Specialty manpower targets in troubleBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7083.2 (Published 15 March 1997) Cite this as: BMJ 1997;314:S2-7083
- Rajesh Jain, deputy personnel director,
- Stephen Atherton, medical director
Is there a doctor in the house? Trust managers Rajesh Jain and Stephen Atherton report on the shortage of consultant manpower facing the NHS
In the past medical workforce planning was based on a command and control system which relied on central workforce planning and a wide range of numerical controls. It is a system that has continually failed to predict the needs of the health service. As long ago as 1992 trust medical directors were reporting that they were receiving very few or no applications for consultant posts, a remarkable change compared with applications in double figures received in previous years. This led the Association of Trust Medical Directors (ATMD) to commission its study of medical workforce planning on which this article is based.(1)
Medical manpower planning
Ensuring an adequate supply of trained doctors has been the responsibility of the secretary of state for health since the NHS's inception in 1948. A royal commission report in 1968 led to an increase in student places from 2500 to 4080 a year; three new medical schools were founded and established schools increased their intake of undergraduates.(2)
Further reviews through the ‘70s and ‘80s culminated in Achieving a Balance which recommended that the number of doctors in training should broadly be in line with future consultant vacancies.(3) Initially there was some concern about an oversupply of doctors, but by 1989 the Advisory Committee for Medical Manpower Planning was predicting that there would be a shortfall of doctors needed to fill career posts by the year 2005.
In 1991 the secretary of state established a new Medical Manpower Standing Advisory Committee with the aim of providing advice on expected demand and supply of doctors over the longer term. In 1993 the committee confirmed an expected shortfall in trained doctors within 10 years and recommended that the number of medical undergraduates produced each year should be increased by 240 to 4470. The committee was however unable to predict the effects of the review of postgraduate training - the Calman report (4) - and of the impact of the new deal on junior doctors' hours of work.(5)
Its successor, renamed as the Medical Workforce Standing Advisory Committee, sought to evaluate the effects of postgraduate training, the new deal, new technology, developments in health care, and changes in skill mix on the likely demand for doctors and again recommended an increase in undergraduate student numbers. Its report in 1995 suggested that the number of medical undergraduate places should be increased to 4970 by the year 2000. The recommendation also took into account the danger, in terms of availability, of placing too much reliance on recruiting doctors from outside Britain.
In 1993, before the new deal was fully implemented, and while the postgraduate review of education was still a matter for debate in the profession, the Joint Planning Advisory Committee (JPAC), the body (now replaced by the Advisory Group of Medical Education Training and Staffing (AGMETS) which advised the government on demand for specialists predicted that there would be 1300 consultant opportunities in 1994.
In fact from November 1993 to October 1994, no fewer than 2800 consultant posts were advertised in the medical press. Of these, 229 attracted no applications at all, 901 attracted three or fewer applications, and 471 remained unfilled. It has become apparent that in many specialties, such as anaesthesia, paediatrics, obstetrics and gynaecology, and psychiatry there are often no applications for advertised posts.
Our questionnaire survey of 510 trusts in Britain achieved a 31% response rate. It showed that many consultant appointments were not made in the period September 1994 to September 1995 because of the lack of suitably trained applicants, and suggests dramatic shortfalls in specialties such as psychiatry and anaesthesia.
Trust medical directors are concerned that the true extent of the shortage of suitably trained doctors for consultant positions has yet to be fully revealed as the new deal and the Calman review of postgraduate education have yet to be fully implemented in trusts.
There have been 479 appointments of training grade doctors to assist trusts in complying with the new deal. The majority are within the senior house officer grade (77%) and mostly within the specialties of general medicine, surgery, obstetrics and gynaecology, anaesthesia, orthopaedics, and accident and emergency. This large expansion in the senior house officer grade is not uniform across the country and has occurred to help trusts deliver a clinical service which has not been planned in conjunction with the development of specialist training. This suggests increasing reliance on the senior house officer as the workhorse of the NHS.
The new deal has been around for five years - its aim to provide adequate medical cover, 24 hours a day, seven days a week while at the same time reducing the maximum number of hours junior doctors work to 56 a week. Our survey showed that the majority of trusts (55%) are still not achieving the 56 hour working week, that only 11% of juniors are working partial shifts, and 7.5% of juniors, mostly in accident and emergency, are working full shifts.
Failure of partial shifts
The failure of partial shift development may well explain the large number of trusts which do not comply with the 56 hour working week. The reasons reported include reluctance on the part of junior doctors, the less than full support of the postgraduate deans, and opposition by consultant staff. Achieving the targets may be possible only by further expanding consultant numbers and insisting on a change to working patterns to those recommended in the new deal.
The impact of the Calman training review has been harder to establish. Respondents to the survey expected additional consultant appointments would have to be made in order to meet the Calman training requirements, but were uncertain as to how many. The NHS Executive has developed a new approach to workforce planning in collaboration with the medical profession (including the royal colleges) and NHS managers from trusts and purchasing authorities.
Described in the forthcoming publication Quality Framework the new approach will actively involve NHS trusts, purchasers, the medical profession, and the NHS Executive at regional and national level, and is made up of the following main elements:
Trusts will produce an annual medical staffing plan as part of their normal business and strategic planning arrangements. The plans should be supported by their main purchasers, and conform to guidelines set out in the quality framework
The plans will be considered by local medical workforce advisory groups, which will provide advice and support on medical workforce arrangements to trusts, purchasers, and regional offices
Aggregated plans from trusts will form an important, and currently absent, input to central workforce planning.
Appropriate workforce plans
In addition, the approach outlined in the Quality Framework emphasises the importance of appropriate workforce plans in ensuring quality patient care provided by doctors. The new approach is based on quality assurance - an appraisal by departments in trusts of service and training commitments, the tasks required, and the skill and competencies needed. Skill and staff grade mix ratios will not be set in tablets of stone, guidance will be given by local medical workforce advisory groups.
It is hoped that this new approach will give better projections of likely workforce changes, and particularly consultant expansion, enabling future national planning to be based on more relevant data.
Clearly long term planning solutions will not solve the immediate and growing crisis in consultant recruitment. How can trusts fill the hundreds of current consultant vacancies?
On 13 February Gerald Malone, the minister for health announced a \P4.5 million boost to the training grade, aimed at increasing the number of specialist registrars by 250 during 1997. It is suspected that this number has been chosen because it is all the Treasury is prepared to pay for rather than because it is what the NHS believes it needs, which is thought to be at least 1000 extra specialist registrars over the next year.
In the meantime trusts are resorting to other methods of filling posts - including trying to recruit from abroad. Since 1 January this has become more difficult because of the difficulties of “equivalence”: marrying the necessary qualifications and training experiences from outside the European Union with the terms of inclusion on the specialist register. A further hurdle has been the decline in British consultant salaries in comparison with countries such as Germany, Austria, Canada, and the Netherlands.
Footloose consultants are more likely to settle in those countries, as well as of course the United States, where average salaries are three times the level in Britain. It is clear that Britain has and will continue to have a serious shortage of suitably trained doctors for consultant positions. While there has been a recent boost to funding an expansion in the specialist registrar grade, many medical directors are worried that funding arrangements do not match the expansion necessary. This funding must be found if the severe consultant manpower shortage is not to continue well into the next century.