Additional options considered for addressing middle-grade rota gaps
As well as the recommendations outlined in the report for addressing rota gaps, the Workforce Task Group also considered a number of other options. None of those listed below were considered long-term, sustainable solutions; however, combined with the main recommendations, they may prove useful to some trusts in addressing their rota gaps.
Trust-funded specialty posts
Clinical fellow posts are created to attract doctors to spend one to two years gaining a specific skill, and to fill the rota gaps. These posts may attract trainees (who are unable to get sufficient training time in their own posts) to take out of programme experience/training (OOPE/T). However, this may leave further gaps in their own rotas, which the RCOG does not encourage.
Some trusts have created post-CCT positions with middle-grade on-call responsibilities. Some trainees may initially prefer to take a post which does not have consultant responsibilities and they may suit a CCT holder who is adding further skills to their portfolio. However, these posts may not be easily appointed to as most CCT holders are likely to be looking for a consultant post, unless they are keen to develop new, specialist skills. These jobs may also potentially create an unacceptable sub-consultant tier.
The trust grade includes a large skill mix of doctors with often creatively designed job descriptions. Some have chosen to leave training, possibly because of failure to pass the MRCOG exam. Others may have been unable to gain a training number or come from a different country with too much O&G experience to apply at ST1. Trusts, individually or within a region, could offer training and appraisal on an individualised basis.
Despite there being an increase in numbers of trust grade doctors from 2011 to 2013, there are still significant vacancies in these posts. These doctors may not be sufficiently trained to take up a middle-grade position, and there is no UK training pathway available to them, apart from that offered at a trust level which differs in quality around the country. Current immigration regulations within the UK make recruitment of overseas doctors difficult. For these reasons, this is not a long-term solution.
Teaching trusts are able to ask doctors studying for research doctorates to work on the on-call rota. However, being on-call may also take time away from a research fellow’s research.
There is a diminishing number of middle-grade staff available to work as locums. Also, there is risk attached to the use of short-term locums as they are not familiar with departmental working patterns, guidelines and the multidisciplinary team. In addition, locums are a costly resource.
Expanding the number of MTI doctors
This scheme is administered by the RCOG, but determined at a national level by HEE. MTI trainees are employed at ST3 level for two years, but must be supervised, or on the SHO rota, for the first few months to familiarise themselves with UK practice. They are in the UK to gain both training and the MRCOG and must be appropriately supervised and supported. There is a current limit on the number of visas that can be issued to support MTI doctors. As a single initiative, the scheme will be unlikely to be able to expand sufficiently to replace vacancies on the middle-grade rotas. An increase in MTI placements would be a welcome development, particularly as O&G remains popular and is consistently filled each year.
There is also potential to expand this scheme for more senior doctors (above ST3) where more experienced doctors from overseas, who already have MRCOG, could undertake further more specialist training.
Offer training schemes to other countries
UK training in O&G is internationally recognised as being of a high standard, only allocating CCT once trainees have a wide range of experience. Where deaneries have the capacity to offer additional training schemes, these could be used by trainees from another country on a formalised basis.
HEE is considering letting departments use their trust-funded posts to offer training to overseas doctors who bring their own funding with them. There would be a concern if the RCOG were not able to select and interview these doctors, particularly if they were coming for a period of up to seven years. It would be important for the training to reflect the skills needed to be taken back to the trainees’ countries of origin. It would also need to be ensured that trainees recruited from other countries are integrated into an education and appraisal structure.
A potential group of doctors is European CCT holders who gain less practical experience during their shorter training programme, but who may have acquired skills of particular benefit to UK practice e.g. greater familiarity with ultrasound. There is an option to recruit European CCT holders to a level between ST3 and ST7 (depending on their practical experience) and offer them UK structured training but without the need for assessment for CCT, as they already hold it.
Develop other health professionals to provide middle-grade duties
It is unlikely that staff who are not medically trained would be able to take over the duties of an O&G registrar, which are wide ranging and include both specialised surgical skills, acute emergency management and general medical knowledge.
The development of nurse specialists in specific roles such as colposcopy and outpatient hysteroscopy already occurs and should be expanded. This could free up middle-grade time for on-call duties etc. but it must not remove sufficient training opportunities for trainees.
The use of physician associates for specific operative roles or specialised clinics will be explored but they would be unable to replace the multiskilled role of O&G middle-grade staff, particularly on-call. Again, access to training opportunities for O&G trainees should not be reduced.
The current crisis and shortfall in nursing and midwifery staff far outweighs the shortfall in medical staffing and so is not a short- to medium-term solution.
The Royal College of Midwives has provided the following statement on this point:
“The RCM accepts that the boundary between midwifery skills and medical skills is not inflexible and that some midwives may develop particular skills in order to sustain continuity of carer, allow more women to benefit from midwifery care at home or in midwifery units or otherwise to improve the care available to women and babies. Good examples of this are perineal repair, cannulation, examination of the new born and undertaking six-week postnatal examination. However this is about adapting the midwife’s role to accommodate women’s requirements, it is not about advancing skills.
"The RCM does not however endorse the extension of the midwife’s role into obstetric, nursing or other spheres of practice where this does not demonstrably improve the quality of or access to midwifery expertise. Whilst the RCM accepts that NHS organisations wish to maximise the flexibility of their workforce, it is not acceptable to permanently alter midwifery roles to compensate for staffing shortages or changes in doctors roles. We do not believe this kind of response solves the fundamental problem of medical shortages but merely moves the problem onto another profession.”
Develop GPs with an extended role (GPwER)
There is discussion between RCGP and NHSE about a credentialed programme to develop GPs with an extended role (GPwER) in women’s health. If this is not formalised shortly, trusts could develop their own local schemes, recruiting GPs to provide specific skills such as work in antenatal care or emergency gynaecology, which would free up middle-grade time for on-call duties. Again, it must not remove training opportunities for current trainees nor access to ‘first on-call’ doctors for clinics. However, general practice also has major recruitment and workforce issues, which need to be factored into any plans. That said, these opportunities may be attractive to some GPs and help retain individuals in the workforce.
There are a group of GPs who initially trained in O&G, some leaving after achieving their MRCOG. They would be an ideal group to work with on a sessional basis, with a specific skill and appropriate CPD. The salary scale for this grade of doctor – previously known as clinical assistants – needs to be clarified nationally. It would need to be equivalent to the pay for a GP locum session.