Written evidence submitted by the Royal College of Surgeons of Edinburgh (RTR0096)
- Workforce pressures are the greatest challenge facing health and social care today. Attracting and retaining high-calibre and appropriately trained professionals is crucial to ensuring a sustainable health and care system across the four nations.
- Retention of staff is the most immediate problem that requires very urgent attention. Action to protect the mental health and wellbeing of staff is particularly important.
- In the short term, the recruitment issue requires immediate action to tackle staff shortages and attrition. This can be in the form of asking those who have recently surrendered their medical licence to return, and recruitment of overseas clinicians, although both have issues which require attention.
- In the longer term, it requires an open and transparent approach to workforce planning which considers workforce supply, patient demand, and new ways of working and delivering care. It further requires an increase in the domestic supply of medical graduates and action to protect the training pipeline.
Introduction to the RCSEd.
- The Royal College of Surgeons of Edinburgh (RCSEd) is the oldest of the medical Royal Colleges. First incorporated as the Barber Surgeons of Edinburgh in 1505, the College is now one of the world’s largest surgical bodies, with almost 30,000 members and fellows in over 100 countries worldwide.
- Despite our Scottish roots and international reach, around half of our members and fellows are based in England. We therefore support the professional development of a significant part of NHS England’s surgical, dental surgical and perioperative capacity.
- The sole focus of RCSEd is patient care, so we actively engage with policy makers and influencers to improve outcomes for clinicians and patients, providing valuable clinical expertise and frontline experience alike. This forms the basis for our response below. Given our remit as a College we focus predominantly on surgical staff, but also offer comment on a broader range of workforce issues within health and social care.
- There are many long-term issues in the supply, training, availability, and distribution of the clinical and support workforce in the NHS. Currently a perfect storm of workforce shortages has developed from chronic underinvestment, a lack of hospital beds/clinical staff, long waiting lists, overwhelmed A&E departments, widespread burnout, a toxic environment, short termism, constant re-organisation, a target culture, overly complex educational, job planning and appraisal systems, pension ‘reforms’ and increasing bureaucracy. This situation has been greatly exacerbated by the current Covid pandemic.
- The NHS employs 1.3million people, making it one of the largest employers in the world. Paradoxically however, it is short of health care workers. With our aging population, it is likely that the clinical staffing situation will continue to deteriorate as medical care needs increase. In addition, obesity, diabetes, and other chronic diseases associated with the Western lifestyle are likely to increase demands on the system. In consequence The Health Foundation estimates that by 2030/31 an extra 488,000 health care staff will be required, a 40% increase in the current workforce.
- The medical and nursing workforce is ageing. Approximately 30% of nurses are expected to retire in the next 10 years, with around one in ten leaving per year. In 2021, there were 43,590 unfilled nursing vacancies in NHS trusts, relating to a 10.5% vacancy rate for Registered nursing staff in England. This is an underestimate, as when a role has been unfilled for two years it is removed from the statistics.
- The doctor to population ratio in the UK is one of the lowest in Europe with 2.8 doctors per 1000 people (OECD). 6000 more GPs were pledged by 2024/25 in the Conservative manifesto for the last General Election, but this is highly unlikely to be achieved. The average age in which doctors are retiring has fallen from 61 years old in 2007/8 to 59 years old in 2020/21.
- Hospital Trusts are large organisations employing thousands of people. Many of the clinical and managerial posts are extremely stressful. There are potentially serious problems amongst staff, such as alcohol/drug abuse, severe psychological illnesses (including suicide) and stress related diseases such as hypertension, cardiac diseases and other chronic disease secondary to a poor diet, shift work and long working hours.
Retention of staff.
- The immediate and overwhelming priority for the NHS is to retain the existing workforce. The workforce are exhausted, highly stressed and where so before the pandemic began; they are even more so now and are in need of support. There is a symbiotic relationship between retention and workforce shortages - spiral
- Many clinicians are surrendering their medical licence before they reach retirement age. 68.5% of clinicians who surrender their medical licence do so for reasons of stress, burnout, bullying or poor workplace culture, with 7% of doctors doing so within three years of qualifying. According to the most recent GMC report on the State of Medical Education and Practice 7% of doctors are taking ‘active steps’ to leave the profession, defined as accepting or applying for another role outside of medicine or enrolling in a training course for a non-medical role.
- Recent NHS staff surveys and the GMC surveys report long hours of work, work stress, a poor working environment, lack of rest or of satisfactory eating facilities, pressure to meet targets and burnout. This has been described as a ‘toxic’ environment. Many issues arise from the poor IT, lack of appropriate surgical equipment, the use of outdated technology such as fax machines and bleepers, bullying behaviour, multiple sites working, frustration, exhaustion at end of the working day, absence of rest, ‘wobble rooms’ or other quiet areas for breaks mid-shift and often simple issues such as being unable to park at the place of work (especially true in cross site working). Each of these needs to be addressed to stem the numbers of NHS staff leaving.
- Most Trusts do not undertake regular health checks on their staff, which seems paradoxical for a healthcare organisation, particularly when preventive medicine is advocated as a national policy. In comparable organisations in the private sector, it is recognised that confidential psychological support, regular health checks and the provision of high-quality exercise and rest facilities are important to the individual and for developing a successful business. In the health service some trusts offer some of these services, but in most hospitals, provision is haphazard and is often a matter of ‘ticking boxes’ rather than providing occupational health services, rest facilities or gymnasiums/swimming pools etc.
- The success in providing vaccines for Hepatitis B, Influenza and Covid by hospital occupational health departments shows what can be achieved with determination, resources, and commitment. The provision of confidential psychological and mental health support as a matter of routine should be standard. Rest rooms and exercise facilities must be available, and their use encouraged and taking of annual leave should also be encouraged. The Medical Defence Union has found that one in four doctors is so exhausted as to cause risks to patient wellbeing. Structuring of rotas to allow for rotation of staff through less stressful tasks, roles or shifts, and to prevent rapid rotation between day and night shift patterns without sufficient rest and adaptation between them is important.
- The provision of hot food and drinks, in particular overnight and at weekends, and increasing availability of free parking are actions which have been shown to have a positive impact on the wellbeing and morale of the NHS workforce. For some, in particular nursing staff, pay and pensions are an ongoing issue which needs addressing in order to improve workplace morale.
- NHS management increasingly acknowledge that work environments are highly pressurised, stressful and in many cases toxic because of the workload and staff shortages. Many initiatives have been introduced which are beneficial to staff wellbeing as they attempt to alleviate pressures and protect staff mental health. However, actions which staff interpret as insincere or ‘box-ticking’ gestures from management towards protecting their mental health have a strongly detrimental affect on staff morale. As the NHS England Annual Staff Survey indicates there are a large number of NHS staff who assert outdated norms and behaviours such as bullying and undermining and a dismissive attitude towards mental health issues. These individuals must be encouraged to reflect and change both their working practices and behaviours as a matter of priority.
- The current consultant contract needs to be reviewed in order to recognise the increasing complexity and responsibilities of the consultant role. The review would need to recognise the different pressures, priorities and responsibilities between medical professionals at different stages of their career. A structured contract that reflects the changing skill set of an individual through their lifetime and which utilises the skills of consultants throughout their career for the benefit of patient care and for other critical roles such as providing education, training and mentoring to junior doctors and trainees is urgently needed in order to increase teamwork and multi-disciplinary approaches.
Immediate, short-term recruitment.
- Given the time-lag in training doctors and nurses the only possible pools of clinicians for immediate recruitment are either attracting overseas clinicians to the UK or by convincing those who have previously left the professions to return.
- There are ethical concerns with bringing in doctors from less developed countries, where their expertise is desperately required. The Medical Training Initiative (MTI) is therefore an important component of ethical international recruitment. This scheme, focused on but not exclusive to the Department for International Development priority countries, brings in clinicians to work and train in the UK for a period of up to two years before returning to their countries of origin. This allows them to contribute to the NHS whilst learning valuable skills to benefit their home countries. This scheme should be expanded. The scheme also suffers from a brain drain when MTI doctors transfer to a Health and Social Care Visa whilst here. This should be prevented. We are aware of some Trusts moving MTI doctors to the Health and Social Care visa in order to transfer them a non-training role, which raises ethical concerns. We believe our International Postgraduate Deanery provides an excellent model that supports overseas doctors and trainees coming into the UK and after they have returned home, thereby developing their own healthcare systems.
- Overseas recruitment however has a number of obstacles. Firstly, the pandemic is disrupting international travel, complicating the process of bringing in overseas healthcare staff. Secondly, Brexit has put barriers in the way of recruiting EU medical and social care staff, including by making the UK a less attractive destination for EU staff who may now deem the country as less welcoming.
- As a consequence, focusing on convincing those who have recently voluntarily surrendered their medical licence to return are a potential source of recruitment which the NHS cannot afford to ignore. These need to be actively headhunted, rather than the passive appeals thus far undertaken. Those who have surrendered their licence fall into two broad categories. Retirees and those who have left the profession early for other reasons, most frequently because of stress, burnout, poor workplace culture or bullying. The latter group are unlikely to return until the culture and working environment is improved sufficiently to protect their mental health and wellbeing.
- An urgent review of the current overly complex ‘retire and return’ arrangements needs to be undertaken. At present there is confusion and variability on how this policy is adopted and a perceived unfairness in how it is enacted in many Trusts. There is a feeling of ageist behaviour and of being treated as ‘second class’. Most choose this option as they were caught in the ‘NHS pension trap’ but still wish to continue to contribute and work in the NHS. Clarifying and standardising this would allow those who do wish to come back and help to do so more quickly and easily.
- Of those who take early retirement, anecdotal evidence from our fellows indicates that work-life balance issues, shift patterns and a desire not to do on-calls, weekend working, or overnight shifts, are a major driving factor. Many express frustration at the lack of flexibility and lack of availability of less-than-full-time working options. Allowing senior consultants who would otherwise be lost to the NHS to work part-time on a weekday basis, specifically to work through the elective backlog, would be beneficial. There is concern that allowing senior consultants to ‘get out of’ the difficult shift patterns their junior colleagues would have to work would damage the morale of junior doctors, but this is a risk that can be managed. Indeed, flexible and less than full time working should be available to all grades, it would particularly benefit young parents.
- A further factor influencing early retirement are issues with pension rules. The changes in the pension rules with increasing complexity combined with the reduction in the lifetime allowance to just over £1 million with under inflation rises for the foreseeable future (from the initial allowance limit of £1.8 million) has resulted in significant tax bills from HMRC to some senior medical staff. Finally addressing this issue is necessary to allow senior consultants to return to help, and indeed to prevent more of them from being forced out of the NHS.
- As well as increasing the number of doctors, there needs to be more imaginative and effective use of other clinical staff. Healthcare professionals should be enabled to work at the top of their scope of practice and expertise. This will enable clinicians to focus their time on what they alone are trained to do, while tasks that other practitioners are skilled and trained to do can be undertaken by them. Effective optimisation of the workforce releases time for care. With more health and care tasks and interventions being delivered by other groups – such as Medical Associate Professionals and Advanced Clinical Practitioners – it is likely that doctors’ remit will increasingly shift towards providing leadership, giving support on difficult clinical matters, and delivering care to those patients with the most complex needs. The College is actively supporting the professionalisation of Surgical Care Practitioners and their regulation by the GMC rather than their original regulator.
- Across the healthcare sector (and in social care), there is widespread support for the Health and Care Bill to be amended to strengthen workforce planning arrangements, along the lines of the amendment previously proposed by Rt Hon Jeremy Hunt MP. That proposed amendment would require the Health Secretary to publish independent assessments of current and future workforce numbers every two years. Lord Stevens of Birmingham has introduced similar amendments in the House of Lords. Requirements such as those proposed would increase transparency and accountability on future workforce demand and our ability to meet those requirements.
- Workforce planning must not focus solely on current vacancies and staff numbers but should consider a range of factors, including (but not limited to) the increasing demand for flexible training and working, shifts in the requirements of patients brought about by an ageing population and new models of care and ways of working, including the utilisation of new and emerging technologies.
- The College has long called for an increase in the number of medical school places available in the UK. The recent increases are very welcome but need to be taken further. The increase in student places must also be matched by equivalent expansions to the number of Foundation Programme and specialty training places, to ensure there is a smooth flow through the training pipeline. This is crucial if we are to stem attrition and make sure that additional medical students result in an expanded medical workforce.
- Further, the pandemic has resulted in a gap in the training pipeline for surgeons when elective care was paused. Over 250,000 training opportunities were lost in orthopaedic surgery during 2020 alone. Trusts need to be mindful of restoring these when planning to address the elective backlog. Any deals with the private sector also need to stipulate as part of the contract that trainees will be allowed in the operating theatre, as private providers do not allow them to be as a matter of course. This is a critical way of improving trainees morale and retention.