Written evidence submitted by The BMA (RTR0070)

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding healthcare and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

There are almost 100,000 overall staff vacancies in the NHS, including a critical shortage of nurses, doctors, and midwives among other colleagues. Additionally, the NHS in England has a much lower doctor to population ratio than comparable nations: the BMA estimates that an additional 50,000 FTE doctors would be needed to raise the doctor to population ratio in England to the average in OECD nations, in order to provide safe and effective care for patients and local populations[1]. The Government must understand the scale of this challenge and meet it with appropriate action. We welcome the opportunity to submit evidence on this subject to the select committee’s inquiry.

1. What needs to be done to recruit extra health and social care staff? 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?

Legislation

1.1   Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the wellbeing and morale of staff working in the NHS and elsewhere. The BMA, alongside almost 90 organisations, including colleagues in the Royal Colleges, influential think tanks and charities, is jointly calling on peers to amend the Health and Care Bill[2] so that it places a duty on the Secretary of State to publish regular, independently verified assessments of the workforce numbers needed, now and in the future, to meet the growing needs of the population. The same amendment was championed in the Commons by the chair of the Health and Social Care Select Committee, Rt Hon Jeremy Hunt, with overwhelming cross-party support. 

1.2   Without its staff there would be no National Health Service. The Government must, therefore, be accountable, through legislation, for ensuring health and care systems have the workforce required to meet the needs of the population, now and in the future. COVID-19 has highlighted and exacerbated the demands on the workforce with burnout leading to significant numbers of doctors considering leaving the profession or reducing their hours. 43% of respondents to the BMA’s September 2021 Viewpoint survey[3] said they were now more likely to take early retirement, while half reported being more likely to reduce their hours. Without significant and sustained action, acute shortages of staff and episodes of unsafe staffing are expected to increase rapidly. Projections by the Health Foundation and REAL Centre show that the NHS workforce would need to grow by over a fifth by 2024/25, on top of current growth, to reduce current staffing shortages.[4] The growth would need to be even higher if the NHS sought to reduce bed occupancy to provide more resilience to health shocks. They estimate that by 2030/31, the NHS workforce would need to grow by 40% and the adult social care workforce by 55%, meaning over 1 million additional full-time equivalent staff.[5]

1.3   Today’s staffing levels are already far behind where they should be. According to BMA research, the number of doctors per 1,000 people in England is 25 years behind comparable OECD European Union nations, second lowest only to Poland. Based on current medical workforce growth rates, we estimate it will take until 2046 for the NHS to reach parity with the 3.7 doctors per 1,000 people that is the average in OECD EU nations today. Our doctor to population ratio is already almost 50,000 FTE doctors short of where it would need to be to meet this average of 3.7 per 1,000 people. Not only does this shortfall impact patient and population care and safety, but it also puts immense pressure on existing healthcare staff, many of whom are being stretched to the limit, being forced to take on extra - often unpaid - work to make up staffing gaps and are increasingly telling us they are close to reaching, or have already reached, breaking point.

1.4   Regular transparent workforce assessments should deliver a shared understanding of the levels of staffing needed to meet national, population-based demand and should inform local and regional recruitment. These reports must be publicly available, and presented to Parliament, to enable proper scrutiny and debate about what policies and investment are needed to prevent instances of unsafe staffing occurring. Importantly, the amendment we are calling for[6] would ensure that these assessments are informed by projected demographic changes, the prevalence of different health conditions, and the likely impact of technology. During questioning in oral evidence sessions, the Prime Minister[7] and Secretary of State for Health and Social Care[8] agreed to engage with this amendment; we hope the Lords’ scrutiny sessions will make progress on a proposal that has such compelling cross-party and cross-sector support.

Short-term

1.5   Given the scale of the current backlog of care and the wider pressures facing the health service, the BMA supports the Health and Social Care Select Committee’s recent calls for a national recovery plan. This must prioritise workforce wellbeing while being honest about the timescales involved in clearing the backlog. 

1.6   Surveys conducted by the BMA show that doctors are exhausted, with one in five BMA members in a recent viewpoint survey (Sept 2021)[9] saying they planned to leave the NHS altogether, and more than two in five planning to retire early. In the short term, protecting and retaining staff is an absolute priority – albeit the measures to improve retention will also help improve recruitment in the longer term. The BMA’s ‘Weathering the storm’ report[10], provided recommendations to governments, commissioners, and employers across the UK to ensure that there are adequate staffing levels to reduce the risk of the NHS being overwhelmed this winter. These recommendations are detailed below.

1.7   Failure in 2021 to offer all doctors a substantial pay rise, and address the years of pay restraint, has had a real and lasting impact on the morale and retention of staff. Not only was last year’s pay uplift sub-inflationary it was also not universal, so those branches of practice (junior doctors and SAS) who had signed multi-year pay deals in good faith pre-pandemic were ruled out of the derisory ‘covid bonus’. The pay uplift was not funded with additional government money either, leaving Trusts to find the uplift out of their existing settlement and GP partners to find the money from their global sum for practice staff’s uplift. Continuing this pattern of pay freeze or pay restraint will only compound the workforce crisis we are now experiencing.

1.8   Punitive pensions taxation rules have led to a growing number of doctors considering retiring early, or reducing their hours, with BMA surveys indicating that two thirds of UK doctors over 55, and one in eight aged between 35 and 54, are considering retiring within three years. The Government must address these taxation rules to ensure that workforce shortages are not exacerbated; the BMA has called for a tax unregistered scheme within the NHS to allow doctors to work the hours they need to without facing financial penalties.

1.9   Staff burnout was significant prior to the pandemic and this has only been heightened; a recent BMA survey (Nov 2021)[11] found that over six in ten doctors were suffering from stress and work-related anxiety. Mental health issues are consistently the highest single category of sickness absence – more than two million FTE days were lost in August 2021 across all staff groups due to sickness, and more than 566,000 FTE days were due to anxiety, stress, depression or another psychiatric illness. Steps must be taken by governments and employers to protect staff’s physical and emotional wellbeing through protecting staff from abuse, catering for their physical needs, and ensuring staff have access to occupational and psychological health services. The Government must also challenge and correct political and media rhetoric regarding the dedication of NHS staff: their efforts deserve to be duly recognised and failing to do so risks both further undermining staff morale, which in turn can affect patient safety and present a false picture to the public.

1.10           Doctors increasingly work as part of multidisciplinary teams with different clinical and non-clinical professionals. However, a huge amount of doctors’ time continues to be taken up by administrative tasks, filling in forms, dealing with correspondence, writing discharge summaries, completing mandatory coding and compliance sections on computer systems, and complying with inspection regimes and revalidation. Given the current medical workforce shortage and that increasing the numbers of doctors will take time, other staff taking on appropriate work from doctors, and reducing unnecessary bureaucracy, could allow doctors to have more time to provide safe, quality care, allowing doctors’ skills to be used in the most efficient, effective way as part of multi-disciplinary teams.

1.11           Financial and organisational priorities discourage many secondary care clinicians from issuing prescriptions for more than a limited period to patients as costs are not being budgeted for within their Trust. This creates unnecessary duplication, with patients sometimes being sent back to their GP for an NHS prescription that they could have received in hospital. Reducing the bureaucratic burden on healthcare professionals by urgently investing in the systems required to facilitate electronic prescribing of prescriptions by secondary care specialists for patients to collect in the community should be a priority.

1.12           International doctors must be supported to concentrate on patient care without having to worry about their immigration status, by granting those who are already on a path to settlement, automatic indefinite leave to remain.

Medium and long-term

1.13           The BMA’s ‘Weathering the Storm’ report offers a range of measures to help retain staff and measures that could help make returning to clinical practice more attractive. This includes offering more support for childcare and returning new parents, and for staff with disabilities; more generous parental leave rights; and offering support for staff going through the menopause.

1.14           There is a clear need for greater investment into the basic IT infrastructure throughout the NHS as a strategy to improve the working conditions and workloads of doctors, and to help retain and maximise the existing workforce. A 2018 BMA survey[12] found that more than half of doctors felt that the current IT infrastructure significantly increased their day-to-day workload, and more than a quarter lost more than four hours a week due to inefficient hardware or systems, further compounding the workforce shortage.

1.15           Systems such as e-rostering and e-job planning, if integrated effectively with existing systems, present opportunities that digital and IT can offer in supporting the workforce through saving clinicians time. Digitising patient records and improving interoperability can help streamline processes for clinicians and patients, alike. Ultimately, this can make the existing workforce effectively go further by reduced wasted time and allowing doctors to see more patients, whilst also reducing the stress staff face as a result of poor IT.

1.16           It is important to recognise that teaching and research are core activities for clinicians, and time needs to be allocated for these activities across the clinical workforce. There is a risk that this allocation will drop as workforce pressures continue to rise. Teaching and research should be included in all service delivery contracts, whether within statutory or private providers, and audited to ensure there is time and space for these activities to improve care quality and effectiveness, and to promote high quality learning and teaching environments and experiences for students and trainees. If these activities are crowded out, we will never be able to address the NHS’s long term workforce supply issues.

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

2.1   Immigration has always played a vital role in the success of the NHS since its inception. The global movement of healthcare professionals into, and out of, the UK means that we must ensure the UK is an attractive and supportive option for those who want to work internationally, recognising the need for the UK to expand training places to promote ethical recruitment.

2.2   IMGs (International Medical Graduates) play a vital role in the delivery of health and social care services in the UK. Around 29% of doctors working in NHS hospitals, and 14% of overall healthcare workers in the UK, are from overseas.[13] It is therefore essential that the UK does everything it can to retain these overseas staff and remove barriers to ethical recruitment and retention for overseas health and social care workers to help plug the workforce gaps the NHS faces. For IMGs this must include high-quality induction programmes, mentorship, and safeguards against exploitative contracts.

2.3   The BMA remains concerned that EU and non-EU nationals will continue to be subject to unnecessary bureaucracy, costs, and inflexibilities, which could compound recruitment problems in the NHS. COVID-19 has highlighted how much we depend upon our international healthcare workforce. At a time when skilled international doctors, nurses and other healthcare workers are risking their lives in the fight against COVID-19 – and most tragically, in some cases dying on the frontline – it is right that the Government should take action to demonstrate our appreciation for the sacrifice and vital service of these individuals.

2.4   Whilst we welcome the fast-track NHS visa to support the recruitment of doctors now the UK has left the EU, the BMA has called on the Government to grant all international doctors currently in the UK and on the route to settlement automatic indefinite leave to remain. This would send a clear signal to our international workforce that they are a valued and integral part of our healthcare system and encourage more of the brightest and best medical professionals to practice in the UK.

2.5   We welcome that the Government has temporarily extended[14] the Health and Care Visa to apply to social care workers, care assistants and home care workers for a 12-month period, but it must now go further to provide a long-term solution for recruiting social care professionals. One in five of the adult social care workforce in England were born outside of the UK (approximately 250,000 people), about 113,000 of whom are from EU countries. Data collected since March 2021 shows a sharp drop in the number of people arriving in the UK to take up adult social care jobs (1.8% of new starters in January-April 2021 compared to 5.2% during the same period in 2019).[15]

2.6   Not only does this impact social care and the vital role that sector plays in our communities, but it has a knock-on impact on other areas of our healthcare system, by placing increased pressure on A&E, primary and community care and making it more difficult to discharge patients who have been treated in hospital back into the community.

2.7   The BMA urges Government to introduce a long-term visa which provides a path to settlement for social care workers and abolish the salary threshold for health and social care workers from overseas.

2.8   Ethical recruitment of doctors from overseas can enable us to partially address shortfalls in homegrown doctors, critical for the delivery of safe patient care. However, international recruitment must not come at the expense of developing countries, so a sustainable long-term workforce strategy is needed.

3. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?

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?

3.1   The current system is wholly inadequate. As mentioned in a previous section, the BMA is calling on peers to amend the Health and Care Bill to place a duty on the Secretary of State to publish regular, independently verified assessments of the workforce numbers needed, now and in the future, to meet the growing needs of the population. Regular transparent workforce assessments should deliver a shared understanding of the levels of staffing needed to meet national, population-based demand and should inform local and regional recruitment. These reports must be publicly available and presented to Parliament to enable proper scrutiny and debate about what policies and investment are needed to prevent instances of unsafe staffing occurring. Importantly, the amendment we are calling for would ensure that these assessments are informed by projected demographic changes amongst the patient population, demographic changes amongst health and care staff (e.g. change in working patterns), changes to the cost of healthcare, new and emerging patient pathways and evidence based treatments, and the prevalence of different health conditions. The coalition supporting this amendment has set out the key principles for amending the Bill here[16].

3.2   The lack of a detailed, long-term workforce plan, built on the data and process set out above, is an oversight which must be corrected if the NHS is to stabilise the current workforce crisis and to have any chance of clearing the huge backlog in care.

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

3.3   Following consultation, the GMC published its revised ‘Outcomes for Graduates’ document in 2018. This sets out what newly qualified doctors from all medical schools who award a UK primary medical qualification must know and be able to do. The GMC also approves curricula and assessments for 65 medical specialties and 31 sub-specialties. These are designed and submitted to the GMC by royal colleges and faculties. All postgraduate curricula must meet the standards set out in the GMC’s ‘Excellence by design’. These standards require that the GMC’s ‘generic professional capabilities’ (2017) are embedded in all postgraduate curricula which has now taken place. The GMC developed the generic professional capabilities framework with the Academy of Medical Royal Colleges to describe the fundamental, career-long, generic capabilities required of every doctor. Given the revision of Outcomes for Graduates in 2018, and the updating of specialty curricula between 2017 and 2020 to incorporate generic professional capabilities, we do not believe there is currently a need for these to be revised.

Could the training period for doctors be reduced?

3.4   Whilst we support competency-based training in place of time-based progression, we do not currently believe there is a safe substitute for the existing five-year undergraduate or four-year graduate entry medical curriculum for students wanting to become our doctors of the future. New doctors tell us that it is not possible to acquire the knowledge and skills any more quickly; shorter courses will not achieve what patients deserve. Training doctors in less time than we do now is likely to compromise their education and reduce the quality and comprehensiveness of patient care. Medicine requires specialisation and sub-specialisation, there remains a risk that in shortening the training period, these important, individual decisions are taken without the same level of experience and become compromised.

3.5   Proposals including a new entry route into medicine via the Medical Degree Apprenticeship and the possibility of applying the Accreditation of Prior Experiential Leaning to medicine are being actively pursued by HEE (Health Education England). In addition, the GMC’s future regulation of Physician Associates and Anaesthesia Associates, and the links between medicine and biomedical science and other healthcare profession degrees, have been put forward by HEE as strong grounds for recognising prior learning and experience towards a medical degree, thereby shortening the period of study. However, taking forward these reforms would bring about fundamental changes to the way doctors are educated and trained, and would involve pushing ahead with proposals that have yet to be fully discussed in depth with the medical profession.

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

3.6   Whilst it’s appropriate for medical school places to be controlled through a Government cap, the Royal College of Physicians (2018 and 2021), the Royal College of Psychiatrists (2019), and the BMA (2020) have previously called for[17] medical school places to be doubled to 15,000 per year within this decade. However, the medical workforce deficit is now worse than previously thought. The Government should, therefore, take advantage of record numbers of people applying (28,690) – a 21% increase on the previous year – and expand medical school places to around 20,471 per annum between 2022-2025 to bridge the gap as soon as 2030.

3.7   Practically, an expansion of medical school places will require a clear long-term strategy and investment to ensure there is enough teaching space, enough educators, enough support for students and enough clinical placements. These medical graduates will subsequently require places on the compulsory two-year national Foundation Programme. A sizeable proportion of them will then go onto specialty training to become GPs or consultants, which will also need to be resourced. Further detail can be found in the BMA report ‘Medical Staffing in England: a defining moment for doctors and patients’.[18]

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

Staff wellbeing

4.1   As previously stated, the risk to the health service that poor staff wellbeing poses is substantial. 43% of respondents to the BMA’s September 2021 Viewpoint survey said they were now more likely to take early retirement, while half reported being more likely to reduce their hours. The poor wellbeing of the healthcare workforce is a significant barrier to the retention of staff. 35% respondents to a November BMA survey said they were experiencing poor psychological health, which had worsened in the last month.[19] This compares to 27% in the previous survey in September. Furthermore, it may take some time for staff to realise the impact of the COVID-19 crisis on their mental wellbeing.

4.2   If the poor wellbeing of NHS staff is not addressed, we will continue to see worrying trends of staff leaving in numbers that affect staff capacity, patient care, and the ability of remaining staff to remain well. A long-term strategy for protecting and maintaining the physical, mental, and emotional wellbeing of the workforce must be a top priority for the NHS.

4.3   A culture of fear, blame, and error in the NHS has led to 95% of doctors sometimes or often fearful of making a mistake on daily basis, with 55% of doctors fearful that they will be blamed for system pressures and failings. A shift towards a culture which values learning over blame and which does not seek to hold individuals responsible for a flawed system is key to promoting a safe environment. 

4.4   The BMA’s ‘Mental Wellbeing Charter’[20] is a resource available to allow providers and doctors to better understand which criteria need to be met to ensure the good wellbeing of staff.[21]NHS England should ensure that any new wellbeing initiatives mirror the recommendations from this charter, whilst all providers should also be asked to show clear plans for how they mean to enact the criteria of the charter.

Abuse of staff

4.5   The abuse NHS staff face remains a significant and unacceptable barrier to retaining the NHS workforce. Reports show that significant numbers of emergency department staff are considering leaving their roles for less stressful positions due to the hostility they face.[22] A July 2021 BMA survey found that two-thirds of GPs (67 percent) said that their experience of abuse, threatening behaviour or violence had got worse in the last year, with half (51 percent) saying they had been personally verbally abused, and 67 percent witnessing violence or abuse against other staff.[23]

4.6   Staff must be protected from any form of abuse or violence (including verbal abuse and that which comes via email/online), with steps taken to provide or enhance security measures where appropriate and swift action must be taken against instances of verbal or physical attacks on staff. This should include assessments of staff security in hospitals and direct assistance to GP practices wishing to undertake security improvements. Likewise, a zero-tolerance approach to bullying in the workplace must be taken by employers.

4.7   Alongside this, the Government must commit to challenging and correcting the political and media rhetoric regarding the dedication of NHS and public health staff. Staff efforts deserve to be duly recognised and failing to do so risks further undermining staff morale which in turn can affect patient safety and presents a false picture to the public.

Punitive pension taxation

4.8   The current pension taxation system serves as a significant driver in senior staff leaving, or reducing their contribution, to the health sector. At present, the steeply tiered contribution rates are exacerbating recruitment and retention issues by unfairly penalising long serving staff. The justification for such tiered contribution rates is to offset the benefit of higher rate tax relief. However, at the current rates this tiering more than offsets the benefit of higher rate tax relief with those paying 14.5% employee pension contribution in effect receiving less than basic rate tax relief. This is the result of the higher rate tax relief being more than entirely removed by the tiered contribution rates. Even taking into account the proposed reduction in contribution rates that is being consulted on by Government, the change to 12.5% as the highest rate does not go far enough, given it still removes at source any and all benefit of tax relief. On top of this the annual allowance (AA) and lifetime allowance (LTA) both attempt to remove this tax relief again. What the system has therefore created is a means whereby doctors find themselves, should they continue to contribute to the NHS, in effect being charged rather than rewarded for doing so. This is compounded by the complexity in identifying when a doctor may be at risk of going above the AA and LTA thresholds. This drives doctors to reduce their work commitments to the NHS or to early retirement, for fear of breaching these thresholds.

4.9   As a result of the pandemic, the issues around the impact on doctors as a result of undertaking extra work or putting off retirement to continue to work within the NHS will be exacerbated in the current tax year (21/22). This arises through the opening values of the member’s pension benefits being increased through an assessment against the previous year’s Consumer Price Index (CPI), which for this year is an allowable increase of only 0.5%. Conversely, the revaluation of pension benefits is based on 1.5% plus the current year’s CPI (3.1%), a total of 4.6%. In addition, despite being sub-inflationary, this year’s pay award of 3% is again assessed against last year’s CPI of 0.5%. Both of these factors may utilise a significant proportion of the available AA, and in some cases may result in a significant AA tax liability even before a doctor has considered taking on additional work.

4.10           Asking doctors to increase their hours, increase their on-call frequency, or take on new roles, risks causing them unprecedented AA tax charges. Unfortunately, no matter how much they would wish to, this will result in many doctors being unable to take on this extra work due to the risk of it causing significant financial detriment. All of this serves to create a situation whereby senior health care practitioners are in effect prevented from contributing further or continuing to remain within the health care sector as a result of this pension system.

4.11           Modelling from the BMA, as well as surveys from the Royal College of Physicians[24], suggest that without decisive action, more than 10% of the consultant workforce is likely to retire within the next 18 months (with a similar proportion of GPs also retiring in that period). It is clear that urgent and significant action is required on this issue. There must be an urgent review of pension taxation as well as reconsidering the appropriateness of tiered pension contributions in a CARE pension scheme. We note the current consultation on the member contributions but would highlight that the proposed changes go nowhere near far enough in addressing the current issues within the system, which are in effect forcing senior health staff to retire early. Options we have considered which we believe will mitigate against the above issues include:

• Introduction of a tax unregistered top-up scheme (similar to that offered to judges) with no tax relief on pension contributions and therefore no assessment against the AA and LTA.
• Mandatory scheme level recycling of employers’ pension contributions for those NHS workers who need to opt out of the scheme because of pension taxation.
• Develop incentives within the schemes to enable doctors to continue to work within the NHS, whether through partial retirement options or through further incentivising later retirement.

Social care

4.12           The current vacancy rate in adult social care is 105,000 (with around 6.8% of roles vacant and the staff turnover rate of care workers at over 34%).[25] Projections indicate that vacancies in adult social care could rise to over 600,000 by the end of 2030, due to rising demands from an ageing population.[26] The recent introduction of mandatory vaccination in the sector has exacerbated staffing shortages further.

4.13           These staff shortages are the result of poor pay, few training opportunities, and a sector suffering from a lack of workforce planning and enforcement of employment rights. Care work is amongst the lowest paid in the economy in general. In 2020/21, care workers earnt £9.01 per hour on average, less than the median hourly pay for sales and retails assistants (£9.22) and the median hourly pay for cleaners and domestics (£9.07).[27] And care workers in the independent sector earn on average around £3,500 less than similar roles in the NHS.[28] Conditions of employment are also a factor, with 24% care workers employed on zero-hours contracts. Staff often don’t get the training and support they need to carry out complex, difficult tasks for vulnerable adults and they lack a career structure – care workers with five or more years’ experience are now paid on average only £0.12 an hour more than new entrants.[29]  Significant funding is required to enable the sector to meet rising demand and to improve the working conditions for social care workers.

4.14           Working conditions, pay, and training opportunities must be improved to encourage individuals to work in the social care sector, as well as to retain those currently working in the sector.

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

5.1   Across primary and secondary care, there are currently 2.9 doctors per 1,000 people in England, while the average in comparable OECD EU countries is 3.7. If the rate of medical workforce growth remains the same, it will take until 2046 before the NHS has the number of practicing doctors needed to match that average. That puts us 25 years behind where we should be today. The BMA has called for legislation enshrining government accountability for safe staffing levels in law (similar to that published in Scotland in 2019) as set out earlier in this evidence submission.

Roles

5.2   An ageing occupational medicine workforce and a clear lack of training opportunities has led to severe workforce shortages within occupational medicine. This workforce has been steadily declining since 2009 – overall, there are currently only 98 specialist occupational physicians working in NHS hospital and community health services in England, compared to 172 in September 2009: this is a decline of nearly half.  The number of all occupational medicine consultants in the UK has fallen from September 2009 to March 2021 by 34%, associate specialists by 38%, specialty doctors by 28% and specialty registrars by 23%. These figures show that a critical situation has deteriorated further.[30] To address the crisis in Occupational Medicine, the APPG on Occupational Safety and Health published a report in 2016 with five recommendations; we think these are still relevant and we believe should be implemented.

5.3   A decline in the number of specialist occupational physicians is particularly salient given the ongoing wellbeing crisis among NHS staff and the vital role these specialists play in ensuring doctors are healthy at work.

5.4   SAS Doctors make up almost 30% of all doctors and are clearly an integral part of the NHS workforce. It is important that all SAS doctors can develop and progress when in the grade.  Recently the Academy of Medical Royal Colleges published a paper calling for SAS doctors to be supported to take on additional roles such as education, research, appraisal, and leadership[31]. To do this, SAS doctors should be able to take specialty-specific exams, provided they fulfil the relevant criteria. Being a SAS doctor and acquiring experience in the SAS grade should not be a barrier to taking exams. Furthermore, NHS Trusts should provide SAS doctors mentors, to provide advice on the opportunities for the SAS workforce, and provide a SAS advocate (as recommended in the 2021 SAS contracts) to provide leadership opportunities for SAS doctors. Finally, Trusts should also develop and recognise SAS doctors as autonomous practitioners, where appropriate to do so.

5.5   Medical academics (doctors working as educators and researchers) play crucial roles in educating the doctors of the future, crafting the curriculum and quality assuring its delivery. Yet over the last 10 years the senior clinical academic workforce contracted by 27% despite a 25% growth in medical student numbers[32]. This trend must be reversed if we are to train the numbers of new doctors required to address the workforce crisis. Additionally, access to teaching and research opportunities may attract staff to traditionally harder to recruit areas.

5.6   GP growth has stagnated, with the overall number of GPs (including trainees) having seen little growth since 2015 when the current data collection method began. As of November 2021, we now have the equivalent of 1,756 fewer fully qualified full time GPs than in 2015. In addition, the number of GP Partners has significantly contracted since 2015. Over the last twelve months alone, the NHS lost 934 GP Partners (headcount). With demand continuing to rise, the GPs that remain are under greater pressure than ever, and many are adjusting their working patterns to LTFT to reduce stress, ill-health, and burnout, or are even leaving practice altogether. Recent survey responses from BMA members suggest this trend is likely to continue (July 2021; just over 2,050 overall respondents) with just under half (47%) of respondents saying they plan to work fewer hours after the pandemic. Alongside the need to reverse the decline in fully-qualified GPs, these trends also indicate an urgent retention issue for GP partners.

5.7   The BMA has highlighted the range of issues around consultant workforce shortages and retention in our ‘Consultant workforce shortages, now and in the future’ report[33]. Even prior to the COVID-19 pandemic, the NHS workforce faced a perfect storm of consultants choosing to retire earlier, a significant proportion approaching retirement age, and a growing trend of younger doctors walking away from a career in the NHS – all of which impact the size of the consultant pool. COVID-19 added significant additional pressure and a growing backlog of care that will also likely impact retention. In addition, we know the role of consultants in care delivery is increasing, with a growing expectation both by the public and medical royal colleges of moving to a system of consultant-delivered care as a way of improving outcomes and making more efficient use of resources. Given the length of time it takes to train a consultant – 12 to 15 years depending on the specialty – immediate action needs to be taken now to grow and to retain the consultant workforce. Delay now will impact the NHS and its ability to deliver timely access and effective services to patients in future.

Geographical distribution

5.8   The distribution of NHS secondary care doctors across the country is currently not proportionate to the population in each NHS region. Specialist care services are often centralised in large cities while providing care to a far greater region, requiring a greater number of doctors as a result – so we would expect to see a larger doctor to population ratio in regions that contain major cities, like London and Manchester. However, we still see significant variation in doctor to population ratio elsewhere. For example, 3.5 million more people live in the Midlands than the North West, but they have 4,000 fewer hospital doctors to treat them. In addition to the uneven distribution of doctors across the country, not a single area in the country meets the OECD EU average of 3.7 doctors per 1,000 people.

5.9   Postgraduate medical training posts have been distributed across England based on historical arrangements, which therefore means that training posts are not fully aligned with local population health needs. Evidence also indicates that postgraduate medical trainees exhibit a greater propensity to remain in the geographical area where they complete specialist training. Consequently, it is perceived that the consultant workforce is much more commonly recruited from trainees who trained locally, with a particular bias towards certain areas like London and the South East and leaving other areas like parts of North England and more rural areas under-doctored.

5.10           It is acknowledged that the geographical distribution of training places therefore affects the future supply of doctors. This is why HEE is reviewing the distribution of training posts in England and has established an Implementation Advisory Group to support this. The redistribution of specialty training places is unavoidable, but investment must also be made in increasing the number of available training places overall to ensure that this program can level up capacity, rather than simply redistribute it.

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

6.1   It is vital that the next iteration of the People Plan takes into account the issues we have already raised and presents a realistic, costed, and achievable plan for long-term staff recruitment in the NHS and public health.

6.2   The previous People Plan announced an intention to increase flexible working in the NHS, and the huge increase in the implementation of working from home and other forms of flexible working during the pandemic shows that it is operationally possible in the NHS. The commitment in the previous People Plan to provide an opportunity for all doctors to apply for flexible working without having to provide justification was welcome, and now must be implemented widely and consistently. Access to flexible working across all specialties and roles (as well as enhancing and expanding flexible training opportunities during post-graduate training) is an essential step towards narrowing the gender pay gap and will support those in the workforce with caring responsibilities.

6.3   Violence against staff remains a considerable issue and more must be done to reduce the violence that NHS staff face in their workplace. The previous People Plan acknowledged this, but more action is still required, such as increasing the penalty for the assault of key workers to 2 years.

6.4   The previous People Plan had a significant focus upon staff safety, and the importance of the health and safety of NHS staff at work has only increased since its publication. The BMA believes there is strong evidence to support extending the use of FFP3 respirators to all care settings where there are confirmed or suspected COVID positive cases. There is evidence[34] indicating lower infection rates among staff working in areas where full respiratory protective equipment is currently recommended, and the WHO now identifies that where respirators are available, they should be considered for wider use - outside of just AGPs - including in the routine care of COVID-19 positive patients.

6.5   The 2020/2021 People Plan committed to offering staff wellbeing services during the pandemic, including a dedicated health and care staff support service including confidential support via phone and text message, free access to mental health and wellbeing apps, and mental health resources and support. The Plan also stated that all NHS organisations should have a wellbeing guardian to consider the organisation’s activities from a health and wellbeing perspective and act as a critical friend, and that NHS organisations should continue to give their people free car parking at their place of work for the duration of the pandemic. These important changes to support staff wellbeing should continue to be funded once the pandemic is over.

6.6   A people plan for social care must mirror the NHS people plan. Working conditions, pay, and training opportunities must be improved to encourage individuals to work in the social care sector, as well as to retain those currently working in the sector. A plan for social care should:

• Create a standard employment contract for care work which includes contracted hours, pay for all hours on duty, sick pay, travel time, and employer contributed pensions.
• Formalise training and introducing an appraisals process for care home staff using the NHS Healthcare Assistant role as a basis.
• Increase basic pay for carers such that all carers are paid a real living wage as a minimum. The real living wage is set at £11.05 per hour in London and £9.90 in the rest of the UK.[35]

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

7.1   The national employment framework is important because it ensures equity in terms and conditions, safeguarding staff, and reducing variation. There are certainly elements of each of doctors’ employment contracts that could be improved through negotiations, to the extent that they might better attract, train, and retain medical staff. This could include, for example, updating contracts to ensure that recognition and remuneration of out of hours clinical activity appropriately reflects the changing shape of the workforce and health service; the consultant contract, for instance, has not been adapted to respond to the increased use of shift patterns that are more commonly seen than when the contract was agreed in 2003.

7.2   Where employers make use of local contracts – i.e. contracts where the terms and pay arrangements may be specific to a given employer – these are often less favourable than the nationally agreed contracts, deviate from best practice, and ultimately will be less effective at ensuring doctors feel appropriately valued. The standard national contracts must be retained as the general model for employment of doctors in the UK, to ensure that national collective bargaining processes can benefit all doctors and employers and seek to address longstanding and emerging barriers to recruitment and retention.

7.3   The existing pay review process for doctors (the Review Body on Doctors' and Dentists' Remuneration (DDRB)), as an element of the current national employment model, has failed in recent years to adequately address the impact of stagnating pay on recruitment, retention, and motivation. We continue to have significant concerns about the approach of the UK governments to the pay review process, the recommendations of which are not treated as binding and can (and have) been ignored. These recommendations have, in any case, been constrained from the outset by the remit letters of UK governments, which undermine the extent to which the process can be considered meaningfully independent. These constraints have resulted in significant long-term pay erosion for doctors, which for some has now reached an astonishing and unjustifiable 28.6% real decline in take-home pay over the period between 2008/09 and 2019/20. While pay is not the sole factor in determining doctors’ morale, we continue to set out in our evidence to the DDRB the significant correlation between sub-inflationary pay awards, the extent to which doctors feel that they and their work are appropriately valued, and the increasing impact on workforce attrition. To the extent that the pay review process is a component of the current model of the national contracts, we believe it is currently failing to fulfil the purpose of appropriately addressing problems with recruitment, retention, and motivation.

7.4   Engagement with BMA members has continued to demonstrate the appetite among doctors for greater flexibility in working patterns and contractual arrangements and the potential positive impact this would have in reducing workforce attrition. We know that the changing demographics and views of the medical workforce have meant that greater numbers identify work-life balance as being a key priority and something that exerts a significant influence over their short- and long-term career plans. Likewise, doctors increasingly report their workload as being a primary driver of their plans to retire. Many doctors who are at a more advanced stage of their career report that undertaking more onerous unsocial hours working patterns takes a greater toll on their mental and physical health, and therefore will seek out contractual arrangements, such as for less than full time working, or that remove components of unsocial work such as on-call, that better reflect their needs.

7.5   There are options around retiring and returning to the NHS on specific contracts to accommodate this, which can be used by employers as a means of retaining experienced clinicians who would otherwise be lost to the health service. The BMA naturally urges NHS employers to make the best possible use of these potential contractual models and believes that they should be strongly encouraged by the Health departments to do so, as an essential retention tool to mitigate the existing workforce crisis.

8. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

8.1   As set out in the newly published 2022/23 priorities and operational planning guidance, ICSs are now required to produce their own whole system workforce plans, building on existing local people plans. HEE and NHS England’s regional teams will support the development of these system-wide plans, which are expected to accelerate the transformation and growth of the healthcare workforce, increase capacity, and to make the NHS a better place for staff to work. In addition, ICSs have also been asked to produce specific mental health workforce plans up to 2023/24, working with local mental health providers, HEE, and other partners.

8.2   While ICSs have a clear and growing role in local workforce planning, it remains vital that government and national bodies take responsibility for workforce shortages and for gaps in specific specialties. The current workforce crisis requires nationwide and coordinated action to resolve and cannot be left to each local health and care system to handle in isolation.  As mentioned previously, the BMA continues to call for an amendment to the Health and Care Bill that would enable proper scrutiny and debate about what policies and investment are needed to prevent instances of unsafe staffing from occurring, strengthening government accountability for workforce planning.

Jan 2022