Written evidence submitted by the British Society for Haematology (RTR0062)

Background to our response:

The British Society for Haematology (BSH) has been bringing haematology professionals together since 1960 to transform the care our members provide to patients. With over 2500 members, we are the largest UK haematology organisation and the only society which covers all aspects of the specialty.

BSH commissioned a 2019 comprehensive review of the UK haematology clinical work force, capturing details from 79 NHS Trusts and interviews with haematology staff[1]. A 2020 comprehensive survey of our membership further identified concerns following the impact of COVID-19[2].

Background on the haematology workforce:

44,000 blood cancers are diagnosed in the UK each year; 15,000 patients have sickle cell disease; almost 10,000 have haemophilia. Over a million people are anticoagulated and many require monitoring.

Care is provided 24/7 by multidisciplinary haematology teams comprising consultant haematologists, post-graduate doctors training in haematology, clinical nurse specialists, pharmacists, physician associates, biomedical and clinical scientists and specialist managers. Haematology teams also provide multiple liaison services advising and helping to care for patients across numerous disciplines including obstetrics, surgery and general practice. Haematologists also run routine and specialist laboratory services which have expanded enormously in scale and complexity and include specialist genetic testing critical for diagnosing a wide variety of blood diseases. There is a trend towards sub-specialisation due to the increasing complexity of care, for example into haematological malignancies (eg leukaemias, lymphomas), paediatric, obstetric or laboratory haematology. Many UK haematologists are also at the international forefront of research.

Background to Haematology workforce issues:

The NHS does not have sufficient employees to meet rising patient demand. The Royal College of Physicians’ most recent census found 48% of advertised consultant posts went unfilled in 2020[3], up from 45% in 2016/17[4] usually due to a lack of suitable applicants. Despite the rise in part-time working at all grades the workforce in haematology has remained relatively static. Even a stable workforce is insufficient given the increasing incidence of haematological conditions, the complexity of newer treatments and an expanding and ageing population. “Better workforce planning and funding of haematology roles” was the issue selected by most BSH members as their top priority.

Health Foundation research finds that by 2030/31, up to an extra 488,000 health care staff are needed to meet demand pressures and recover from the pandemic – the equivalent of a 40% increase in the workforce, double the growth seen in the last decade[5]. This major workforce boost will require significantly more funding for the NHS – at least 3.2% annual real terms funding increases for health, around £70bn extra by 2030/31.

Starting more than a decade ago, the Department of Health Workforce Review Team recognised the need to expand numbers of haematology doctors[6]; however, this has not occurred. Over coming years, more than one in ten consultants will retire, triggering a further decline in numbers.

COVID-19 has worsened the existing workforce crisis, impacting morale, which 69% of consultants reported had declined during the pandemic[7], and bringing forward the retirement plans of more than one quarter of the consultant workforce. Three-quarters of those who responded to our BSH member survey felt that stress is an increasing part of their day-to-day work and over 80% are concerned about the well-being of those in the haematology profession.

What are the main steps that the BSH recommend?

• Data capture: The BSH are one of 90 health organisations that support the amendment tabled by Baroness Cumberlege to the Health and Care Bill to improve workforce data capture and projections[8] by mandating the regular publication of independent assessments of current and future health and care workforce numbers.
   
• Training junior doctors: We support widespread calls to expand medical school places. There is a gap between the number of doctors completing training and vacancies available, with a 2016/17 census showing 1,542 consultant jobs advertised but only 853 training certificates of completion awarded. Royal College of Physicians (RCP) analysis shows an “unprecedented increase” in those considering NHS careers, which has already translated into higher numbers of applications for education and training[9]. Training takes time; these measures are urgent.
   
• Promote specialist training: More than 1:10 consultant haematologists will retire soon and there is an urgent need to train replacements. However, the Medical Trainee/Foundation Year Doctor numbers within haematology departments dropped by more than a third (36%) over recent years surveyed – from 1.43 FTE per department in 2016, to 0.92 FTE in 2018. This shortage of new recruits coming up through the ranks echoes a trend highlighted by the British Medical Association (BMA) of fewer medical school graduates applying to specialist training.,
   
• Awareness: Raise the profile of the haematology profession via the media and social media, and engagement in schools and colleges including the Prince’s Trust Programme. Advertising roles more broadly than NHS jobs – for example, LinkedIn, Indeed etc – may also reach professionals working in industry, particularly for scientific roles.
• Non-traditional routes to recruitment: Support and promote alternative pathways into the profession, including apprenticeships and programmes such as Step Into Health to encourage employment from the armed forces. Given greater interest in NHS careers during the pandemic, the NHS People Plan notes “We must seize the opportunity to recruit directly into entry-level clinical roles, apprenticeships and non-clinical roles”[10].
   
• International recruitment: It is critical that UK government policy continues to support streamlined pathways to recruitment for overseas medical and nursing staff, and ensures the UK is accessible and welcoming to trainees and doctors from countries outside the UK. Eventually, domestic training should expand to reduce the need for international recruitment which deprives countries that themselves have workforce shortages of staff.
   
• Promoting flexibility: We support the NHS People Plan commitment to flexible working[11]; it is important to ensure this is backed up by provision of necessary IT/ office equipment. The BSH member survey found around half our members wanted better employer support in terms of IT (51%) and training in new practices (40%). According to the RCP[12], the proportion of consultant physicians working less than full time grew from 14% to 23% from 2009 to 2019. Sabbatical leave could help retention and skills development. Employers should take account of the need for different working practices at different stages of life including caring responsibilities, menopause, and older age (explored further in the BMA report[13]). Similarly, the strong response from retired consultants to join the COVID-19 response suggests more could be done to encourage former staff members to rejoin the NHS, as acknowledged in the recent NHS People Plan[14].

• Pay and workplace culture: The BMA[15] notes that consultant pay in England has declined by over 30% in real terms over the last decade which is not good for recruitment or retention. We urge the government to progress swiftly with implementing the recommendations of the Department of Health and Social Care’s Independent Review into the Gender Pay Gap in Medicine, published in December 2020[16], as per NHS People Plan. The 2019 Royal College of Physician survey has found 20% of consultants experienced, and 25% witnessed, bullying or harassment[17]. The 2020 survey noted that 35% of consultants had experienced being undermined and 35% had witnessed a colleague being undermined; this was more common among women and consultants from an ethnic minority[18].

• Three roles need to be expanded:
• A 2020 Haematology Workforce Working Group publication[19], identified clinical scientists as a highly under-recognised and underutilised workforce resource adequate funding for clinical scientist trainees is essential[20].
• Physicians Associates can provide invaluable support across many areas of the haematology spectrum and are being trained in large numbers in universities across the UK but their function is limited by lack of appropriate regulation, meaning that they cannot be independent prescribers or order certain investigations.
• Specialist haematology pharmacists are critical in monitoring of routine drugs and chemotherapy.

What is the best way to ensure that current plans for recruitment, training and retention can adapt to future care changes?

Workforce planning strategies include:

• improving data collection to ensure an accurate picture of staffing needs, shortages and projections 
• Training and development budgets and plans in departments
• Developing talent pools that can be called upon when vacancies arise
• Incorporating flexible and agile working where possible
• Providing good IT links and devices to staff
• Assigning mentors and “buddies” for new staff
• Flexing requirements for specific qualifications when appropriate e.g. removing the need for MSc if higher level IBMS qualifications specific to their discipline are present
• Widespread introduction of novels ways of working and services led by pharmacists, PA’s and nurses into haematology departments across the country.

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

In the short term, recruitment must target both domestic and international suitably qualified staff, with no cap on workers from outside the UK. In the medium term, domestic training should ramp up to ensure sufficient staff are available locally, with caps introduced incrementally and increasing over time.

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?

We support the WHO Global Code of Practice on the International Recruitment of Health Personnel[21], and welcome its greater adoption as part of the recent update to the UK Code of Practice[22].

We welcome the government’s efforts to increase recruitment over the short-term including via the fast-track Health and Care Worker Visa. The NHS People Plan16 outlines several steps to boost international recruitment. We urge speedy progress.

The professional regulatory bodies should consider how to best streamline registration requirements. There may also be scope to reconsider the requirements for certain jobs – for example, within labs to remove IBMS accredited degrees, and allow more flexibility for staff without these degrees to “top up” knowledge and skills from universities.

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:

a.              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 BSH is part of a coalition of almost 90 health and care organisations calling for stronger provisions on workforce planning in the Health and Care Bill. We support an amendment to the Bill originally tabled by the Rt. Hon. Jeremy Hunt MP and now re-tabled by Baroness Cumberlege, supported by Lord Hunt of King’s Heath, Baroness Brinton and Lord Stevens of Birmingham. 

The 2019 BSH workforce report[23] highlighted the imbalance between haematology doctors retiring and those in training; this indicates the current system for determining how many doctors should be trained to meet long-term need is not adequate. Workforce issues have been identified in haematology for a long time, including in a rigorous 2011 Centre for Workforce Intelligence analysis of training needs submitted to the Department for Health, which noted that for Haematology ”recruitment is an issue”[24] which serves as a prompt to urgently reassess how best to encourage staff into the specialty and avoid future workforce issues.

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

The drivers for recently updated medical specialty curricula to make them more patient-focussed, more general in the early years and more flexible in career structure were the independent Shape of Training (SoT) review[25], the GMC review of the curricula and assessment standards and introduction of the GPC framework[26]. Haematology 2021 Curriculum “will ensure that trainees develop the competencies and skills required to be a general haematologist with the ability to support all acute hospital medical takes, other specialties and the community medical teams”.[27]

c.              Could the training period for doctors be reduced?

The Royal College of Pathologists has resisted the move made by other specialties to reduce training by a year (becoming ST4-ST7) as a result of extending core medical training to the three-year Internal Medical Training (IMT). The dual clinical:lab-based nature of haematology training is unlikely to allow for a reduced training period without compromising the knowledge and skills of trainees at the CCT.

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

We support widespread calls across the profession to further expand medical school places. Where possible, training places should be offered to domestic students to ensure a sufficient domestic workforce.

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

Low morale, sickness and absences are affecting the haematology workforce. Between October 2017 and October 2018, the average number of sick days/ haematology department was 796 across all staff, 27% of which were linked to stress or mental illness, exacerbated by high workloads.

COVID has exacerbated existing issues within the healthcare system, with many medical staff stretched even further. Specific impacts within the haematology profession include staff being called on for urgent redeployment to COVID wards, for care of suspected vaccine-induced thrombosis, a growing backlog of unmet needs and concerns about the long-term impacts of COVID on staff mental health. The BSH 2020 member survey found the majority of members have experienced changes in relation to remote working because of the pandemic[28] - although positives were identified including successful remote working, 48% felt that spending too much time at a computer screen had a negative impact on their professional well-being. Additionally, 48% of members were concerned about the impact of less opportunity to involve patients’ families and communicate face-to-face, 44% were impacted by staff shortages, 36% by low morale, and some by working extended hours and cancelled leave.

In a 2020 report[29], the BMA found around one-quarter of consultants are over 55, and six in ten intended to retire before the age of 60. Reasons included: job satisfaction, wellbeing, workload, ill-health, bureaucracy and pension taxation rules. Additionally, younger doctors have many good reasons not to rush into joining the consultant workforce - career breaks, research attachments and more maternity leave as the proportion of female doctors increases exacerbate the imbalance between those leaving and those joining the consultant pool.

A key action[30], would be changes to the NHS pension tax arrangements. A 2019 survey by the Royal College of Physicians found >50% of 2,800 doctors surveyed retired earlier than previously planned, with most citing pension concerns as a reason[31].

We commend the 2020 BMA report[32] which highlighted many helpful key steps in motivating the workforce to stay.

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

Data on regional variation in vacancies is available from the Royal College of Physicians' survey of the consultant workforce[33].

A particular issue within haematology is too few junior doctors joining haematology, leading to an imbalance with consultants approaching retirement. Vacancy rate for Trainee/Foundation Year Doctors is 9%; which impacts safe clinical cover.

There is a particular shortage of recruits to paediatric haematology. Greater awareness of haematology career paths and measures to streamline training in paediatrics may help.

Vacancies [34] are very high in haematology laboratories, with the highest at 24% for Band 8 clinical scientists. Nursing vacancies are, at 15%, compared to 11.1% for nursing generally during the survey period (2018/19). Rotating staff into specialist areas to improve exposure and skills would help increase recruitment into those areas.

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?

The next iteration of the NHS People Plan should acknowledge the great strain those working within the NHS have been under for many years, particularly during the pandemic, and take steps to reward staff for their service and ensure a more sustainable workplace moving forward. This must include issues of pay, improving culture in terms of work-life-balance and flexible working

Specifically, the People Plan should also acknowledge shortages within haematology and take steps to address these with more funded training places and offering protected time for existing staff to retrain and undertake other professional development.

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?

Suggestions regarding flexible working, pension schemes and “retire and return” have been highlighted above.

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?

Changing the structure of the health system will put additional pressures on staff in the short term. Unless staffing shortages are addressed, measures to improve care cannot succeed.

Assuming adequate staffing, integrated care systems could theoretically help meet local needs, provide more patient-focussed care, improve efficiency, and create a more collaborative and rewarding working environment. The haematology profession already involves extensive partnership-working across disciplines including nurses, biomedical and clinical scientists, pharmacists and allied health professionals as well as medics. Care is becoming increasing complex as patients live longer with more complex conditions; within haematology this has led to increasing sub-specialisation by consultants. Both factors underline the need for better coordination of care between hospitals, GPs, social care, and mental health services.

Conclusion 

Despite the challenges facing haematology professionals, our members continue to show drive, energy and passion for their profession. Urgent action is required to support them in return. A supported and resourced workforce is critical to providing high-quality care that people expect and deserve. We are grateful to the Health and Social Care Committee for shining a spotlight on this important topic.

January 2022