Worrying about the pressures on the NHS as winter approaches has become an annual ritual for physicians, particularly colleagues working at the front door of our hospitals. Of course, the reality is a worrying picture all year round as the NHS remains underfunded, underdoctored, and overstretched, and we have to deal with the impact every day.
Last winter, the RCP’s focus was on securing more funding for social care, followed by healthcare. Despite the government committing to some additional funding, much more needs to be done. We hope that this will be addressed in next month’s budget.
Surge in admissions
This year, our main concern is that clinical staff – and ultimately patients – will bear the brunt of the inevitable surge in admissions. When I attend RCP events around the country, I ask the audience to raise their hand if they work in a hospital with rota gaps for medicine. A majority always does.
As physicians, our morale is seriously affected by the fact that there are simply not enough of us to deliver the quality of care to which we aspire. However, we are determined to minimise the impact on patients.
We have therefore decided to concentrate on helping hospitals to prepare for winter. At the beginning of November, we will publish practical guidance for clinical and system managers, sending it to hospital chief executives, our fellows and members.
Chief executives, medical directors, managers and physicians of all specialties need to work together to ensure that the necessary systems are in place. In particular, they need to make sure that physicians providing specialty rotas alongside the general take are able to deliver responsive 7-day services. As well as referring to good practice, much of which we have been involved in producing, our new guidance will address morale, working conditions and systems.
It addresses key factors that hospitals should be thinking about all year round, but especially in the run-up to winter. We think that hospitals must:
- improve delivery of care by implementing good practice, as reflected in current standards and guidance.
- put in place an organisation-wide plan for improving patient flow through the hospital.
- put facilities and plans in place to protect the physical and mental wellbeing of the workforce.
- work in partnership with other local services to minimise unnecessary occupancy.
Fixing the system
We can and will continue to produce such guidance, but the bottom line is that we need more doctors – now, and all year round. The increase in medical school numbers is welcome, but those doctors will not enter the workforce until 2022 and beyond. In the meantime, there is no single fix. But there are several small steps, each of which could help.
- Allow EU citizens working in the NHS to remain. The government must guarantee that EU nationals will be able to remain in the UK following our exit from the EU, so that they can continue to provide patients with support and care.
- Expand the Medical Training Initiative that provides trainee doctors from all over the world with the opportunity to work and train in the UK for 2 years. It provides hospitals with a high-quality, longer-term alternative to using locums to fill rota gaps. However, the number of visas is capped at 750, and the system could support many more. We need to work with the Home Office and the Department of Health to increase the number of visas available.
- Establish an MTI-like programme for doctors from non-priority countries. The MTI prioritises applications from Department for International Development priority countries and World Bank low income and lower-middle income countries, but many other doctors want to sample life in the NHS. Countries such as Australia have more doctors than training places. We should be talking to them, and arranging training links. Many of these countries are in the Commonwealth and have close links to the medical royal colleges. We need to work with the Home Office, the Department of Health and the General Medical Council (GMC) to facilitate this.
- Include more specialties on the shortage occupation list. The government has a list of shortage occupations that have special arrangements for immigration. Some specialties are already included, but others – such as geriatrics and respiratory medicine – could be added. We need to explore the options with the Home Office and the Migration Advisory Committee.
- Encourage physicians to remain part of the workforce as long as possible. Our Medical Workforce Unit has collected worrying data on the retirement plans of physicians. Reasons are mixed, including the pressure of work, pension rules and onerous revalidation requirements. There are many things that we could do, such as supporting people to work part time and exploring an exemption from pension rules, as with judges. We need to work with the Department for Work and Pensions and the GMC to think creatively and flexibly.
- Make training more flexible and target workforce gaps. Flexibility emerged as one of the key messages from the Shape of Training review. The final report said ‘Patients and the public need more doctors who are capable of providing general care in broad specialties across a range of different settings’. The needs of patients and doctors ‘should drive opportunities to train in new specialties or to credential in specific areas’. We should work with the GMC, other medical royal colleges and hospitals to develop pilots in key areas.
- Stop the ‘snakes and ladders’. We also need to be more flexible when it comes to overseas training. We should have ways of accrediting prior learning so that doctors choose to return to the UK after their sojourn abroad. We should work with Health Education England (HEE), the GMC and the medical royal college training boards to agree a system.
- Offer sweeteners to work in less popular specialties and regions. Trainees gravitate towards big cities and their benefits, such as better access to tertiary services for training. Can we not be flexible and provide more short-term or day-release attachments in tertiary centres? Can we follow general practice’s lead and provide extra resource or facilities for those willing to work in more remote areas? We need to work with HEE, hospitals and tertiary training centres to develop and implement plans to improve flexibility.
- Promote the role of physician associates. We are delighted that the consultation on the regulation of physician associates and other medical associates has now opened. Regulation needs to happen as soon as possible. It will pave the way for innovative and new models of care, putting patients at the centre, and sharing the workload among those able to deliver it. Until then, we should all encourage hospitals to only employ people who are on the Physician Associate Managed Voluntary Register.
As you can see, these solutions fall into two broad categories:
- making the UK an attractive and accessible place for doctors from other countries
- making the profession more flexible.
The former will help us in the short term, but it is the latter that will lead to long-lasting change – change that we need.
The priorities of new entrants to the profession are different from those of us who joined the NHS in its first 50 years. They seek an ever-better balance between their working and personal lives. More of them want to work part time so that they can follow other interests and desires.
Flexible model of care
Perhaps a system that is supple enough to enable them to do that will contribute to the development of an ever-more-flexible model of care – because that is what we need, as the population continues to change and health challenges become more complex.
The patients and doctors of the near future will be used to responsive, 24-hour, 7-day services in every element of their lives. They shop online in the small hours of the morning, work out in the gym until late in the evening, and watch the latest series of their favourite TV show at a time that suits them.
The provision and delivery of health and social care should be no different. We need to consider how people currently live and how they want to live, and respond accordingly. All the evidence suggests that the workforce will be happier and more productive as a result, and patient outcomes will improve.