Staffing by numbers in the NHSBMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7362.453 (Published 31 August 2002) Cite this as: BMJ 2002;325:453
We need to think in terms of teams and what they achieve
- Fiona Moss, associate postgraduate dean ()
Worldwide, the variation in the number of doctors and nurses employed per capita is huge, but little guidance or evidence exists about the optimum number for any given system of care. Fewer doctors and nurses per capita work in the United Kingdom than in other developed countries. There is a consensus that not enough healthcare professionals work in the NHS and that some problems of the NHS—for example, waiting lists, waiting times to see specialists, and access to radiotherapy—would be ameliorated with more trained staff.
Over the past decade the number of doctors working in the NHS increased by 44%, and further expansion is planned. So, the Audit Commission's latest report, Medical Staffing, based on data collected in 2001 from 88% of acute trusts in England and Wales, is timely.1 The Audit Commission has prepared individual tailored performance reports for each trust Some interesting signposts emerge from the national findings. Restricting junior doctors' working hours to 56 hours a week (the “New Deal”) is a priority for hospitals in the United Kingdom. Financial penalties have forced change. Most training posts in emergency medicine, radiology, and pathology are now compliant with the New Deal, but for other specialties the average posts per trust that are compliant ranged from 39% to 45%. The favoured solution to managing with fewer “doctor hours” is to appoint more doctors, mainly in non-consultant career grade posts. Doctors in these posts often fulfil roles equivalent to those of specialist registrars. This fastest growing group—up fourfold in the past decade—has been dubbed the new “lost tribe,”2 and the Audit Commission's report indicates that few have adequate opportunities for study. Doctors available to fill such posts will become difficult to find, the report says. Other options—for example, introducing physician assistants or other support workers, 3 4 —must therefore be explored if current restrictions on hours, let alone the more stringent European working time directives, are to be met.
Staffing difficulties are not just about numbers. It is crucial that scarce human resources are used wisely. The 2000 review of workforce planning in the NHS, A service of all the talents, correctly placed emphasis on better integration of professional groups and described workforce planning as poorly integrated with the needsof, and unresponsive to changes and developments in, the service.5 Although there have been enormous changes in delivery of care, little energy has been expended on exploring which team structures are most appropriate for today's patients and, importantly, for today's staff. We continue, largely, to work in old ways—and it is stressful. For example the shift in balance from inpatient to ambulatory care with shortened inpatient stays, and fewer beds and wards, has gnawed away at the security of a medical “firm” and its patients—being based on one or two wards. “I can never find a nurse who knows my patients” is a regular refrain. The difficulties of working in ways suited to a previous era are felt daily by doctors and nurses throughout the NHS.
Hospitals employ different numbers of doctors. To provide a “reasonable measure of whether trusts are generously or tightly staffed,” the Audit Commission report enumerates the number of doctors employed per trust as “whole time equivalents per 1000 admissions.” The number varies widely (2.6-14.1 doctors per 1000 admissions, with a median of 4.7), and even for similar hospitals it varies by a factor of two. And here lie the problems at the heart of many statistics about staffing in the NHS. Doctors are only one part of the clinical workforce, and the significance of staff numbers in terms of output or outcome is not easy to determine. For the test of adequacy of staffing is not just about how many doctors or nurses there are but how they work and what they achieve. For example, take two acute trusts. Trust A employs one doctor per 200 admissions for patients with chronic obstructive pulmonary disease and Trust B employs two doctors per 200. What does this tell us? Should we assume that Trust A is the more efficient and that its doctors are more hard working than those in Trust B? Should Trust A, perhaps more tightly staffed, perhaps with a different population, consider appointing another doctor? Maybe not. Even this level of specification, more detailed than that available for the Audit Commission's analysis, lacks the information about approaches to care or composition of clinical teams necessary for making useful conclusions. For it is just possible that some of the difference in admissions per doctor is because Trust B but not Trust A has a fully functioning multiprofessional respiratory team that—with active links with local primary care teams and, through early intervention, an acute respiratory assessment service6 with an option for “hospital at home” care—has reduced the need for admission for some patients with chronic obstructive pulmonary disease.
Better team working, communication skills, and organisational skills have been identified as important ingredients of a more holistic, patient centred approach to the delivery of clinical care, but despite some change professional boundaries remain solid.7 Setting up local workforce confederations to bring together and manage professional educational levies may force or even inspire a more integrated approach to education and development. But meanwhile, better use of the skills available in the NHS will happen only if all workforce planning becomes an interprofessional exercise and staffing is seen in terms of teams that deliver care. If money was available for respiratory services in Trust A, how should it be used? For another doctor? Or perhaps a respiratory physiotherapist or specialist nurse? The Audit Commission asks hospitals to improve their information systems. Their next review of medical staffing is in four years' time. Maybe by then it will be possible to provide data that reflect the functioning of clinical teams.