Richard Smith: Dumfries and Galloway NHS 2—Recruitment is the number one problem

richard_smith_2014Richard Smith visited and wrote about the NHS in Dumfries and Galloway in 1980, 1990, and 1999, and this series of blogs describes what he found in 2016. A feature article provides a summary.

The thing that currently pleases Angus Cameron, the medical director of the Dumfries and Galloway Health Board, is that the board did extremely well in the GMC survey of trainees. They “hate coming here,” he says, but they have a very good experience when they do—and they do well in their exams. They hate coming because they don’t want to leave their partners and flats in Glasgow, and—despite the good experience as trainees—they don’t want to come back when fully trained.

The recruitment problem is most acute in general practice but affects most—but not all—specialties. A few years ago there were dozens of doctors competing for every place on the GP vocational training scheme, but now it’s only half filled. This problem is not unique to Dumfries and Galloway, but its more acute there than in most places. Plus trainees are now ranked with those at the top getting first choice on where they go. They tend to choose the big cities, meaning that Dumfries and Galloway tend to get those at the bottom, sometimes presenting serious problems to trainers. (My immediate reaction to this was that—as with the weaker teams in the draft in American football—places like Dumfries and Galloway should get the best not the weakest.)

Some of the towns in the region, particularly in the West, which is the most remote, have been trying to recruit GPs for years without any serious applications. GPs have responded to the problem by doing extra sessions, recruiting advanced nurse practitioners, and merging practices, but it’s a downward spiral: remaining GPs are put under greater pressure, making them more likely to retire early or do something else. The government bringing down the size of the “pension pot” (the amount you can put into a pension without being penalised) means that GPs in their late 50s gain little by continuing to work.

The Scottish government is now offering a £20 000 bursary to trainee GPs who join practices in Scotland, hoping to attract GPs from England who may be under even greater pressure than many of their Scottish counterparts. But, as the GPs all told me, English GPs tend to earn more than the Scottish, negating the value of the bursary.

Stranraer, the second biggest town in the region and the most Westerly, has the acutest problem. There were until relatively recently 14 GPs but now there are nine and three advanced nurse practitioners, and all but two of them are over 55. One of the three practices may close within weeks. Even with the £20 000 golden handshake it looks as if it will be impossible to recruit more than one or two GPs. It is surely time to begin to think about different models, including practices that are nurse-run with doctor support, more input from pharmacists and others, or providing services from the hospital (although it runs mostly on locums). This is a problem that more and more health authorities will have to face. Azeem Majeed, professor of primary care at Imperial, has built a model with a colleague showing that England will need 25 000 more GPs by 2025 to continue the present model of care. Even if they could be afforded they cannot be created.

Recruitment to secondary care

Recruitment of secondary care doctors is patchy. There seem to be few problems in paediatrics and obstetrics and gynaecology, but the gradual disappearance of staff grade doctors may present problems in the future.

The increasing specialisation of medicine presents problems for a region like Dumfries and Galloway with a population of 147 000. One problem is that even if subspecialists can be recruited they are likely to be on their own, which is professionally unsatisfactory. A second problem is that the subspecialists are either unwilling to take general medical admissions or are not fully comfortable with the body systems with which they are less familiar. This is unfortunate in that the majority of medical patients, most of them elderly, have multiple problems not just one. The organisation of medical services and the needs of patients seemed to be headed in opposite directions. The reluctance of subspecialists to do a general take puts greater pressure on those that are, and one physician said to me bluntly “I’m burnt out.”

Interestingly Dumfries and Galloway does not employ oncologists. Instead the oncology service is provided from Edinburgh. Perhaps the future for other mostly non-urgent services is for them to be provided from Edinburgh or Glasgow. An obvious risk for Dumfries and Galloway is that as services provided from cities come under pressure it’s the services outside the cities that will suffer the most. But if Scotland does come to have three rather than 14 health boards, as is being discussed, then services may well come to be organised in different ways.

There’s also a problem with volume as evidence grows of the relation between large volume and better outcomes. This is a problem for most surgical services but particularly vascular surgery. It was worries about quality that stopped emergency surgery in Stranraer; could similar worries lead to the demise of some surgical services in Dumfries?

There are also worries about volume with obstetric services, which ideally would have more than 2000 births a year. The hospital in Dumfries has around 1400, but the number is falling. Outcomes, however, are good, and it’s impossible to imagine mothers travelling to Glasgow or Carlisle to give birth.

Radiologists are in short supply nationally, and Dumfries and Galloway has severe problems. Increasingly radiology services are being centralised with radiographs and scans being read by radiologists far away. Laboratory services also lend themselves to centralisation.

Recruitment problems arise not only with consultants but also with trainees. The problem is less with numbers and more with experience. In some specialties, including medicine and anaesthetics, the trainees sent to Dumfries and Galloway are junior, meaning that consultants have to do much more than would be necessary with more senior trainees. Several people told me that the most senior doctors on the medical wards at night might be only two or three years into their postgraduate training.

There don’t seem to be problems with recruiting nurses, particularly now that the University of the West of Scotland trains nurses in Dumfries. I heard a lot, however, about shortages of care workers, which affects hospital services in making it more difficult to discharge patients. The Scottish Government recently allocated £250 million to increase the number of care workers, but half of the money went legitimately to increasing the salaries of care workers to the living wage. People can easily get less demanding and equally or better paid jobs in supermarkets and the like.

Richard Smith was the editor of The BMJ until 2004.