The state of medical education and practice in the UK 2018 The state of medical education and practice in the UK 2018 Read the report and tell us what you think about our findings at www.gmc-uk.org/somep2018 Published by: General Medical Council Regent’s Place 350 Euston Road London NW1 3JN Telephone: 0161 923 6602 Website: www.gmc-uk.org To ask for this publication in Welsh, or in another format or language, please call us on 0161 923 6602 or email us at [email protected]. Published December 2018 © 2018 General Medical Council The text of this document may be reproduced free of charge in any format or medium providing it is reproduced accurately and not in a misleading context. The material must be acknowledged as GMC copyright and the document title specified. Printed on 100% recycled paper. 978-0-901458-99-5 A catalogue record of this book is available from the British Library. Contents Contents Foreword 06 An information resource 08 Executive summary 10 A workforce strategy to ensure the progress of the past 70 years does not stall (Chapter 1) 10 The profession is at a critical juncture 10 New evidence shows how doctors on the frontline are experiencing current pressures 10 What we are concerned about 11 Call to action 11 What is needed now 12 Supply – the medical workforce (Chapter 2) 12 Doctors joining the profession 12 Supply of new doctors from outside the UK 13 Doctors leaving the UK profession for at least one year 14 Supporting doctors working under pressure (Chapter 3) 15 Types and sources of pressure 15 Longer hours but less care 15 Deterioration of work-life balance 16 Impacts of the pressure 16 Strategies to deal with pressures 16 A quality workforce: ensuring standards, applying fairness (Chapter 4) 18 Ensuring standards 18 Fairness in fitness to practise 19 Supporting doctors to uphold standards 20 How we and others can build a sustainable workforce (Chapter 5) 21 Improving the supply of doctors 21 Better support to retain and attract doctors 21 Taking a more systemic approach to maintaining and improving standards 22 General Medical Council 01 Contents Chapter 1: A workforce strategy to make sure the progress of the past 70 years does not stall 23 Introduction 24 The profession is at a critical juncture 24 Breaking the vicious cycles of workforce supply and pressure-induced short-termism 25 Specific pressures on certain groups of doctors in particular roles and situations 26 Supply of new doctors to the UK register 28 Supply of new doctors from the European Economic Area 28 International medical graduates 28 UK medical schools 29 Retaining existing doctors 30 Workforce strategy 31 This year’s report – the evidence in support of action 33 We can avert the risk of the progress of the last 70 years stalling 34 Getting things right 34 Chapter 2: The medical workforce 37 Introduction 38 The changing shape of the medical register 39 Number of licensed doctors grew faster than the UK population in the past two years 40 Number of licensed EEA doctors remains steady 41 UK-trained doctors increasing in numbers 41 Number of GPs continues to grow, but at a slower rate than specialists 44 GP growth is largest in England 45 Trends in the numbers of specialists vary by specialty 46 Some smaller specialties are shrinking in size and ageing 48 There are recruitment challenges across certain localities 48 The supply of new doctors into the workforce 55 Half of all new doctors are non-UK graduates (EEA graduates or IMGs) 55 Increase in doctors joining from eastern and central Europe and the Baltic countries, relative to the rest of the EEA 57 Decline in doctors joining from North America and Australia 57 Future supply of UK-trained doctors 59 Medical students pass 40,000 mark 59 Welcome increase in doctors entering training in general practice and emergency medicine, but decline in psychiatry worrying 60 Breaks in training 61 02 General Medical Council Contents Doctors leaving the workforce 62 Younger UK graduate and IMG doctors are increasingly leaving the profession to go overseas 62 Over half of doctors leaving the profession for at least one year are under 50 years old 64 Doctors’ future intentions to leave the profession 65 Evidence of doctors changing their work patterns in response to pressures 65 Intentions to reduce hours and work part time 65 Younger doctors’ intentions to leave the UK workforce are concerning 67 Non-UK doctors are more likely to be considering leaving to go abroad 67 Intentions will not always turn into action, but a third are considering leaving clinical practice 67 One in four doctors has already reduced their hours as a result of pressures 68 System and environment pressures leading to nearly 30% of doctors considering career changes 69 There are positive signs that the shape of the workforce is improving, but much still needs doing 70 Chapter 3: Supporting doctors working under pressure 71 Introduction 72 Evidence sources used in this chapter 73 Doctors’ experiences of working in a pressurised environment 74 Types of pressure 74 External pressures: workload and administration 74 External pressures: staff and other resource availability 75 How doctors are experiencing pressures 76 Deterioration of work-life balance 78 Effects of pressure on doctors 80 Support from management 80 Support from colleagues 81 Mentoring and reflection 82 Stress-related absences and thoughts of leaving the profession 85 Strategies doctors are implementing to manage pressures 87 Work-related strategies 87 Smarter ways of working 87 Prioritising immediate patient care at the expense of other activities 90 Changing ways of working 93 Personal coping mechanisms 102 Achieving work-life balance, avoiding burnout 103 Pressures are felt differently amongst the profession 103 Conclusion: pressing need for more support 105 General Medical Council 03 Contents Chapter 4: A quality workforce: ensuring standards, applying fairness 107 Introduction 108 Medical education 109 Enhanced monitoring 109 Impact of enhanced monitoring and statutory action 111 Enabling all groups to reach their potential 113 A common threshold for safe practice 115 Focus on quality for revalidation 115 New guidance on reflection 115 Collaborating to improve working environments 117 Emerging Concerns Protocol 118 Collaborative quality assurance of training environments 120 Raising concerns 120 Doctors in training raising concerns 120 Raising concerns and leadership 121 GMC response to raising concerns 122 When doctors fail to meet standards 123 Complaints about doctors 123 Complaints continue to decline 123 Reforms to fitness to practise 125 Provisional enquiries 125 Fairness in fitness to practise 129 Chapter 5: How we and others can build a sustainable workforce 131 Introduction 132 A: Improving the supply of doctors 133 General Practice 133 The GP Register and the Specialist Register 134 Enabling IMGs to access PLAB more quickly 134 Making training more flexible and relevant 134 Medical associate professions 135 Internationally based doctors treating patients in the UK 135 Strengthening oversight of the training environment 135 Medical Licensing Assessment 135 Supporting doctors who are not on the GP Register or the Specialist Register and not in training 135 Incentivising good workforce culture and employment practice 135 04 General Medical Council Contents B: Better support to retain and attract doctors 136 Supporting good workplace culture and wellbeing 136 Enhancing support to doctors who are new to practice in the UK 136 Offering greater support to providers in enhanced monitoring 136 Credentialing 136 C: Strategic approach - Taking a more systemic approach to maintaining and improving standards 137 Enhancing insight into distribution of doctors across the UK 137 Strategic approach to front-line engagement on continuing professional development 137 Conclusion 137 Glossary 138 A note on research and data 139 References 144 Acknowledgements 150 General Medical Council 05 Foreword Foreword Medicine can be a fantastic career. It continues to attract talented applicants and many doctors remain highly motivated and satisfied. Most are able to provide good and often superb levels of care to patients despite the pressures that our health services are under, across the four countries of the UK. And those pressures are considerable. No one can particular concern is that 21 per cent of 45-54 be in any doubt that steadily rising numbers of year old doctors, and two-thirds of 55-64 year patients with more complex health conditions, olds, intend to take early retirement by 2021. coupled with the evident gaps in the medical These doctors are among the most experienced workforce, are testing the ability of doctors and have much to offer to both patients, and the to deliver the level of care that they want for next generation of medics. patients – the care that we all wish to see for our loved ones. Our findings come against a backdrop of uncertainty with a possible Brexit ‘no deal’ and The professionalism, commitment, and uncertainty around how EEA qualified doctors determination of the UK’s medical workforce will be able to join the UK medical register after in providing that care is second to none. But we leave the European Union. That group makes it is clear that the costs for some doctors – to up nine per cent of licensed doctors in the UK, their own well-being and work-life balance – are and they are vital to our health services and significant, and not sustainable. patient care. Research commissioned for this year’s edition of As the UK medical regulator, we are doing The state of medical education and practice in the everything possible to prepare for the various UK paints a clear picture of the effects that those scenarios possible in March 2019.