Rural Forum outline proposal for training scheme to help UK Rural Recruitment and Retention Feb 2014 Dr Malcolm Ward, Chair RCGP UK Rural Forum

Background Recruitment and retention of the GP workforce is becoming a serious issue for the profession as a whole but it is nearing crisis point in many rural areas across the UK and particularly so in remote Highland and Island practices where there remains a responsibility for unscheduled care and sometimes blue light receiving GP run community hospitals. Many health boards have GP practices where it has not been possible to recruit the necessary GPs. Ayrshire and Arran, Caithness, and Argyll all have rural practices where the health board has needed to take over the running of the practice, staffing them entirely through locum arrangements. The Rural Forum recognizes that the factors contributing to the emerging crisis are wide and varied. This proposal seeks to help address some of the contributing issues and the Rural Forum (RF) believes that even a small impact will be beneficial and a step in the right direction. Initiatives toward solutions The R F recognises that there will be no one size fits all solution to the numerous factors affecting recruitment and retention of the remote and rural GP work force. The Dewar centenary Group and others are exploring potential solutions which include a number of models such as Hub and Spoke, Practice twinning, & Practice Federations. National Education Scotland (NES) run a Rural Fellowship with 12 places a year where newly qualified GPs can have a year in a remote rural practice with GP supervision and mentoring to get the with GP supervision and mentoring to support the development of attributes and insight that will prepare them for life as a remote rural . A Rural Track GP Specialty Training programme has recently been developed by NES and these 4 year schemes have been constructed to allow the development of rural-specific capabilities and to gain the appropriate competences to work as an independent GP. There is a need to attract more young people to experience life in remote and rural practice and a need to promote more widely these existing schemes which, with better marketing could be expanded. Across the UK schemes for promoting and enabling rural GP work experience should be developed for 16-18 yr old school students and there is a need to get rural GP input into the curriculum in all our medical schools. The North of Scotland Faculty in 1998 established the Highland 1

Schools Medical Mentor Scheme (HSMMS), to help Highland school pupils understand and prepare for a career in medicine. This Scheme has now been absorbed into the NHS Highland Doctors at Work scheme. Application for this is open to pupils in S5 and S6 who are actively considering a career in Medicine. It is run in June and September each year and application is via School Guidance teachers. The complexity of factors affecting the recruitment and retention conundrum is well expressed by the “Mind map” developed by Miles Mack a member of the Dewar Centenary Group and is attached as an appendix. However there are factors that can deter many young Doctors from working in remote and rural areas and particularly with regard to social isolation for spouses and young families that are challenging to overcome. Whilst it is important to continue to try resolve or minimise the impact of these issues there is also an opportunity to try attract older established GPs into the rural work force. The inspiration for this proposal was a result of the experience the Rural Forum chair who took a post in very remote and rural practice toward the end of his professional career and soon became very aware of the lack of provision for induction, and the limited opportunities for getting the updating of the skills required for this relative change in career direction in a convenient and suitable timeframe. However this proposal, with the appropriate promotion, might also attract young doctors who after completing F2 feel unsure about their future career direction and undertaking the proposed course might be just the experience to attract them into remote and rural practice. BASICs provide excellent courses for GPs and other health care professionals to update/maintain particular skills. The current focus is on providing usually weekend courses for GPs to update specific skills training e.g. Emergency pre-hospital care adults, Advanced Life Support (ALS) and paediatric pre-hospital care and ALS and largely taken up by health professionals that are in post. However a longer block course combining a number of key training elements might be more suitable for established GPs considering a career change to remote and rural practice. Currently there does not appear to be such a course provision. There are numerous reasons why an established GP might wish to consider a relative career change to remote and rural practice:   

A change in family priorities/circumstances e.g. children “leaving the nest” for university education or work and so no longer needing to reside in a semiurban/urban area. A desire to live in a rural area to pursue outdoor activities hitherto denied due to family circumstances such as stated above. Opportunity to move to adopt a rural lifestyle and release capital by benefiting from the house price differential by moving from semi-urban/urban to rural setting. 2



Seeking a change of working pattern from dealing with large list, high consultation practice with short consulting times to work in rural lower list practice where there is more time for patient care and with a more comprehensive service provision e.g. with OOH/unscheduled care and community hospital/intermediate care.

The main deterrent for established GPs to make this change is the fear factor due to loss of confidence over past skills that have not been maintained in relation to the provision of unscheduled and emergency care. The following proposal is geared to providing an en-block course which would provide the necessary skills update training to enable such GPs to make the transition to remote and rural practice with confidence. After consultation with key BASICs personnel we believe that with appropriate additional funding BASICs would be able to provide much of the course requirements in a block one stop setting. Proposal in outline That the RCGP enters dialogue with the 4 National Governments to explore funding options to set up a course specifically designed for GPs wishing to try their hand in remote and rural practice. The RF is networking with agencies already providing GP education with the aim of using/adapting existing resources where possible to reduce development costs. It is anticipated that much of the course work would be modular and accessible on-line but with some formal venue based course learning and hands on practical experience. It is hoped that BASICS Scotland will be able to provide a substantial element of the core training with specialist modules being provided by other agencies. It is hoped that practical experience in A&E and management of common orthopaedic presentations can be gained via involving District General Hospitals. This could be provided by perhaps a 2 to 4 week attachment and we will explore the practicality of ensuring that each candidate gets some basic obstetric experience. Whilst obstetric services in primary care is midwifery led UK wide there may be occasions when a remote GP is faced with a home delivery unexpectedly when the midwife cannot be present e.g. due to adverse weather conditions. It would be sensible to engage DGHs that cater for remote and rural practices to ensure a reciprocal understanding of the nature of remote and rural practice. If enough DGHs took part it might be possible for the majority of candidates to participate on a non residential basis but residential options may be require for some. The final stage of the training would involve a say 2 week placement in a remote and rural Practice but where there is constant GP supervision and mentoring by an experienced remote and rural GP. Draft list of skills/training/course elements:   

Adult life support Paediatric life support BASICs trauma management/Pre-hospital emergency care (adult and paediatric) 3

     



Management of common medical and emergencies. A number of sessions in busy A&E department with training around management of common orthopaedic fractures and A&E presentations. Obstetric basic update with perhaps at least 2 supervised normal deliveries in maternity units. Management of psychiatric emergencies in remote areas: Compulsory admission for psychoses, management of severe depression/potential suicide/self harm. Dispensing/cost effective prescribing module. Module providing guidance and awareness of A) avoiding/reducing the pitfalls associated with social and professional isolation that can be part of working in remote areas. B) Promoting the positive aspects of providing care to remote communities and the many lifestyle benefits. At least 2 weeks supervised experience in an approved remote and rural practice

This list is draft only but we need to ensure that the programme does not become too intense or over complicated. The objective being to provide update training for experienced GPs in the subject areas that might otherwise put off potential applicants due to atrophy of specific skills no longer applicable to their current General Practice placement. The consensus view of consultees to date is that the course assessment should be on a formative basis not summative and that the course should not be planned as a formal requirement to enter remote and rural practice. The proposal could be piloted before wider role out and course taster videos could be produced to give potential applicants a better understanding of what would be in store. Agencies with an expressed interest in participating as training providers BASICS Scotland Already have considerable experience in delivering training suitable for remote and rural practice. The Medical Director Dr Colville Laird suggests BASICs could provide the following core elements and have already developed on-line modules:    

PHPLS- Certified by The Advanced Life Support Group ILS- Certified by The Resuscitation Council PHEC ( Pre-hospital Emergency care) – Certified by the Faculty of PreHospital Care of The Royal College of Surgeons of Edinburgh. The Common Medical Emergencies Course is run by us. BASICS do not examine and certify this but could if required. BASICS have two courses which we could run as one or could be mixed and matched as felt appropriate.

4

Psychiatry modules Psychiatrist Dr Alys Cole-King, co-founder of, and training lead for “Connecting with People” has considerable experience in delivering training directed at primary care and in rural areas. It is hoped that much of the course could be on line but with perhaps 2 days face to face learning to complete the training. Dispensing module The RF is working with the Buttercups Dispenser Training agency to adapt their existing dispenser distance learning course material to provide a course suitable for a GP with no or little dispensing experience. Target candidates   

Newly qualified GPs who are unsure of what kind of practice they wish to work in. Established GPs who are considering a career change from urban to rural practice. Locum GPs wishing to work in remote and rural areas. If over time a sufficient numbers were to complete such a course this could provide a pool of GPs that R&R Practices could rely upon, knowing the locums would have the appropriate knowledge and skills. The objective here would be to encourage those that need the training to undertake it rather than creating a requirement that might deter locums from offering services to remote and rural practices.

Possible incentives A significant incentive for the scheme could be to award a large number of revalidation learning credits if awarded on successful completion of the course however gaining all the 250 learning credits required for a 5 yr revalidation cycle in one year is not allowed. A stipulation has been made that there must be 50 learning credits per year. This could be seen as a disincentive to achieve more in any given year which seems a rather short sighted approach. Perhaps when GPs make significant learning/training effort in a given year bonus points could be allocated toward future years say 50 credits for the relevant year and perhaps up to 25 for each year of the remaining years of the 5 year cycle. All the other appraisal and revalidation criteria would still need to be fulfilled over the 5 yr period e.g. 360 degree feedback, clinical audits, complaint reflections, SEAs etc. Other incentives could be explored e.g. perhaps to provide core funding for the course so that the delegate, e.g. if a GP in practice, could afford to pay for a locum to cover his/her absence from the Practice, and young graduates could undertake the course after completing F2 without financial penalty.

5

Perhaps funding provision could be provided to support a practice that “loaned” their GP candidate say for a year or so on trial so that if the candidate decided against a long term move they could return to their previous practice. There has been debate as to whether eligibility for such a scheme should be for those who express interest in moving to remote/rural practice or just those who have committed to do so. Perhaps a greater financial incentive could be awarded to those who commit to working in a remote area however this might reduce the numbers participating. Perhaps this could be resolved by providing a refund of the candidate fee for those who commit to remote practice having completed the course. Funding and costs Possible sources of funding costs could be:     

Charity funding particularly for one off development costs. Candidate course fee. Educational grants from National Governments, Health Boards/PCOs who have a vested interest in resolving recruitment problems and who have high locum costs. Educational grants via commercial/pharmaceutical industry sponsorship. Practices with long standing vacancies could perhaps refund course fees in part or full to candidates who take up posts on successful completion of course in return for a minimum period of service commitment.

Estimation of course costs: This would be subject to developing the course format in detail but the Rural Forum Steering Group is working with BASICs Scotland to work up estimates of course running costs and will explore possible inclusion/adaptation of existing relevant on line course material. Provisional estimates for course development to date include: £15K for the psychiatry modules, £11K for the dispensing modules. Running costs would be dependent on numbers participating. The BASICS course material is already developed but running costs for the online course and direct trainer delivered elements are being worked up. A survey is planned to try and estimate the likely take up of this course provision. Discussion It can be argued that a course providing update on the above skills would be an asset for a GP working in any practice given that any GP may occasionally be faced with a medical emergency and be first on the scene. However it would be reasonable to expect that a significant proportion of candidates would gain sufficient interest and confidence to apply to take up a post in remote and rural practice either as a permanent career change for at least a significant period of time and has the potential to attract both established mid career GPs and, with the appropriate promotion, young doctors on the threshold of career direction choice. This proposal 6

can complement existing training and education initiatives such as those provided by NES, BASICs and others institutions. Even small numbers of GPs that might make a permanent career change could make a significant positive impact on the recruitment and retention crisis that faces remote and rural practices not only in Scotland but across the UK. Many R&R practices are highly dependent on locum cover which can be extremely costly and these disproportionate high costs could be reduced over time if proposals such as this did improve recruitment and retention in remote and rural areas. This proposal was formally endorsed in principle by the RCGP Extended Leadership Team in January 2014. Representatives of the following agencies have been consulted in the preparation of this proposal:  RCGP Scotland Rural Strategy Group  BASICs Scotland  National Education Scotland (NES)  NHS Highland  Dewar Centenary Group  Medical Director of a remote and rural CHP  GPs providing care in remote and rural practices  Dr Alys Cole-King  Buttercups Dispenser Training  The Dispensing Doctors’ Association  Dr Iain Jamieson GP appraiser

7