Intended for healthcare professionals

Careers

Too many doctors

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1548 (Published 15 March 2012) Cite this as: BMJ 2012;344:e1548
  1. Ingrid Torjesen, freelance journalist, London
  1. Ingrid_torjesen{at}hotmail.com

Abstract

The Centre for Workforce Intelligence is predicting a 60% rise in the number of consultants by 2020. In an attempt to raise awareness and debate about the associated problems, the centre has published seven possible scenarios. Ingrid Torjesen investigates

Moving towards a service delivered by trained doctors rather than trainees is the way to deal with a boom in the number of trainees coming through the system, not blocking the career progression of certain groups, argue doctors’ leaders.

If the NHS continues to train hospital doctors at current levels there will be 60% more consultants by 2020, the Centre for Workforce Intelligence warns. If all these doctors are awarded consultant posts, consultants’ salaries alone will cost the NHS £6bn a year by 2020—£2.2bn more than in 2010. And this week the Department of Health warned the parliamentary select committee on health about the continuing increase in the number of consultants.1

The centre’s report Shape of the Medical Workforce: Starting the Debate on the Future Consultant Workforce, published at the beginning of February, models seven potential scenarios and their effect on the consultant workforce to illustrate the opportunities and challenges faced by existing doctors, doctors in training, employers, and workforce planners (box).2

The seven modelled scenarios

  • No change to current patterns of recruitment and deployment of trainees and doctors

  • A shift towards general practice to achieve a 50:50 ratio with hospital specialty training posts

  • Lowering the retirement age to 60 years

  • Setting the size of the consultant workforce by using the demand criteria of the medical royal colleges

  • Introducing a consolidation period whereby 50% of trainees work for an additional “consolidation” year after specialty training year 4 before completing their certificate of completion of training (CCT)

  • Moving employers to a “consultant present service” where a consultant is in the vicinity at all times (or is able to return to the hospital within a short timescale)

  • Introducing a multilevel career structure that recognises different levels of expertise, competence, and intensity of work

As the report’s subtitle indicates, the aim is to stimulate debate, but doctors’ leaders are worried that financial concerns may dominate future workforce decisions rather than what is best for the care of patients and also that trained doctors risk having their ambitions for career development and progression stymied.

By 2020 there could be 2800 more doctors with a CCT than the NHS will need, projections indicate. The report says: “Early discussion is needed to confirm whether the current supply is what is required for the future, and if not, to support the system to take any necessary action now in order to:

  • Find solutions for current trainees;

  • Maximise benefits from investment in training;

  • Consider other service delivery models that could maintain or improve quality and be more productive, such as a trained doctor-delivered service.”

The report goes on: “It is vital that an urgent debate now takes place, to reach agreement on what the system should do next. This should include discussion on the interplay between the current trainee workforce and future service requirements, in the context of what is needed to secure high-quality and highly productive care for patients.”

It adds: “We recognise that discussion of a potential oversupply may raise concerns for hospital-based specialty trainees, many with expectations of employment as a consultant as part of their career progression. It is essential that trainees have access to better information to enable them [to] make individual career choices. This will help secure future supply and a good return on investment, as well as help to maintain morale and motivation for current trainees, who need to understand what their future is likely to hold.”

Mark Porter, chairman of the BMA’s Central Consultants and Specialists Committee, emphasises that the scenarios modelled by the report are illustrations rather than recommended solutions.

The modelling suggests that it is unaffordable to continue to run the pyramid system where the numbers of consultants and also correspondingly the numbers of trainees are expanded, he says. “That is a reasonable thing to point out, but I’m really not sure that I agree that the conclusion to be drawn from that is that we have a kind of tiered consultant grade with gateway access beyond which some people will not progress.

“It is really important not to let a justifiable concern about the figures let us get carried away into recasting the consultant grade, which itself might need to look at its working practices but does not necessarily need to renegotiate its contract or recast its entire shape.”

Tom Dolphin, chairman of the BMA’s Junior Doctors Committee, admits: “The workforce projections are quite worrying in terms of knowing where people are going to go once they have finished their training. We have to make sure that the people coming out of their training are used to their full potential and capacity rather than being put into jobs that don’t allow them to achieve their full potential.”

Some of the proposals modelled, such as that trainees take an extra year before completing the CCT to consolidate experience, “aren’t particularly welcome and don’t really address the problem: they just store it up for a few further years down the line,” Dr Dolphin says. “We have to ensure that we continue to aim for a training structure service where care is primarily delivered in hospital by consultants present in the hospital.”

Andrew Goddard, director of the medical workforce unit at the Royal College of Physicians, warns that if the service is restructured to introduce new lower grades for trained doctors in addition to consultant posts, “less scrupulous trusts would happily employ lots of sub-consultant doctors to provide their service because it was cheap, but it wouldn’t necessarily be the best thing for patients.”

However, he agrees that there needs to be a debate about what to do with all the doctors gaining their CCTs, because there are not enough jobs for them. This might mean introducing new banding grades in addition to full consultant posts, but he emphasises that it is crucial that these grades are not dead end posts. “We have to ensure career progression from whatever new grades might be created in the future,” he says.

The NHS has more consultants than ever before, but appointments have slowed down considerably as a result of the Nicholson challenge to make £20bn in efficiency savings. However, to counter this, pressure is growing to reorganise hospital care so that consultants provide more of the direct care and care round the clock, for the benefit of patients but also of doctors in training.

In January the Academy of Medical Royal Colleges published a comprehensive review of the benefits to patients of consultant delivered medical care, arguing that consultants should deliver more direct care, including at weekends.3 This followed Medical Education England’s report by John Temple in 2010, which argued that to ensure enough time for good quality education and training the NHS needs to move to a consultant delivered service where consultants are more directly responsible for the delivery of round the clock care.4

The Dr Foster Hospital Guide 2011 concludes that hospitals have lower death rates during weekends and evenings if senior doctors are delivering the service,5 and in September 2011 a report from NHS London calculated that there are 500 excess deaths in the capital’s hospitals every year at weekends because fewer consultants are available than on weekdays.6 A study coauthored by the NHS’s medical director, Bruce Keogh, last month found higher death rates for weekend admissions and called for hospitals to introduce seven day rotas to ensure the availability of trained staff at weekends.7

The Centre for Workforce Intelligence says that rather than seeing an oversupply of trained specialists as a threat, it could be seen as an opportunity to provide consultant or trained doctor services and improve quality of care and outcomes. One of the other scenarios modelled by the centre’s report is to increase the proportion of doctors trained for general practice, something it recommended in its previous report Shape of the Medical Workforce: Informing Medical Specialty Training Numbers and something that the medical profession agrees is needed.8

However, Dr Goddard points out that the NHS has tried to shift the balance towards GPs and away from hospital medicine over the past 10 years and has struggled. The reason for this is one of the two issues that the Centre for Workforce Intelligence ignores in its latest report but that will have a profound impact on the medical workforce in the future.

The number of whole time equivalent GPs has not risen by as much as had been hoped, because many GPs qualifying now are women who often opt to work part time, Dr Goddard explains. In addition, roughly half the registrars training in hospital medicine are women, and the number of consultants who are working less than whole time is increasing rapidly.

“Even though you think we are producing all these extra doctors, what you might find is that because many of them are women and they would prefer to work part time or less than whole time, that actually needs to be really seriously thought about because it is having a major impact on how [the] GP workforce model has not delivered what was intended,” he says.

Dr Goddard says that the other issue the report ignores is the proposed changes to the structure of education and training, which will come into force when the Health and Social Care Bill is passed. It will see local education and training boards plan the numbers and types of doctor trained for their area. He emphasises that it is important for Health Education England to maintain control over the total training numbers for different specialties to ensure that there isn’t a disparity in training between different parts of the country. “Otherwise you will then start to get disparity in patient care, and that is particularly true for the small specialties, which they are likely to forget about.”

Another of the report’s modelling scenarios shows that the number of additional consultants would be reduced if doctors were encouraged to retire at 60—the standard retirement age for the NHS pension—rather than the current average retirement age of 62.

Dr Porter says that this contradicts government plans to have people working longer. “I know it’s not compulsory working until you’re 66 or 67, but the government deftly wants to put economic pressure on people to stay active in the workforce until much later.

“Taking the retirement age up from 62 to 66 would make the problems that the Centre for Workforce Intelligence have identified massively worse. Nobody expects the retirement age that people choose to suddenly jump from 62 to 66, but there will be an effect as people find themselves staying active economically longer, as the pension scheme does not support earlier retirement.”

Footnotes

  • Competing interests: None declared.

References