Doctors' and dentists' remuneration (DDRB) review body - 2022-2023 pay round: evidence

G. Education and Training

Medical Trainee Recruitment – Process

152. NHS Education for Scotland (NES) is the statutory education and training body for NHS Scotland.

153. The recruitment of medical trainees is predominantly undertaken on a UK-wide basis, some of which is by competitive entry, and some where progression is based on satisfactory performance (known as run-through training). A 4-Nation recruitment process has been maintained throughout the pandemic and remote/virtual interviews continue to be utilised in place of face-to-face interviews.

154. There are separate UK-run recruitment processes for the various stages of medical specialty training i.e. entry into (i) Foundation-level training, (ii) first year of specialty training (Core & ST1 level) and (iii) higher specialty levels (ST3+). The start dates for most posts are spread from August to September of each year, with a subsequent recruitment round available later in the calendar year for posts starting the following February. Any unfilled vacancies at the end of the recruitment rounds are passed to Health Boards to fill through local action, usually using locums, although Boards do have flexibility in terms of how they wish to advertise them to improve their attractiveness.

155. A small number of medical specialties either do not have UK agreed recruitment processes or are only recruited within Scotland; these specialties are recruited to using the Oriel system and are managed by NES.

156. All rounds of UK-wide recruitment for 2021 are now complete, with the data that follows below demonstrating the end of year position.

Medical Trainee Recruitment – Additional Training Places

157. Each year, the Scottish Shape of Training Transition Group (SSoTTG) undertakes an assessment of medical trainee establishment, the factors influencing recruitment fill rates and requests from specialty training boards, Royal Colleges and other relevant parties to increase the established number of core or specialty training posts in any given medical specialty in response to demand/attrition and Ministerial priorities. This process aligns with medical workforce modelling intended to achieve a planned and sustainable medical workforce.

158. Due to Covid-19, the consultation was undertaken virtually in 2020 and 2021, based upon recommendations made by NES who liaised with service providers and Health Board representatives. Since 2014, there has been 474 expansion posts created overall (including 139 that will be created and recruited to within the 2022 recruitment process).

159. There are currently 1,184 established GP training places in Scotland, 99.5% of which are filled.

160. An extra 51 Foundation trainee posts were created and recruited to in 2021, with another 54 to be added in 2022 (105 extra places overall). These posts will offer greater exposure to General Practice and Psychiatry and it is hoped this will encourage uptake at speciality training level. This increase in the number of Foundation places is necessary given the increased output of medical school graduates, following the creation of additional medical undergraduate places in Scotland, with these rising from 848 in 2015/16 to 1210 in 2021/22.

Medical Trainee Recruitment – 2021 Outcomes

161. The 2021 medical trainee recruitment position is positive, with 92% of all advertised posts having been filled successfully. A total of 1049 trainees have accepted posts throughout the 2021 recruitment process and, despite achieving a higher fill rate in 2020 (96%), there have been 23 more posts taken up this year when compared with last year (1026). There has also been a greater number of posts taken up this year than any other on record.

162. Following the conclusion of all recruitment rounds, 39 medical specialties have filled 100% of advertised posts. This number is down on 2020 when 44 specialties filled all of their advertised posts. Headline data from 2021 recruitment is as follows:

163. Foundation Training – for the August 2021 start date, 818 new trainees took up post in the two year Foundation training programme. 825 posts were advertised overall (99% fill rate) and this is inclusive of the planned expansion of 51 places as per the Workforce Plan.

164. Core & ST1 (Specialty Training Year 1) Run-through Training – 96% of posts that were advertised at Core & ST1 level have filled (799 from a possible 829). This is a slight reduction when compared with 2020 when 98% of posts filled (798 from a possible 817), however the headcount is slightly higher.

165. Higher Level Specialty Training (ST3+) – of the 313 posts that were advertised at ST3+, 250 filled successfully (80% fill rate). While the fill rate was considerably higher in 2020 (90%), the number of filled posts is actually greater this year (228 in 2020).

166. The trend in recruitment to Mental Health specialities at ST4 level remains a concern, however this issue is not unique to Scotland and similar difficulties are being faced across the UK. Although recruitment to Core Psychiatry remains strong, only 42 of 86 (48.8%) ST4 level posts filled, however this was an increase in headcount compared to 29 in 2020 (67%) and 30 in 2019. The Royal College of Psychiatrists Scotland and NES continue to collaborate in a Choose Psychiatry Campaign initiative. It is hoped that with a greater supply of trainees and a larger pool of applicants coming out of Core Psychiatry, this will translate into better fill rates at higher levels in future years. Core Psychiatry training has a duration of 3 years.

Medical Trainee Recruitment – Actions to Improve Recruitment

167. The following actions are currently underway in an attempt to improve the attractiveness of medical education & training in Scotland, and ultimately improve recruitment on the whole.

• Less than Full Time (LTFT) training is now an integral part of postgraduate training in Scotland and is available to all grades of trainee in all specialties who require more flexibility, subsequently increasing the attractiveness of a career in medicine. A NES evaluation in September 2020 showed that LTFT training has been achieved in many specialties but not all – and work has continued since then towards achieving WTE (Whole Time Equivalent) for all trainee establishments.
• We continue to work with NES to streamline selection and recruitment processes, improve flexibilities within medical training to assist movement into and through specialties, and offer Out of Programme opportunities so that trainees can undertake clinical training/experience, research or take a career break.
• We continue to offer Broad Based Training (BBT) that provides flexibility within training programmes and offers an insight into several shortage specialties. This is especially useful for trainees who have not decided which area they want to specialise in. Over 2 years, trainees spend time in GPST, Psychiatry, Paediatrics and General Medicine. Recruitment into BBT in 2021 is the most successful it has ever been, which increases the likelihood of those trainees opting to progress in one of the four shortage specialties once they complete the BBT programme.
• In an effort to make GP training a more attractive career option, Scotland also offers one-off taxable bursaries of £20k for GPSTs; the criterion being posts in locations that were historically "hard-to-fill" and in remote and rural locations. There is a one-off payment of £20,000 which is offered across Scotland in the following programmes – Caledonian, Rural Track. Ayrshire and Arran, Dumfries and Galloway, Glasgow Clyde, Lanarkshire, and Eastward and Westward programmes in the East region.
• Across the 2021 recruitment rounds, a total of 104 posts were advertised with the bursary attached and 102 of those posts were accepted in these areas (initially there was 100% acceptance but two candidates later withdrew). Previous analysis, by NES, of the bursary incentive impact/outcome, suggested that it is not necessarily increasing the overall number of GPSTs going into the system, but that the incentive has helped distribute trainees more evenly across Scotland (i.e. away from the Central Belt). The GPST scheme is currently being reviewed and evaluated by a Scottish Clinical Leadership Fellow.

UK-wide - Special Circumstances

168. Applicants are still able to state at the point of application whether they have any special circumstances that require their placing in a specific geographic region. Subject to applicants meeting the conditions for special circumstances and being eligible for an offer, they are then allocated a post in their preferred region.

169. Changes were made to the special circumstances paperwork for 2020 to make evidence requirements clearer for applicants; and this guidance remained in place for 2021 applications.

2021 Special Circumstance Applications

170. The following table shows the number of applications and approvals in each round:

Recruitment Round	Eligibility		Appeals		Total Approvals
	Applications Received	Applications Approved	Appeals Received	Appeals Approved
Round 1	160	84	44	19	103
Round 2	39	22	5	3	25
Round 2 Re Advert	47	29	6	3	32
Totals	246	135	55	25	160

171. The number of applications received increased by 51.85% compared with 2020 and the number of applications approved increased by 53.41%.

172. 54.87% of applications were approved at the eligibility stage this year, compared with 54.32% in 2020. This demonstrates that the changes made in 2020, including the addition of an evidence checklist to the special circumstances application forms, has helped to make the process clearer to applicants.

Medical Trainee Recruitment – Strategic response to Gaps in Training

173. The Scottish Government is fully aware that there are on-going challenges in recruitment and retention across NHS Scotland for certain categories of trainee recruitment and in filling established posts. Whilst, in overall terms, Scotland continues to do well in filling trainee posts, we recognise that more needs to be done at a strategic level to being more attuned to trainee needs.

174. Accordingly, , we are continuing to work in a collaborative way with Scottish and UK partners to implement the recommendations of the UK Shape of Training Steering Group report, published on 11 August 2017.

175. Through the UK review process, real benefits for patients, service providers and trainees were identified. Accordingly, all Health Ministers attach considerable importance to delivering changes in medical education and training which will align to key transformational priorities and commitments. . The Scottish Government Shape of Training Implementation Group continues to oversee this important phase of work, and has identified early priorities for curricula change, credentialing of specialist skills, and enhanced training for GPs. The scale of change required is considerable and will therefore take time to fully come to fruition, but Ministers wish to maintain the considerable momentum already achieved.

176. There is now an overarching theme of work in improving junior doctors' working lives which encompasses strategies to improve retention and make the role safer and more effective in providing patient care and gaining learning. Developments across NHS Scotland include the launch of the lead employer model which removes the complexity of doctors having to change employer when they rotate through training placements. Remaining with one employer has reduced costs for employers in Occupational Health and other employment checks and given trainee doctors the stability of longer term contracts making rental or mortgage applications easier and reducing the burden of paperwork.

177. The development of the Turas platform now provides an integrated platform for the training and employment information, reducing duplication of data entry for trainees. Work continues to integrate Turas People, the HR module, with eESS the national HR system. Priorities for the lead employer work is to support automation of applications for LTFT working and study leave, further support of rota management and the review and redevelopment of support for trainee wellbeing in the new integrated Trainee Development and Wellbeing Service.

178. The Scotland Deanery is responsible for ensuring the quality management of postgraduate medical education and training to the standards set by the General Medical Council (GMC).

The General Medical Council: Sets standards for ensuring that doctors are trained to an appropriately high level. It is the regulator for undergraduate and postgraduate medical education in the UK.

The Scottish Government: Facilitates and supports the delivery of postgraduate medical education in Scotland. NES is directly accountable to the Scottish Government; as are all NHS Scotland health boards.

Health Boards in Scotland: Deliver the training, either in hospitals or general practice surgeries. Doctors in training enter a programme and rotate through a number of hospitals or practices to make sure they get a wide range of experience in their chosen specialty. They have to cover a curriculum that is approved by the GMC before completing their training.

179. The Scotland Deanery and NES quality manage the training delivered by the boards on behalf of the GMC to make sure it is delivered to appropriate standards and covers the curriculum for the specialty. This is done by getting regular reports and feedback from the trainees and the Boards themselves, as well as a programme of visits.

GMC Training Survey 2021

180. The National Training Survey (NTS) is the largest annual survey of doctors in the UK. The NTS covers both doctors in training and their trainers. NES use the data from the NTS as a key element in managing the quality of their training. In addition, NES supplements the NTS data with the Scottish Training Survey (STS) which is undertaken by trainees at the end of each post.

181. For 2021, the GMC used the 2019 NTS as the comparator year, given that the 2020 survey was specifically pandemic-focused and did not provide a useful comparison. This meant that the current training picture can be compared with the pre-pandemic landscape. Over 63,000 doctors in training and trainers completed this years' survey across the UK. 76% of all trainees responded, and 32% of all trainers. Although this is much higher percentages than in 2020 (47% and 22%), it is lower than response percentages in 2019 (95% and 45%).

182. The GMC has noted 4 key findings in the 2021 NTS:

• Almost nine in ten trainees described their clinical supervision as good or very good, with 8 in 10 stating they are on course to meet their curriculum competencies/outcomes for this year.
• Nine out of ten trainers have stated that they enjoyed supporting the next generation of doctors.
• 33% of trainees, 25% of secondary care trainers and 22% of GP trainers have explained they felt burnt out to a high, or very high, degree because of their work. Trainees in ophthalmology and general practice posts had the highest increase in burnout levels. For trainers, this was felt most acutely in public health, general practice and occupational medicine.
• 55% of GP trainers, 44% of secondary care trainers and 44% of trainees felt their work was emotionally exhausting to a high, or very high, degree with 29% of trainers highlighting they were not always able to use the time allocated to them to train.

183. The STS was analysed so that both low and high performing training environments could be identified according to quantitative analysis. In addition to this, NES created a 5-year longitudinal trend for the STS data to again identify both the low and high performing units.

184. 75 good practice letters were issued throughout Scotland in 2020/21 - the breakdown by Specialty Quality Management Group and Health Boards are:

Specialty Quality Management Group	Number of Good Practice Issued
Diagnostics	2
Emergency Medicine & Anaesthetics	2
Foundation	35
General Practice	19
Medicine	1
Mental Health	5
Obstetrics & Gynaecology and Paediatrics	2
Surgery	9

Board	Number of Good Practice Issued
Ayrshire & Arran	4
Borders	2
Dumfries & Galloway	1
Fife	1
Forth Valley	4
Grampian	5
Greater Glasgow and Clyde	8
Highland	9
Lanarkshire	7
Lothian	12
Tayside	8
Western Isles	2
General Practice Across Scotland	10

Medical Trainee Progression – Mitigation of Covid-19 Impacts

185. The vast majority of trainees achieved training competencies and progress as expected in 2021 Despite the challenges of the pandemic, progression has been maintained in the majority of specialties, Some specialties have seen a greater impact on progression (e.g. obstetrics & gynaecology, some surgical and diagnostic programmes) due to a reduction in training opportunities following the cancellation of elective work and the challenges in restarting this. The speed of clinical service recovery will continue to impact on the availability of training opportunities. There remains concern that the current service pressures throughout Scotland, are continuing to have an adverse effect on trainees gaining certain competencies. Although curricula requirements have been derogated to support progression, the criteria for the award of the Certificate of Completion of Training (CCT) has not. This could result in a significant accrual of unmet competencies and delays to CCT in the coming years. As there are differences between specialities and variation across regions Specialty Training Boards will review this data and consider if there is a need for enhanced training approaches to mitigate training gaps (e.g. simulation-based education).

186. NES have developed and issued guidance to mitigate impact on training with future surges of Covid-19 and associated disruption to services. This will give consistency, rigour and transparency to further deployment decisions with an aim of minimising training disruption over the short and medium term. Those trainees nearing the end of their training programmes will be prioritised in terms of being assisted to catch-up on lost training time so they are prepared for final assessments towards achieving their CCT. Robust and systematic monitoring processes are now in place with regular communication between NES and Board Directors of Medical Education and specialty Training Programme Directors, reporting to Scottish Government as required.

Measures to Retain Overseas Doctors

Supporting International Medical Graduates – Softer Landing, Safer Care

187. Commencing work in a new environment is challenging for all new members of staff and this is further compounded for those who are also transitioning into a new country. This transition has been described in 3 phases: loss, disorientation and adaptation. The GMC reported that between 2010 and 2014, 5.9% of International Medical Graduates (IMGs) were investigated due to a complaint received against them compared to 3.9 % of UK medical graduates. NHS Scotland is keen to attract and retain the talent of overseas medical doctors and help them thrive professionally which will benefit the patients they care for.

188. IMGs will be used to a different culture within their own society and different systems of healthcare delivery in their own country. These doctors are well educated and well trained; however their training may be different to those of an equivalent grade who have trained solely in the UK.

189. Work is therefore underway within the service to better support doctors taking up post within NHS Scotland who have graduated from a medical school outwith the UK. A programme of work titled 'Softer Landing, Safer Care' is being rolled out within Health Boards, with the support of Directors of Medical Education and Medical Directors, which will provide IMGs with a 2-week period of enhanced shadowing/induction alongside current trainees, focusing on:

• The interface with primary and social care
• Ensuring familiarisation with common acronyms used
• Roles and responsibilities e.g. drug and fluid prescribing
• Referral system, forms, etc.
• The health culture in NHS Scotland which is different to other countries, e.g. Patient-centred care, Realistic Medicine, Multi-disciplinary Team working ethos, flat work hierarchy, Safety culture, regulation, Adults with Incapacity, Vulnerable Adults Policies, Child Protection, etc.
• Communication at the work place between Doctor and Patient or Doctor and Colleagues

190. The changes in immigration regulations with the expansion of the Shortage Occupation List are likely to result in an increase in IMGs coming to work in Scotland and it is important we ensure that they are appropriately supported and able to provide better patient care.

Scottish Trainee Enhanced Programme

191. The STEP (Scottish Trainee Enhanced Programme) is a training course for IMGs in GP and their trainers which is held twice a year in Scotland. It has been running since 2014 and offers trainees an early insight into challenges they might face in GP training within the UK. This programme has now been established for Psychiatry trainees (Psych STEP). Through workshops and small group discussions, trainees can explore their own strengths and weaknesses and gain insight into predictors of success. Educational supervisors are encouraged to attend along with their trainee. During the pandemic, the programme has been delivered virtually over two half days. Attendance at these virtual events remains very high with excellent evaluation. A formal evaluation is currently taking place and will be completed in 2022. There is also a regular review of the programme to ensure that the material covered is appropriate for both trainees and educational supervisors.

192. NES continues to collaborate with the Royal College of Physicians & Surgeons of Glasgow to provide additional educational sessions for IMGs particularly on communication skills.

193. NES run a working group focussing on advancing equity in medical education for a wide range of trainees with protected characteristics. The group is co-chaired by three Postgraduate Deans and has wide stakeholder representation including service and undergraduate colleagues with the aim of sharing good practice. The GMCs equality and diversity framework has been used to map out current activity. Active Bystander training has been rolled out to all educators and is currently planned for delivery to all 6000+ trainees in Scotland in 2022. This provides a framework for trainees to challenge poor behaviour.

Attrition Rates through Training

194. NES monitor progression through training and completion of training but currently do not focus on attrition, as attrition may not be well defined if a trainee leaves and then returns.

195. The GMC website contains publicly available reports on ARCP outcomes for postgraduate training which show those trainees who do not progress or who have delayed progression in training. They also report on progression from FY2 to specialty training and exam progression.

Medical Undergraduates

196. The Scottish Government convenes the Medical Undergraduate Group (MUG) to consider the annual Scottish Medical School intake. This Group's main purpose is to ensure an appropriate supply of good quality trained doctors to meet the needs of NHS Scotland's medical workforce whilst avoiding, or minimising, the possibility of medical unemployment.

197. For 2021-22, Scottish Ministers approved a medical undergraduate intake of 1,117 in January 2021. Due to the impact of Covid-19, with no final exams, and grades being awarded on teacher assessments only, additional students met the terms of their conditional offer and another 93 places were added to the intake, making a total of 1,210 places.

198. At the point of delivery of this report the 2022-23 intake has yet to be agreed. However, there is a Programme for Government commitment to increase the number of medical undergraduate places per annum/double the number of Widening Access places over the lifetime of this Parliament. The MUG Meeting in January 2022 will determine the intake for 2022/23.

Graduate Entry Medical Programme (ScotGEM)

199. The ScotGEM programme is a component of Scotland's approach towards meeting the current and future needs of NHS Scotland. It forms part of Scotland's commitment to create a more sustainable medical workforce and encourage more people into a career in healthcare, whatever their background. It is a four-year programme that funds 55 students starting in the academic year 2018/19 and so the first cohort will graduate in the summer of 2022. It has a focus on careers in primary care and remote & rural working – offering students the opportunity to experience how rewarding working in these settings is. The programme offers students a 'return of service' bursary of £4K per annum.

Healthcare Professionals (HCP-Med) Programme

200. This innovative course, which commenced in 2019/20 allows experienced healthcare professionals to enter medicine and combine part time study with their existing job, with large parts of the course delivered online. It is designed to target high calibre candidates who are more likely to be retained by NHS Scotland.

Specialty and Associated Specialist (SAS) Doctors Development Fund

201. There are approximately 1300 SAS grade doctors and dentists working in NHS Scotland. They make up about 25% of the senior medical workforce and are often appointed to these posts at an early stage in their career compared to those pursuing a Consultant position. In keeping with our coherent strategic approach to medical and dental workforce issues, we continue to place considerable importance in ensuring that the aims and objectives which underpin this programme and provide significant funding (£500k per annum) .Feedback from the doctors and dentists who have benefitted from the fund is that they are grateful for the development opportunity it affords, and a survey of Clinical Directors, whose SAS Doctors and Dentists have used the fund to enhance their skills, reported service benefits.

202. The programme aims to direct national funding to those SAS Doctors and Dentists whose clinical teams are seeking to develop new or improved clinical services, or to enhance their role within the clinical team, and where funding is not otherwise provided by the employing Health Board. If approved, funding is available to support costs for training, salary backfill, or completion of training to apply for a Certificate of Eligibility for Specialist Registration (CESR). In addition, funding has enabled the appointment of an Associate Postgraduate Dean (a SAS Doctor) to provide leadership of the programme, the creation of a national network of Educational Advisers (who are themselves SAS Doctors or Dentists) to support local SAS Doctors and Dentists, and to guide them (and their employing Health Boards) to make best use of this funding opportunity.

203. In 2020-21, the SAS Development Programme approved funding applications from 42 individual SAS Doctors and Dentists, to apply for funding for bespoke training and development. Unfortunately, due to Covid-19, some planned secondments for top-up training for CESR were necessarily postponed, in whole or in part. In addition, some in-person courses were cancelled resulting in underspend, such as the University of Newcastle's course on sedation for dentists, while others had their start dates postponed. Such deferral of training from this financial year contributed significantly to the 15% underspend, although these costs are largely deferred into 2021-22 when it is hoped that this training can safely commence.

204. Please see further details of the SAS Development Programme, including the 2020-2021 annual report.