Evidence submitted by the Royal College
of General Practitioners (WP 66)
INTRODUCTION
1. The Royal College of General Practitioners
submits this Memorandum of Evidence to the Health Committee's
Inquiry into Workforce needs and planning for the health service,
and expresses its willingness to give evidence at a later date.
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education; training; research;
and clinical standards. Founded in 1952, the RCGP has over 24,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
How effectively workforce planning, including
clinical and managerial staff, has been undertaken, and how it
should be done in the future
3. Workforce planning for such a large and
diverse organisation as the NHS is a complex task which requires
considerable expertise. It has not worked well to the extent that
whilst there has been a major expansion of the consultant workforce,
the number of GPs has only risen slightly so that, for the first
time, we have roughly the same number of GPs and consultants in
the NHS. International studies looking at the ration of generalists
to specialists suggest that health outcomes, including mortality
rates, correlate to this ratio with better outcomes where the
number of generalists exceeds the number of specialists. Of course,
the NHS needs good specialists but it needs many more good generalists
and the two can work together in balanced partnerships.
4. In recent years such planning has been
blighted by constant changes in the mechanisms used without giving
any single mechanism time to establish itself.
5. At a national level the mechanism for
planning the medical workforce, lead by the Specialist Workforce
Advisory Group, was disbanded as a result of the recommendations
of A Workforce for all the Talents. The subsequent Workforce
Numbers Advisory Board tried to grapple with all the clinical
staff in the NHS, and was doing innovative work around clinical
scientists for example, when it was disbanded. The parallel mechanisms
for planning based on National Service Frameworks simply replaced
the criticised vertical silos representing professional groupings
with horizontal ones representing artificial and incomplete patient
groupings. Additionally, planning of this sort tends to be related
to single disease conditions, whereas the majority of elderly
people live with more than one chronic condition.
6. At a local level Local Medical Workforce
Advisory Groups, Non-Medical Education & Training Consortia
and, later, Workforce Development Confederations, were introduced,
under-resourced, poorly supported at a senior level and abandoned.
7. Shifting the Balance of Power made
any attempt at centralised planning difficult and centralised
control impossible. From the General Practice point of view, the
disbanding of the Medical Practices Committee has blocked any
progress that might have been possible in redressing the imbalances
between the most well doctored and the least well doctored Primary
Care Trusts and this imbalance remains at a ratio of almost two
to one, with the least well-doctored areas correlating highly
with areas of deprivation. It is for this reason that the College
believes GP workforce distribution to be an health inequalities
issue.
8. All policy announcements, including Commissioning
a Patient-led NHS, should have, as an integral part of the document,
a careful and considered analysis of the workforce consequences
of the policy.
9. Technological change cannot be accurately
predicted in the timescale of medical workforce planning but an
effective process of horizon scanning should inform such planning.
10. The requirements for health care of
an ageing, but increasingly healthy, population need to continue
to be addressed.
11. There is a need for new schemes and
incentives to encourage GPs to work in deprived areas.
12. Private providers must be planned into
the total provision of service and either must directly contribute
to training and career development of health service staff or
must pay a premium to use staff they have had no part in training.
How will the ability to meet demands be affected
by financial constraints; the European Working Time Directive;
increasing international competition for staff; early retirement
13. Financial constraints are already causing
problems. A number of Strategic Health Authorities have cut back
on training of General Practitioners by as much as 10% to reduce
costs. Given the transfer of work into the community this cannot
be anything but short-sighted. It also contradicts the advice
the WRT were disseminating two years ago to deliver adequate numbers
of GPs for England.
14. The future effects of the European Working
Time Directive from 2009 are being considered by a national Stakeholder
group. However one of the key solutions for hospitals—transferring
work to the community—has not been complemented by appropriate
planning of the primary care workforce to accommodate such increases
in workload.
15. At present there is little evidence
of wholesale emigration of doctors or other key staff. However,
neither is there any evidence of coherent planning to retain staff
in circumstances of changing demography. While the NHS medical
education and training systems stand comparison with the rest
of the world, there will always be people keen to come here to
work and train. Increased numbers of UK medical graduates and
the recent changes in immigration regulations have signalled that
the NHS sees itself as soon becoming self sufficient. Whether
this turns out to be accurate or not remains to be seen. There
are widely differing views.
16. Early retirement is multifactorial.
It is noted that the large number of GPs anticipated to retire
in 2003-04 and in 2004-05 did not do so and the question is asked
whether they delayed retirement to secure the pension enhancements
of the nGMS contract to be introduced. There is no coherent strategy
within the NHS to accommodate changing aspirations of the workforce
at differing stages of their careers.
To what extent can and should the demand be met,
for both clinical and managerial staff, by changing the roles
and improving the skills of existing staff; better retention;
the recruitment of new staff in England; international recruitment
17. Skill mix in all its facets will continue
to be important in seeking solutions to health care resources.
However, planning this requires inter-disciplinary co-operation
and not just one professional group "dumping" on another.
The long term effects of changing the job expectations of groups
of staff need to be evaluated.
18. Retention is an issue and all surveys
show that constant change and a feeling that they are not valued
are the major determinants for people leaving the service.
19. Recruitment, like retention, needs to
demonstrate to people that they are valued. Part of this is having
coherent personal and professional development strategies. The
recent sudden change in the funding and management of the Flexible
Careers Scheme (retrospectively applied in year) is a major disappointment
and an example of appalling practice which can only de-motivate
staff and inhibit recruitment. A real sense that there is no connection
or continuity between training and employment or between various
stages of employment is a barrier.
20. International recruitment is a complex
issue with, on the one hand, recruitment from within the EEA and
the reciprocal acceptance of qualifications and, on the other
hand, the sudden and unheralded announcement changing the immigration
rules to greatly disadvantage applicants from outside the EEA
will change the balance of applications. Ethical considerations
also play a part in recruitment from under-doctored countries
and the local domino effect in places such as Southern Africa
is of concern.
How should planning be undertaken?
21. Planning must be centralised to even
out imbalances and inequalities and to manage scarce resources
but there must also be scope for local innovation.
22. Flexibility can be managed by appropriate
systems of control. It need not imply anarchy.
23. There are many examples of good practice
but usually developed to deal with local circumstances. Transplanting
these without careful thought has not always been successful.
Dr Maureen Baker
Honorary Secretary of Council, Royal College of General
Practitioners
17 March 2006
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