Abstract
The North West Foundation School is home to 1,100 foundation trainees employed at 12 hospital trusts. Despite oversubscription to the Foundation Programme every year since 2011, University Hospitals of Morecambe Bay Foundation Trust (UHMBFT) has struggled to fill foundation training posts relying on locum doctors to sustain service provision. We did a study to explore the reasons for this and identify possible solutions. Final year medical students at Lancaster University and foundation doctors based at UHMBFT and Central Manchester Foundation Trust were invited to complete a structured questionnaire and then attend a focus group to expand on their answers. Location was identified as the single biggest factor affecting where foundation applicants applied to, followed by perceived reputation of the hospital trust and job track. Participants identified free/heavily subsidised accommodation or the offer of additional qualifications in leadership or teaching as the main incentives that would have a positive effect on applications to geographically undesirable trusts. These incentives would need to be well publicised, particularly on foundation school websites, UK Foundation Programme websites and trust websites. Overall these efforts should lead to savings in recruitment costs, a reduction in vacant training posts and thus a decreased reliance on locum doctors, culminating in improved patient care.
Background
In 2005, the UK introduced foundation training for newly qualified doctors – a two-year supervised educational programme spanning a variety of clinical placements and specialties.1 Entry into the foundation programme is via the Foundation Programme Application Service, a nationally run, competitive application process. Applicants apply by ranking all foundation schools in the UK, which are divided geographically, in order of preference.2 Once allocated to a school, applicants then rank, in order of preference, the programme in which they would like to work, of which there are more than 200 in England alone.3 Finally, applicants then rank which track or series of posts in a two-year rotation they would prefer. The aim is to provide the relevant clinical experience for trainees to gain all competencies in the foundation curriculum.
The foundation programme became oversubscribed in 2011, and has remained so since.1 The lowest-ranking applicants, who do not secure a post in the initial allocation, enter a reserve list and are allotted to vacancies resulting from withdrawals (Fig 1).1 So far, every applicant to the foundation programme has secured a placement. Because of the nature of the ranking and preference process, applicants on the reserve list are unlikely to secure their original preferred track, programme or school.
Number of trainees placed on initial reserve list and subsequently placed in UK foundation posts.
North Western Foundation School
The North West Local Education and Training Board is host to the North Western Foundation School, which has 1,100 foundation trainees employed in 12 hospital trusts and covers a large geographical area – Greater Manchester, Cumbria and Lancashire. University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBFT), situated within this school, is made up of two sites where foundation training can take place: Royal Lancaster Infirmary in Lancaster, Lancashire and Furness General Hospital in Barrow-In-Furness, Cumbria. Both of these locations are far from the area's primary city, Manchester (Central Manchester Foundation Trust (CMFT) provides foundation training there).
Despite the oversubscription of the foundation programme as a whole, UHMBFT's foundation programme has had vacant posts at the commencement of foundation years 1 and 2 despite the trust having the lowest entry score requirements across the school. The aim of our study therefore is to explore the factors that affect medical undergraduates’ decisions about where to do their foundation training and the measures that could be put in place to improve recruitment and retention to low-preference locations, such as UHMBFT.
Methods
We surveyed final year medical students at Lancaster University and current foundation doctors, at both UHMBFT and CMFT, about the factors that affected their choice of where to do foundation training. They were also asked to identify potential incentives that undersubscribed hospital trusts could use to attract applicants. After completion of the questionnaire (Appendix 1), these factors were then explored in further detail in recorded focus groups comprising 8 final year medical students from Lancaster University, 24 FY1 doctors from UHMBFT, 18 FY2 doctors from UHMBFT, 27 FY1 doctors from CMFT and 17 FY2 doctors from CMFT. We analysed data from the survey and focus groups both thematically and by discourse analysis in an anonymised format.
Results
Overall, 94 people responded to our survey. 91% (85/94) of respondents used the internet to research foundation training in general, foundation schools and foundation programmes (85/94). The most frequently named were the Deanary, Foundation School, UK Foundation Programme Office website and local trust websites. 25% (23/94) also spoke to friends and colleagues about training and working in particular areas (Figs 2 and 3).
Resources used to research locations for foundation training.
Websites used to research foundation training. FPAS = Foundation Programme Application Service; GMC = General Medical Council; IMG = international medical graduate; UKFPO = UK Foundation Programme.
Factors affecting choice of foundation school.
Factors affecting choice of trust. DGH = district general hospital; TH = teaching hospital.
Incentives suggested by participants. DGH = district general hospital; TH = teaching hospital..
The most important factor in choosing where to undertake foundation training was location, which was mentioned by all 94 participants. Location was most important in terms of both choosing the overall foundation school to apply for and also in choosing which programme (Figs 4 and 5). The reputation of the foundation school and the perception of the standard of training within the associated hospital trusts were also important. When considering which trust to prioritise in their preference scale, after the physical location of the hospital, the content of the tracks offered was the next most important factor, cited by 53/94 respondents (56%).
The general consensus among most participants, particularly those based in Central Manchester, was that, apart from a substantial increase in pay or a lump sum to compensate for travel costs and time, there was very little that would entice them to actively apply to an area that wasn’t of their choosing. However, if they were allocated a trust in an area that they found undesirable for FY1 then they identified incentives that would increase morale, improve job satisfaction and greatly reduce the likelihood of them applying for a standalone FY2 post in a different trust or foundation school.
They emphasised the need for good accommodation, in which a sense of community with fellow colleagues could be built and such that going home would be a pleasure (Fig 6). By contrast, participants perceived current hospital accommodation to be dated, lacking good wi-fi and limited to one or two people per dwelling, with their close colleagues spread out over different buildings. Good accommodation was especially important for participants whose family homes were far away or who didn’t know the area well.
The next most popular identified incentive was additional qualifications or CV boosters – ie the opportunity to obtain a qualification that their counterparts in other more popular trusts, might not get during their foundation training. Leadership qualifications, teaching qualifications, subsidies towards specialty examinations or more study leave (particularly in FY1) were all very popular options.
Discussion
In 2010, Patel and colleagues did a similar study of medical students from three different medical schools.4 They also reported that geographical location was the most important factor affecting medical students’ choice of training programme.4 Before the introduction of foundation training, McKeown and Boohan researched the choice of hospital for pre-registration house officers (equivalent to FY1), and again location was the most important deciding factor.5
This finding is recognised across the country, the Workforce Review Team has reported a deficit of not only junior doctors but also consultants across the north west of England, Yorkshire, the Midlands, east of England and south-east Coast. Data from the Royal College of Physicians show that London has the most consultant physicians per head of population. Along with other factors, the higher consultant numbers relative to the population helps to lower hospital standardised mortality ratios and to make these hospitals more attractive to applicants. Better recruitment numbers in London have been linked to the fact that 86% of registrars remain in the locality they are trained in; however, as evidenced by difficulties experienced in the North Western Foundation School, the ‘locality’ can be spread over 100 miles, with a natural preference for teaching hospitals identified.6,7
During the focus groups, the importance of location was expanded upon. Participants discussed the value of a good social life, being surrounded by people, and being in an area that they knew well, especially when entering into what they believed to be a stressful job. Others reported being committed to a mortgage, partner or having young children to look after, making relocating and long commutes unfeasible. Some participants talked about not knowing anything about UHMBFT; others were aware of adverse media attention, which led to negative connotations about the quality of care within the trust.
Similarly a large proportion of participants also believed that where foundation training is undertaken affects applications for specialty jobs. Several believed that smaller hospital trusts, district general hospitals and hospitals that are not perceived to be prestigious would not look as good on their CV or application form. However, statistics taken from the 2014 destination survey of exiting FY2 doctors show no significant difference in the numbers of trainees securing their first choice specialty training job between UHMBFT and CMFT.
Yet between 2011 and 2014, 30 applicants withdrew their application after they were allocated to UHMBFT compared with only five withdrawals at CMFT (Fig 7). Of the 30 withdrawals, 16 were a result of failure to pass final examinations or language tests, or to graduate because of time missed in medical school. However, the other 14 either withdrew without reason, chose to relocate to their home country or applied to transfer to a different foundation school, and these applicants are the ones who could be encouraged, at that early stage, to stay within programme. Provision of early information and promotion of the benefits of the trust, the incentives that UHMBFT will offer that no other trust will have, and the local area, could mean that some of those 14 stay in the process, reducing the cost of a second recruitment round and the potential need to appoint locums.
Number of withdrawals from Foundation Programme Application Service, 2011–14. CMFT = Central Manchester Foundation Trust; UHMBFT = University Hospitals of Morecambe Bay NHS Foundation Trust.
The inevitable, but difficult, question that also comes to mind, looking at the high proportion of withdrawals because of failed examinations, is whether the candidates allocated to UHMBFT are not as high achieving as those allocated to CMFT, which emphasises the need to attract not only more candidates to UHMBFT, but also high-quality and motivated trainees to improve patient care and help reduce recruitment costs by decreasing the number of withdrawals after allocation.
Recommendations
Location, the most important factor affecting where foundation doctors choose to train, cannot be changed, but there are four key improvements that a trust could take to reduce withdrawal from the application process once foundation track has been allocated, improve morale and job satisfaction (and thus patient care) and reduce switching trusts between FY1 and FY2. The incentives suggested in this study came from medical students and foundation trainees, the demographic to whom a less geographically desirable trust needs to pitch to.
First, trusts could introduce free or heavily subsidised high-quality group accommodation near hospital sites. The cost of providing this accommodation can be offset by potential savings made from decreased recruitment costs to fill the vacancies caused by withdrawals or migrations and decreased locum spends.
Second, all foundation trainees could be offered the opportunity to undertake additional relevant qualifications, such as clinical leadership or teaching courses. Such qualifications could be delivered on a cohort basis, thereby reducing the costs of each individual pursuing their own qualification. Links to universities and medical schools are usually well established (which is very much the case with UHMBFT and Lancaster Medical School) and could be mutually beneficial, with foundation doctors using their skills to help with the education of undergraduates.
Third, the trust could offer access to research and development opportunities in topics that trainees are most interested in. Participation in research is a more and more central aspect of trainees’ professional development, but opportunities can be limited, particularly for junior trainees such as foundation doctors. Therefore trusts that provide and advertise this opportunity well could be viewed very favourably.
Finally, the trust could improve its presence on the local foundation school website and ensure that its individual trust website advertises the unique incentives offered compared with the rest of the school. The most important thing when offering any incentive is letting potential applicants know that it exists. The popularity of websites and word of mouth need to be exploited to obtain optimum benefits for the trainee, the trust and ultimately patient care.
Several trainees based at Furness General Hospital stated that they felt panicked when allocated to a hospital they knew nothing about. Trainees in this situation need to feel welcome at a trust, and information about the area and the job they’re there to do – to have the fear of the unknown removed by the simple act of information giving. Let them know about the benefits of working in the trust and how their training will differ, for the better, from that of their colleagues in other trusts. This information is best communicated via the use of online media.
Once changes are initiated, we recommend that a similar study should be repeated in 2–4 years, during which time one or two full foundation programme cohorts go through the system, to assess any potential improvement in recruitment and retention numbers to a geographically less desirable trust.
- © Royal College of Physicians 2016. All rights reserved.
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