‘Personal Views on Healthcare in Wales’
Martin Rolles, Standing Welsh Committee of the Royal College of Radiologists
It is too small to solve its medical staffing problems in isolation
Wales struggles to recruit and retain hospital consultant staff, and this affects high quality service provision. Wales needs to train more doctors, but this alone cannot remedy the situation. It needs to recognise that the medical profession is mobile and international, and has to find ways to attract good staff from the UK and the wider world.
The NHS is not all about consultants, but they are unavoidable. In many specialties in Wales there are chronically unfilled consultant posts. This reflects a national shortage. In a seller’s market, where all UK regions and hospitals compete for the best appointments, less wealthy peripheral areas with hard-pressed units will always be at a disadvantage compared to large prestigious centres. From a UK perspective, Wales has the added barriers of being perceived as culturally distinct, geographically remote, and of having a health system which is increasingly divergent from NHS England. For those of us who live and work in Wales, some of the advantages may be clear. For an ambitious Specialist Registrar, freshly qualified at a major English centre, the benefits of moving to Wales are likely to be less obvious.
Wales has two successful medical schools which attract students from across the UK, and internationally. People who train in Wales may want to settle down locally, though that is not a given. An increase in Welsh medical undergraduate numbers is likely to increase overall numbers of doctors in Wales, but it is not safe to plan specialist services on assumptions of what a first year medical student might want to do 10 or more years later. A better bet is to increase the numbers of juniors, and specialist trainees in Wales and to foster them so that they want to stay. In some key specialties, such as diagnostic radiology, current specialist training numbers are insufficient to fill either the current consultant vacancies or the anticipated retirement of senior consultants, even if all trainees stay in Wales. Most specialist training numbers are part of national recruitment schemes and are therefore not entirely within Welsh control. Flexibility to increase numbers is hampered by a perennial question of who in Wales should pay for extra trainees. A priority should be for Welsh Government and the Wales Deanery to sort this out.
We have to ask honest questions about why people would want to train and work here.
Doctors are free to move across the border in both directions, and Wales needs to try to ensure that this diffusion is at least balanced. Wales cannot afford to be inward-looking. It has to be able to offer the best contemporary standards of training when compared to other parts of the UK, and it has to promote itself. Trainee recruitment becomes more difficult if there is a perception that training opportunities in Wales are out of line with the rest of the UK, or that Welsh trainees will not be able to compete for consultant posts against those from other parts of the UK.
Incentive schemes have been proposed to keep graduates and trainees in Wales. Whilst this may be useful in some situations, there is a danger that these critical consumers will simply go elsewhere if they think their future options are going to be too restricted. Welsh trainees will expect to be able to gain experience outside Wales, either as part of specialist training schemes requiring placement at national centres, postgraduate degrees, or overseas fellowships. This should be regarded as a positive thing, accepting that one cost of Out of Programme Experience is that it increases overall training time and slows the production of new consultants. Maternity leave and Less than Full Time Working also affect training throughput. As an example, the average time for completion of the South Wales Clinical Oncology SpR training scheme, nominally five years, is now over eight years.
Staffing problems vary by specialty and by geography. Recruitment is generally more difficult outside South East Wales. Uneven coverage in terms of filled posts and absolute numbers of posts, mean that all-Wales figures for specialists per capita can be misleading. Staff in peripheral units often have poor cross-cover, and are limited in the practise of their craft by infrastructure issues. They are less likely to do the sort of interesting non-clinical things that lead to national recognition or clinical excellence awards. Professional isolation, which affects morale and performance, is a real issue without local colleagues, and is exacerbated by reduced interaction with the national body. It is just possible to travel from Swansea to London for the day to attend a professional meeting. It is quite difficult to do a day trip from Aberystwyth to Cardiff.
Realism is needed. Geography is unavoidable. What works in the South Wales conurbations is not necessarily appropriate for rural Wales.
The traditional District General Hospital model is evolving, albeit reluctantly, to reflect the changing needs of service provision in an increasingly specialised world. This is an opportunity for innovation. Where consultant-based services have no prospect of recruitment, they need to be redesigned. Current staffing difficulties are going to get worse, to the extent that services in some key areas, which are already struggling, will become unsustainable in their current form. Chronic reliance on locum services is expensive and does not usually fix the underlying problem. Service planning cannot rely on goodwill. Peripheral hospitals need high-calibre professionals, not missionaries. There is a significant challenge to the profession and to NHS Wales to raise the perceived value of Welsh consultant posts.
The points made above relate mainly to economics and strategy. There is a wider cultural issue when thinking about recruitment of doctors from the EU and further afield. The medical profession is cosmopolitan. Parochialism is damaging. Non-British doctors are not simply employed to fill gaps in the rota: the profession in Wales is greatly enriched by overseas recruitment in all spheres. The tone of much of the current public and political discourse is a worrying threat to this.