Written evidence submitted by The General Medical Council (RTR0132)

Our role

1            The General Medical Council’s (GMC) role is to protect patients and improve medical education and practice across the UK. As part of this, we oversee UK medical education and training, and we set the standards that doctors need to follow throughout their careers. We also take action where necessary to prevent a doctor from putting the safety of patients or the public’s confidence in the profession at risk.

Summary

2            COVID-19 has shown how crucial a well-supported and effective NHS and healthcare system in all four countries of the UK is, and the most vital part of the healthcare system are the doctors, nurses and other healthcare professionals who need to be supported in carrying out their roles.

3            We see support for the workforce as crucial to our role as a regulator and our objective of protecting the public. Only with the right workforce with the right skills working in compassionate, inclusive environments can the public be best protected. We are therefore pleased to support the Committee through the following ways:

4            Looking at the insight from these sources, we have concluded that there are a number of common themes that the Committee should focus on. These are:

 

5            Further detail on these points is contained in response to the Committee’s specific questions below.

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?

 

6            In the short-term, retention is vital for creating a sustainable workforce and it will have the biggest single impact on overall workforce numbers. The ongoing pandemic continues to affect doctors’ career intentions and the medical workforce. In 2021, 23% of doctors said they were planning to leave the profession, up from 19% in 2020. This year 7% of all doctors said they had taken ‘hard steps[*]’ towards leaving the profession, up from 4% in 2020 and 3% in 2019.

7            That is why we need to improve retention by urgently addressing the reasons doctors leave practice. Our data shows that improving retention is fundamentally about improving working environments and making the workforce feel more valued. We provide more information about how to do this later in this response.

8            The UK has also recently seen increasing levels of overseas-trained doctors joining the register and contributing to the NHS medical workforce. The GMC has responded to this growing demand by adapting our registration processes. We have taken steps to satisfy ourselves that overseas applicants meet all necessary standards, whilst avoiding delay for doctors wishing to work in the UK.

9            In the medium-term, the health system as a whole has to assess what types of professionals it needs to train and recruit to meet patients’ needs. Given the pace of change in healthcare and the length of time it takes to train a medical trainee to consultant or GP level, it is important that workforce planning takes into account how doctors who are training now might not practise the same way as doctors who trained 10 years ago. This will require a more flexible definition of professional roles and a focus on continuous professional development. 

10       That is why we are working with Government to amend the Postgraduate Medical Education and Training Order to support a number of reforms to specialist and GP registration with the outcome that it will be more accessible to a wider group of applicants by broadening out the evidence we will accept that enables them to demonstrate their knowledge, skills and experience and make the process swifter and less bureaucratic.

11       To meet longer term workforce planning needs, governments across the UK will have to make decisions on the number of medical school places. We expect these decisions will need to be considered in the context of an increasingly ageing population, with accompanying changing healthcare needs and consequential increase in workforce demands. The role of the doctor, alongside roles of the wider clinical workforce, will likely alter in response to these changes, and therefore should also be taken into account.

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?

 

Standards for medical education and training
 

12       The way we set the educational standards for all UK doctors through undergraduate and postgraduate education and training will ensure current plans will evolve and adapt to meet future needs.

13       We approve postgraduate curricula, working with the statutory educational bodies, governments and employers to assure the quality and content of curricula. And through our focus on Generic professional capabilities in recent years, embedded through those curricula, we have increased the emphasis placed on wider professional skills such as communication, team-working, and working with evolving technology. We also set outcomes for undergraduates through Outcomes for Graduates, ensuring that doctors coming on to our register from UK medical schools have the skills, knowledge and capabilities that they need to meet patient needs.

Good medical practice

14       We believe that a broad training approach based on developing the right range of skills, as set out above and in line with the principles of Good medical practice, (our core guidance for doctors, which we are currently revising), is essential because this will ensure the workforce has the skills it needs to meet patients’ needs, today and in the future. It also provides the basis for the outcomes that we set at each stage of education and training.

15       In addition, we also believe that there is a strong case for greater involvement of employers in considering the content of courses, and for identifying the requirements for doctors at various stages.

      The Committee may wish to consider how to encourage greater employer input into future outcomes and into curricula at every stage of medical education and training.

Medical associate professions

16       As part of planning for the healthcare workforce of the future, we need to think critically about which professional is best placed to provide care and what changes are needed to the way teams work together. Nurses, pharmacists, physiotherapists, and others have taken on more responsibilities during the pandemic, so we have already seen a shift and it is important that workforce policy planners actively consider skills mix as they develop future workforce plans

17       The forthcoming regulation of MAPs, or PAs and AAs, is a key case in point. These roles, trained to the medical model will be well placed to relieve doctors of some tasks, freeing them up to work nearer the top of their licences.

18       To seize this opportunity, national bodies and workforce planners will actively need to consider how best to deploy PAs and AAs, and consider how quickly they want to expand the number of these. Additionally, employers will need to be clear about the roles, remit and skills of PAs and AAs and what is expected of them.

      This planning for the increase and deployment of PAs and AAs should take place across the four UK countries. While there are different approaches across the four nations, high-level central coordination would help ensure preparedness and consistency

      NHS England (NHSE) should review current placement tariffs to make the PA/AA roles more attractive to employers.

      Government, NHSE and health education bodies should explore the most appropriate clinical governance arrangements for PAs and AAs. We understand that in some organisations PAs and AAs are grouped with nursing or allied health professions, rather than being managed as part of medical staffing.

      To maximise the workforce contribution these roles can make, we encourage the Committee also support the extension of prescribing responsibilities to these professionals. We are currently advising DHSC on the education, training and patient safety considerations involved.

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

Our role

19       As a professional regulator, we have no direct responsibility for recruitment to the medical workforce. As such it is not within our gift to determine the correct balance between domestic and international recruitment of health and social care workers in the UK workforce.

20       We also do not set the number of places UK medical schools can offer. These are set by Government and the Office for Students, as medicine is an intake-controlled subject. However, we do want to be assured that medical schools have adequate clinical placement capacity for the numbers it proposes to offer. 

21       As the regulator for doctors, we do and will ensure that only those applicants with the necessary knowledge, skills and experience for practice in the UK are granted registration and access to their profession. We do this by setting the standard for registration, assessing applications for registration and holding and maintaining the medical register. Because of our unique role we can provide data and insight about trends in domestic and international registration which we have provided below.

Our registration data

22       Our 2021 report The state of medical education and practice in the UK reflects the UK’s reliance on international medical graduates (IMGs) in the medical workforce.

[†]

23       Our reliance on overseas doctors means the UK’s health services must commit to support them to thrive and succeed. We should be proud of the diversity of the UK’s medical workforce. However, we must continue to work together to ensure that all healthcare environments are inclusive and fair, and we know that further action needs to be taken to achieve that ambition. We set out our thinking on that later in this response.

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?

Developing a more flexible registration framework

24       We are currently working with Government to reform the legislation which governs our processes. With legislative change, our ambition is to develop a simplified, more flexible and accessible registration framework that requires all applicants to demonstrate that they meet the same single standard for registration. This will apply regardless of whether an applicant is a UK or IMG and applying for full, specialist or GP registration.

25       This flexibility will enable us to support UK and IMG applicants to use a range of evidence to demonstrate that they have the necessary knowledge, skills and experience to meet our standards. In the meantime, to improve our processes we are:

26       These will incorporate EEA specialist qualifications post-Brexit but also be open to all IMGs who are qualified specialists and GPs.

27       These reforms and the new pathways we create, will give doctors more flexibility in how they apply for GP/specialist registration and allow us to accept a wider range of evidence from applicants to demonstrate their knowledge, skill and experience for specialist/GP registration. 

28       These changes are of particular relevance, not to only internationally qualified specialists/GPs, but also UK based specialist and associate specialist (SAS) doctors and who are seeking recognition of their specialist qualifications and experience to work as a consultant or GP in the NHS.  

      We therefore ask that the Committee consider encouraging the Government to progress regulatory reform swiftly to enable us to deliver these improvements.

The current context

29       The Professional Linguistic Assessment Board test (PLAB) tests doctors who qualified abroad to assure us they have the right skills and knowledge to practise safely in the UK.

30       During the pandemic many countries closed their test centres. Despite the restrictions introduced in the UK, we kept our PLAB centres open and have invested in building and staffing a new temporary social distanced Clinical Assessment Centre to increase our testing capacity. This expansion will accommodate up to 15,000 candidates per year when operating at full capacity.

31       In 2021 we registered over 12,000 doctors from outside of the UK. Since the start of 2022, we are seeing an average of 250 international doctors joining the UK workforce per week, having met our standards through PLAB tests or other routes.

32       It is important to note that PLAB is not the only full registration pathway for IMGs. In addition to the PLAB route, we introduced a new Acceptable Overseas Regulators Exam pathway that recognises certain overseas registration exams as an alternative to PLAB and enables overseas doctors to demonstrate that they meet our criteria. They may apply on the basis that they hold an acceptable postgraduate medical qualification (PGQ) or if they are accepted onto a GMC pre-approved sponsorship scheme. Our 2021 The state of medical education and practice report shows that by mid-2021 50% of IMG applications for full registration were granted via the PGQ and sponsorship pathways. This is broadly in line with trends seen in previous years.

 

 

 

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?

33       There are several lessons that can be learned from the pandemic, including the need for flexibility in the system. We made a number of changes to curricula, removing some duplicative assessment whilst still meeting the required outcomes, and we are continuing to work on the potential for further changes here. There are clear opportunities to help diversify the medical workforce through opening up different routes to qualification and showing greater flexibility in how outcomes are demonstrated, in particular through greater use of remote technologies, and identifying where examination is and is not useful.

34       In addition, leaving the EU removes the requirements around set periods of time for both undergraduate and postgraduate training and education. Our Generic professional capabilities for postgraduate training and Outcomes for Graduates for undergraduate education are based on the principle that we should be assessing capability, not on how long people train for or the number of times they repeat a skill. All postgraduate curricula have now been revised to reflect this, and the pandemic has demonstrated the ability to make changes without compromising on the standard expected.

35       Working with royal colleges, we need to build on this by ensuring that training is appropriate to the requirements for doctors at each stage, with outcomes that reflect the needs of the health service. We can base this in future on what is the right training to gain the capabilities that are needed, exclusively considering outcomes rather than basing decisions on minimum training periods.

36       We want to work more closely with employers to ensure that we have the right outcomes to meet patients’ needs. The outcomes are designed to reflect the requirements for doctors, but, as these change and different service requirements emerge, we will want to work with others across the system to ensure that the expectations of doctors are correct. This would need to be linked to clear workforce planning around the appropriate roles for various members of the workforce and required numbers. 

      We believe that there should be greater input into outcomes and curricula from employers to reflect changing patient needs. The Committee may wish to recommend that the GMC and colleges must continue to ensure proportionality in assessment to reduce assessment burden where it is safe and appropriate to do so. 

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?

37       There is currently no comprehensive process for assessing future needs for the different kinds of profession. Any such plan would have to consider a range of factors, including the changing patterns of health and care needs, changing patterns of care and skill mix, and other factors such as the geographical factors that lead to different ratios of doctors to patients in different parts of the UK.

38       The GMC would wish to be closely involved in any such process, both because we could help provide the data and evidence needed, and because we would need to be involved from an early stage in any changes to UK education and training numbers, to ensure that quality and standards of training provision could be assured.

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

39       We set the educational standards for all UK doctors through undergraduate and postgraduate education and training. We also:

40       We have recently completed a review of all post-graduate curricula for doctors to ensure that they are in line with our Generic professional capabilities. The ability to recognise outcomes, not time has also enabled us to recognise more capabilities achieved outside training, and it is also important that the service recognises the skills and capabilities of those who do not take up traditional training routes including SAS and locally employed doctors. As we review Good medical practice we will consider if changes are needed to the Generic professional capabilities.

41       In Outcomes for Graduates (revised 2018) and the Practical Procedures List  (revised 2019) we set out what newly qualified doctors from UK medical schools need to know and be able to do before they can register with us. This focused on readiness for practice, delivering patient focused care and managing uncertainty, which are also the main themes that guided the Medical Licensing Assessment (MLA) content map, which in turn will also drive curriculum focus.

42       Furthermore, in early 2024 we will launch the MLA which focuses on the essential professional skills, knowledge and behaviours needed for safe practice in the UK (and covered in the MLA content map). 

43       In developing our MLA, we want to concentrate on what is expected of a new doctor rather than specifying the length of a course; we want to identify the knowledge, skills and behaviours needed to practise medicine safely rather than setting an arbitrary time-spent requirement for education and training. We believe this approach offers flexibility and adaptability in bringing new doctors into the UK healthcare system whilst still maintaining standards.  

44       Also, through the MLA we will, for the first time, create a common threshold hold for safe practice and a consistent, core element to the assessments held at all UK medical schools. The MLA will also be taken by those international doctors who would currently gain registration through sitting the PLAB test. The introduction of the MLA will strengthen our ability to monitor and approve the standard for entry to the profession over time. In this way, we will be able to ensure that our standards match patient need and doctors new to the register are well prepared to provide safe care. The MLA will also assure us and the wider healthcare system that doctors have demonstrated the core knowledge, skills and behaviours that we require for their point of registration and bolster the confidence that patients, employers and colleagues can have in doctors new to the register, regardless of the medical school or the country where those doctors received their training.

Could the training period for doctors be reduced?

45       Prior to exiting the European Union (EU), UK undergraduate and postgraduate training was governed by the EU’s mutual recognition of professional qualifications directive, which stipulates:

46       This has long been counter to our principle that time spent in training is not what we should measure. In our view, the focus needs to be on whether trainees have achieved our outcomes for the relevant part of training and completed the curriculum, so that we are confident they are at the high standard we expect. Now that the UK is no longer bound by the Directive, there is the opportunity to recast how requirements are set, so as to be focused on outcomes being met rather than on time. As the regulator, our absolute priority will remain patient safety, which means that the standard expected of trainees, and the quality of training, will remain paramount, and the high reputation of UK training will be maintained.

47       At undergraduate level, the introduction of the MLA from 2024 will provide assurance that newly qualified doctors have demonstrated the core knowledge, skills and behaviours required for their first clinical posts, regardless of undergraduate programme length.

48       At post-graduate level, royal colleges submit their curricula for approval by the GMC. As well as the potential for shorter specialty training, we have already started to use the flexibilities from being outside the EU. For example, the directive requires a minimum time period spent in a hospital setting, even for non-hospital-based specialties. This has meant that if an individual misses even a few days of training, they can be required to return to a hospital setting to make up the time difference at the end of their training. Since this rule no longer applies, we have allowed trainees in this position to complete their course, provided they have met all the outcomes.

49       There are some risks to this approach that will need to be considered. Moving out of line with the EU may make the UK a less attractive place to study for EEA nationals[‡] who would not be able to have their shorter UK qualifications recognised should they decide to return to their home country. Equally, any changes may result in issues around recognition of UK qualifications in the Republic of Ireland, whose regulators might be unable to recognise diverging UK qualifications. This may have a corresponding impact on cross-border healthcare provisions.

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

50       This is a decision for government as medicine is an intake-controlled subject managed by the Office for Students. As noted above, if there is to be expansion of medical school places, we want to be assured that the school has adequate capacity, including clinical placement capacity, for the numbers it proposes to offer, to ensure medical students receive the necessary quality of training. If this should include establishing new medical schools, the work necessary for the GMC to give approval would need to be built into any plans.

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

51       In 2020 we commissioned our Completing the picture report  which surveyed 13,158 doctors to find out why they left UK practice and if they were likely to return. Some of the key factors doctors gave for leaving included:

 

52       Other less commonly mentioned reasons included:

53       These findings help explain why the UK is not retaining the doctors we need to and what we need to address, which is mainly doctors’ satisfaction with their role, workload and workplace culture. Otherwise, we will continue to haemorrhage skilled and experienced doctors faster than we can recruit new ones, at a time when patient demand is increasing.

      We recommend the Committee consider the series of actions from our Caring for doctors, caring for patients report (set out below) on how working environments can be improved.

Leadership and doctors’ work environments

54       The Completing the picture findings and Dr Suzanne Shale’s 2019 research, How doctors in senior leadership roles establish and maintain a positive patient-centred culture, and our independent report, Fair to refer? are strong evidence that healthcare environments that prioritise the health and wellbeing of their staff will retain more of them and deliver better care.

55       Staff wellbeing is linked to improved experiences for people using services, increased productivity, and the willingness of staff to continue working in challenging and complex environments. It is therefore essential that leadership is more sharply focused on creating an inclusive and supporting environment for healthcare professionals.

56       The GMC has stand-alone guidance on leadership and management which applies to all doctors and we will use the review of Good medical practice to look at how we can strengthen messaging on leadership.

57       We invite the Committee to consider whether:

      Every organisation employing doctors should introduce a key performance indicator to assess if leadership is compassionate and inclusive.

      System regulators, improvement bodies and funding and commissioning bodies should check that there are mechanisms to support and assess compassionate and inclusive leadership.

 

Burnout and doctors’ wellbeing

 

58       In terms of burnout and work-related stress, our The state of medical education and practice report (2021) found that ‘high workloads/long hours’ were the most common reason given for feeling dissatisfied (35% of dissatisfied doctors gave this reason), and the taking of hard steps toward leaving the profession was much more likely in doctors reporting a high level of burnout or who were dissatisfied.

59        To help us address these issues we commissioned our independent report, Caring for doctors Caring for patients, by Professor Michael West and Dame Denise Coia. The report examined the factors that impact on the mental health and wellbeing of medical students and doctors.

 

60       The report developed the ABC of doctors’ core needs, autonomy/control, belonging and competence. These are important and relevant needs for all doctors in any setting.

 

61       Therefore, we invite the Committee to consider the following points and recommendations for organisations across the healthcare system:

Autonomy and control

      Organisations should consult all of their healthcare staff and gather feedback about how healthcare teams are established and maintained, how their work is organised and delivered and the response to concerns to ensure a focus on learning not blame;

      All healthcare employers should provide all doctors with places and time to rest and sleep, access to nutritious food and drink, the tools needed to do their job and should implement the BMA’s Fatigue and Facilities charter;

      NHS England, NHS Wales, NHS Boards in Scotland and the Department of Health (Northern Ireland) should fully implement the BMA’s and NHS Employers’ Good Rostering Guide (see New Deal Monitoring Guidance in Scotland) in all healthcare environments.

Belonging

      Primary care organisations should explore how other specialties of doctors, such as SAS doctors, can support GPs, and what other opportunities there are from further integration so that primary and secondary care can work together more seamlessly;

      Organisations should review team working and ensure that all doctors are working in effectively functioning and, ideally, multidisciplinary teams with a shared purpose and clear objectives (one of which is team member wellbeing). Team members should be clear about their roles and meet regularly to review their performance, including inter-team/cross-boundary working. Quality improvement should be a core function of all teams;

      All UK healthcare organisations that have not already done so, should start and implement a programme of compassionate leadership across all healthcare sectors; and they should obtain feedback from doctors and healthcare staff to evaluate its effectiveness. It should include mechanisms such as KPIs to ensure clinical leads and other leaders of doctors at all levels in the healthcare system are recruited, selected, developed, assessed and supported to model compassionate and collective leadership.

Competence

      Organisations should review their workload to use their resources in the most efficient way, and to ensure workloads do not exceed doctors’ ability and capacity to deliver safe, high-quality care. Initiatives are underway across the UK to increase staffing numbers and this should be supported by additional solutions including, but not restricted, to:

Equality, Diversity and Inclusion

62       Our 2021 Barometer survey data indicated there is significant variation in doctors’ experiences based on factors like disability, ethnicity, and where a doctor gained their primary medical qualification (PMQ).

63       There continues to be the need for meaningful action to address longstanding inequalities, and the impacts of racial discrimination and disadvantage. This is a bottom-line issue for the NHS – there are many doctors who are prevented from contributing to their full potential and at a time of ongoing workforce pressure, it should be a priority to fix that.

64       This is not a minority issue for doctors. In 2020, 38% of all licensed doctors in the UK were from a minority ethnic background and this proportion is growing. We know these doctors do not have a fair and equitable experience in their medical education and training, and that they are significantly more likely to be referred to our fitness to practise process by their employer.

65       We also know from the Fair to Refer? report, that some groups of doctors are isolated by ‘insider/outsider’ dynamics. This impacts on their chances of support and progression. Our work currently focuses on doctors who need support the most and encourage challenging of the system and organisations where we see support lacking.

66       We would invite the Committee to make recommendations that ensure all doctors have the support they need to succeed and provide quality care and continue to push for action on ethnicity and race. Not only will this promote overall inclusivity in environments with its associated universal benefits for all, but importantly it will also target race equality. We encourage the Committee to consider:

      The use of regulatory levers to drive a stronger focus on eliminating ethnicity differentials in education and training providers. For example, as part of our quality assurance process for postgraduate training providers, we ask for documented action plans to record how they are tackling attainment gaps.

      Asking national, systems, and local bodies, for a stronger focus on closing local disciplinary gaps. We believe that tackling the disparities in referrals based on race and place of primary qualification is an upstream intervention that will locally drive better focus on ensuring tailored understanding of individual needs and support. This could include prioritising collecting data to support clinical governance systems and Board-level conversations.

      Asking that all parties recognise and support the power of data. We will continue our close support of the work and ambitions of the Medical Workforce Race Equality Standard (MWRES) as a powerful tool to measure and drive progress.

      Asking employers and trusts to consider how they assure themselves that they have inclusive and supportive environments in place, including their race equality action plans, equality training, inclusive performance objectives for leaders, and networks of coaches and mentors for all staff.

      Asking that interventions are supported by investment in evaluating the impact and to share those outcomes. Understanding what works will also be key to understanding what initiatives should be amplified or scaled up once proven to be effective.

67       The pandemic has brought renewed focus on the tragic impacts of inequality. The impact has been particularly felt in the NHS. Nearly 40% of our registrants have a black, Asian and minority ethnic background and there are long-standing inequalities and issues of discrimination and disadvantage. In this environment we are committed to demonstrating strong leadership on these issues as a regulator.

68       Our The state of medical education and practice report shows that Asian doctors feel less supported by their immediate colleagues. While there were also notable differences in workplace experiences by ethnicity, these appear to be largely driven by PMQ, with White UK graduates and UK graduates from other ethnic backgrounds reporting similar levels of burnout and satisfaction.

69       However, doctors from a black and minority ethnic background, particularly Asian/ Asian British doctors, are less likely to agree that they are supported by their immediate colleagues or that they are part of a supportive team. This echoes the 2019 Fair to refer? research which found that doctors from a black, Asian and minority ethnic backgrounds are often treated as ‘outsiders’ in the workplace, receiving poorer support. Doctors from a black, Asian and minority ethnic background, independent of whether they obtained their PMQ inside or outside the UK, were also more likely to have taken hard steps towards leaving the UK medical profession (10% compared with 5% of white doctors).

70       We would welcome the Committee adopting the four broad recommendations from the Fair to Refer? report setting out practical steps for the system to address this disproportionality and support doctors:

      Introduce a UK wide framework and standards for the provision of feedback to, the effective induction of, and the ongoing support of, all doctors.

      Identify and address systemic issues that may affect doctors’ professional performance. When undertaking an assessment of a doctor’s performance or responding to a concern, take into account the context in which they work with a focus on learning, not blame.

      Senior leaders to engage regularly with all staff, listening to and taking action in response to concerns regarding fairness. Implement a strategy of active inclusion and mechanisms to mitigate the risk of disproportionality in discipline and referral processes.

71       We remain committed to working with our stakeholders to exert our influence over the system to tackle long standing racial inequalities. We are actively supporting employers to improve the fairness of working environments and reflecting that in our process for employer fitness to practise referrals. And we are strengthening our regulatory requirements of those responsible for the design and delivery of medical education and training.

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

72       We are currently unable to provide an analysis of recruitment and retention issues by some geographical locations. This is because our register data is not straightforward to summarise at a town level.

73       We have been happy to help with decisions around the most appropriate new locations for medical schools, drawing on our knowledge of existing medical school provision, the availability of high-quality clinical placements and the benefits of a new medical school to a region’s healthcare provision. 

74       Students do not always stay in the locale of their medical school, but some medical schools are making significant efforts to target students who live and want a long-term career near to their medical school. Efforts around widening participation in medicine are also helping to attract students who have a greater likelihood of staying local for their medical careers as well as education and training.

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?

75       We join others in the system in stressing the importance of inclusive, compassionate leadership, supportive working environments and equality for all healthcare professionals.

76       It is well documented here and elsewhere that leaders and working environments affect doctors (and other healthcare professionals) satisfaction and career plans. It is important that the next iteration of the NHS People Plan has creating working environments that are safe, fair and, inclusive for all staff and patients, regardless of their background or personal characteristics, at its core.

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?

77       Doctors’ expectations of how their medical careers will look has changed as a result of generational, societal, and technological shifts. To attract, recruit and retain more doctors, our view is that workforce planning needs to consider the medical profession in a less defined, traditional way. Doctors who may be returning to practice after some time may be more attracted to a role that focuses on their leadership skills and capabilities rather than returning to the same service they left and may also want to work in a more flexible way than before.

78       In the short term, it is important therefore that there are contractual arrangements which allow doctors to work with the flexibility which our data suggests is becoming increasingly desirable. In the Barometer survey 2021, 22% of respondents reported that they were working part-time. In the National Training Survey 2021, 16% of respondents reported formally working Less Than Full Time (LTFT) as approved by their deanery/Health Education England local team. A further 3% had considered applying for LTFT training but decided not to.

79       In the longer term, consideration must be given to the length of time it takes to train a medical trainee to consultant or GP level, the paths doctors intend to take to get there, and how they intend to practise once they arrive. Workforce planning must take these changes into account and not assume that the doctors training now will practise in the same way as those who trained even just ten years ago. This might mean new contractual arrangements, increased headcount, and/or greater use of multidisciplinary teams. While our evidence is specific to doctors, the same patterns and considerations are equally true of many professions in health and social care.

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

80       Integrated Care Systems (ICS) should take a leading role in supporting workforce planning, and in encouraging and incentivising good leadership and workplace cultures.

81       We endorse the ICS people functions and its aims for workforce planning using analysis and intelligence; supporting the health and wellbeing of staff; supporting inclusion and belonging for all; valuing and supporting leadership at all levels, and lifelong learning. By making these issues central to their role as local strategic health and care leaders, then patients will receive better care meaning better health outcomes overall.

82       Sustainability of the workforce will be key to ensuring integrated services are delivered successfully and as outlined previously in our response, we are working with stakeholders to enable greater flexibility in medical education and training, helping to support the workforce needs whilst maintaining standards and expectations.

83       Inevitably when new models are implemented, this results in new structures being designed and new opportunities for some whilst others may be disadvantaged by these changes. We know from the work we have been doing with the Medical Workforces Race Equality Standards (MWRES) team that representation at senior level for some protected groups within the profession is poor and is one factor (but not the only one) that will help drive more inclusive cultures. This is, therefore, a massive opportunity for ICS to recognise and address poor representation at senior levels and to shift the dial as these new models are implemented.

84       We note the opportunity that ICSs provide for a more collaborative and place-based approach. We believe that greater collaboration will increase opportunities for delivering and receiving care. Our ambition is to work in partnership and embed patients’ experience in everything we do.

85       As we set out in our response to NHSEI’s Consultation on Integrating care – next steps to building strong and effective integrated care systems across England, we believe that there are opportunities for regulators to work with ICSs in future to co-ordinate providers across their region in a way that would also support our plans for a more accessible and flexible registration framework.

86       The Health and Care bill places a general duty on Integrated Care Boards to promote education and training, and a general duty in respect of research. We know research in healthcare is important because it leads to better patient outcomes. As we are responsible for assuring the quality of education and training and identifying where our standards are not being met, we would welcome consideration of how ICS’s structures can be used to improved access for students and doctors to training opportunities which could help attract and retain staff within their local area.  

Conclusion

87       The pandemic has provided an opportunity to look at areas related to workforce where there have been significant learnings and we have previously provided the committee with evidence on this.

88       In particular, we invite the Committee to consider recommendations around culture, leadership and equality, diversity and inclusion, and making the health services a better, more inclusive and supportive place to work for all staff by:

89       In building a workforce with the right skills and knowledge for our future healthcare needs, we need to continue to develop and improve the education and training systems for doctors. There are opportunities to build more flexible approaches to postgraduate training. The UK is no longer bound by EU directives that prescribe time rather than outcomes for undergraduate medical training, this could also be considered.

90       Modern healthcare provision is about multi-professional teams and not individuals. Workforce planning must therefore make the most of skills and capabilities that different professionals can bring.

91       Flexibility will be key, both in planning, and supporting the flow of future doctors and other professionals into the workforce. We are working with Government on regulatory reform to develop a simplified, more flexible and accessible registration framework that will enable us to support UK and IMG applicants as they join the workforce. We, therefore, ask that the Committee consider encouraging the Government to progress regulatory reform swiftly to enable us to deliver these improvements.

Summary of Recommendations

The Committee may wish to consider the following:

Education and training

      How to encourage greater employer input into future outcomes and into curricula at every stage of medical education and training.

      Recommend that the GMC and royal colleges must continue to ensure proportionality in assessment to reduce assessment burden where it is safe and appropriate to do so. 

Adapting for Future Care Change - Medical Associate Professionals

      Planning for the increase and deployment of PAs and AAs should take place across the four UK countries. While there are different approaches across the four nations, high-level central coordination would help ensure preparedness and consistency.

      NHSE should review current placement tariffs to make the PA/AA roles more attractive to employers.

      Government, NHSE and health education bodies should explore the most appropriate clinical governance arrangements for PAs and AAs. We understand that in some organisations PAs and AAs are grouped with nursing or allied health professions, rather than being managed as part of medical staffing.

      Maximise the workforce contribution these roles can make by supporting the extension of prescribing responsibilities to these PAs and AAs. We are currently advising DHSC on the education, training and patient safety considerations involved.

A flexible and accessible registration framework to support recruitment

      Encouraging the Government to progress regulatory reform swiftly to enable us to deliver a flexible and accessible registration framework to support recruitment.

Actions to support retention

Leadership and working environments

      Every organisation employing doctors should introduce a key performance indicator to assess if leadership is compassionate and inclusive.

      System regulators, improvement bodies and funding and commissioning bodies should check that there are mechanisms to support and assess compassionate and inclusive leadership.

Burnout and wellbeing

Autonomy and control

      Organisations should consult all of their healthcare staff and gather feedback about how healthcare teams are established and maintained, how their work is organised and delivered and the response to concerns to ensure a focus on learning not blame;

      All healthcare employers should provide all doctors with places and time to rest and sleep, access to nutritious food and drink, the tools needed to do their job and should implement the BMA’s Fatigue and Facilities charter;

      NHSE, NHS Wales, NHS Boards in Scotland and the Department of Health (Northern Ireland) should fully implement the BMA’s and NHS Employers’ Good Rostering Guide (see New Deal Monitoring Guidance in Scotland) in all healthcare environments.

Belonging

      Primary care organisations should explore how other specialties of doctors, such as SAS doctors, can support GPs, and what other opportunities there are from further integration so that primary and secondary care can work together more seamlessly;

      Organisations should review team working and ensure that all doctors are working in effectively functioning and, ideally, multidisciplinary teams with a shared purpose and clear objectives (one of which is team member wellbeing). Team members should be clear about their roles and meet regularly to review their performance, including inter-team/cross-boundary working. Quality improvement should be a core function of all teams;

      All UK healthcare organisations that have not already done so, should start and implement a programme of compassionate leadership across all healthcare sectors; and they should obtain feedback from doctors and healthcare staff to evaluate its effectiveness. It should include mechanisms such as KPIs to ensure clinical leads and other leaders of doctors at all levels in the healthcare system are recruited, selected, developed, assessed and supported to model compassionate and collective leadership.

Competence

      Organisations should review their workload to use their resources in the most efficient way, and to ensure workloads do not exceed doctors’ ability and capacity to deliver safe, high-quality care. Initiatives are underway across the UK to increase staffing numbers and this should be supported by additional solutions including, but not restricted, to:

      A programme to deploy and develop alternative roles to enable doctors to work at the top of their competence, supported by effective multidisciplinary team working in all areas of healthcare, and to support doctors to return to work after a break in practice;

      A review of new technologies being used in UK healthcare systems to increase efficiency, working with the voluntary sector, and focusing on preventive care; and

      A programme of process improvements that increase productivity especially by supporting communication in regular team meetings between healthcare staff.

Inclusive environments

      The use of regulatory levers to drive a stronger focus on eliminating ethnicity differentials in education and training providers. For example, as part of our quality assurance process for postgraduate training providers, we ask for documented action plans to record how they are tackling attainment gaps.

      Asking national, systems, and local bodies, for a stronger focus on closing local disciplinary gaps. We believe that tackling the disparities in referrals based on race and place of primary qualification is an upstream intervention that will locally drive better focus on ensuring tailored understanding of individual needs and support. This could include prioritising collecting data to support clinical governance systems and Board-level conversations.

      Asking that all parties recognise and support the power of data. We will continue our close support of the work and ambitions of the Medical Workforce Race Equality Standard (MWRES) as a powerful tool to measure and drive progress.

      Asking employers and trusts to consider how they assure themselves that they have inclusive and supportive environments in place, including their race equality action plans, equality training, inclusive performance objectives for leaders, and networks of coaches and mentors for all staff.

      Asking that interventions are supported by investment in evaluating the impact and to share those outcomes. Understanding what works will also be key to understanding what initiatives should be amplified or scaled up once proven to be effective.

      Introduce a UK wide framework and standards for the provision of feedback to, the effective induction of, and the ongoing support of, all doctors.

      Identify and address systemic issues that may affect doctors’ professional performance. When undertaking an assessment of a doctor’s performance or responding to a concern, take into account the context in which they work with a focus on learning, not blame.

      Senior leaders to engage regularly with all staff, listening to and taking action in response to concerns regarding fairness. Implement a strategy of active inclusion and mechanisms to mitigate the risk of disproportionality in discipline and referral processes.

      Establish a UK-wide mechanism to deliver the recommendations, share good practice and undertake ongoing monitoring of data concerning the key issues identified in this study.

Jan 2022

[*] Hard steps include contacting a recruiter, applying for (or attending training to prepare for) a new role, or applying for another role outside medicine.

[†] Data from Figure 35, p82 The state of medical education and practice in the UK. Data collected from mid-year snapshots (June 30) of preceding 12 months. Excludes doctors granted temporary emergency registration and FiY1 doctors (6868) granted earlier registration to aid pandemic response.

[‡] EEA nationals currently make up around 4% of the undergraduate medical student population