Problems in the surgical workforce
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7206.2 (Published 07 August 1999) Cite this as: BMJ 1999;319:S2-7206
The expansion in consultant numbers required for the Calman report has been inadequate. John Carruth reports on the detailed consequences for his own specialty of otolaryngology
The government has deceived us. We accepted the Calman report on the understanding that consultant numbers would increase, but the government has failed to provide an appropriate expansion. As a result, the surgical workforce is in chaos. The Calman report repeatedly stressed the need for consultant expansion, calling for “increases in the number of consultants” throughout the document.1 However, these comments were all in the text - the increase was not quantified, and there was no reference to it in the formal proposals.
Since The Plan for Action: Achieving a Balance was published in 1988, attempts have been made to equate the number of registrars emerging from specialist training to the number of consultant retirements each year. However, these attempts have gone disastrously wrong in obstetrics and gynaecology, and, unless there is a rapid increase in the number of consultants, in my own specialty of ear, nose, and throat (ENT) there will be 10-20 “superfluous specialists” holding the certificate of completion of specialist training (CCST) in each of the next 10 years. The failure to increase the number of consultants and, therefore, of registrars means that many well motivated and well qualified senior house officers will be unable to obtain a higher training post.
SHO grade expanded
The new deal, which reduced junior doctors' working hours, provoked task forces to introduce large numbers of additional senior house officers. Galasko and Smith state that the Royal College of Surgeons of England recognises 4674 senior house officer posts for basic surgical training and that 3700 senior house officers have registered a preference to pursue a career in surgery.2 In the year 1999-2000, 1000 senior house officers will complete a fifth senior house officer post and become eligible to undertake higher surgical training. As only 338 registrar posts will be available, 662 eligible senior house officers will be unable to find a registrar post.
There is a moratorium on any increase in the number of senior house officer posts. Each year 2600 doctors register, half of whom express an interest in pursuing a career in surgery. Thus the number of senior house officers increases each year by 1300, with just over 300 registrar posts available. If none of these committed and dedicated surgeons transfers to another specialty, there will be 1900 senior house officers eligible to undertake higher surgical training in 2000-1 and a similar number of registrar posts available. If this is repeated in 2001-2 there will be almost 3000 eligible senior house officers and just over 300 registrar posts.
Thus many well trained senior house officers cannot and will not be able to find a suitable job within their preferred career structure. In fact, the position is worse than that described as the royal college admits that the figures can be validated only from the start of 1997. In addition, some of the increases in registrar numbers proposed to the Specialty Workforce Advisory Group have been substantially reduced, particularly in ENT.
Effects on ENT Senior house officers and registrars in ENT comprise 10% of those in all surgical specialties. There are 408 senior house officer posts, and about 30 specialist registrar posts become available each year. The Royal College of Surgeons' annual survey of all senior house officers registered with the college (60% of senior house officers) shows that about 340 have expressed a desire to pursue a career in ENT. Almost 60 of these have already acquired a fellowship in either general surgery or general surgery with otolaryngology. In cumulative totals, 19 have been registered since 1995, 101 since 1996, and 176 since 1997.
Many senior house officers have, therefore, spent a long time in the specialty already and have gained a higher qualification. It is unrealistic to think that these committed ENT surgeons would be in a position to change career.
Current prospects
In 1993, when the Calman report was produced, there were 430 ENT consultant surgeons in England and Wales. In 1999 there are 460 (an annual increase of 1.15%), equivalent to one ENT consultant surgeon for every 115,000 of the population. Planning the Medical Work Force suggests an annual expansion after 1998 of 1%.3 In 1993 the Minimum Requirements for Otolaryngology Departments in NHS Hospitals suggested that there should be one ENT consultant surgeon for every 80,000 of the population. Since then there have been dramatic changes.
Continuing increase in activities demanded from consultants, including provision of a clinical services director, a programme director for registrars, and an educational supervisor for senior house officers
Requirements for audit, regular formal teaching, and supervision of junior doctors
Provision of continuing medical education and, soon, involvement in clinical governance with reaccreditation
Reduced contribution from junior doctors to clinical practice
It is reasonable to suggest that, with the additional work required, there should be one ENT consultant surgeon for every 60,000 of the population; a doubling of the present number.
Future consequences
The profession knows that numbers must increase, but senior members of the NHS Executive have been quoted as saying, “You have managed five years post-Calman without an increase in consultant numbers and, therefore, no increase is needed.” In addition, the health secretary Frank Dobson has stated that the government has no responsibility for expanding consultant numbers but has devolved this responsibility to hospital trusts without any increased funding.
Trusts have continued to protest that financial problems and the uncertainty of future contracted demand have prevented them from appointing more consultants. Instead they have been obliged to appoint large numbers of non-consultant, career grade surgeons to cope with the clinical load and the demands of the patient's charter. Department of Health statistics in 1997 showed that in the previous 10 years there had been an increase of 13% in consultant numbers compared with an increase of 591% in non-consultant, career grade surgeons.
The Joint Committee on Higher Surgical Training (JCHST) has recently introduced instructions to limit the number of middle grade posts to no more than one for each consultant in a department. These posts include specialist registrars, associate specialists, staff grade posts, and all the other non-consultant career grade staff in less clearly defined posts. This will allow the appointment of nearly 280 non-consultant career grade surgeons in ENT in posts that are almost invariably taken up by surgeons who do not have the CCST and are not on the specialist register.
In England and Wales 189 ENT consultants are 50-65 years old. If all these consultants retire at age 65 there will be 118 posts available within the next 10 years (12 a year), and if they retire at 60 there will be 189 posts available in the next 10 years (19 a year). In ENT there are 183 specialist registrars in post. This means that about 30 will emerge with the CCST each year from the six year training programme, well in excess of the 12-19 consultant posts available each year.
What next?
This problem has already occurred in obstetrics and gynaecology, but a study of a cohort of unemployed specialists has thrown little light on how it should be managed. Perhaps they will be taken up by trusts on short term contracts as associate specialists, staff grades, or in less clearly defined jobs. There must be an immediate increase in consultant numbers in all surgical specialties, particularly in ENT, to provide posts for those registrars who will achieve the CCST within the next few years and so that registrar numbers can be increased to accommodate those well qualified senior house officers who have spent several years in surgery and who, at present situation, will not be able to obtain a higher training post.
Committee wavers
The Specialist Advisory Committee (SAC) in Otolaryngology formulated a plan in 1998 to increase the number of registrars and, thereby, to provoke an increase in the number of consultants. The plan was never implemented. Although the Specialty Workforce Advisory Group originally accepted this increase in registrar numbers, it subsequently reversed this decision on the grounds that the specialty of otolaryngology would not be able increase the number of its consultants sufficiently to accommodate the additional registrars.
In addition, hospital trusts have not approved consultant posts for financial reasons, and consultants in post have resisted the appointment of further consultant colleagues for fear of a reduction in private practice. There is the further complication that up to 65 surgeons, who were offered the possibility of mediated entry, may be added to the specialist register in otolaryngology. Of the 100 who applied, 14 have already been accepted, 11 have been asked to pass the intercollegiate examination, and 40 have been asked to pass the intercollegiate examination and to undertake a period of further training of 4-12 months.
More consultants needed
Consultants are being asked to do more work, both clinical and administrative
Many specialist registrars will achieve the CCST but will find no consultant posts available
Even more dedicated, well qualified, and experienced senior house officers will be unable to obtain a higher training post or any surgical posts within the training grades
All right thinking surgeons welcome clinical governance, but it cannot be achieved adequately with the current surgical work force
The surgical colleges, the senate, and the academy must convince government that the number of consultants must be increased. This was promised in the Calman report, would enable the aims of clinical governance to be achieved, and would provide a satisfactory career structure for aspiring surgeons. Jarman et al have shown that England has the worst ratio of doctors to head of population in the Organisation for Economic Cooperation and Development countries after Turkey and Korea.4 They also found that ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the better these ratios, the lower the death rates in both cases.
The time has come for the population to demand an adequate health service and for the profession to insist on the promised increased in the number of consultants.