Flexible Trainees in Scotland – What Becomes of Them?

Caroline J MacEwen*, 1, Shona Olson2, Christine Rea3, Gillian Needham4, Jackie Taylor5, Jane Montgomery6, Margaret Chambers7

1 Associate Dean, Flexible Training, East Region, Scotland.

2 Flexible Trainee, North Region, Scotland.

3 Database Manager, East Region, Scotland

4 Postgraduate Dean, North Region, Scotland

5 Associate Dean, Flexible Training, West Region, Scotland.

6 Associate Dean, Flexible Training, South East Region, Scotland (until 2004).

7 Associate Dean, Flexible training, South East Region, Scotland (from 2004)

Correspondence to: Caroline J MacEwen, East of Scotland Deanery, Level 7, Ninewells Hospital, Dundee, DD1 9SY

SMJ 2006 51(3): 21-23

Abstract

Introduction: demand for less than full time training is increasing. The contribution of such trainees to the trained medical workforce is not clear. 

Methods: All full time and less than full time trainees in Scotland were ‘tracked’ at the completion of training 

Results: 80% of less than full time trainees took up a consultant post of which 93% were in Scotland. 82% if full time trainees took up a consultant post of which 80% were in Scotland

Discussion: Less than full time trainees become consultants at the same rate as their full time counterparts. They are commonly geographically tied and are therefore more likely to remain in Scotland and contribute to retention of doctors in this country.

Introduction

Flexible training, also known as less than full time (LTFT) training, has been available in the UK in one form or another for more than 25 years. Demand for access to this type of training is increasing. A recent survey indicated that 29% of male respondents and 75% of female respondents would consider part-time working at some stage in their careers.1

There are, however, misconceptions amongst senior medical staff and NHS management about this group of doctors.  It has been suggested that training on a part-time basis is “tantamount to professional suicide” 2  and there are perceptions that there is both a high ‘drop out’ rate and that flexible trainees do not ultimately contribute significantly to the skilled consultant led service.

To explore this further, all SpRs in Scotland, both full time (FT) and less than full time, were ‘tracked’ at completion of their training to identify the grade of post that they moved to and its geographical location.

Methods

Each of the four deaneries in Scotland collected information about the destination of all FT and flexible SpRs at completion of training. Data about the grade of post they moved to and its geographical location were collated on a database. The study covered 7 years for flexible trainees: 1998 to 2004. FT trainees were studied for 4 years: 2001 to 2004. The reason for the different time periods being studied is that tracking the outcome of flexible training has taken place since the Calmanisation, but, due to larger numbers this has not taken place with full time trainees until more recently.

Results

Ninety three flexible SpRs completed their training in this 7 year period.  Seventy four (80%) of these took up consultant posts in the UK and 69 (74% of the total) of these were in Scotland.  Of those obtaining a consultant post in the UK, 93% have remained in Scotland.  (Table I)

Table I     Exit details of Scottish flexible SpRs (1998-2004) and FT SpRs (2001-2004)

*  (Includes move to working at the Drug Industry, change to another training  programme, unable to trace).

Three hundred and eighty one FT SpRs completed their training in the four year period. Three hundred and twenty four (82%) took up consultant posts in the UK and 242 (64% of the total) of these were in Scotland.  Of those FT SpRs obtaining a UK Consultant post, 80% stayed in Scotland.  (Table I)

The outcome of the remainder is shown on Table I.

Discussion

This survey highlights the effectiveness of flexible training in the training of doctors for consultant posts, both within the workforce and particularly within Scotland, and should help to dispel some of the myths surrounding flexible training.

There is increasing and appropriate demand for access to flexible training. This is, in part, a consequent of the increased numbers of women in medicine, but also reflects a desire from both sexes to achieve a better work-life balance. In 2001 flexible trainees in Scotland accounted for 7% of all doctors in training, a majority of which is female (unpublished data from the four Scottish Deaneries).

Prior to the junior doctors “new pay deal” coming into effect in December 2002, supporting flexible trainees had relatively few financial implications for employing trusts or service divisions.  Basic salary costs on a pro-rata basis were available from the Deaneries, which had established a network of dedicated advisers. Additional costs for out of hours work through Additional Duty Hours (ADH) payments were the responsibility of the employing trust and proportionate to the hours worked. However, with the introduction of payment bandings, flexible trainees fell into bandings which resulted in the employer bearing a disproportionately greater financial burden. In effect, flexible trainees were costing more per hour than their full time equivalents. An example would be a flexible Pre-Registration House Officer working 24-40 hours per week, who would be paid an average hourly rate of £19.22, compared to full-time equivalent working 48-56 hours, who would earn £13.84.3 In addition the new contract effectively removed the option of job sharing. Consequently placements have been turned down, usually by head of service budget holders, because they are considered not to be affordable by the employer.

Deanery waiting lists for access to flexible posts have been increasing, as availability of flexible training has ceased in many divisions with failure to renew flexible contracts in others. An interim two year fixed funding package from the Executive was negotiated for 2002/03 and 2003/04, but no additional financial help for trusts has been forthcoming.

Flexible training is thus in crisis, and although further re-negotiation of the pay agreement for flexible trainees has taken place and has now been implemented,4 the full details of this on budgets remains to be evaluated.  In any case, the damage caused to the acceptance of flexible training by the previous pay agreement will take considerable time and effort to reverse. While flexible trainees are encouraged to take a FT training number and remain integral to the existing SpR complement, this commonly makes rotas non-compliant and also results in wasted training opportunities.  Currently 45 whole time equivalent SpR training posts are lost in Scotland annually because flexible trainees are holding full time numbers, but are only utilising 50-80% of the training opportunity (unpublished data from all four Scottish Deaneries).  Employing flexible trainees on a supernumerary basis avoids this loss of training opportunities but is a major disincentive to hospitals because they require to pay the banding for these additional trainees even when their rotas are already compliant.  Perhaps a case might be made for central funding to cover the entire costs of flexible training (basic salary and banding) in order to encourage hospitals to take on flexible trainees, especially as this would be a good investment for NHS Scotland because these trainees have a higher chance of remaining in Scotland than other trainees. “Slot shares” are another affordable method, but these are usually only feasible in larger specialties.

The implications of reduced access to flexible training on the recruitment and retention of doctors in the NHS in Scotland are, as yet, largely unexplored.  However, with an increasing number of young female doctors, associated with a national shortfall in the medical workforce, problems with access to part time working of any type pose a high risk strategy, which has been recognised in England with the introduction of the Flexible Careers Scheme.5

This survey has identified that 80% of the flexible SpR leavers took up consultant posts, the majority of which (93% overall) were in Scotland.  A comparable 82% of the full-time SpR leavers took up consultant posts (80% of these in Scotland). Contrary to expectations, the proportion of those moving into non-consultant career grade posts was equal for both full time and less than full time trainees. The ‘drop out’ rate (those who either left medicine or the UK completely) was higher, at 9%, from the full time trainees than from those who trained on a flexible basis (6%).  Such doctors represent a net loss of trained medical manpower from a country with an acute shortage of doctors.

Workforce planning in the NHS is a complex challenge, but is central to reform of our healthcare systems. In Scotland, a review of the Scottish Medical Workforce was commissioned by the Scottish Executive and was published in July 2002.6 This wide-ranging report made a number of recommendations, mostly accepted and agreed to be taken forward by the Scottish Executive Health Department.7 One of the key messages is that more doctors are required to support a specialist delivered service, and that career options need to be developed to aid the recruitment and retention of doctors. This report formally recommended more flexible opportunities for employment and career development.

A further issue, particular to Scotland is maintaining recruitment and retention in the face of competition from the much larger NHS. Only 55% of Scottish medical graduates end up working permanently in Scotland and 62% of overseas doctors who complete their training in Scotland leave. 8,9 This study is relevant to this issue as the flexible workforce has a high proportion of doctors who have strong reasons to stay in Scotland, usually for family reasons.  This is not a constraint for most full-time trainees of whom a larger proportion moved away from Scotland.  A significant number of flexible trainees have become consultants during the last 7 years, the majority of this geographically stable group of doctors being retained locally and appointed to their training region.

The government has pledged to support family friendly policies within the NHS.   Recognition of the value of flexible training by the medical profession should encourage uptake of this form of training, not only in Scotland, but throughout the UK.  This survey has highlighted that these developments should help to improve recruitment and retention of doctors in NHS Scotland.

References 

1 Jackson C, Ball J, Hirsch W, et al. Informing choices – the need for career advice. London: National Institute for Career Education and Counselling, 2002. 

2 Sundaram R. An insider’s guide to flexible training. BMJ (Careers Focus) 2003 s61                       

3 Newman M.  Pay Review urged for flexible posts. Hospital Doctor: 2004; 26 Feb, p3. 

4 Scottish Executive. Health Department.  NHSD circular PCS (DD) 2005/7. New flexible training (previously known as less than full time training) arrangements for doctors in training. 

5) Department of Health. Flexible Careers Scheme.  Available at http://www.nhscareers.nhs.uk//nhs-knowledge_base/data/5455.html  (Accessed 19^th June 2006) 

6) Temple J. Future Practice – Proposals of an Advisory Group Commissioned by the SE to Review the Scottish Medical workforce. (The Temple Report).  Edinburgh: Scottish Executive, 2002 

7) Scottish Executive. Future Practice, a Review of the Scottish Medical Workforce. The Response of the Scottish Executive. Edinburgh: Scottish Executive, 2002. 

8) MacDonald R, Cross P. Recruitment and retention crisis in Scotland. BMJ (Careers Focus) 2005; 1: 6-7 

9) Temple J. Securing Future Practice: Shaping the New Medical Workforce for Scotland. The Report of a Short-life Working Group. Edinburgh: Scottish Executive, 2004

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