Realising the Fourth Dimension
Abraham Theron , Royal College of Anaesthetists
“… a fourth dimension has been added due to a realisation that a key factor is
the well-being and engagement of staff ”
– A Revolution from Within
A dedicated, competent and compassionate workforce is any health care system’s greatest asset. This is however the most expensive resource in healthcare and it is essential to ensure as much value from one’s workforce as is possible.
Recruitment and retention are the two overwhelming issues in Wales. We should therefore actively help the newly formed Health Education and Improvement Wales (HEIW) to address both of these with workforce planning, pre- and postgraduate training, new models of working and incentives, not only to retain our own graduates, but also to recruit and retain graduates from outside Wales.
Mitigating the potential impact of Brexit is an important consideration and the Academy of Medical Royal Colleges rightly acknowledges the need for the NHS to have access to staff from overseas, both from the EU and beyond.[i] The Royal College of Anaesthetists (RCoA) workforce census report highlights that anaesthetic departments continue to have trouble in filling hospital rotas.[ii] In hospitals across Wales, 60% of anaesthetic departments reported a gap in the consultant rota approximately once a week (compared to 26% in England on the same measure).[iii]
The GMC Working Paper on doctors with a European Primary Medical Qualification[iv] shows that for the specialty of anaesthetics and intensive care 12.6% of doctors on the UK Specialist Register are European Economic Area (EEA) graduates. For Wales, this figure is 14.5%, demonstrating the reliance that hospitals across the country place on non-UK staff to provide high-quality patient care.
A 25% increase in training places in the two Welsh Medical Schools – consistent with the 25% increase in medical training places announced in England[v] – should help meet the aim to facilitate and slightly over-supply doctors for the future. This is provided that these places are taken up and lead to graduation. Analysis from the RCoA suggests that the attrition rate for anaesthetists in training between core and specialty programmes is at a reasonably consistent rate of 27%.[vi] The evidence suggests that Graduate Entry Medicine (GEM) provides better local retention of medical graduates and expansion of university numbers should predominantly focus on this group[vii].
I whole heartedly support ‘Contextual Admission’ into medical schools as well as ring-fenced places[viii] for Welsh speaking candidates and pupils who were educated in Wales. More should be done to attract pupils in secondary education, not only to medicine, but to the health and social care system as a whole, because it is not only doctors we need.
Pathways from medical school entry into foundation training should be explored, with a view to deliver maximal retention. The aim should be to offer every Welsh Medical Graduate a Foundation placement in Wales, allocated on rank according to academic results. Financial incentives in the critical short specialties (GP, Psychiatry, Paediatrics and A&E) and areas should be considered as a last resort, but consideration should be given to extend this to consultant posts where there is a significant antisocial hour working pattern in job plans, i.e. A&E.
Recruitment into the anaesthetic trainee programmes in Wales has significantly improved over recent years in part due to us listening and working closely together with our trainees to improve their experiences during training. However, a December 2017 report by the RCoA, on the morale and welfare of anaesthetists in training, found that 85% of respondents were at a heightened risk of burnout. The report, based on more than 2,300 anaesthetists in training who responded to the RCoA survey, also found that 64% of respondents felt that their job affected their physical health and 61% their mental health.[ix]
Retention is more important than recruitment.
Increased work stress in both Health and Social care is damaging our workforce’s health, which in turn is detrimental to the care we provide to our patients. We need to look after everybody in need and this includes our current workforce. Much more emphasis should be put on Emotional Intelligence and Resilience training in both under- and postgraduate settings.
As suggested in the recent parliamentary review, ’A Revolution from Within’[x] we will need to start thinking outside the box and be innovative with new and different models of care in all areas of medicine, in order to remove unnecessary workload from doctors, to enable them to focus on the care that can only be delivered by them. We should be able to give clear guidance on how we can create truly integrated care models with multidisciplinary allied health care professionals, in particular extending the roles of Medical Associate Professionals.
Despite an increasing workload, doctors have the added pressures of dealing with the ever-rising expectations of patients and punitive regulation from the GMC. I strongly encourage Welsh Government and the medical profession in Wales to use the opportunity to contribute to the recently announced review into medical malpractice. I feel public expectation should be actively managed to agree what is a realistic expectation from the NHS, free at point of care, with limited resources.
There are concerns amongst medics that they may not be able to receive the support they need for postgraduate continuing medical education (CME) throughout their careers in Wales. HEIW need to give assurances that CME will both be valued, supported and funded in the future.
Medical engagement in the Welsh NHS is low and the medical workforce feels undervalued and undermined. We need long term stable leadership at every level of the NHS in Wales. Doctors should be empowered to take up leadership roles wherein they are supported by managers and are given the resources necessary to be effective and influential.
The manner in which staff are treated affects the way they in turn treat patients. This makes their experience of the workplace and how they are cared for very important. The behaviour of leaders shape the culture of an organisation. We need collective compassionate medical leaders to create a compassionate workforce.
Clinical leadership is essential if we are to introduce the recommendations from ‘A Revolution from Within’. As stipulated in recommendation 9, dynamic clinical leadership is needed to increase the capacity to drive transformation nationally, regionally and locally.[xi]
‘Leadership and team’ is one of nine domains in the GMC’s ‘Generic Professional Capabilities’[xii] that are due to be introduced in all new postgraduate medical curricula. This will help, but on its own is unlikely to deliver the leaders we need and it does not target medical students who in my view should at least be exposed to the attributes of good clinical leaders.
Doctors with these attributes should actively been sought and identified as early in their postgraduate training as possible and then be signposted and supported to undergo targeted leadership and management training as they continue towards completion of medical training. It is important that these trainers have the Emotional Intelligence and Resilience needed and that their peers respect them.
Academi Wales is at present doing an exceptional job of training some of these individuals in their posts as Welsh Clinical Leadership Fellowships and we are awaiting their participation as new consultants in the Welsh NHS with anticipation. Several consultants do however still find themselves in leadership roles without the training they need to be successful. Every effort should be made to enable and support this group with the resources needed to have access to such programmes.
In the Welsh Advisory Board of the RCoA response to the white paper ‘Service fit for the future’[xiii] we stated that it is important to ensure clinical memberships on all Boards as we do not believe the proviso for the involvement of senior management, below the level of Executive Director, will guarantee sufficient clinical representation.[xiv] I also believe that clinical leaders should be more involved in Welsh government, other than via public health and the Chief Medical Officers.
Medical leaders should be given at least some tools to succeed. In recent times some medical leaders were only used to drive austerity. Limited immediate resources without support for the vision of a more efficient service in the future have made a difficult job impossible and we have lost leaders and managers who could have contributed a great deal in the future.
It is essential that all medical leaders are given enough time allocated in their job plans to fulfil their duties properly, taking on these roles should not be to the detriment of their families and work life balance. Their health and wellbeing are as important as the rest of the workforce.
Leaders also need peer support. We have an Anaesthetic CD network for all CD’s in Wales. We meet in person twice a year where we discuss common problems and solutions. We have also recently created a What’s App group where we can bounce ideas off each other and ask for help. Thought should be given on creating a similar support structure for leaders in each health board, where problems are being shared and to help leaders to appreciate another’s point of view.
I foresee that the medical leadership will develop further in years to come and my hope is that it will expand to the extent that they will develop their own national specialty where they will be getting the guidance and support for continuing education they need to take the whole of the healthcare in the UK forward.
At the most basic level it comes down to a cup of tea. Coffee, tea and milk once provided to staff are now removed in almost all areas. Dedicated staff working in hard pressed clinical areas do not have the time to leave to buy a drink and face the threat of discipline if they dare to touch the patient’s allocation! Is this really how we want to treat any of our hard-working workforce?
In summary, we can enable our workforce to deliver compassionate care, to all our many patients in Wales – if they are treated with compassion. Students and trainees that observe a NHS looking after its workforce, will be much more inclined to stay; and our current workforce will get the motivation they need to continue…
Consultant Anaesthetist, Cardiff & Vale University Health Board
Deputy Clinical Director Perioperative Care
Chair of the Welsh Advisory Board of the Royal College of Anaesthetists
Vice Chair of the Academy of Medical Royal Colleges of Wales
[i] Academy of Medical Royal Colleges. Brexit: Academy of Medical Royal Colleges Position Statement. July 2017.
[iii] Royal College of Anaesthetists. Briefing: The anaesthetic, intensive care and critical care workforce. December 2017
[iv] General Medical Council. Our data about doctors with a European primary medical qualification in 2017. November 2017
[vi] Royal College of Anaesthetists. Briefing: The anaesthetic, intensive care and critical care workforce. December 2017
[vii] Prof Keith Lloyd, Swansea University Medical School. Supplementary Response to Welsh Government Consultation of Medical recruitment. Published 28 February 2017.
[viii] Prof Keith Lloyd, Swansea University Medical School. Supplementary Response to Welsh Government Consultation of Medical recruitment. Published 28 February 2017.
[ix] Royal College of Anaesthetists. A report on the welfare, morale and experiences of anaesthetists in training: the need to listen. December 2017
[x] The Parliamentary Review of Health and Social Care in Wales. A revolution from within: Transforming health and care in Wales. Final report. January 2018
[xi] The Parliamentary Review of Health and Social Care in Wales. A revolution from within: Transforming health and care in Wales. Final report. January 2018
[xiii] Welsh Government. White Paper Consultation Document. Services fit for the future: Quality and Governance in health and care in Wales. June 2017
[xiv] Royal College of Anaesthetists’ Welsh Board. RCoA response to the consultation on the White Paper: Services fit for the future. September 2017