Evidence submitted by the Medical Women's
Federation (WP 92)
SUMMARY
1. For over 30 years the NHS medical workforce
has benefited from the Flexible Training Scheme, which made provision
for postgraduate training for doctors who for personal reasons
required to work less than full time. This has developed and grown
in parallel with the increasing number of women in the medical
workforce. It has enabled many hundreds of doctors gain specialist
qualifications and to continue to develop their professional careers
and by allowing them time for their personal responsibilities,
it has prevented them from taking career breaks and premature
retirement from the NHS. The flexible training scheme has been
shown to produce trainees who were able to gain appointment to
hospital consultant posts, the majority of whom would then return
to full time work within the NHS.
2. More recently the Flexible Careers Scheme
funded retainer and returner programmes, which allowed doctors
to remain in the medical workforce during periods when they might
otherwise have taken career breaks and been lost to the NHS. In
the three years that the flexible careers scheme was centrally
funded, over three thousand doctors were appointed to it and so
remained in professional practise, making an active contribution
to the NHS.
3. In the past two years central funding
for both these schemes has been withdrawn and those doctors already
in these schemes must now rely on funding being made available
locally by NHS Trusts. At a time when many NHS Trusts are in financial
crisis, the result is the reduction in the numbers of doctors
in flexible training and a reluctance to appoint any further applicants
to either scheme.
4. At a time when almost 70% of the graduates
from British medical schools are women, this represents a significant
immediate loss to the NHS workforce of doctors trained in Britain
at public expense, and unless action in taken to reverse this
situation by ensuring funding for these or similar schemes, a
potential cumulative loss of trained doctors in future years.
Costs
5. Approximately £250,000 to train
a doctor Total cost of a returner scheme General Practitioner(GP)
is £60,000, a one off cost. Once a returner scheme GP has
returned to general practice, they continue to practice. Retainer
Scheme GP working four sessions per week costs approximately £12,000
per year.
BACKGROUND
6. In its report on Future NHS Staffing
Requirements (March 1999) the Health Select Committee reported
on Doctor Numbers and acknowledged the Government's acceptance
that the intake into medical schools needed to be increase by
1,000 (20%). The report added that, during this process, a major
factor in medical workforce planning is the extent to which the
UK has become dependent on overseas qualified doctors as the majority
of new registrants with the General Medical Council were from
overseas. This report endorsed the Government's decisions to increase
intake at medical schools by 1,000 places a year with the aim
to become self-sufficient in doctors.
7. The report considered if the increased
intake could create an over-supply of doctors. It stated:
"An increase of 1,000 in the annual medical
school intake, in the view of MWSAC [Medical Workforce Standing
Advisory Committee], would not produce a domestic over-supply
by the year 2020 under any realistic scenario. It should be noted
that past predictions and actual increases in medical student
intakes have consistently fallen below demand for doctors in the
UK. The consequence is the current need for a substantial increase
in medical student numbers. Because small percentage point shifts
in wastage and growth rates over time have large effects on the
number of medical graduates required these indices need to be
kept under constant review."
8. Following from this it was considered
necessary to retain all trained and registered doctors within
the medical workforce and to allow them facilities for their full
professional and career development and it is relevant to note
that among its recommendations this report suggested that the
Department of Health should ask the Medical Workforce Standing
Advisory Committee to look in more detail at the training with
the aim of achieving a flexible medical workforce.
9. Since then there has continued to be
considerable recruitment of doctors who have trained overseas
and there has recently been much publicity about the difficulties
that some of them have had in gaining employment, to the extent
that the needs of doctors who trained in Great Britain have received
little public attention.
10. The majority of doctors graduating from
medical schools in Great Britain are women, in recent years over
65%. These young women have achieved their places at medical school
in open competition and continue to distinguish themselves academically
and professionally through their training and the early stages
of their careers. Like other women in contemporary society the
majority of them marry and have families, two-thirds of women
doctors have children by their mid-30s, a stage when most will
still be in training posts. However several studies over the years
have shown a high level of continued commitment to a career in
Medicine and the majority continue to make significant contributions
to the NHS, provided they can maintain their links to the NHS
as trainees and career post doctors who are employed with a less
than full time commitment during the comparatively few years when
they have responsibilities for the care of young children. The
majority of them then return to full time employment and remain
professionally active years later than many of their male colleagues.
11. Given the current trends in medical
school intake, adequate provision of flexible training opportunities
after qualification is essential to ensure that the needs of both
the NHS' current and future workforce and of these women doctors,
are met.
FLEXIBLE POSTGRADUATE
MEDICAL TRAINING
12. Part time postgraduate medical training
and working in the NHS was pioneered under the leadership of Dr
(later Dame) Rosemary Rue in the 1960s. As a single parent herself,
and with responsibilities regionally for the medical workforce,
she recognised the need to retain trained women doctors within
the NHS and so she pioneered "Returner schemes" for
those who had retired from medical practice when they started
a family. She rapidly realised the difficulties that these women
encountered when they attempted to re-enter professional life,
so she started a part time training scheme to allow those with
young children to remain professionally active during their child
bearing and rearing years.
13. This scheme grew in size and spread
throughout the branches of medicine. It also became more widespread
and flourished in several parts of the country and was adopted
nationally by the NHS in 1969 as the part time postgraduate medical
training scheme. The general administration of the scheme locally
and nationally, including the acceptance of trainees for the scheme
and the approval for training posts, was over seen by associate
postgraduate deans attached to the postgraduate deaneries throughout
the NHS. Many of the key features of this scheme were retained
when it became the Flexible Training Scheme, which was introduced
in 1993.
14. Data from cohort studies of doctors
suggests that the period of five to seven years after qualification
is a critical time for retention of female doctors. However the
evidence suggests that retention rates of women doctors in the
NHS can be improved by the provision of appropriate opportunities
that accommodate their family responsibilities:
"of a cohort qualifying in 1988, 10% were
not currently working at five years, compared to 6.5% of male
doctors, but of the 1993 cohort only 6.2% of female doctors were
not currently working compared to 4.2% of male doctors."
15. This scheme has allowed many hundreds
of women doctors to remain professionally active contributing
to the NHS while continuing with their professional postgraduate
training and career development alongside their male colleagues.
The quality of this training is high and has allowed a comparable
number to achieve career consultant posts within the NHS when
compared with colleagues who have trained full time:
"A survey of all flexible Specialist Registrars
(SpRs) and matched full time controls who left the training schemes
in three Postgraduate Deaneries between April 1996 and March 2004
showed that the outcomes of training were broadly similar with
92% (104/113) of flexible SpRs obtaining a Certificate of Completion
of Training compared to 90% (172/191) of full time SpRs. 81% (91/113)
of flexible SpRs worked as consultants compared to 77% (147/191)
of full time SpRs."
16. In 1999, the Medical Women's Federation
reported to the House of Commons Employment Sub-Committee of the
Education and Employment Select Committee that: Part time doctors
accounted for 15% of principals in general practice, and 12.2%
of career grade doctors among the hospital medical staff, including
2,190 consultants. Only 3.5% of junior doctors were working part
time.
17. Since that time the numbers of part
time trainees have continued to increase year on year.
"In 2005, 6% of all trainees were training
less than full time, with up to 14% of all Specialist Registrars
in some regions. They were generally working 60% of the time of
their equivalent full time colleagues."
18. However the national funding stream
for flexible training was withdrawn in the middle of 2005 and
in the report to COPMeD in May 2006, this figure had fallen to
5%. The fall from 2,413 to 2,143 is the first drop of this size
since the scheme began. It was also highlighted that:
"There were 141 trainees with an agreed
post hoping to commence flexible training within the next six
months across the UK, this is a reduction compared to the last
years figure of 284, indicating that the downward trend will continue.
This has also to be seen against a rise in full time trainees
of 17.7%."
19. The removal of the national funding
stream for flexible training, and the pressures on NHS budgets
are already having an effect. The change means that flexible trainees
should work in standard posts. Commonly two trainees share one
full-time slot and both work 60% of full-time. The disadvantage
is that it may be difficult to find a slot-share partner even
in London. Doctors cannot start training flexibly until they have
a partner. This could restrict access to training in some areas
and especially in specialty and subspecialty posts. Flexibility
is lost: most trainees in a slot share are restricted to 60% because
of financial implications.
20. Flexible training keeps female doctors
in the workforce at a critical time in their lives. Part-time
training is not synonymous with part-time commitment, and those
who have been through the scheme go on to make a long term, often
full-time time contribution to medicine and the NHS.
FLEXIBLE CAREERS
SCHEME
21. The success of the flexible training
scheme lead in time to a realisation that some women on completing
their postgraduate training would still need flexible working
patterns and would initially require less than full time employment
as hospital consultants and in career posts in general practice.
There was also an acknowledgement that the majority of women doctors
are not geographically mobile and may be required to relocate
in response to their partner's careers. To meet these needs and
to allow the NHS to continue to benefit from their contribution,
the flexible careers scheme was developed with an entirely
separate funding stream and launched nationally in November 2002.
The Scheme was administered and funded nationally by NHS Professionals
but postgraduate deaneries were responsible for arranging placements
and signing off work programmes for those who were on the returner
and retainer part of the scheme.
"The Hospital Scheme included funding for
part time career grade posts and funding for six months whole
time equivalent salary for those who had been out of medicine
(a `returner') package. For the first time there was a retainer
package for those in training grades who were unable to work half
time with appropriate incentives to encourage study leave and
further training. There was also a General Practice Scheme for
returners and funding for new part time posts. A General Practice
retainer scheme had existed for some years."
22. The Flexible Careers Scheme has been
invaluable for two main groups: those returning to medicine after
a break, and those who are unable for a short period to work half
time or more, usually because of caring responsibilities, often
combined with location moves due to their partner's career moves.
"Review of the experience in three deaneries
showed over a two year period that the majority (40 out of 63)
rapidly made a successful transition back into clinical medicine
and within a six month placement were able to secure training
posts (24) or career grade posts (16)."
23. These studies have demonstrated that
the returner element of the Flexible Careers Scheme has been an
effective way of helping those who have been out of medicine to
return to practice and also for some an opportunity to remain
in professional practise after a move and before more long term
employment can be negotiated in a recognised training or career
post.
24. The Department of Health instructed
NHS Professionals to stop their involvement with this scheme at
the end of 2005. From 2006 the Flexible Careers Scheme was devolved
to Postgraduate deaneries and Strategic Health Authorities(SHA).
Funding was devolved to SHA for the Scheme for 2005-06, but this
was insufficient even to cover existing commitments, and there
is no central funding identified for 2006-07. The lack of continued
funding means that in many regions new applicants have not been
accepted, and with the local pressures on funding the Scheme is
currently regarded by many as dead.
25. There will always be doctors who leave
clinical medicine but who will wish to return to practice and
who are capable of making a valuable contribution. In particular,
as the number of women in the medical workforce increases, those
taking short career breaks to have children or to follow their
partner's career will rise. It has been shown that many of these
have continued to work in the NHS. Given the substantial national
investment required for medical training, a scheme which allows
individuals a quick route back to clinical practice after a short
career break is a highly cost-effective.
26. The total number of enquiries was over
8,000 from the launch of the scheme by the Department of Health
in 2002 till NHS Professionals creased to have any role in it
at the end of 2005; an indication of the scale of interest in
it. The scheme did not offer an appropriate solution for all but
over 4,000 applications were received and by the time NHS Professionals
responsibility for the scheme ended on 31 December 2005 over 3,000
doctors had been approved to join the scheme. The schemes were
mainly used by female doctors during the years when they are caring
for young children or by male doctors reducing their commitment
towards retirement or delaying retirement. Doctors were overwhelmingly
positive about the scheme and about NHS Professionals' contribution
with many offering personal thanks for their help. In hospitals
over 450 part time consultants were appointed, mainly young women,
for many of whom this scheme prevented their loss to the NHS workforce.
27. Retaining doctors in this way could
reduce the numbers needing to return in future. Although the scheme
came out of the Improving Working Lives initiative a major concern
was always that the cost of training new doctors is significantly
higher than the cost of retraining or retaining qualified doctors.
The average cost of a Hospital doctor on the scheme was around
£15,000 per year so overall around £30,000 in total
per doctor; compared with the figures of somewhere between £200,000
and £300,000 which have been quoted to train a new doctor.
28. When viewed against the strategic planning
of the medical workforce, and the previous investment in highly
trained and competent individuals, it is surely short sighted
that there does not appear to be further funding available at
national level to continue this valuable scheme.
29. Instead it appears that present policies
and the funding of training, have:
"effectively ended the hugely successful
flexible career scheme".
Report by Health Editor The Times 16 June
2006
THE PRESENT
SITUATION
30. The website advertising NHS Professionals,
included at Annex C,[26]
would appear to suggest that it has a responsibility for fostering
flexible working within the NHS. However the organisation no longer
has responsibility or funding for the Flexible Careers scheme
and feed back from those doctors who make contact suggests that
the organisation now has the needs of the NHS trusts as its priority.
The needs of the individuals in the workforce who register are
considered as a poor second.
31. While NHS Professionals claim to assist
in appraisal and training, they are not perceived by the doctors
registering to support individuals who are seeking to obtain further
training and career development. The mentoring from the Postgraduate
Deanery which has characterised the flexible training scheme from
it inception and which was also a part of the flexible careers
scheme, is missing, and many as a result are opting out from this
service and attempting, especially in General Practice once they
have their accreditation, to arrange their own locum work without
any professional supervision. In the long term this will lead
to professional isolation cannot be for the greater good of either
the NHS or of the individuals concerned.
32. In the hospital specialties, trainees
may gain their Certificates of Specialist Training (CSTs) through
flexible training and some of these are not able, by reason of
their family responsibilities, to apply either for full time consultant
posts or work distant from their homes. Several of these are known
at this stage to be leaving medicine because they cannot obtain
less than full time work in their geographical area.
33. While a career break with young children
is easy to justify both personally and publicly, these are women
who have continued to contribute to the NHS while training in
their specialty, and who are now lost to the NHS workforce at
what could be the peak of their professional contribution. They
are women with intelligence and drive and we cannot assume that
they will not make successful careers for themselves elsewhere
if they are not given some encouragement to return to medicine
before they loose the skills that they have worked hard to acquire.
34. With the changing working patterns resulting
from the European Working Time Directive, attitudes towards flexible
working in Medicine are beginning to change, but with the current
financial difficulties in many Trusts, flexible working is unlikely
to be given high priority for funding by them in the near future.
Numbers of female medical students have exceeded male for several
years and there is evidence that a significant number of doctors
will wish to work flexibly at some point in their career. Provision
needs to be made for flexible working to avoid staffing difficulties
in future.
35. Regrettably much evidence about the
present position is anecdotal as this section of the medical workforce
is no longer the responsibility of Postgraduate deans or of NHS
Professionals and neither is able to collect the statistics that
would paint a more complete picture. The Department of Health
may in the long term be able to define how many trainees and trained
hospital specialists and GPs are not working in the NHS, but short
term reviews and accurate figures of this drain from the trained
workforce are not currently available.
36. Such evidence as I have found is gathered
from personal experience and is in Annex A and Annex B.[27]
It tells the story of reducing levels of funding and declining
numbers of part time trainees all over the country, with a serious
impact on individual lives and careers. In the long term the demand
for flexible working in the NHS will increase and if the NHS does
not tackle the problem a new staffing crisis is likely in spite
of the increasing numbers of doctors who are being trained and
graduating from British medical schools.
Medical Women's Federation
23 September 2006
26 Not printed here. Back
27
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