Monday, 7 May 2018

Wales 'Future NHS (2) - grow our own staff or depend for ever on other countries?

Wales was officially part of England during the early years of the NHS  and this is reflected in the organisation of the Welsh NHS ,more a regional sub branch than an integrated health service for Wales. Devolution could have produced more control of doctor and nurse training - a system reflecting the geography and needs of the people.  Instead our government took over the administration of health services but not the training and recruitment of doctors and nurses for Wales.
The other UK small nations have been more proactive and better resourced, helped by their political importance and greater historical investment in some of their facilities. As in other things devolution for Wales also devolved the chronic under investment in the Welsh Health Service. No catch up funding.

Scotland {pop. 5.4m}has 5 medical schools. Northern Ireland {pop 1.8m} opens its second medical school next year in Londonderry. Magee College, University of Ulster, already has a well regarded school of nursing and this new medical school will have a postgraduate entry and an annual intake of 120 students. The Republic of Ireland, a nearby EU country with a population of  4.7million, has 6 medical schools, 5 undergraduate (one of which specalises in foriegn students) and one postgraduate.

According to the GMC we only have one medical school in Wales {pop 3.06m,} which presumably means that the small postgraduate medical school at Swansea is listed under "Cardiff" The figures they give is total medical student numbers in Wales 12016/17 are undergraduate 1,521 students and postgraduate 61. the undergraduate courses are generally 6 years long and the postgraduate ones 4 years long. This suggests an annual "production" of  doctors in Wales of around 330 . The GMC breakdown shows ethnicity amongst other things and figures from the National Assembly which funds Welsh Students assembly suggest that the number of Welsh domiciled students entering the local medical schools is around 20% of the total. I've asked for figures of the number of Welsh Students studying in the rest of Britain but they have not been provided.

A legacy of the UK's imperial past is the widespread use of foreign doctors. In the past students were attracted here from the colonies as were young doctors in training.  In the early years of the NHS the idea was that they stayed here a few years then returned with  their knowledge to their own countries but the UK became ever more dependent on these foreign doctors. In more recent times doctors from the EEC have come, attracted in part by the higher salaries doctors enjoy here compared with continental Europe .

In recent years the conversion of nurse training to a university degree qualification and the inadequacy of local nurse training numbers has led to foreign recruitment of nurse on a large scale,. Countries such as the Philipines  encourage their nationals to train as nurses, in large part to work abroad and send money home to their families, boosting the economy of their country. Taking the gift of nurses from the developing world may fill the gap but leaves us open to future shortages if these countries improve their own economies and  health services, so needing their own nurses and being able to provide a good wage, or if political instability or conflict reduces the supply.

I have asked the Welsh Government for the numbers of doctors and nurses we in Wales need annually, No answer. I have been informed though, that only 20% of Cardiff medical students are officially Welsh domiciled. I could not find out how many welsh students are at medical school in the rest of the UK where the Welsh Government and the Welsh NHS will be subsidising them through grants and bursaries.

The UK has for decades relied on foreign staff and acts as if the supply will always be there, Training doctors and nurses is expensive here and restricted to applicants with high academic qualifications. In order to improve the UK supply you may need not only more places on courses but also more doctors and nurses involved in teaching and expansion of the university departments. These UK degree courses are already oversubscribed with lots of intelligent young people turned away every year.  The higher number of women doctors and the predominance of female nurses also means that "in house" creche facilities and  transport from childcare facilities to school and back are needed. Doctors and nurses from the developing world are more likely to leave their families at home.

Wales needs to decide whether to adopt self sufficiency in staffing the NHS or continue to rely on the generosity of the developing world. Some countries have always planned on self sufficiency.

                                                Icelandic medical students in training.

In Iceland, {pop. 380,000} the policy has always been to train their own doctors and nurses. They produce 48 doctors a year from their only medical school in Reykjavik.  Their infant mortality is the lowest in the world, their longevity  figures are impressive (highest life expectancy for men in the world, women's in the top 10} and they train doctors using the Australian model through the medium of Icelandic. There is no private practice although there is a fee system for GP visits.

Other countries have different systems. The irony of the shortage in Wales is that  some of the areas where staff are hardest to retain are the last strongholds of the welsh language. Although welsh speaking nurses are in evidence, welsh speaking doctors are not so much and the Welsh government policies are not helping . The " Gifted and Talented" program in Welsh Schools encourages the academically outstanding to make the most of themselves, go to  Russell Group universities and especially Oxford and Cambridge. The planned new acute hospital between Narberth and St Clears will bring a large influx of staff who are unlikely to be well speaking and because of its geographical isolation will be looking for homes in the area, or possibly not coming at all. The choice of a job is not just about filling a vacancy but about what is best for your partner and family. Cities are ideal as there is more chance of getting a job for your partner, more choice in childcare and education for your children and, especially if you are in training and will need to move on, more chance to find suitable accommodation. 

Most ambitious students may well end up going to "well known"medical schools of which there is a good choice in England if you make the grades. The financial support is the same whether or no you decide to study in /Wales,  in contrast to Scotland where only if you stay in your country to study medicine or nursing (or any other degree except those not offered in Scotland}will your fees be paid.

Many countries with remote rural areas struggle to get doctors to settle there and it may lead to adoption of more high tech diagnostics in the GP type units, efficient extraction of the very sick and injured to specialist hospitals, as happens in the highlands and islands of Scotland, and sometimes long journeys to get specialist operations like hip and knee replacements, as in Sweden, where the expert surgery is done away from home and the rehabilitation provided by the local hub.

What we need in Wales is not isolated organisation of GP and hospital services dictated by local authority boundaries but leadership from our government to shape a future for healthcare in Wales. 



Siân Caiach




Sources:
Student numbers :https://www.gmc-uk.org/-/.../201617-medical-school-annual-return-overall-student-n
www.bbc.co.uk/news/uk-northern-ireland-foyle-west-43595014
www.nursinginpractice.com/article/nurse-training-places-wales-will-increase-10-2018

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