Memorandum submitted by Mrs Ann Lloyd, Director, Health and Social Services Department, Welsh Assembly Government and NHS Wales (GLOB 24)

1. Wales and its health economy is impacted by globalisation.

2. Globalisation offers challenges and opportunities for both NHS staff and patients.

3. NHS employers in Wales demand the skills levels necessary to be able to treat and care for the population of Wales. For those individuals with higher skills, opportunities overseas are now more readily available and individuals from overseas have increased opportunities in Wales.

4. UK health departments have recruited from both overseas and the EU. In Wales we have successfully recruited doctors and dentists from the EU and overseas. Together with EU and overseas nurses and allied health professions the NHS in Wales has benefited in the past from migration of workforce. Further Wales will support UK efforts to manage migration and assist migrants from developing countries to contribute to health in their home country as recommended in 'Global Health Partnerships' Lord Crisp 2007.

Dentistry

5. The new contractual arrangements for NHS dentistry came into force on 1 April 2006. Information provided by Local Health Boards and the NHS Business Services Authority indicate that well over 97 per cent of those dentists providing NHS care signed up for the new contract and are continuing to provide NHS dental services. Contracts signed by these dentists account for a little over 95 per cent of NHS dental services being provided prior to 1 April. In addition to those dentists who did not sign the new contract a small number chose to reduce the amount of NHS dentistry they provided.

6. Funding of the new contract has seen an additional £30 million invested in NHS dentistry from 2006-07 onward and this represents an increase of the net spend in dentistry of over 89% since the Assembly was established and some 35% over the forecast expenditure for 2005-06.

7. It is recognised that where dentists haven't signed up to the new contract or have reduced their NHS commitment this can cause short-term difficulties for those patients affected. However, patients do not have to sign up for private dental services if they do not want to and if they need to find an alternative dentist who provides NHS care then they should contact their Local Health Board.

8. One of the main benefits of local commissioning for the NHS under the new arrangements is that it gives LHBs increasing influence about how NHS dental services for their area are developed to meet local needs. Historically, when a dentist has left the NHS or reduced their NHS commitment, the LHB had no power to replace the lost capacity. With local budgets now devolved to LHBs, they retain the funding for NHS dentistry which enables alternative local dental services to be commissioned. LHBs are already using their new powers under the reforms to bring in new services - something they were not able to do under the old system.

9. In May 2005, £5m was made available to take forward the Personal Dental Service (PDS) pilots schemes which allowed dentists to move to the new contract arrangements earlier and gave dentists more freedom in the way they treated patients and enabled the existing level of NHS provision to be secured. In Wales 181 PDS pilot schemes were approved. These secured NHS care for 702,387 patients, and 206,637 new patients to counter the 74,037 who lost NHS provision as a result of those dentists who did not elect to take up the new contract.

10. Currently 19 of the 22 LHBs in Wales have capacity for additional NHS patients. At the moment we have a small proportion of non UK dentists. There are dentists from most parts of the EU at this time and we are receiving an increase of Greek and Polish enquires.

Nursing and Allied Health Professions

11. Nurses and allied health professionals who are granted asylum in the UK are faced with an overwhelming number of agencies and barriers, which they have to negotiate when seeking professional registration. Internationally recruited staff experience similar issues. Currently there are 8 nurses that have qualified abroad and are refugees in Wales, on the Royal College of Nursing (RCN) database that could be helped to achieve registration and in so doing, be part of the Welsh nursing workforce.

12. The Welsh Assembly is funding a pilot project to facilitate and support these 8 refugee nurses, currently registered with the RCN database, who are seeking registration and employment in Wales, through the Nursing and Midwifery Council (NMC) regulatory system. This project would provide a model for helping internationally qualified healthcare professionals, by identifying pathways that could be employed towards their successful registration in Wales. The costs associated with this pilot project are justified alone on the basis of having 8 more nurses available to work in Wales, with the additional benefit of providing a model for other internationally qualified nurses and other healthcare professionals.

13. Refugee nurses participating in this pilot project were recruited from the RCN Refugee Nurses database. They were invited to undergo a programme to facilitate their entry into the NHS workforce in Wales. These refugee nurses were offered appropriate assessment procedures in order to establish their individual professional needs. The University will develop the infrastructure to support this, including the provision of trained staff and the development of documentation. Once an assessment has been made, and individual development programme will be designed and delivered.

14. Skills for Health (SfH) provide a whole health sector voice to identify sector skills needs and influence provision, although do not provide training directly. SfH goals include: driving forward and managing workforce competencies, profiling the UK workforce, identifying sector workforce needs, influencing education and training supply to meet sector needs and improving workforce skills.

15. These outcomes will be achieved by the development of national occupational standards and competency frameworks, which can be applied to all healthcare staff and the functions that they carry out. They will help with job design and the measurement of performance across the service. In addition to developing the competencies Skills for Health are also carrying out implementation projects to both test and illustrate how they can be used in the workplace.

International Medical Graduates

16. The Home Office changed the Immigration Rules for Postgraduate Doctors and Dentists in April 2006. Subsequently Department of Health published guidance stating that doctors with limited leave to remain should only be considered for training programmes if they had sufficient right to work in the UK to complete the programme. The British Association of Physicians of Indian Origin (BAPIO) lodged a Judicial Review to challenge both of these actions.

17. The table below sets out the grounds of the Judicial Review, and the outcome.

Welsh Perspective

18. Up to 40% of the training grade places in Wales may be filled with International Medical Graduates (IMG) at present. This figure is higher than some other parts of the UK (especially Scotland and Northern Ireland).

19. The review may have an impact on Wales, as it is possible that some UK/EEA applicants could be displaced by IMGs. However this has always been the case.

20. Previously the filling of vacant posts through the old appointment system of individual advertisements at various times throughout the year has resulted in a mix of UK/EEA nationals and IMGs being appointed.

21. The principle has always been to appoint the best candidate and the displacement of UK/EEA nationals by IMGs has been masked by the old system as the numbers have been small at each appointment.

22. MTAS amplifies the possible numbers displaced, as all of the appointments are being made at the same time, and therefore the figures may look adverse (but in fact are likely to be no different if one aggregated the data from the old system)

23. We have had a large number of IMG applicants in the current MTAS round and if they are excluded it is entirely possible that there will be a significant proportion of posts unfilled.

24. IMGs may have had a preference for Wales in MTAS based upon the historic % of posts which have been successfully filled by IMGs.

25. The quality of the current MTAS applications by IMGs is variable, and it is likely that a number will not make the cut for interview, and those called for interview may not be above the line.

26. If we fail to fill our posts in Round 1, it is possible that we may not fill them in Round 2. In some specialties in Wales, applications by UK/EEA nationals have been very small, and if IMGs are excluded there may not be a competitive field to fill these posts.

27. Career management and matching individual's aspiration with the needs of the service are the key issues which we are being to address in Wales. The short timetable for the introduction of MTAS has limited implementation of career management, although trainees have had access to detailed material prepared by each of the Royal Colleges about individual specialties.

28. The Unit of Application and specialty choices within MTAS has allowed those individuals who have a geographic requirement to stay in Wales to chose up to 4 different specialties all within the UoA (Wales Deanery).

29. Clearly there will be individuals who will be disappointed as a consequence of the outcome of MTAS this year. Those individuals will be UK/EEA nationals and IMGs, who have been unsuccessful in a competitive recruitment round

 Conclusion

30. Overall globalisation is having a positive effect on the health of people in Wales, but it is undoubtedly challenging. It will highlight and reward the individuals who are best placed to rise to the challenges, with consequences for those who do not, or cannot, adapt.

 28 February 2007