Written evidence submitted by the British Association of Dermatologists (RTR0066)

The British Association of Dermatologists (BAD) is a charity whose objectives are the practice, teaching, training and research of Dermatology. It works with the Department of Health, NHS England & Improvement, NHS Digital, NHSX, CQC, patient bodies and commissioners across the UK, advising on best practice and the provision of Dermatology services across all service settings. We also collaborate with GMC, the statutory health boards, medical schools and multi-professional Royal Societies to promote and implement training standards across the entire healthcare work force It is a membership organisation representing greater than 95% of consultant dermatologists in the UK.

The Dermatology GIRFT report (published 9th Sept 2021) highlighted the severe workforce shortages in dermatology due to long term restriction on training numbers. Dermatology training is highly competitive with many applicants applying for each training post. The English data from the GIRFT report shows that there were just 508 (WTE) dermatology consultants and 159 (WTE) vacancies. This is reflected in the data collected by the RCP on workforce and obtained in 2019 by the All Party Parliamentary Group on Skin via Freedom of Information requests to NHS Trusts in England, showing a dearth of Dermatology Consultants over large geographic areas. Even Trusts in major cities, including London, are unable to fully recruit Consultant Dermatologists. http://www.appgs.co.uk/publication/view/2019-audit-of-uk-dermatology-coverage/

It is essential that shortages in the dermatology medical workforce are addressed if we are to provide equal access to quality dermatology care.

The GIRFT dermatology national report highlights that,

‘....shortages in the dermatology medical workforce are having a serious impact on the efficient functioning of nearly all units. This was the most important problem raised by managers and consultants, meaning discussions about resolving workforce problems dominated all but a handful of visits. Workforce shortages are a key factor in the increasing use of high-cost locums and other short-term initiatives in an attempt to control waiting lists. Around a third of units have very serious staffing shortages, with some closed to routine dermatology referrals and only providing an urgent skin cancer service. In some areas of southern England, where neighbouring units have partially or fully closed, there is very limited access to NHS consultant dermatologists.’

We would like to highlight a few key points:

•          Workforce shortages has resulted in inequitable access to good care and delays in diagnosis with significant impact on quality of life for patients with skin disease of all ages. Shortages affect all areas, but are particularly severe in district general hospital secondary care sites, which in turn puts increased burden of work on large tertiary centres, who already struggle to meet service and training needs.

•          Skin cancers are the UK’s most common cancer with around 240 000 cases in England per year, many of whom are now waiting over a year for treatment as a result of the pandemic on top of chronic workforce shortages. Data from 2018-19 show that dermatology delivers more two-week-wait (2ww) suspected cancer referrals than any other specialty. Suspected skin cancer referrals account for 21% of all 2ww suspected cancer referrals. Dermatology delivers almost all of these consultations, with plastic surgeons seeing the rest https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2019/07/Cancer-Waiting-Times-Annual-Report-201819-Final-1.pdf.  2ww referrals for skin cancer have doubled from 2012 to 2019, https://www.england.nhs.uk/statistics/statistical-work-areas/%20cancer-waiting-times/

•          The burden of skin disease is significant, representing 23% of the presentations to primary care. Dermatologists deal with eczema which is the commonest disease affecting the population in infants and acne which is the commonest disease in adolescents. 

•          The referrals to secondary care services continue to grow in number and complexity, year-on-year. This is due to patient demographics, ageing population, increasing numbers of skin cancer and the increasing use of systemic therapies which require careful monitoring. These increasing referrals results in many UK hospitals now failing to meet targets or resulting in reallocation of priorities so that people with severe skin disease are commonly (even before Covid) waiting many months to see a dermatologist.

•          An increasing gap for the consultant workload is time to deliver education and training not only for the NTN Specialist Registrars but also for medical students, junior doctors, GPwERS, GPs, nurses, ACPs, PAs, Pharmacists etc. An audit in 2019 performed by the BAD reported that 95% of consultants supervise, teach and train on a daily basis, providing leadership, and educational and clinical governance in order to support and develop heterogenous service teams. 86% of Dermatology Consultants supervise and train nurses. The need to educate and train is likely to increase, and a critical mass of specialists needs to be maintained to deliver service as well as training.

•          There is more part time working and portfolio careers in the workforce which requires more people to be trained to keep the same number of whole time equivalents. The covid-19 pandemic also threatens to increase the number of doctors leaving the profession and retiring early due to burnout, stress and retirement driven by the e.g. pensions legislation/cap.

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?

• Improve medical, nursing and AHP workforce calculations taking into account increased LTFT/ retirement/ population needs.
• Increase medical student numbers to allow for greater health care needs of ageing population.
• Undertake analysis of leaving staff to understand reasons for loss of doctors who are in training and other NHS staff who leave early.
• Improve wellbeing of current NHS staff, so NHS remains a competitive employer
• Understand reasons for loss of senior doctors through early retirement and how to retain in NHS for longer.

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?

• Better understanding of healthcare needs and workforce needs by annual on-line focus group discussions of key staff groups at different stages of career.
• Analysis of key factors affecting job satisfaction in these groups.
• Resolve outstanding perverse incentives in pension scheme for early retirement.
• There should be recognition that staffing planning is difficult and cyclical and as a consequence that short periods of oversupply is inevitable.   This may require surplus staff to be retained for periods of a year or so to avoid shortages when the cycle moves into deficit.  Instead, the NHS tends to force out surplus medical staff through early retirement or emigration leading to shortages a few years later. Understand geographical inequalities in service provision (including secondary care services in district general hospitals) and develop plans to mitigate this variation with incentivisation and support.

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

• International recruitment systems should facilitate movement of outstanding calibre employees who wish to move the UK for family, personal or career reasons.
• The NHS should not be in a position of actively recruiting basic level doctors and nurses because there are inadequate locally trained staff.
• NHS trained professional staff should not be in a position where they feel obliged to leave the UK because no satisfactory career progression exists (as has happened in the past when the staffing calculations have temporarily swung into surplus for a few years).

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?

• Work with individual specialist societies and Royal Colleges to identify granular detail of where there is need. 
• Programmes should offer local flexibility and flexibility by specialty.
• Offer greater support to existing specialist society based CESR programmes (e.g. by supporting examination fees and education grants).

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?

• In Dermatology there has been a cap on specialist training numbers for decades resulting in a depleted consultant workforce.  This cap has been acknowledged informally to dermatology advisors by HEE employees on various occasions over the last 20 years.  The underlying and fixed assumptions leading to this cap should be addressed.  This cap is the main reason for the shortages now in dermatology, as the specialty has been obliged to turn away good trainees for many years. 
• The number of training numbers does not take into account the high number of LTFT consultants in the specialty (higher than any other medical specialty). Workforce planning should take into account LTFT working.

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

• The dermatology curriculum was updated 2021.
• Curricula for GP trainees and other health care professionals should be aligned, with consistent minimum standards agreed to implement these curricula. Efficiencies in dermatology education and training with the support of evidence-based “short contact high impact” learning.

Could the training period for doctors be reduced?

• The breadth of the dermatology curriculum includes management of skin disease of all ages, it also requires medical, surgical, paediatric and histopathological skills. 4 years is the minimum length of training to ensure competencies for completion of specialist training.

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

• There should be reliable review of workforce requirements alongside review of retention of doctors in training in order to feed into the number of medical school places.

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

• Burnout/ stress due to working longer hours than renumerated and required.
• Loss of team working for junior doctors in some roles.
• Changing expectations of work-life balance.
• Wellbeing/ support in junior doctors and senior doctors.  There has been a loss of the camaraderie in medicine over the last 20-30 years.  There used to be acknowledgement that medicine and nursing was highly stressful involving very long hours.  Recreational facilities, staff rooms, sporting facilities, separate eating facilities have all been removed to save money in hospitals over the last 30 years, as the focus has been on process rather than people.
• Early retirement for domestic, financial and lifestyle reasons.
• Removal of financial incentives for very senior doctors to stay in the NHS after the age of around 55 – linked to…..
• Pension issues – the reduction in the benefits of the NHS scheme and the incorrect conviction held that the scheme remains generous to those age 55 and over continues to push senior staff into NHS retirement.

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

• The dermatology GIRFT report has highlighted the significant geographical unwarranted variation in workforce shortages. The current lack of dermatologists means that newly trained consultants choose to go to those centres where there are more colleagues for support. This leads to the larger centres growing larger and around 30% of hospitals being very short staffed so they cannot maintain a full range of services.

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?

• Understanding what the issues are that make people leave and where they go is the important first step in addressing this.
• The culture of the NHS remains focussed on process and most NHS employees consider that the NHS people plan talks the talk but does not walk the walk.

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?

• The current models create financial ceilings particularly for senior clinical nurses in hospitals that do not use ACPs and consultant nurses and for many hospital consultants (particularly if CEA awards are reformed badly).
• Consequently, there is a financial incentive for some senior clinical nurses move into non-clinical roles and some senior consultants to move into private practice. 
• Consideration should be given how to provide the financial incentives to retain the best senior clinical staff within the NHS.
• Financial incentives are not sufficient to retain staff if not matched with other factors leading to job satisfaction such as control of stress and wellbeing; however perverse financial incentives such as financial ceilings or pension issues can be effective at driving senior staff out of the NHS.

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?

• Ensuring a good working environment, valuing staff, listening to staff, respecting staff.
• Effective and integrated team working across the health care professions and social care.

January 2022