek experience abroad should also be optimised.
There must be careful consideration at national level of the workforce numbers needed and the resources required to deliver these. This should include a detailed examination of training numbers across specialties and the impact of the pandemic; more training numbers are needed to ensure existing trainees do not experience undue pressure to sit examinations when they do not feel ready.
Consideration is needed for the maintenance of whole-time equivalent (WTE) trainee workforce capacity in view of the proportion of trainees working LTFT. Many who need or wish to do this (often for personal reasons) are required to work in ‘slot shares’ reducing their hours to 60% of the maximum to ease funding/rostering-related issues. This significantly hampers service provision and progression in training, causes financial distress and impacts morale. Trainees who need to work LTFT should not be discouraged, and given the impact of the pandemic and the increasing rates of wellbeing-related issues, more may feel that this is applicable to them. Some trainees wish to continue working LTFT post-CCT (certificate of completion of training) which will have significant implications for future workforce planning. Similarly, provision should be made to maintain the WTE trainee workforce capacity in consideration of the rising numbers of trainees taking parental leave, the protection of which should be a priority as a protected characteristic of the workforce.
The post-CCT workforce should be expanded to reflect different working patterns that necessitate an increased number of CCT holders. These include more consultants who are resident when working ‘out of hours’ and fewer consultants working more than 10 programmed activity (PA) sessions due to pension-related issues.
Exception reporting is a contractual mechanism whereby trainees can report patient safety, rostering and training concerns. The current practice is not working optimally as the individual is expected to report exceptions themselves which is difficult given existing constraints/pressures. A better model is required for monitoring working hours. If working hours were properly reviewed and recognised, rota needs could be better assessed, reducing pressure on trainees. However, clinical services should consider their response to inadequate junior doctor staffing levels; accepting these levels is not good practice and could create significant patient safety concerns.
f) Curricula and training requirements
Curricula should be regularly reviewed to ensure they meet the expectations for a doctor in specialist training. However, the ability of departments to meet these training requirements needs consideration; those departments which face difficulties need to be supported to help their trainees. If trainees are not adequately trained, this will impact on progression and retention.
Greater flexibility is needed to ensure competency-based training is more reactive/responsive for those who need to change progression plans. Currently some trainees are asked to give training programme directors (TPDs) 12 months’ advance notice if they wish to finish a training level earlier than expected, which in practice can be very challenging to achieve.
There should be improved quality assurance of educational supervision. It should be recognised in consultant/SAS doctor job plans and through sufficient PA time, with the expected delivery of a robust training programme. The supervisor appraisal process should be reviewed to ensure it assesses all aspects of trainee supervision, and collecting trainee feedback on the quality of supervision should be routine.
More focus on development and progression would be possible if trainees were not expected to undertake so many tasks below their current level of training. Instead, these tasks could be supported by medical associate professionals and/or used to provide opportunities for more senior medical students, including through the development of apprentice-style roles.
g) Training length
Training is very challenging and highly pressured. Length of training should not be reduced purely to meet increased demand for post-CCT doctors. Shortening the period of training without adjusting training requirements may have serious consequences, and further increase trainee attrition. Some trainees report feeling pressured into sitting examinations when not ready, and some are concerned about the training time/opportunities lost to the pandemic and how they can progress with confidence.
There is wide variation in the prevalence of LTFT training across specialties. Many trainees who are LTFT feel their length of training is unnecessarily drawn-out and would benefit from more tailored approaches. Jane Dacre’s review into the gender pay gap in medicine recommended minimising increases in overall length of LTFT training by focusing on acquisition of competence rather than time served, an approach which offers greater flexibility.
h) Trainee numbers
Caps on the number of medical places available at medical schools should be decided based upon the number of students that the health services can train to expected standards. More students are needed to deliver an expanded workforce, but this puts pressure on training opportunities. Exposure of medical students to particular specialties during training is very variable and may impact on subsequent recruitment to those with significant workforce issues. Serious attention should be given to how increased student numbers can be adequately supported through increased availability of resources.
Some trainees report wanting to complete training as quickly as possible due to factors that impact on their personal lives and career progression (e.g. lack of geographical stability). The aim should be for trainees to enjoy their training and to want to explore available opportunities. If the following issues are not considered, and with the added impact of the pandemic, trainee attrition will increase.
a) Bullying and harassment
Bullying and harassment still occur too frequently, exacerbated by the hierarchical nature of specialty teams. Bystander apathy enforces the perception that this is normal behaviour. Bystander training should be included in all training programmes and be mandated in the inductions of hospital Trusts. Until this issue is appropriately dealt with across all specialties, there will continue to be trainees who leave due to this issue.
b) Burnout and wellbeing
Levels of burnout are rising; the impact of the working environment and disruption to training should not be underestimated. Many challenges are not new and there is a continued perception that trainees are regarded as a training number rather than as an individual. Many trainees reported the benefits of rest areas and provision of 24-hour hot food during the first wave of the pandemic. However, these have now been removed from many Trusts. Small changes can make a big difference to a tired doctor. Genuine compassion and care for the workforce would have a significant impact.
Many departments are providing wellbeing and support resources to help doctors in need. However, there remains a reluctance to engage with these due to a number of factors (as previously discussed). The health service requires a culture change to see this rectified. Addressing staff attitudes at all levels is required.
c) Finances and human resources
Development opportunities and financial security are attractive aspects of a medical career. However, junior doctors have given many unpaid hours to help over-stretched services, and to meet heavy demands of training. There are many personal expenses and sacrifices.
Neither the Academy nor the ATDG has a remit to cover pay and terms and conditions issues. However, these obviously have an effect on trainees. If the value of pay continues to erode, it will have an impact. It is important to ensure pay levels (and pensions issues) are kept under review and maintained appropriately. Opportunities to reduce financial costs of training that fall to the individual should be encouraged, e.g. provision of funding for first examination attempts, and subsidising indemnity provision and GMC registration could help reduce this financial burden considerably.
There are many challenges that trainees face when changing departments in a new hospital. The frustrations of navigating HR departments, occupational health and payroll are considerable, with inadequate contact details provided and a lack of response to correspondence. Protocols to resolve missed payments are often inadequate. When considering mortgage/rental payments and other lifestyle factors, this has considerable impact on wellbeing. Significant improvements in this process with adequate staffing and better communication would make a considerable difference. As a basic requirement, trainees should be paid correctly and on time from when they start their post. There should be a named contact to correct any issues promptly. Many trainees report waiting considerable time to get IT/security login details when starting in new Trusts. This causes significant frustration and potential patient safety issues.
Communication with trainees at local and national level can be improved. Many changes are taking place within individual training programmes/departments; trainees should be consulted throughout the process and updated regularly with progress. The uncertainty of change often brings discontentment; good communication can ensure that trainees are involved and engaged in the process from the beginning. The tone of communication can also be improved with more consideration of the impact for the recipient.
e) Monitoring trainee numbers/attrition
Monitoring trainee attrition rate and the reasons for this is crucial. Prevention is better than cure and therefore more robust interventions at an early stage to help improve the circumstances for a trainee will be beneficial. Exit interviews would be of considerable value and anonymised data should be available to colleges for review. Consideration is needed for potential barriers to trainees explaining why they are leaving; in smaller specialties or challenging circumstances (incidences of bullying and harassment), trainees may feel reluctant. Support and reassurance should be available, and efforts made to remove perceived barriers.
Better and more transparent monitoring of the number of doctors in training at particular times, the number of those who are LTFT/out of programme/on parental leave etc, and an indication of future intentions in relation to these factors is needed. This would enable more continuous data to identify changing patterns more promptly, and better predictions for workforce planning.
f) Impact of training on personal lives
Trainee doctors may encounter personal challenges including sickness either of themselves and/or of a family member. However, there is often a lack of flexibility to support those facing challenges. Some trainees are separated from family due to geographical requirements of training. Those with experiences of the inter-deanery/inter-regional transfer process report unempathetic and unsupportive processes which are not transparent, with many unable to resolve their issues. It is unsurprising that a trainee doctor may choose to leave in these circumstances. There remains a culture that a trainee should do whatever is required to complete a training programme, no matter what the sacrifice. Again, there needs to be a culture change and improved mechanisms for (re)allocating placements. Training programmes with fewer geographical moves, and incentivising less popular locations (so trainees who can be more flexible have an incentive to do so) should be considered.
Other factors which would significantly improve work-life balance and therefore retention include availability of childcare either onsite or near-site, improved availability of parking, access to secure cycle storage and shower facilities, and greater flexibility with annual leave requests.
g) Availability/accessibility of training opportunities
Inequalities in training exist between different regions of the UK. Trainees in some regions may not have access to particular training opportunities and make alternative arrangements, frequently in their own time. This adds considerable challenge to a pressured training programme and provides further stimulus for attrition, particularly if compounded by difficulties with examinations/progression.
There are also specific issues related to individual specialties that should be addressed if the standards expected of post-CCT doctors are to be maintained. These include recognition of particular aspects of training and protected training time. All specialties should review these individual needs. There are also many opportunities within training programmes including research, teaching or specialist training. Greater flexibility is needed to help trainees engage with these opportunities (e.g. accessibility of OOPE/R), and concerns regarding the prolongation of training should not be a factor to discourage trainees.
There are many study days/courses/conferences that trainees should attend to keep up-to-date with the latest specialty developments, some of which are mandatory. They are expected to take part by submitting abstracts and delivering presentations to meet requirements for progression. However, many trainees have difficulty obtaining study leave and/or accessing study budgets. They often fund these opportunities themselves, particularly as study leave budgets are insufficient to cover costs. Time periods allocated for study leave should be reviewed; with increased use of virtual formats, trainees may not require a full day of leave. The provision of more flexible allocations (e.g. hourly allocation) would allow trainees to pursue more training opportunities.
Some trainees pursue leadership roles (representing trainees on committees or chairing trainee committees). Engagement is encouraged for trainee progression but roles often require significant time commitments. Since provision of ‘professional leave’ is patchy, many trainees use annual leave, which is unsustainable for wellbeing. Reviewing the processes for professional and study leave allocation, and improving accessibility of study budgets, would remove considerable frustration.
h) Reflection and recognition
Anxiety associated with making an error/mistake is felt by many trainees. Errors can and will happen to everyone. How we manage these errors is very important. Fostering an honest, safe and open environment for discussion is key to ensure that others can learn from mistakes and prevent them from happening again. A blame culture still exists and this needs to change to foster a healthy working environment for trainees. We also need to be better at recognising good practice from trainees across the different specialties. Acknowledging achievements in training provides encouragement and recognition of trainees’ hard work and commitment.