Future Practice: A Review of the Scottish Medical Workforce
3. SUPPLY OF DOCTORS
sources feeding more doctors into the system through the education route.
recruitment from Scotland (as well as from elsewhere in the UK, the EEA and from overseas); and
retention (including those who are returning to work).
81. In chapter 2 we summarised the expected demand for doctors in the short, medium and long term. This chapter focuses on the supply of doctors and how it can be improved through recruitment, retention and the education of new doctors. These mechanisms have effect over different time scales and can be summarised in the diagram below. However, there needs to be further investigation to confirm or modify their respective costs benefits and priorities.
Chart J: Expected impact of supply side interventions
3.1 Recruitment and retention
Proactive management of recruitment and retention is important.
A positive Scottish identity will support recruitment.
Flexible working and measures to delay retirement are important.
There are particular issues concerning remote and rural areas, overseas doctors and academic and research medicine.
Managing recruitment and retention in the medical market
82. Recruitment and retention are part of the supply side of workforce planning. They need to be addressed positively and actively, and should be fully integrated into the new mechanisms being established to plan and secure the workforce for NHSScotland. Targets and the accountability for meeting them should be defined.
83. There is considerable movement of medical staff into and out of the Scottish market - primarily from elsewhere in the UK as well as from elsewhere in the EEA and from overseas. More information on these flows is urgently needed. Maintaining recruitment and retention in the face of increasing competition from England in particular is essential. Improving retention can increase numbers in the short term, while measures to increase training output will take time to bite.
84. Maintaining or increasing recruitment in a competitive medical market dominated by the much larger English NHS requires Scotland to establish a separate marketing identity. If successful, this could have both a short-term impact and improve recruitment for the longer term.
85. Recruitment and retention issues apply across the full continuum of doctors' careers, from generating interest in medicine at school, through minimising wastage in training, to delaying retirement. Targeted incentives could improve recruitment packages and also assist retention of existing staff by encouraging commitment to their current post and perhaps less interest in alternative employment elsewhere or in retirement.
86. Conditions in the medical labour market are a factor in contract negotiations and the pay review body process at UK level. We consider that there are aspects of market conditions that are particularly significant for Scotland because of its geography and demography and the profile of its medical workforce. There needs to be scope, within a national framework, for selective incentives in terms and conditions of employment geared to the market conditions in Scotland.
87. Incentives could be particularly relevant to remote and rural areas. They should also apply where doctors, based in a larger centre, are geographically isolated in their professional sphere making recruitment or retention difficult.
Presenting a positive market identity
88. incentives are not simply a question of formal contract terms. There is much that can and should be done to promote wider aspects of the appointment. We were struck by the imaginative and successful approach in Shetland where the Board worked with its community planning partners to identify and promote the benefits of the whole experience of work and life in Shetland. Scotland has a very positive image as a place to live, and the Shetland approach to building on this image could, in our view, work elsewhere.
89. Within this overall positive image for Scotland, effective recruitment and retention needs to address perceptions of the doctor's work. This is closely tied to morale among existing doctors - it is difficult to recruit to a low-morale job or to retain staff in such positions. Morale issues in the current service include:
the overall image of the NHS;
pressures arising from staff shortages;
lack of clarity of roles and responsibilities, particularly as flexible team-working becomes more widespread;
for many doctors less remuneration in Scotland compared to colleagues in England due, for example, to smaller GP list sizes in remote and rural areas and limited access to private work in the secondary care sector;
the demands of bureaucracy and management tasks for which the doctor is unsuited or unprepared;
uncertainty about future career options; and
difficulties in accessing flexible working and development opportunities.
The way opportunities for a medical career in Scotland are presented needs to recognise such concerns but these issues also need to be addressed in themselves.
90. There is some evidence that the imbalance between the sexes in the intake to medical schools may be due to a comparative lack of interest in medical careers among males. Confirmation of this evidence is being sought. However, when taken with the recent trend of falling applications to medicine, we feel that there should be a specific, co-ordinated effort to promote the image of careers in health in Scotland and specifically in medicine, targeted at students in schools and higher education. This would be an important investment in the long-term sustainability of the service. It should be led strategically at a national level, but focused on local activity for immediacy and relevance. It can no doubt be linked to wider efforts to promote awareness of and public influence on health services.
91. Delaying retirement. Doctors approaching retirement age are less likely to retire early if their work can change, for example to reduce hot clinical demand (especially in the craft specialties) and to make positive use of skills that benefit from experience, such as teaching and management. This is well recognised and there are many examples of doctors who individually have managed a change in the nature or pattern of their work or have retired and returned to work on a different basis. Well managed arrangements for step down towards retirement and for return could make a significant contribution to morale and to capacity in the service even though the numbers involved may be relatively small.
92. Flexible working and training. There is an increasing expectation that there should be flexible working and training opportunities. There are many doctors for whom such flexibility is essential if they are to progress in their careers or their professional development while meeting family and other commitments outside their working lives. For others, flexibility gives them more control over how they organise their lives or develop their career. In either case, improving flexibility helps to retain staff and is also a positive factor in recruitment. Opportunities for career breaks and for sabbaticals can help longer-term retention. This is particularly so in remote and rural areas where there is a need to provide opportunities to maintain clinical skills. Better career and succession planning would improve the attraction of medical careers and the sustainability of the service.
93. Proleptic appointments. Provided good employment practice is not compromised nor the requirements for competitive appointments ignored, the circumstances appropriate to proleptic appointments (where a doctor may undergo training in the expectation that he or she will occupy a particular post when trained) should be explored.
94. Morale. As indicated in paragraph 89, morale is a retention factor as well as a recruitment factor, and the issues identified in that paragraph need to be addressed.
Measures to fill gaps
95. There are current gaps in certain medical specialties where urgent action is required. These include histopathology and radiology (which support other specialties creating a knock-on impact on a range of services) as well as psychiatry. A world-wide shortage in radiology in particular makes retention, let alone recruitment, difficult. This tends to be exacerbated by the pressure on existing staff wherever there are long-term unfilled vacancies. There are also local situations where particular factors produce local shortages in a specialty which is otherwise in reasonable supply.
96. Such situations require one-off intensive consideration in order to apply the measures to manage demand and supply proposed in this Report in a targeted way. That consideration must include demand issues (such as service re-design and networks) as well as recruitment and retention problems for the specialties or locations involved.
Specific remote and rural interests
97. Recruitment and retention difficulties can be most intense in remote and rural areas. Selective additional investment in incentives should be considered. Particular effort is needed to ensure that flexible opportunities for working and training are relevant and effective for the remote and rural environment. Remote and rural versions of training, continuing professional development (CPD), career planning and imaginative uses of IT are needed to handle the difficulties created by travel, distance and isolation from colleagues. The lead given by RARARI in developing thinking in these areas is invaluable, and needs to be carried through at a strategic level.
98. The development and promotion of a rural 'package' for doctors and their families, as in Shetland, is particularly important. It should improve awareness of the distinctive, and in many ways very positive, aspects of practice in such an environment. It should also seek to assist with issues such as children's schooling, spouse's employment, and contact with relatives elsewhere (bearing in mind that for professional as well as career reasons the doctor may need to relocate within a relatively short time).
Doctors from overseas and from elsewhere in the EEA
99. Scotland has a tradition of playing an important part in the international medical community.
A significant proportion of its workforce either qualified elsewhere in the EEA or outside the EEA ( overseas). Of the Scottish medical workforce (including general practitioners) in 2000, 3.3% had qualified elsewhere in EEA and 10.2% outside the EEA ( overseas). The overall ratio of overseas doctors across the medical workforce has remained broadly constant since 1995. The proportion of overseas doctors is highest in the non consultant career grades (staff grade 42.7% and associate specialist grades 35.5%). It is also high in the training grades (SHO 18.7% and the registrar group 18.1%).
100. We consider that the position of overseas doctors should be included specifically in the examination of the career and training grades that we have recommended. It is important to build on Scotland's longstanding reputation for assisting the development of medicine in other countries by providing some of those countries' doctors with high quality medical education and experience before they return home.
101. Overseas doctors fulfil an invaluable role within the workforce which should not be lost through deterioration in the attractiveness of posts offered in Scotland. Many, however, have found their way into non consultant career grade positions where they have felt their career aspirations frustrated. Equally many in the SHO grade have found it difficult to progress in their career. There is scope to improve training and particularly to provide opportunities at higher specialist training level.
102. In shortage specialties direct recruitment of overseas doctors to career grade positions seems to us to be an option that should be explored with some urgency.
Doctors in academic and research medicine
103. Universities play a key role in training the future workforce across all specialties. Their requirements to secure a cadre of doctors able to lead on research, teaching and innovative service must be recognised and supported. We would support strong local partnerships between NHSScotland and the universities to ensure that their workforce needs are secured.
104. There are additional pressures on the retention of clinical academics in Scotland due to the recent increase in the number of medical schools in England and the need to provide for the expanding teaching and research workforce. The research base in Scotland, both in terms of numbers and of quality, will be difficult to sustain without growth in the Scottish medical schools.
Chart K: NHSScotland Medical Staff - % by Country of Qualification
Recommendations (recruitment and retention)
26 Manage recruitment:
27 Promote Scottish medical careers:
facilitate local incentives within a national framework;
promote a positive Scottish identity; and
engage schools and education institutions.
28 Maximise retention: This is urgent
delay retirement by step-down and return options;
improve scope for and attitude to flexible training and working; and
address morale factors, including positive changes in work practices.
29 Take particular actions for remote and rural areas through:
selective additional investment;
rural 'packages' for doctors and other health professionals and their families;
targeted recruitment, training and career planning for remote and rural practice; and
arrangements for continuing professional development and for maintaining clinical competence.
30 Maintain and support the contribution of overseas doctors:
31 Support academic and research medicine: