Written evidence submitted by FSRH (RTR0117)

Introduction

1. The Faculty of Sexual and Reproductive Healthcare (FSRH) is the largest UK multidisciplinary professional membership organisation representing more than 15,000 members working at the frontline of Sexual and Reproductive Healthcare (SRH) in a range of settings in the community and primary care. Our members are SRH specialists, GPs, nurses, midwives, pharmacists and other healthcare professionals delivering services commissioned by local authorities, clinical commissioning groups, NHS England (NHSE) and Office for Health Improvement and Disparities (formerly Public Health England) in England.

2. Our goal is to ensure that high standards in SRH are achieved and maintained through appropriate funding and commissioning to ensure access to SRH services and realise our Vision for high-quality and holistic SRH across the life course. As such, we oversee the Community Sexual and Reproductive Healthcare (CSRH) Specialty training programme, a six-year run through programme from ST1. Doctors who CCT become CSRH consultants who have been trained to deliver specialist care, but also to be systems leaders, designing and supporting services provided by the multidisciplinary SRH workforce.

3. As a professional membership organisation whose members deliver SRH and preventative services across a range of settings, our response will focus on the pressing issues facing the sustainability of the SRH workforce. In August 2021, we published a survey of our members across the UK, whose results we share in this submission. Between August 2021 and January 2022, we received more than 500 responses from members in England, based in the East of England, London, the North West, the South West and Yorkshire and the Humber. More than half of respondents work in general practice, with others working in specialist SRH services, integrated contraceptive and genitourinary medicine (GUM) services, hospitals as well as independent and voluntary sectors.

Workforce shortages and specific roles and/or geographical locations where recruitment and retention are a particular problem

4. Health inequalities are most acutely felt in remote, rural, coastal and inner-city areas which experience the highest levels of deprivation; many of these areas struggle to attract and retain doctors. In recent years, there have been welcome efforts to tackle these problems, from Health Education England’s (HEE) work on the geographical distribution of training posts and local initiatives to recruit and retain staff in remote and rural locations. However, the CSRH specialty has fallen way behind, and the SRH workforce is facing a recruitment crisis.

5. The CSRH specialty has experienced a deficit in training numbers since its establishment in 2010. In 2011, the Centre for Workforce Intelligence (CfWI) recommended the introduction of 35 specialty training posts to secure a sustainable specialist workforce; however, only 20 were funded. HEE recognised that training numbers were few and unlikely to provide the CSRH service required for the future.

6. Currently, many areas of England, particularly deprived areas, do not have any CSRH consultants in post. As the recent annual report by the Chief Medical Officer (CMO) on the health of coastal towns rightly points out, coastal communities face challenges with access to services as well as with service delivery, where they struggle to reach the critical mass needed to sustain specific services. The south coast of England is a case in point for SRH, with a lack of consultants in Kent, Surrey, and Sussex and no CSRH training posts in these counties. Shortages are also seen in the South West and North of England.

7. A small number of CSRH consultant posts unevenly spread across England leaves whole areas without any SRH leadership to support delivery of care to the population. It leaves the wider workforce delivering SRH in community and primary care without any clinical support from CSRH specialists and limits their training opportunities. This situation accentuates differences in quality and standards of patient care across the country, fuelling health inequalities.

8. From 2018 to 2020, more than half of advertised CSRH consultant posts across England were left unfilled due to a lack of applicants, or because applicants from other specialties did not have the competencies required for the posts. Regarding the appointments that were made, some posts had to be advertised more than once because the employer could not attract enough applications, leaving the posts vacant after the previous post holder had left.

9. The CSRH consultant workforce is also retiring at a faster rate than the CSRH trainees are completing their training. In a workforce mapping survey we ran in 2018, more than 1/5 of respondents stated they intended to retire by 2023. Our specialty team has heard from many FSRH consultant members that they don’t feel they can retire because there is no one available to fill their post.

Wider SRH workforce shortages

10. Widespread and persistent staff shortages require a strategic approach focused on tackling both immediate vacancies and longer-term arrangements for workforce planning. Apart from funding and commissioning barriers, workforce shortages are the main factor leading to decreased access to SRH care for patients, with the COVID-19 pandemic compounding the problem. A respondent to our survey explains:

“We are constantly under-recruiting/ chasing our tail- moderately high turnover of staff; staff off long term sick with mental health and long COVID issues and other staff may request to reduce sessions, so the recruitment is always less than we need.”

11. A staggering number of respondents to our survey (75%) stated that their service was currently experiencing workforce shortages due to unfilled staff vacancies; staff sickness or unavailability due to both COVID and non-COVID related reasons; and retirements. Around 20% of staff who were redeployed in previous waves of the pandemic have not returned to work at their SRH service yet. Our members explain:

“Many staff who have been redeployed have not returned. Lack of skilled practitioners already trained putting a small team under more pressure to train new staff.”

“Several community clinics closed during pandemic and not re-opened, staff shortages due to sick leave, lack of nurses trained to fit LARC.”

“Capacity issues at times due to COVID and long-term understaffing has meant very increased waiting times.”

12. Additionally, 42% of respondents have been unable to provide care to a patient because their service is not commissioned to provide that service and/or because fragmented commissioning makes it difficult. More than half of respondents said that their service did not receive adequate funding to provide a full range of SRH care. One of our members said:

“No full contraceptive services available at the practice or in immediate area and difficult, at times impossible to access in wider town.”

13. Our data reflects the findings evidenced in the 2020 report of the Parliamentary Inquiry into Access to Contraception by the All-Party Parliamentary Group on SRH [1]. The inquiry found that women in England are facing difficulty in accessing contraception, with many being bounced from service to service, which will result in more unplanned pregnancies and increased demand for maternity, abortion care and child services.

14. This unwarranted variation in access and quality of SRH care across the country will not be resolved if we do not have the right leadership and workforce in place to plan and deliver SRH services for all.

Steps to recruit extra staff

15. The recent increase in medical school places is welcome, but there is a significant lag time between entry into medical school and the completion of CSRH specialty training. The increase in student places must be matched by equivalent expansions to the number of CSRH specialty training places, to ensure there is a smooth flow through the training pipeline.

16. The specialist SRH workforce supply gap is the result of a chronic lack of funding for CSRH specialty training posts. CSRH specialty training posts are 50% funded by HEE and 50% by the service. Currently, we recruit at ST1 level and try to rotate trainees into areas where services are not consultant-led. However, this is proving difficult as local authority-commissioned employing trusts tend to insist on trainees’ clinical commitment to their area, when the trainee might need to rotate into other areas. Even without rotation, it is often impossible for cash-strapped local authorities to match the 50% HEE funding locally. Fully funded CSRH training posts, negating the need for the trusts to fund 50% would solve this problem.

17. Our plan to increase the supply of CSRH consultants is practical and achievable, and we have capacity to deliver it. We would like to see one new fully funded CSRH specialty training post per HEE region for the next three years. We would also like be able to recruit trainees at ST3 level, attracting doctors from specialties with high attrition rates such as Obstetrics & Gynaecology as well as those who have completed training in General Practice, but would like to pursue a career as leaders in women’s healthcare.

18. Establishing training posts on the same funding basis as Public Health and opening recruitment at ST3 level would reduce training time and greatly improve the opportunities open to potential trainees in CSRH. This approach would also support the delivery of the recommendations in the CMO’s annual report 2021, particularly around HEE’s geographical redistribution programme and increasing “Specialty training placements (including public health) in coastal areas”.

19. The current barrier to funding CSRH specialty training posts has a direct impact on the sustainability of the whole SRH workforce as SRH consultants are systems leaders who design and support services provided by other members of the multidisciplinary SRH workforce. Investment in CSRH consultant posts is an investment in the whole SRH workforce.

20. In addition, CSRH consultants have received extensive training in Public Health enabling them to ensure that SRH services are focussed on prevention and health promotion and tackle health inequalities.

Fit-for-purpose contractual models for the purpose of attracting, training and retaining the right numbers of staff with the right skills

21. Improved opportunities for flexible training and working are paramount. Contracts must provide sufficient time to allow for education and training, supervision, research, continuing professional development (CPD) and other professional duties – as well as clinical responsibilities – to enable doctors to have meaningful, rewarding and varied workloads. Our members have been telling us that this is not always the case in SRH.

22. The fragmentation of commissioning responsibilities in SRH has created disincentives for the training and education of the specialist and non-specialist SRH workforce. The split in commissioning means that responsibility for training is, at best, unclear.

23. In England, specialist SRH service contracts used to specify that they were required to train local GPs, medical students and nurses, but a lack of funds from public health to pay for these courses means that in many cases this requirement has disappeared. We believe that all local authorities must be financially supported to ensure that service specifications for SRH services include training.

24. GPs and their teams play a vital role in the provision of contraceptive care with 80% of women accessing contraception from their GP. Yet access to Long-Acting Reversible Contraceptives (LARC), the most effective and cost effective methods to prevent unplanned pregnancies, is restricted as a result of fragmented commissioning, a lack of funding available for its provision, limitations inherent to the GP contract and reduced capacity in general practice, with fewer GPs and practice nurses training or retaining essential skills in this area. Responding to our survey, our members have told us the following:

“The pressures on general practice are enormous. Our family planning trained nurse is leaving and she has done most of our implant work.”

“GP contract does not encourage partners to provide increased services for LARC.”

“Not enough sessions to provide LARC appointments - it is rationed due to contracts - I am only allowed to offer 4 intrauterine contraception appointments a week (4-month wait currently!).”

“I am the only GP providing coil removal and fitting. I have been off sick for 14 weeks and now returning. The volume of work exceeds my capacity.”

“We are unable to manage short notice LARC requests as I am the only intrauterine device (IUD) fitter and work one day a month in this role as a locum.”

25. Primary care provision of LARC for the purposes of avoiding unplanned pregnancies is commissioned by local authorities, who have been under severe budgetary pressure for the past decade. Around 11% of councils reduced the number of contracts with GPs to fit LARC in 2018/19. This adds further pressure on community SRH clinics, but there is no evidence of a corresponding increase in contractual support for them, including on workforce training [2]. Uncertainty around the future of LARC services and a lack of communication with public health commissioners reduces the incentive for GPs to train in LARC fitting and removal or maintain their training qualifications, again resulting in reduced provision for patients. Cuts mean less incentive and opportunities for GPs and practice nurses to provide contraceptive care, as evidenced by our members:

“The level we are commissioned and paid to provide is less than that required by our population. If we overperform we don't get paid.”

“Have max number of patients we can see per year due to capped contract.”

26. The Royal College of General Practitioners (RCGP) and the Royal College of Nursing (RCN) have raised concerns about training and maintaining qualifications to fit LARCs [3]. There is evidence of frontline staff being dissuaded from accessing training because they are often expected to self-fund training and do it in their own time. There are also growing concerns that many GPs trained to fit LARCs are due to retire soon. The fragmented commissioning environment and pressures on primary care mean there is little incentive for younger GPs and practice nurses to replace them, as illustrated by the quote below:

“Lack of funding for training new LARC providers when older GPs retire. Succession planning made very difficult.”

27. The SRH primary care workforce must be adequately resourced to provide LARC fittings, and access training, with local contracts keeping with costs of provision, training and maintaining access to this essential service.

Specialty and Associate Specialist (SAS) doctors

28. SAS doctors are vital to the sustainability of SRH services. SAS doctors make up a large proportion of doctors working within SRH, with many taking up senior roles. Data from the General Medical Council (GMC) shows that SAS doctors are performing enhanced roles, most having responsibility for training others, which is the case with SAS doctors in SRH. However, more than a third of SAS doctors themselves report difficulties in accessing CPD opportunities and often do not have the same support for career development and progression.

29. The 2021 contracts are an important milestone for the SAS workforce. We support the introduction of a new specialist grade in the SAS contract reform. This will provide new opportunities for progression within a SAS career, acknowledging the invaluable contribution made by this part of the SRH workforce. The introduction of this new grade will help to recruit, motivate and retain SRH doctors.

30. It is vital that doctors are better supported in their journey to access specialist status via the Certificate of Eligibility for Specialist Registration (CESR) with the GMC. CESR is an important route to increase the number of CSRH consultants in the medium term. However, the CESR route can be quite complex, difficult and expensive with potential inconsistencies. We would welcome work to streamline the CESR process to ensure it is straightforward.

31. Our vision is a fit-for-purpose SRH workforce led by consultants and SAS doctors, whose commitment to high standards of care is recognised by the medical profession as well as across Government and arms-length bodies with responsibility for workforce planning and development.

Factors driving staff to leave the healthcare sector

32. Apart from the workforce issues outlined previously, workplace stress and mental health issues play a significant role in driving staff away from the sector. Despite an incredible show of resilience throughout the COVID-19 pandemic, under-funding, increased demands and insufficient staff numbers has proved very challenging for the SRH workforce, as shown in a member’s quote below:

“Members of admin and clinical staff moving away from employment in NHS due to stress/new opportunities in private work.”

33. As noted in the 2021 Health & Social Care Committee’s report of the inquiry into workforce burnout and resilience in the NHS and social care, “Burnout is a widespread reality in today’s NHS and has negative consequences for the mental health of individual staff, impacting on their colleagues and the patients and service users they care for.” Our members’ survey corroborates this view, with half of respondents experiencing feelings of work-related burnout currently or in previous waves of the COVID-19 pandemic. At present, a quarter of respondents are experiencing burnout. Worryingly, many respondents have felt unable to report it to their employer.

34. We fully support the recommendation in the Health & Social Care Committee’s inquiry report that “chronic excessive workload is a key driver and must be tackled as a priority”, and that this “will not happen until the service has the right number of people, with the right mix of skills across both the NHS and care system.”

35. Additional support provided to health staff during the COVID-19 pandemic should be maintained during the recovery period and beyond, to stop further staff from leaving. Furthermore, employers and the Department of Health and Social Care (DHSC) need to ensure that SRH services are accessible to all who need them.

Adequate system for determining number of doctors and other healthcare professionals to meet long-term need

36. There remains a clear and pressing need for accountability on workforce planning at a national level. We strongly support the proposed amendment to the Health and Care Bill requiring the Health Secretary to publish independent assessments of current and future workforce numbers every two years. This would increase transparency and accountability on whether we are training enough staff to meet future demand.

For further information please contact:

Camila Azevedo

External Affairs Manager

Jan 2022