International GP Recruitment. Lancashire and South Cumbria STP Proposal

Transcription

1 International GP Recruitment Lancashire and South Cumbria STP Proposal November 2017

2 Executive Summary In Lancashire and South Cumbria, the challenges of recruiting and retaining a skilled primary care workforce are a growing concern. There is an ageing workforce and simply put not enough younger replacements coming through. What's more, a growing ageing population with complex needs, poor health outcomes and deprivation levels that place some localities at the top of the Index of Multiple Deprivation rankings, underline the fact that "doing nothing" is not an option. In this context, healthcare commissioners and providers have been actively considering opportunities and plans to increase the workforce, create new roles, train staff and work more effectively in partnership. In response to the demonstrable difficulties in GP recruitment, planned retirements, high average patient numbers per GP, and the anticipated increase in population, Lancashire and South Cumbria health care partners have come together and agreed to jointly develop and submit a proposal for the NHS England International GP Recruitment programme. This proposal outlines the rationale for the need to recruit GPs from abroad to work in Lancashire and South Cumbria and the plan to recruit and support the local integration of 140 GPs under the NHS England International GP Recruitment scheme. There are a number of anticipated key positive outcomes as a result of recruiting International GPs; besides achieving progression towards the national average of patients per GP and improving services for patients and access for the population, the increased pipeline of GPs from abroad will reduce some of the pressure on hard working GPs in the area and ensure that CCGs are proactively positioned to respond to anticipated turnover and population increase. Successful recruitment of International GPs will also provide the essential resource required to achieve maximum coverage of primary care services for the population, including hard-to-reach and highly deprived areas. This will allow for a focus on public health to combat the deprivation and life expectancy inequalities across the footprint. What's more, thorough planning to ensure smooth transition through key points of the recruitment and local integration process and effective management of the programme, with key performance indicators identified and agreed, will ensure successful delivery of the programme and effective integration of International GPs in the community, minimising attrition rates. In this context, this proposal plays a pivotal role in enabling the Healthier Lancashire and South Cumbria Sustainability and Transformation Partnership (STP) achieve its ambitions for having the right workforce, at the right time, at the right place to deliver high quality care and by ensuring capacity, capability and resilience in the primary care workforce. Across the STP footprint there is a maturing workforce governance structure, within which the management of the programme will fall. The dedicated Programme Board, with on-going support from the STP Primary Care Staff Education and Training Group and strategic oversight from the NHS England GPFV workforce steering group, will monitor progress against agreed deliverables and provide on-going assurance of quality and success to the programme stakeholders. 2

3 Table of Contents 1. Introduction International GP Recruitment Programme: National Update and Application Requirements National Update - October Application Requirements Recruitment Needs (STP Level) GP Vacancies Practice Engagement Geographical Information GP Retention Financial Information Local Context: Our Health Environment Healthier Lancashire and South Cumbria Sustainability and Transformation Partnership (STP) Morecambe Bay - Better Care Together Pennine Lancashire - Together A Healthier Future Fylde Coast - Your Care, Our Priority Central Lancashire - Our Health Our Care West Lancashire The Population The Health Profile Deprivation Levels Local Context: The Primary Care Landscape Overview of Lancashire and South Cumbria GP Practices, Federations and CCGs GP Workforce Profile: Current Position and Challenges

4 4.3 The Lancashire and South Cumbria Case for International GP Recruitment Requirement A: Recruitment Needs (STP Level) Requirement B: GP Vacancies Requirement C: GP Practice Engagement Requirement D: Geographical Information Requirement E: International GP Retention Requirement F: Current Interventions to Retain the Existing GP Workforce GP Retention Scheme Targeted Enhanced Recruitment Scheme (TERS) Induction and Recruitment (I&R) Scheme GP Career Plus Scheme Concluding Remarks APPENDICES Appendix 1: Overview of L&SC STP GP vacancies Appendix 2: Sample papers and presentations delivered by NHS Morecambe Bay CCG and its two Federations, Bay Medical and South Cumbria Collaborative (August October 2017) Appendix 3: Detailed breakdown of the number of GP vacancies within the footprint/geography Appendix 4: Preliminary brief and survey sent to GP Practices (May 2017) Appendix 5: Communications and Engagement Plan Appendix 6: HEE NW support offer to practices Appendix 7: Briefing to GP Practices (September 2017) Appendix 8: List of practices that have confirmed their interest to recruit an overseas GP Appendix 9: CCG pro-forma to capture detailed area information for marketing purposes Appendix 10: "Thinking about being a GP in Lancashire and South Cumbria?" - Brochure

5 Appendix 11: List of Lancashire and South Cumbria GP training practices Appendix 12: GP Retention scheme paper outlining the process and approval process (August 2017) LIST OF TABLES Table 1 Population projections by children, working age and pension age, Lancashire-12 area, Table 2 Population projections per Lancashire Clinical Commissioning Group (CCG) area Table 3 List sizes by CCG September Table 4 List of Federations per CCG/area, including number of member practices and population covered per Federation Table 5 All GPs (excluding Registrars, Retainers & Locums) in L&SC NHS Sustainability and Transformation Partnership (STP) & Clinical Commissioning Groups: Headcount by age band, March Table 6 Percentage of Practitioners being 55 years old and over Table 7 Number of patients per GP in L&SC STP Table 8 STP share of extra doctors in general practice by 2020/ Table 9 STP indicative target and expected supply Low end threshold Table 10 STP Share of extra doctors in general practice and gap to be met by 2020/21 (NHS England, August 2017) Table 11 Issues, concerns and recommendations for the International GP Recruitment programme by GP Practices Table 12 Quote from GP Career Plus scheme pilot site regarding challenges to employing GPs under the scheme

6 1. Introduction The GP Five Year Forward View (GPFV), published in April 2016, identified that there has been a firm rise in patient expectations, a target driven culture and a growing requirement for GPs to accommodate work previously undertaken in hospitals, or in social care. This has resulted in unprecedented pressure on practices, which impacts on staff and patients. Small changes in general practice capacity have a big impact on demand for hospital care, so the need to support general practice in underpinning the whole NHS has never been greater. General practice is the bedrock of the NHS with over 90% of patient consultations within the NHS taking place in general practice. Our plans need to be ambitious and transformational as well as strategically sound and locally sensitive. We are cognisant of the raging levels of deprivation, socio-economic, geographical and political drivers that exist in our communities. In Lancashire and South Cumbria, increasing demand, constricted supply of GPs and recruitment and retention challenges are creating growing pressure on the system as patients seek access to primary care in inappropriate settings. It is therefore essential that we take action to address the challenges associated to supply and retention of GPs. This proposal presents a strong case for the pressing need to recruit 140 GPs from abroad to work in Lancashire and South Cumbria and the plan to recruit and support the local integration of these GPs under the NHS England International GP Recruitment scheme. Specifically, the proposal gives an overview of the scheme, its requirements and the national plans, describes the local context and the primary care landscape, and exemplifies the Lancashire and South Cumbria position against these requirements. Last, it should be noted that some of the processes or plans outlined in this proposal may be subject to amendments and/or enhancement as required pending confirmation of the remit and plans of the national GP International Recruitment Office and other relevant national and regional updates. 2. International GP Recruitment Programme: National Update and Application Requirements While GP training places are increasing year-on-year and many GPs are returning to practice, many practices continue to face recruitment issues, and newly qualified GPs are often working as locums rather than joining a practice as a permanent GP. Some older GPs are also leaving the profession early. This is leaving a gap between the number of doctors practices want, and the numbers they are successfully recruiting and retaining. The General Practice Forward View (GPFV) as part of its commitment to strengthen the primary care workforce included a commitment to deliver a major international recruitment drive to attract up to 500 appropriately trained and qualified GPs from overseas by A programme to deliver this commitment commenced in the autumn of 2016, focusing on a number of high priority areas of the country in advance of the planned expansion of the programme to other areas from April On 22 August 2017, NHS England announced a major expansion of the International 6

7 GP Recruitment (IGPR) Programme. The expanded programme will now accelerate the original plans, and aim to recruit 2000 GPs from overseas by National Update - October 2017 On 20 October 2017, NHS England issued an updated guidance for commissioners on the International GP Recruitment Programme. This document replaces the guidance that was published in March 2017 and details the revised application process that should be followed by CCGs/STPs wishing to join NHS England's International GP Recruitment Programme. It is stated that a national GP International Recruitment Office will be established to organise and run the scaled up international recruitment programme. The role of this office will be to coordinate the recruitment, provide support for and relocation of recruited doctors, working closely with regional and local colleagues and partner organisations. In addition, it is explained that, given the increased scale of recruitment, the role of the office is likely to include responsibility for a range of tasks such as procurement, recruitment and relocation. These tasks are currently undertaken locally by the recruitment schemes already participating in the programme. Under the expansion, it is anticipated that responsibility for these tasks would move to the national office. It should be noted that, although initial interviews with International GPs will be undertaken nationally, this process will only focus on assessing whether GPs are suitable for the programme. Following this stage, the national team have advised that regional and local teams will be working jointly to link suitable candidates up with practices. Furthermore, it has been emphasized that GP practices will be actively involved in this part of the selection process as they will naturally expect to lead on the decision making process for the GPs they would like to appoint. NHS England is currently procuring a national framework of approved recruitment, relocation and training companies to support the programme. This framework should be operational by the end of November It is likely that procurements under the framework will be undertaken nationally with suppliers appointed to deliver services across defined source countries. Further information, timelines and the date the centre is expected to be fully operational will be given at forthcoming national announcements. 2.2 Application Requirements Given this change in approach, the guidance confirms that commissioners wishing to join the programme are no longer required to develop detailed proposals demonstrating how recruitment, training and relocation will be delivered locally. Instead, it is recommended that any future applications to join the programme should focus on the salient points outlined below: Recruitment Needs (STP Level) Future applications should set out the recruitment needs of an STP footprint. These applications may however outline why any recruitment scheme should focus on specific areas within an STP footprint where recruitment needs are more acute. 7

8 2.2.2 GP Vacancies Applications should include a detailed breakdown of the number of GP vacancies within the footprint/geography that will be filled with the appointment of GPs recruited from overseas as part of the programme Practice Engagement Applications should detail the engagement that has taken place locally with GP practices within the footprint/geography. The application should list all of the practices that have committed to employing an overseas GP recruited as part of the programme. Practices will be involved in the selection process of overseas GPs Geographical Information The application should provide information on the geography and explain how it could be promoted as a place to live and work to overseas GPs. Any existing promotional materials about the geography should be attached to the application GP Retention The application should explain how recruited GPs will be supported and integrated into the local primary care workforce and wider community. The application should also detail the measures that will be implemented locally to support the long-term retention of recruited GPs. One key element that applications should consider is how retention incentives can be built into terms and conditions within the contracts of employment that recruited GPs will have with their employing practice, including defined contract lengths and claw back measures of training and relocation costs if a recruited GP exits their contract early Current Measures to Support the Existing Workforce The application should outline the measures that are being undertaken locally to support and retain the existing GP workforce. The decision making panel is keen to see evidence of how any international GP recruitment schemes locally will complement existing measures to support and retain the existing workforce Financial Information The programme will be fully funded by NHS England. The funding is available to support the process of recruitment, including sourcing and selecting applicants, training, relocation and accommodation costs. Future applications to join the programme do not therefore need to include a request for budget for these elements. Applications should however include costings for any local measures to support the integration of recruited GPs and their long-term retention. It is currently forecasted that up to 2,500 per GP will be available to support integration and retention measures locally. Further planning in 8

9 conjunction with NHS England regional teams and STPs will agree staffing requirements for delivery of the programme at local and regional level. Practices employing international GPs in the programme will remain responsible for all usual employment responsibilities, including salaries. 3. Local Context: Our Health Environment 3.1 Healthier Lancashire and South Cumbria Sustainability and Transformation Partnership (STP) Healthier Lancashire and South Cumbria is a partnership of organisations coming together to improve outcomes and care for local people, reduce pressures on services and make best use of our financial resources. Organisations are involved in improvements that need to happen across the whole region and are working to develop local plans in five areas. These are the Blackpool & Fylde coast, Pennine Lancashire, central Lancashire, West Lancashire and Morecambe Bay. They provide a way in which all organisations and groups involved in health and care can join up locally. The five local areas are illustrated in the map that follows (Image 1). Image 1 The five local areas in Healthier Lancashire and South Cumbria 9

10 3.1.1 Morecambe Bay - Better Care Together Better Care Together is a review of health and social care services for Morecambe Bay. It is being led by ten health organisations known as Bay Health and Care Partners. This area covers north Lancashire and south Cumbria Pennine Lancashire - Together A Healthier Future Together A Healthier Future is a programme to improve the health and care system in Pennine Lancashire, which is made up of East Lancashire and Blackburn with Darwen areas Fylde Coast - Your Care, Our Priority Health and care organisations on the Fylde Coast are working together to make Your Care, Our Priority. To achieve this ambition health and care professionals are brought together, alongside the community and voluntary sector, to create one integrated healthcare system on the Fylde Coast. This means joining up different parts of health and care services so that they work seamlessly together Central Lancashire - Our Health Our Care Our Health Our Care is a programme which aims to deliver joined up health and social care to everyone throughout Greater Preston, Chorley and South Ribble West Lancashire This area holds a unique geographical position, which requires leaders to look in the directions of both Lancashire and Merseyside. The West Lancashire Local Delivery Plan involves wide ranging partner working; not only with Lancashire wide colleagues, but also with local partners such as CCG colleagues in Southport and Formby, West Lancashire Borough Council, Virgin Care, Southport & Ormskirk Hospital NHS Trust, Lancashire Care NHS Foundation Trust, social care, its active voluntary community and faith sector, GP membership, patients, carers, and staff. 3.2 The Population The population of Lancashire and South Cumbria is approximately 1.7 million and is increasing 1. For the Lancashire-14 area 2, a 4.5% increase is projected over the 25-year period, resulting in an expected population of million by For the Lancashire-12 3 area, the percentage increase is projected to be higher at 5.9%, with the number expected to reach million. 1 Based on the number of people registered with a GP in 2016/2017, according to NHS England, STP footprint analysis pack Lancashire and South Cumbria, Five Year Forward View Lancashire-14 refers to the twelve districts in the Lancashire County Council area and the two unitary authorities of Blackburn with Darwen and Blackpool 3 Lancashire-12 refers to the twelve districts in the Lancashire County Council area (excluding Blackburn with Darwen and Blackpool) 10

11 Although the working age population is predicted to start to decline within 5 years, the older population are predicted to continue to increase, with more falling into the over 65 age bracket each year as life expectancy increases over the period. 4 Age % change, number of years from Aged 0 to , , , , Aged 16 to , , , , Aged , , , , Table 1 Population projections by children, working age and pension age, Lancashire-12 area, The population is served by eight NHS clinical commissioning groups (Image 2). East Lancashire CCG covers a large area and is the second largest CCG in the county by population, after NHS Morecambe Bay CCG. It is ranked 7th out of 237 CCGs for growth 6 (Table 2). Image 2 Lancashire and South Cumbria CCGs 4 Projections based on data published by Lancashire County Council Insight (June 2016) 5 Source NOMIS 6 Lancashire Insight ONS interactive map with population projections available at 11

12 Area 2014 (000) 2019 (000) 2024 (000) 2039 (000) % change, number of years from Rank out of 237 CCGs 7 Blackburn with Darwen CCG 8 Blackpool CCG Chorley and South Ribble CCG East Lancashire CCG Fylde and Wyre CCG Greater Preston CCG Lancashire North CCG 9 West Lancashire CCG Table 2 Population projections per Lancashire Clinical Commissioning Group (CCG) area The Health Profile Numerous studies have shown that geographical variations in life expectancy can largely be accounted for by individual and area-based deprivation. The Marmot Review published in 2010 highlighted the fact that people living in the poorest neighbourhoods will on average, die seven years earlier than people living in the richest neighbourhoods. The difference in disability-free life expectancy is even greater, with the average difference between the most and least deprived areas being 17 years. The health of people in Lancashire and South Cumbria varies greatly when compared to England. Within the county there are wide differences between the most and least deprived areas. For example, in the most deprived areas life expectancy at birth for men is 10.2 years lower and 7.1 years lower for women, when compared to the least deprived areas ( ). Significant findings for Lancashire & South Cumbria 11 include: In 2013 to 2015, life expectancy at birth (LE) for females in Lancashire-12 (82.1 yrs), Blackburn with Darwen (80.8 yrs) and Blackpool (79.4 yrs) is significantly lower than England (83.1 yrs). Male LE in Lancashire-12 (78.5 yrs), Blackburn with Darwen (76.5 yrs) and Blackpool (74.3 yrs) is significantly lower than England (79.5 yrs). The gap in LE between each local authority in Lancashire-14 and England as a whole was greatest in Blackpool where the difference is 5.2 years lower for males and 3.7 years lower for females. 7 Where the CCG ranked 237 had the highest projected rate of population increase 8 Blackburn with Darwen, Blackpool and West Lancashire CCGs have population numbers that are the same as the local authorities 9 The CCG as from 1st April 2017 covers South Cumbria too and is renamed to NHS Morecambe Bay CCG 10 Source Office for National Statistics available at groupsinenglandz2 11 Data available at Lancashire-14: life expectancy and life expectancy at 65 (March 2017) 12

13 Prevalence and incidence rates for cancer, cardiovascular disease and liver disease are all above national rates and residents in the more deprived areas tend to have higher levels of premature and overall mortality from these conditions. There are issues around mental health and wellbeing, with residents in the most deprived areas nearly twice as likely to have mental health problems compared to those in the least deprived areas. This includes common mental health issues such as depression and anxiety, and more severe disorders such as schizophrenia. 3.4 Deprivation Levels The Department for Communities and Local Government (DCLG) released the 2015 English Indices of Deprivation on 30th September 2015, and the figures were published down to the lower layer super output area level. The 2015 figures reveal that seven local authorities across the footprint, Blackpool, Burnley, Blackburn with Darwen, Hyndburn, Pendle, Lancaster and Preston, had at least one of their eight local authority deprivation summary measures ranked in the 50 most deprived positions. This was up from six authorities in the previous 2010 indices. Lancaster became the seventh owing to a relative deterioration of its local concentration ranking. Lancashire's most deprived areas are in urban centres of towns in East Lancashire, Preston and Blackpool. These are localities that have undergone major economic and structural change over many years, and face various issues. Out of the eight CCGs in Lancashire and South Cumbria, the two NHS areas covering Blackburn with Darwen and Blackpool are in the 20% most deprived in England. The other six CCGs fall into the 40-80% deprived range nationally. Blackpool has the most deprived rankings in Lancashire and South Cumbria for all eight of the local authority summary measures. The authority also had the top most deprived rankings (1st in England) for the rank of average score measure and the rank of local concentration measure. This latter measure identifies 'hot spots' of very high levels of deprivation. 4. Local Context: The Primary Care Landscape 4.1 Overview of Lancashire and South Cumbria GP Practices, Federations and CCGs There are 8 CCGs and 246 GP practices that service 1,747,605 registered patients across Lancashire and South Cumbria (June 2017). The smallest list size is 1053 and the largest list size is The table that follows (Table 3) gives an overview of the list sizes broken down by CCG. 13

14 CCG Code CCG Pcode June Q Blackburn with Darwen Total 173,936 00R Blackpool Total 172,919 00X Chorley & South Ribble Total 182,139 01A East Lancashire Total 379,565 01E Greater Preston Total 213,731 01K Lancashire North Total 360,960 02G West Lancashire Total 113,036 02M Fylde & Wyre Total 151,319 Lancashire Total 1,747,605 Table 3 List sizes by CCG (September 2017) There are also nine Federations listed in the table below and broken down per CCG/area (Table 4). CCG / Area Federation name Legal form East Lancashire East Lancashire Union Private company limited by shares Blackburn with Blackburn with Darwen Private company Darwen limited by shares West Lancashire OWLS CIC Private company limited by shares Lancashire North North Lancashire Medical Private company Services Ltd limited by shares (superpractices) East Lancashire Pendle Care Direct Private company limited by shares East Lancashire Ribblesdale Private company Fylde & Wyre Fleetwood Community Care limited by shares Private company limited by shares Population covered 250, , , , , , ,000 4 Number of member practices South Cumbria South Cumbria Primary Care Collaborative Private company limited by shares 166, Table 4 List of Federations per CCG/area, including number of member practices and population covered per Federation 14

15 4.2 GP Workforce Profile 12 : Current Position and Challenges In Lancashire and South Cumbria (L&SC) STP there is a total of 976 Practitioners (Table 5 13 ). All Practitioners (excluding Retainers, Registrars & Locums) England Under Unknown 34, ,593 5,350 5,456 4,877 5,230 4,295 1, ,478 L&SC STP Table 5 All GPs (excluding Registrars, Retainers & Locums) in L&SC NHS Sustainability and Transformation Partnership (STP) & Clinical Commissioning Groups: Headcount by age band (March 2017) The data demonstrate that 10.8% of the total count of Practitioners fall into the >35 age band and 21.4% are 55 years old and over (Table 6). All Practitioners (excluding Retainers, Registrars & Locums) % Under 30 % Under 35 % 55 and over England 34, L&SC STP Table 6 Percentage of Practitioners being 55 years old and over The average number of FTE GPs per 1,000 patients per practice in England is However, in Lancashire and South Cumbria the ratio is significant higher than the national average (Table 7 14 ). All Patients and over Patients per practice Patients per GP England 58,272,634 3,332,586 6,777,325 23,184,698 14,906,312 5,545,714 3,191,235 1,334,764 7,818 1,391 L&SC STP 1,742,530 94, , , , , ,882 42,463 6,970 1,621 Table 7 Number of patients per GP in L&SC STP 12 Data provided by NHS Digital (March 2017) 13 Data extracted from the General Practice Detailed Tables March STP [1.18MB] spreadsheet - Tab 4a 14 Data available at 15

16 Recent NHS England data (June 2017) outline the expected share of extra doctors in general practice per STP by 2020/21 (Table 8) and highlight the requirement for Lancashire and South Cumbria to meet the indicative share of 109 GPs (low end threshold). Table 8 STP share of extra doctors in general practice by 2020/21 However, when considering the indicative target and expected supply per STP it becomes clear that our supply does not meet low end threshold 15 (Table 9) and updated data highlight there is a demand-supply gap of at least 116 GPs for the STP GP indicative share of 115 (mid point) to be met by 2020/21 (Table 10). Table 9 STP indicative target and expected supply Low end threshold 15 RED: Supply does not meet low end threshold AMBER: Supply is between high and low end thresholds GREEN: Supply does meet high end threshold 16

17 North Region share of national target DCO DCO GP STP Indicative share STP GP indicative share (mid point) Target Supply of number of newly FTE doctors qualified by 20/21 GPs Retirements Other net Gap to be met leavers and through other joiners local initiatives Lancashire Lancashire & South Cumbria 115 1, Total ,516 2,794 2, ,078 Table 10 STP Share of extra doctors in general practice and gap to be met by 2020/21 (NHS England, August 2017) What's more, GP practices across the footprint report that they are struggling to recruit both salaried GPs and partners on a permanent basis, particularly GP partners, because of national workforce issues; given the number of GPs anticipated to retire over the next 5 years, practices are concerned that this will further exacerbate existing workforce challenges and pose risks to continuity of provision locally; they often have to manage vacancies through the use of temporary or locum GPs; they are finding it increasingly difficult to source locum medical cover for gaps in frontline general medical services provision; they are finding it challenging to maintain continuity of care and clinical quality with the need to use more temporary locum medical staff; they are concerned that a reduction in the number of general practice trainees will result in an increased risk to workforce capacity over than next 5-10 years; they have concerns that financial austerity will introduce further financial challenges to sustaining frontline services. A recent local survey carried out across the GP Practices in Lancashire and South Cumbria (June October 2017) confirmed the concerns reported by GP practices. Specifically, 172 practices (out of a total of 243) reported they are currently struggling to fill a total of 60 GP vacancies, whilst at the same time 136 GPs advised they plan to retire within the next 5 years (Appendix 1). 4.3 The Lancashire and South Cumbria Case for International GP Recruitment This proposal presents the rationale and evidence required to support the Lancashire and South Cumbria application to recruit 140 GPs under the NHS England International GP Recruitment programme. Specifically, this proposal illustrates that 1. across the footprint there are increasing challenges in GP recruitment and retention with the STP GP practices currently struggling to fill in 60 GP vacancies; 17

18 2. recent data give evidence of an increasingly ageing GP workforce across the footprint, with 21.4% of the existing GP workforce (192 Practitioners) within the age range of 55 years old and over; % of GPs in Lancashire North fall in the age group. A rural population of 165k has been served, however, the population has increased to 365k from April 2017 due to change in boundaries and the inclusion of South Cumbria; 4. high deprivation levels present additional challenges for GP recruitment, with two of the eight NHS areas in the footprint covering Blackburn with Darwen and Blackpool falling in the 20% most deprived areas in England; 5. the ratio of patients per GP is significantly higher than the national average; 6. the STP is required to meet an indicative share (low end threshold) of 109 GPs; however, the estimated STP supply does not meet low end threshold and there is a gap of 116 GPs to be met by 2020/21. What follows is additional evidence and detailed responses broken down by the 6 application requirements entailed in the updated NHS England guidance for commissioners, issued on 20 October Requirement A: Recruitment Needs (STP Level) The updated guidance recommends that "any future applications to join the programme should set out the recruitment needs of an STP footprint" and that "they may outline why any recruitment scheme should focus on specific areas within an STP footprint where recruitment needs are more acute". In this context, Lancashire and South Cumbria healthcare organisations concluded it would be a reasonable approach to submit a single application across the STP footprint and to identify a single organisation to lead the programme on behalf of the STP. NHS Morecambe Bay CCG has offered to lead the programme on behalf of Lancashire and South Cumbria STP. A working group has been established to develop the application for the International GP Recruitment programme. A Programme Board has also been established by the NHS England area team to support and assure delivery of the GPFV and the STP primary care work streams with representation from health and care stakeholders across the footprint to include, NHS Clinical Commissioners, HEE, the LMC, secondary care, local professional networks, voluntary sector, social care and communication and engagement specialists. The working group and the Programme Board have already been working closely with HEE NW and local partners to collectively consider potential challenges and opportunities and develop a local plan to support retention of International GPs. Initial discussions have focused on the preferred approach or method for distributing overseas GPs equitably across the footprint with the challenge being that the 8 CCGs across the footprint vary greatly in terms of population size 18

19 and health care needs, recruitment and retention challenges and geography/location (hard to recruit areas). Given the recruitment challenges across the system, especially in the "hard to recruit" areas, and the high levels of deprivations in certain localities, an option currently considered as a preferred approach involves distributing GPs proportionately through a weighted formula-based approach for resource allocation that captures comparative levels of area need based on the following dimensions: "Hard to recruit" area (e.g. geography, deprivation levels) (45%) Existing capacity / urgent recruitment needs to ensure sustainability (35%) Complexity of population care needs (20%) It is anticipated that the Programme Board might have to address challenging issues such as, overseas GPs unwilling to continue working on a specific area after a relatively prolonged period of time or GPs requests for a different placement (for a variety of reasons) shortly after they commence work in a specific area. Appropriate measures will be considered and put in place, for example, scheduled rotas and strong support for local integration that will promote healthy and fulfilling working and living conditions and a positive overall experience for overseas GPs. It should also be noted that NHS Morecambe Bay CCG has two Federations, North Lancashire Medical Services in the north area and South Cumbria Collaborative in South Cumbria, and also a super practice Bay Medical in Lancashire North area, and that both Federations and the super practice are extremely engaged and enthusiastic with the prospect of driving International Recruitment for Lancashire and South Cumbria. Sample copies of presentations and papers already delivered by the CCG and the Federations are enclosed in Appendix 2. It is envisaged that the two Federations will play a pivotal role as change agents across the footprint, championing the programme amongst GP Practices in Lancashire and South Cumbria. Numerous studies in the literature have demonstrated a plethora of significant advantages in identifying change agents roles when driving large scale transformation, including: Reducing the pressure on the centralised team to deliver change; Identifying issues on the ground and raising them quickly to the project team; Gathering feedback on the communications campaign and feedback to the change team; Identifying key resistors of change; Assisting with managing resistance to change amongst their colleagues; Becoming super users and therefore assist in training of users. In this context, Lancashire and South Cumbria is in a uniquely advantageous position to have in place a strong programme leadership and management infrastructure to ensure successful delivery of the International GP Recruitment programme. 19

20 6. Requirement B: GP Vacancies The updated guidance recommends that applications should include a detailed breakdown of the number of GP vacancies within the footprint/geography that will be filled with the appointment of GPs recruited from overseas as part of the programme. Appendix 3 gives a detailed breakdown of the number of GP vacancies per CCG GP vacancies per GP practice (existing) GP vacancies per GP practice (known or forecasted, for example, due to GP retirement plans) 7. Requirement C: GP Practice Engagement The updated guidance recommends that applications should detail the engagement that has taken place locally with GP practices within the footprint/geography. The application should list all of the practices that have committed to employing an overseas GP recruited as part of the programme. Lancashire and South Cumbria commenced preliminary engagement with its GP Practices early in May A short survey (Appendix 4) was circulated alerting practices to the programme and asking for information in relation to existing GP vacancies, plans to recruit for existing vacancies with a GP or with another healthcare profession, expressions of interest in recruiting a GP from abroad to fill in current vacancies (with access to allocated funding and structured support from local and regional organisations) and GP retirement plans in the next 5 years. The first round of data analysis revealed a poor response rate from GP Practices of 35%. This response rate highlighted the need for the development of a detailed communications and engagement plan for the programme. The first draft of the dedicated communications plan was developed in June 2017 and it has been continuously refined and updated following national and regional updates about the scheme. The most up to date version of this plan, which has been endorsed by the GPFV Programme Board, is enclosed in Appendix 5. Following a HEE presentation to stakeholders, outlining the HEE support offer to GP practices and an overview of the Induction and Refresher scheme (Appendix 6), an updated briefing for GP Practices was produced and shared with stakeholders across the system (Appendix 7). This series of interventions and activities in combination with a second round of engagement with GP practices, which included direct phone calls and verbal briefings (July 2017 to September 2017), improved considerable the response rate to the survey questions issued previously in May Out of a total of 243 GP practices, 172 responded to the survey questions (Appendix 1) highlighting the following significant results: There are 60 live GP vacancies in Lancashire and South Cumbria. 136 GPs plan to retire within the next 5 years. 20

21 119 GP Practices expressed their interest to recruit GPs form abroad, whilst 8 practices advised they were unsure and 19 stated they were not considering International GP Recruitment. Additional feedback obtained by GP Practices through conversations and group discussions has revealed a number of concerns and recommendations for the Programme Board s consideration: Due to past IR history locally, we need to work hard to obtain GP Practice Buy-In Big cultural change for the IRs need significant support on a daily basis to adapt and ongoing mentorship/coaching/cpd/ as well as addressing their social, environmental needs, relationship building and active networks programme such as First Five Another demand on training practices but hopefully spoke practices may release this pressure need neighbourhood approach and sign-up Need structured and consistent Induction Programme Risk of a lot of effort for limited positive outcome, if they decide to go back home early! The geographical isolation may present a challenge in terms of recruitment and retention of international GPs There are many independent practices within the area that may have a lack of capacity in terms of estates to accommodate additional GPs The retention rate for internally recruited GPs within the locality is unknown. Capacity of training practices and trainers to accept international recruits on top of the GP Trainees and Foundation Year 2 doctors in GP placements Table 11 Issues, concerns and recommendations for the International GP Recruitment programme by GP Practices A list of all the practices that have confirmed their interest to recruit an overseas GP to present is included in Appendix Requirement D: Geographical Information The updated guidance recommends that applications provide information on the geography and explain how it could be promoted as a place to live and work to overseas GPs" and that any existing promotional materials about the geography should be attached to the application. It has also been noted that there is a intention for the national International GP Recruitment Office to develop a national website which will aim to promote the advantages and benefits of living and working in England. It is anticipated that this website will also hold local web pages for every locality/area deemed successful to deliver the International GP Recruitment programme and that the national office will ask these localities to submit marketing materials promoting the advantages of living and working in the specific area (subject to further announcements about national plans and guidance for local delivery). In advance of forthcoming guidance, Lancashire and South Cumbria has developed a CCG proforma (Appendix 9) aimed at capturing unique marketing points for each locality that will be used 21

22 to inform the national website and other relevant promotional materials. A draft brochure entitled "Thinking about being a GP in Lancashire and South Cumbria?" has also been drafted and it will include essential information on subject matters such as lifestyle, transport, education and housing (Appendix 10). The brochure, which will be developed further as soon as further information and guidance is issued by the national centre, will be influenced by the recently launched guide for foreign doctors entitled "Living and working in the UK as a GP: a guide for overseas doctors and their families" (Royal College of General Practitioners, October 2017). The guide, launched in conjunction with the NHS in England, Scotland, Wales and Northern Ireland and with the General Medical Council (GMC) and the BMA, is aimed at making overseas doctors more comfortable working in the UK. This informative guide helps doctors and their families learn more about life in the UK, and provides them a wealth of support to help them make the move as smooth as possible. The document goes into detail on a variety of topics, including the relevant qualifications for GPs in Britain, important professional organisations, and the routes doctors can take into general practice roles. As part of the communication and engagement plan developed for the programme, a series of web based information will also be utilised to include websites such as We are Lancashire booklet We are Lancashire video The Lancashire North GP Federation (pilot site for the Career Plus scheme) has also recently launched the GP recruitment film Come Join Us which is available on the website and on twitter #comejoinus and #gp recruit and #GP career+ and this will be an additional valuable asset for the local area campaign. 9. Requirement E: International GP Retention The updated guidance recommends that applications should explain how recruited GPs will be supported and integrated into the local primary care workforce and wider community, including details of measures that will be implemented locally to support the long-term retention of recruited GPs and details of relevant costings. In addition to the work being progressed in the field of communication and engagement as detailed in the preceding section, Lancashire and South Cumbria has been working closely with HEE NW and local partners to collectively consider additional challenges and opportunities and 22

23 develop a local plan to support the long-term retention of International GPs. Preliminary conversations have focused on the theme of local induction for overseas GPs and dedicated support provided through the Induction and Refresher scheme. To this end, the working group for the programme is collating information and contact details about existing training practices (Appendix 11) and is also reviewing existing databases of active trainers and mentors in GP Practices across the footprint. However, conversations have progressed considerably and have led to the development of a long term retention plan which includes the following key themes: Making doctors and their families feel welcome. The points below, although not mandatory within the cost envelope, are cost effective and would have a significant impact. a) Social element making sure the doctors and families are integrated within their communities and with other international recruits. Some events, forums, WhatsApp groups and so forth maybe prove to be of great help. This support should extend beyond the 3 years contractual delivery of the scheme. b) Practical issues advice for doctors about practical issues, housing, bank accounts, access for schools and nurseries, finding a GP, local transport, car hire and so forth. c) A named contact to signpost to all of the above is imperative an option could be to identify or recruit change agents/coordinators in training practises (or where deemed appropriate) to provide the required signposting consistently. Free peer mentoring service. The working group has been involved in conversations with existing national International GP Recruitment pilots in an effort to identify existing best practice and generate ideas and has come across the GP-S initiative - a free peer mentoring service for General Practice, offering coaching and signposting service for General Practice based in Nottinghamshire, Derbyshire and Lincolnshire (available at ). A service similar to GP-S will be available in Lancashire and South Cumbria to offer coaching and signposting service to new recruits. Education and CPD. There aren t currently any local education arrangements for doctors in the Induction and Refresher scheme, but it might be a sensible approach for a group of doctors and has a number of benefits. Regular teaching sessions provide a really good forum for discussion about local guidelines, referral guidance, prescribing discussions and clinical updates. Similarly, these initiatives could continue after completion of the scheme maybe led by local clinical tutors, or the doctors could access local GP teaching through CCGs. A dedicated educational programme, suitable to the needs of the GPs and the specific needs identified from an individual learning needs analysis, could also be delivered and it will involve a combination of in house and external speakers, modelling UK GP specialty training schemes. The programme will include peer group reflection and learning, educator led sessions, role play, on-line learning and pastoral support including resilience, working under pressure, where to seek help both during the Induction & Refresher training and when working as NHS GPs, for the full 3 years of the contract. A similar education programme of this kind is currently being delivered successfully in Oxford. The curriculum includes NHS systems, primary and secondary care interface, roles of allied 23

24 professionals in primary care, other sources of support beyond the GP Practice, e.g. drug and alcohol support, MIND, IAPT. The programme also includes development of professional behaviours including GMC expectations, ethics and ensures high level communication and consultation skills framed in the UK NHS patient centred model. Practical support is also provided in regards to appraisal and revalidation, and governance within the NHS. The assessment and training programme described demonstrates a clear commitment to ensuring high quality and effective recruitment and training. The training package is developed to include both a varied curriculum and methods of training. This option will be explored further subject to further notices and guidance issued by the national centre and details of the work to be delivered nationally. Furthermore, it is intended that the recruited GPs will be invited to attend the CCGs Protected Learning Time clinical education events (PLTs). We will also facilitate links into the local education establishments to support their CPD. Future development of GPs. Initial thinking includes providing encouragement for extended GP roles training as GPSI or a clinical fellowship with some CCG funding. Training for supervisors. Induction and Refresher placements currently take place in accredited environments and usually by a GP trainer. This may not be possible if the numbers of International GPs recruited are large. HEE NW have a two day scheme for training foundation clinical supervisors. A similar approach could be adopted for International GP supervision. This would involve a facilitator for every 10 supervisors trained and a venue for the teaching. Facilitator. Costs would include c 500 per day for 2 days, with 1 Facilitator per 10 doctors. Approved trainers and those currently approved as CS for foundation would not need this training. Regarding approval of GP Practices, ideally supervisors should be in an approved environment. A hub and spoke arrangement would be a sensible approach as per national documentation. Those not supervised by an approved trainer (ES) would need a monthly meeting with a trainer and sign off at end by them. The programme would need to pay the ES for this 250 per half day. Length of placement. The current Induction and Refresher scheme funds up to 6 months placement. The induction doctors (those who haven t worked as GPs in the UK before) usually need the full 6 months and some may need longer. There would need to be a contingency for this. The Programme Board has also taken on board national recommendations for considering claw back measures of training and relocation costs should an overseas GP exits his contract early. Specifically, it is indented that the contract of employment will detail terms and conditions of employment, including a provision for providing Extended Access, salary commitment, and a mutual obligation to commit to 3 years minimum employment, to provide stability and certainty for GPs recruited as part of this process. The contract will also include appropriate clauses requiring a GP to reimburse a specific amount of relocation and training costs if he was to exit his contract early, for example, two thirds of costs would be reimbursed if one was to exit the contract within 12 months of relocation. 24

25 Engagement interviews. A suitable engagement team will be placed to conduct interviews in months 3, 6 and 12 of employment to ensure that both the overseas GP and the GP Practice are satisfied with the way the placement is progressing and that all expectations from both side are being met. As part of the process, the attrition rate will be monitored. Any exits from the scheme will be explored, with robust exit interviews undertaken with all leavers. 10. Requirement F: Current Interventions to Retain the Existing GP Workforce The updated guidance recommends that applications should outline the measures that are being undertaken locally to support and retain the existing GP workforce, including evidence of how the International GP recruitment programme will complement existing local measures to support and retain the existing workforce. Lancashire and South Cumbria has a dedicated STP primary care team responsible for assuring delivery of the work streams detailed in the GPFV. In relation to this programme of work, a range of schemes and measures are being progressed to support and retain the existing GP workforce and which the International Recruitment programme is envisaged will complement. An outline of these schemes is presented in the sections below GP Retention Scheme In March 2015, the return to practice scheme was revised and re-launched, providing an opportunity for GPs who have previously been on the GMC Register and on the NHS England National Performers List (NPL) to safely return to General Practice after a career break, raising a family or time spent working abroad. It also supports the safe introduction of overseas GPs who have qualified outside the UK and have no previous NHS experience. The CCGs have embraced the scheme however the area still faces significant challenges when recruiting GPs. The GP retainer scheme is intended to ensure that doctors who may be thinking of leaving practice or those who can only undertake a small amount of paid professional work can keep in touch with general practice and retain their skills. Our workforce intelligence suggests that the use of this scheme will be greater in the future, with a number of GPs wishing to work part time. A paper outlining the process for processing and approving applications was discussed and signed off by the NHSE GPFV workforce steering group on 10 th August 2017 (Appendix 12). The process was ratified by the Contract Procurement Committee on 29 th August Seven applications have been submitted since 1 st April 2017 and all seven have been approved Targeted Enhanced Recruitment Scheme (TERS) National TERS were agreed for Blackpool (16) and South Cumbria (8) in Round 1. For Round 2 there is local agreement to offer TERS to support recruitment to cover the 18 appointed in Blackpool (there are no vacancies in Blackpool in Round 2) and for the vacancies in Lancaster 25

26 for Round 2. There has not been a decision whether those appointed in round 1 in Lancaster will receive a TERS but the funding has been set aside for a maximum of Induction and Recruitment (I&R) Scheme Numbers on the scheme have been particularly low for Lancashire and South Cumbria, less than five. On discussion with stakeholders it has been proposed that the scheme should also be discussed at appraisal stage; for example, if a doctor was planning to leave UK or have a career break, support on how to navigate the scheme will prove particularly helpful. Still, it is envisaged that the scheme will be fully utilised when in place to support the International GP Recruitment, which in turn will help boost numbers at the I&R scheme GP Career Plus Scheme Lancashire North GP Federation is one of the national pilot test sites and has worked to develop a GP pool across 12 practices within the Lancashire North CCG area. The target has been for the GP pool to host eight GPs undertaking a range of work (clinical, mentoring, leadership) to support these 12 practices. The target has been met with 8 GPs recruited into the pool by the end of July However, challenges have been noted in relation to the future employment of GPs once the APMS contract ends. Specifically, the following issues questions have been raised regarding the APMS contract being classed as an NHS contract and whether this affects the Federations ability to pay into the NHS pension scheme for employed GPs. This is our greatest barrier to employing GPs who wish to access NHS Pensions. As this contract we hold ends in April and was for the duration of the pilot only, we will be unable to access NHS pensions after April and this is causing a restriction on employment. We do feel this is a barrier to the development of federations nationally who find themselves in a position where contracts are no longer available due to Accountable Care System developments. Table 12 Quote from the Lancashire and South Cumbria GP Career Plus scheme pilot site regarding challenges to employing GPs under the scheme 11. Concluding Remarks The preceding arguments, alongside the evidence provided, present a strong case for Lancashire and South Cumbria to submit an application for recruiting 140 GPs under the NHS England International GP Recruitment programme. 26

27 Specifically, this application has exemplified the rationale for the pressing need to recruit 140 overseas GPs and by highlighting that 1. across the footprint there are increasing challenges in GP recruitment and retention with the STP GP practices currently struggling to fill in 60 GP vacancies; 2. recent data give evidence of an increasingly ageing GP workforce, with 21.4% of the existing workforce falling into the age range of 55 years old and over; % of GPs in Lancashire North fall in the age group. A rural population of 165k has been served, however, the population has increased to 365k from April 2017 due to change in boundaries and the inclusion of South Cumbria; 4. high deprivation levels present additional challenges for GP recruitment, with two of the eight NHS areas in the footprint covering Blackburn with Darwen and Blackpool falling in the 20% most deprived areas in England; 5. the ratio of patients per GP is significantly higher than the national average; 6. the STP is required to meet an indicative share (low end threshold) of 109 GPs; however, the estimated STP supply does not meet low end threshold and there is a gap of 116 GPs to be met by 2020/21. In addition, the application has provided aadditional evidence and detailed responses broken down by the 6 application requirements entailed in the updated NHS England guidance for commissioners, issued on 20 October This application has been endorsed by the Programme Board on behalf of the Lancashire and South Cumbria STP. Lancashire and South Cumbria is submitting this application for the attention of the the NHS England regional office (north) in advance of the forthcoming deadline for submissions on 30th November

28 APPENDICES Appendix 1: Overview of L&SC STP GP vacancies Updated responses to IR questions - 4th Appendix 2: Sample papers and presentations delivered by NHS Morecambe Bay CCG and its two Federations, Bay Medical and South Cumbria Collaborative (August October 2017) Locality meeting presentation: This presentation was delivered to a locality meeting, the S Lakes GP practices on 14 th September 2017 and includes a section dedicated to International GP Recruitment. The GPs and Practice Managers had the opportunity to discuss overseas recruitment during this meeting. Sept2017LocalityMtg v2.pptx Paper submitted to the South Cumbria Collaborative Federation Board meeting in August 2017: Paper to Fed Board MB.docx Agenda for South Cumbria Primary Care Collaborative Board with paper enclosed. SCPCC Agenda docx 28

29 Notes from Furness Practice Manager meeting International GP recruitment is on the agenda and paper was then circulated. The paper was also discussed at the North Lancashire Federation Meeting. SCPcc pm minutes Furness docx Appendix 3: Detailed breakdown of the number of GP vacancies within the footprint/geography all ccgs collated IR.xlsx Appendix 4: Preliminary brief and survey sent to GP Practices (May 2017) Preliminary engagement with GP Appendix 5: Communications and Engagement Plan LSC International GP recruitment comms pla Appendix 6: HEE NW support offer to practices AC international recruitment preston au 29

30 Appendix 7: Briefing to GP Practices (September 2017) UPDATED IR briefing September 2017 FINAL Appendix 8: List of practices that have confirmed their interest to recruit an overseas GP all ccgs collated IR.xlsx Appendix 9: CCG pro-forma to capture detailed area information for marketing purposes CCG proforma doe comms - IR scheme.do Appendix 10: "Thinking about being a GP in Lancashire and South Cumbria?" - Brochure Geographical Information - the L&SC Appendix 11: List of Lancashire and South Cumbria GP training practices L&SC Training GP Practices (HEE NW da Appendix 12: GP Retention scheme paper outlining the process and approval process (August 2017) GP Retention scheme process pdf 30