Making rural hospitals sustainable – It is both quality hospital doctors and GPs we are short of… Please don’t be tempted to reduce standards..

Nigel Edawards writing for the Nuffield Trust 12th July 2016 in a report entitled “Making rural hospitals sustainable ” debates how we might proceed.

NHSreality feels that the rationing of staff, and the selection of inner city and suburban (mainly female) students for Medical School, (as they perform better, are in good schools, and have similar peers) means that many just will not work in the shires… They would rather not work, or delay work to have a family… Mr Edwards does not address the long term effects of short-termism and rationing in places at Medical School and Nurse training. Recruitment problems are compounded in general practice, because of the high failure rate at recent MRCGP exams. It is both quality hospital doctors and GPs we are short of…

While the UK does not have the extremes of geographical remoteness found in some parts of the world, there are a number of areas – some with relatively sizeable populations – which have difficulty creating safe and viable services.

In some places, this is due to their distance from major hospitals; in others it may be the result of sparsely distributed populations with poor public transport links and low rates of car ownership.

What are the issues?

Getting the workforce right

A major issue facing rural and remote hospitals is the problem of recruiting and retaining the right number of staff with the right skills to do the job.

Standards and training requirements upheld by Royal Colleges and regulators often require minimum numbers of patients or a specific number of consultants – which in rural areas can be difficult, or even impossible, to meet. Even if the required numbers of staff could be recruited, the resulting rotas are often unaffordable due to relatively small numbers of patients.

Moreover, an increasing shift towards sub-specialisation within certain fields of medicine has created a skills gap and a shortage in general physicians and surgeons competent in dealing with a range of emergency patients. In rural areas this is especially prevalent – and it is difficult for trusts to acquire a critical mass of doctors who are able to cover all elements of care.

These gaps are also hard to fill with new doctors. The low volumes of work and isolation from other professionals in remote areas often make these positions undesirable for new trainees.

Other factors make recruitment difficult too. For example, Cumbria has more than 50 vacancies in a consultant workforce of over 200, with critical shortages in acute medicine, paediatrics and other key specialties. This means that its hospitals are highly dependent on locum cover, which may reduce the attractiveness of posts to permanent staff.

And in some cases, the right clinical professionals for rural hospitals are not just difficult to recruit; they may not even exist. For instance, in anaesthetics, some newly qualified consultants are not able to cover the intensive care unit.

Inflexible standards and regulation

There are certain specific challenges facing rural and remote services that are not acknowledged by regulatory standards, since some of the assumptions made by external bodies that regulate services were based on models from large urban centres. This is a particular issue when standards revolve around the number of staff and facilities in a trust, rather than the results of care for patients. The evidence that staffing standards and models are directly linked to outcomes is actually not very strong. The volume effect is not significant for all procedures.


It’s also noteworthy that the relatively high fixed-cost element of running hospital services means services that see fewer patients tend to be disproportionately expensive, with little opportunity to attract additional activity to cover costs.

So what are some of the solutions?…..


NHS to recruit 400 doctors from India in desperate bid to plug …

RCGP could allow GP trainees extra chance to pass CSA …

MRCGP ‘fairest’ means of ensuring safe GPs,

 reports for Pulse 12th July 2016: 400 potential new GPs trapped in MRCGP limbo as GP leaders call for reform

The RCGP has estimated that around 400 doctors are stuck in limbo after repeated failures to pass its MRCGP exam, prompting GP leaders to call for the college to ‘look again’ at the exam.

The figures were revealed in minutes seen by Pulse of a meeting between the college and campaigners working on behalf of many of these doctors.

They have been in talks around potential alternative routes to registration, such as further training and an alternative licensing assessment.

GP leaders – including the former RCGP chair – have called on the RCGP to look at reforming the training process.

But the RCGP has said that developing an alternative assessment model would not be cost effective and would require an overhaul of the current regulatory framework.

It follows the row over the differential pass rates between white and black and minority ethnic doctors taking the CSA, which led to the college undergoing a judicial review.

The court ruled the MRCGP was lawful but urged the RCGP to take action around the number of BME doctors and international medical graduates failing the exam.

Candidates are given four attempts to pass the exam, after which they are barred from taking it again – unless there are exceptional circumstances.

GP Dr Narveshwar Sinha has been working on behalf of around 100 of these doctors, and minutes from his meeting with the college seen by Pulse, discuss the number of doctors ‘who have not attained the MRCGP’ – which the college estimates as ‘possibly around 400.’

Dr Sinha has been calling for these trainees to have further supported training time before undertaking an alternative assessment to the MRCGP.

However the RCGP has said many of these doctors already have difficulty providing robust evidence of their clinical skills and knowledge for the existing ‘equivalence’ routes to registration, such as the Certificate of Eligibilty for GP Registration (CEGPR).

The college’s minutes state: ‘CEGPR is generally not intended for doctors who had not managed to attain MRCGP and that it is usually for already trained and experienced GPs from abroad.’

But Dr Sinha told Pulse: ‘These 400-500 doctors who are already here, why don’t we use them rather than struggling to find doctors from Europe, or India or wherever else?’

This comes after Pulse revealed NHS England was in talks with recruiters about a ‘pipeline’ of nearly 600 European GPs, who could come to the UK in the next three years as part of GP Forward View commitments to recruit 500 GPs from overseas.

RCGP chief examiner, Dr Pauline Foreman told Pulse while the College was sympathetic to the problem faced by the GPs Dr Sinha represents, they couldn’t reasonably overhaul the exam.

Dr Foreman said: We explained to Dr Sinha that his proposal is not deliverable within the current legal regulatory framework, and that many of the changes required to enable it are not within the remit of the College.

She added ‘it would not be reasonable or proportionate’ for the College to develop a new licensing exam ‘for the small group of doctors who are unable to reach the standards’.

But former RCGP chair Dr Clare Gerada told Pulse she agreed the GPs could help the workforce crisis, and – while she didn’t think the CSA was discriminatory – the ‘whole process of working in the NHS disadvantages overseas doctors.’

Dr Gerada said: ‘I do think we should look again at alternative routes to MRCGP. Not letting people in who are not good enough, absolutely not. But we should be looking at alternative spaces where these GPs can work.’

Dr Krishna Kasaraneni, chair of the GPC’s education, training and workforce subcommittee, said: ‘We’re set on the mindset that an exam proves somebody’s competence, the exam proves you can perform in that exam. Certain aspects overlap with competence, but because they’ve passed an exam doesn’t make them a good GP, and failing doesn’t make you a bad GP.’

‘What we need to be able to do is to train GPs in an atmosphere where they get proper training in general practice from day one, rather than identifying problems when they’ve failed the exam a few times.’

When you can’t afford the targets, lower the standards..

This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

2 thoughts on “Making rural hospitals sustainable – It is both quality hospital doctors and GPs we are short of… Please don’t be tempted to reduce standards..

  1. Gurjinder Bhari

    The MRCGP/General Practice ship has sailed. What the Royal College haven’t/chose not to notice is the arrival of the Physician Associates, trained on a 2 year graduate programme (clinical 2nd year) in the same medical schools with an attenuated curriculum that then allows for an ‘apprenticeship’ at a career option of their choice, very much like the pre-MRCGP. With any medical specialty, nothing beats hands-on experience, and a head-start at the right GP surgery means that there is no competition whatsoever from a recently graduated MRCGP for the same cohort start year.

  2. Pingback: Closing hospitals can help us save the NHS | NHS reality. An NHS soapbox. Speakers' corner for the NHS.

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