Health Committee Inquiry into Workforce Planning


British Medical Association Memorandum of Evidence

March 2006 Executive summary
A major criticism of NHS workforce planning has been that it has failed to examine workforce requirements in an integrated fashion looking at service needs, preferring to look at each professional group, particularly doctors, in isolation in relation to assumed demand for its services. Although this memorandum deals for the most part with medical workforce planning, overall service needs should drive the planning process across all health service staff groups.

Medical workforce planning operates on two levels. At the macro level it deals in aggregate supply and demand whilst at a micro level it seeks to allocate numbers amongst competing sectors and specialties, paying particular attention to training requirements.

Successive reviews at the macro level have assessed the likely supply of doctors under certain assumptions and compared it with prospective NHS demand, the stepping off point being the existing position. As a result, no comprehensive needs-based evaluation of that position has been undertaken. This has cemented in a shortfall of doctors hidden by long hours of work and perverse incentives for substitution.

Substantial changes to working arrangements have taken or will shortly take place which will severely impact on the ability of the workforce to meet existing let alone prospective demand, including for example the European Working time Directive and system reform.

The Wanless Review’s workforce model looking at the government’s proposed increases in the NHS workforce concluded that looking 20 years ahead, the planned increase in the supply of nurses was almost sufficient to match demand, but the planned increase in doctors would fall well short of demand, totalling around 25,000 after 20 years. The Review concluded however that skill mix change and new reward mechanisms could ameliorate the position. Other research suggests that depending on skill mix change to meet the gap might be misplaced as labour cost savings could be offset by higher resource utilisation.

Ideally, workforce planning should be concerned not only with numbers of staff but also with recommending mechanisms for meeting demand via the effective deployment and rewarding of NHS staff to maximise their contribution to direct patient care. The role of incentive in encouraging additional labour supply from the existing workforce should not be underestimated.

For the workforce as a whole there has been a dramatic increase in non-clinical workload with management and administrative duties, teaching and training taking up an increasing share of available time.

Summary of recommendations
  • The demand for doctors is affected more radically by short term changes in NHS delivery systems than has hitherto been recognised by planners and governments should avoid making the sorts of change which exacerbate the position without first evaluating the impact.
  • More account needs to be taken of medical advance and technological change in workforce planning than is currently the case.
  • Skill mix change is not a universal panacea and should be carefully evaluated for both its cost and effectiveness before being introduced.
  • Workforce planners should concern themselves with recommending change as much as with predicting it.
  • More attention should be paid to designing incentives for encouraging recruitment, retention and changes in working practices.
  • The need for a strong and effective regulatory environment should be tempered by recognition of its impact on the resources available for patient care.
  • The way in which doctors make career choices is an important issue affecting recruitment into both the profession itself and individual sectors and specialties and should be taken into account in workforce planning.
  • Whilst the service needs of NHS providers are a major variable in the process, overall resource constraints also impact on providers’ capacity to employ or contract with NHS staff.
  • The difficulty with which some doctors obtain posts at varying points in their careers is symptomatic both of the impact of funding pressures and poor medical workforce planning at the micro level.

Introduction
1. The BMA is pleased to contribute to the Health Committee’s inquiry into Workforce needs and planning for the health service, which is examining how effectively workforce planning, including clinical and managerial staff, has been undertaken and how it should be done in the future.

2. A major criticism of NHS workforce planning has been that it has failed to examine workforce requirements, notably those for professional staff, in an integrated fashion looking at service needs, preferring to look at each professional group, particularly doctors, in isolation in relation to assumed demand for its services. Inevitably, this memorandum concentrates on workforce planning as it relates to the medical workforce but it also attempts to place the demand for and supply of doctors in a wider context, in discussing the role of skill mix change. The recommendations are also generally a applicable.

History
3. Medical workforce planning operates on two levels. At the macro level it deals in aggregate supply and demand whilst at a micro level it seeks to allocate (insufficient) numbers amongst competing sectors and specialties largely, though not exclusively, on the basis of staffing norms.

4. The history of overall medical workforce planning in the UK - the macro approach - is a well known one and we do not intend to deal with it in any great detail. Suffice to say it has consisted of a number of major reviews at irregular intervals beginning with the Goodenough Committee in 1944 and culminating in the setting up of a standing body – the Medical Workforce Standing Advisory Committee (MWSAC) – in 1991. The format of such reviews has, with increasing levels of sophistication in modelling, been to assess the likely supply of doctors under certain assumptions and to compare it with (fairly crude) measures of prospective NHS demand. The third report of MWSAC in 1997 for example recommended:
  • An increase of about 1,000 in the annual intake of medical students.
  • The development of clinical courses with graduate entry.
  • Holding constant the number of undergraduate medical students from overseas.
5. In addition it set out its longer term aims in relation to overseas recruitment: We favour self-reliance as a long term goal, that is relying largely upon UK doctors although not aiming for a workforce comprised entirely of UK doctors. (Go to reference 1 here).
6. This distinction between self-reliance and self-sufficiency is an important one and has implications for future medical workforce planning, implying as it does a significant though stable role for international medical graduates (IMG). We should perhaps not overlook the potential contribution of refugee doctors already present in the UK in this respect.

7. Furthermore, the stepping off point for medical workforce planning has always been the existing position and no needs-based evaluation of that position has been undertaken. The starting position has always been a shortfall of doctors relative to demand and a very low stock relative to population by international standards – masked to some extent by long working hours and a remuneration system that did not encourage substitution of labour. Progressive changes to junior hospital doctor contracts and the threat of the European Working Time Directive have been major factors in altering this perverse incentive.
    8. Notwithstanding this, the present approach to workforce planning means that the effect of any changes to the way in which the current workforce works will be felt long before the impact of future recruitment. Getting the numbers of doctors wrong has, furthermore, potentially serious consequences. The ratios of doctors to head of population served, both in hospital and in general practice, seem, for example, to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases. (Go to reference 2 here)

    The present situation
    9. The government having accepted MWSAC’s recommendation on medical school intake, the 2000 NHS Plan (go to reference 3 here) Tpromised a further increase of 1,000 in medical school places to nearly 7,500. It also pledged to deliver by 2004:
    • 7,500 more consultants.
    • 2,000 more GPs.
    • 20,000 extra nurses.
    • 6,500 extra therapists.
    10. In 2002, Delivering the NHS Plan made further commitments to deliver by 2008:
    • 15,000 more GPs and consultants.
    • 30,000 more therapists and scientists.
    • 35,000 more nurses, midwives and health visitors.
    • 10,000 more general and acute beds.
    11. In 2005, 7,106 home students were accepted at UK medical schools together with 179 applicants from the European Union and a further 545 from elsewhere overseas. (Go to reference 4 here)

    12. However, substantial changes to working arrangements have taken or will shortly take place which will severely impact on the ability of the workforce to meet
    existing let alone prospective demand. These include:
    • The European Working time Directive.
    • The full impact of consultant job planning under the 2003 contract.
    • The impact of clinical governance on available clinical time (see below).
    • The increasing feminisation of the workforce and its implications for flexible working.
    • Increasing preferences for part-time working amongst the workforce as a whole.
    • System reform – particularly patient choice and plurality of provision.
    • Transferring activity from a hospital to a community setting.
    We examine two of these issues – governance and system reform in more detail later in this memorandum.

    The Wanless review
    14. The Wanless (go to reference 5 here) workforce model assessed the implications of the increased activity projected in the Review for workforce demand, assuming for the most part current levels of workforce productivity. There were two exceptions:
    • Doctors’ working hours were assumed to fall to 48 hours a week in line with the Working Time Directive.
    • Average length of stay for inpatient admissions to hospital was forecast to fall in line with the estimates set out in the National Beds Inquiry.
    15. Wanless forecast the need for substantial increases in the demand for health care workers over the 20 year time frame covered by the Review. His ‘solid progress’ scenario implied a need for an additional:
    • 62,000 doctors
    • 108,000 nurses
    • 45,000 professionally qualified therapists and scientists.
    • 74,000 health care assistants (HCAs)
    16. The Review’s workforce model compared these estimates with the increased supply expected if the Government achieves the plans for additional training, recruitment and retention set out above. This comparison revealed that the planned increase in the supply of nurses was almost sufficient to match demand, but the planned increase in doctors would fall well short of demand. Indeed this gap would start to emerge before the end of this decade and would be around 25,000 after 20 years.

    17. The Wanless Review had, however, high hopes for the roles of skill mix change and new reward mechanisms in helping to ameliorate the position.

    Skill mix and service redesign
    18. The Wanless Review explored the potential contribution that skill mix changes could make to the potential mismatch between the demand for and supply of doctors. Its Interim Report (go to reference 6 here) highlighted evidence suggesting that Nurse Practitioners could undertake at least 20 per cent of the work of doctors while maintaining the safety and quality of care. If, Wanless concluded, 20 per cent of GP and junior doctors’ work were shifted to Nurse Practitioners, this would eliminate any potential capacity constraint in doctor numbers.

    19. Research evidence shows that Nurse Practitioner consultations are longer, so more nurses would therefore be required to deliver a given level of activity. In a Cochrane review of skill mix in primary care, Laurent and others concluded that whilst patient health outcomes were similar for nurses and doctors, patient satisfaction was higher with nurse-led care. However, there were resource implications in that nurses had longer consultations and higher rates of patient recall than doctors. There were no significant differences in hospital referral rates or patient attendance at accident and emergency units. However, patients managed by nurses were more likely to be admitted to hospital. Savings on nurses’ salaries were generally offset by nurses’ higher resource utilisation and impact on physician workload was variable. (Go to reference 7 here).

    The role of incentive
    20. Although skill mix change could make a major contribution to eliminating any potential skills mismatch over the 20 years, there will clearly also need to be an increase in the number of doctors and nurses over that already planned. Wanless argued that this should be achievable if pay modernisation resulted in improved recruitment and retention. The role of incentive has been insufficiently explored by workforce planners in the past. Higher rewards for doctors have undeniably contributed to the increased popularity of medicine as a career. The rise in applicants in 2004 represented an increase in home applicants per place from 1.71 to 1.97, only just below the 1997 level (2.04), when the current expansion in places began. However spiralling student debt may be the next major disincentive and workforce planners should be aware of this. In this context, the BMA’s 2004 survey of medical student finances (go to reference 8 here) showed average 5th year debt of £19,248, an increase of 16% over its 2003 level. The role of incentive in retention should not be ignored. Research commissioned jointly by the BMA and the NHS Confederation during the new GP contract negotiations (go to reference 9 here) found, for example, that:
    • Over one third of GPs (36%) reported that ‘having insufficient financial incentive to stay in general practice was an important factor influencing their retirement decisions.
    • Almost half of GPs (47%) felt that financial considerations were an important influence on their planned retirement age. The scenario most likely to postpone retirement was a retention bonus lump sum payment of £15,000 for each year retirement was deferred beyond the age of 60.

    The outputs from workforce planning
    21. To date, the major output from overall medical workforce planning has been a recommendation to change (usually increase) the UK medical school intake. This has been because the methodology implicitly assumes increased derived demand for doctors arising from increased NHS activity. As we have seen, there might be scope for deflecting some of this demand to other staff groups although this does not affect the underlying premise that more activity equates with a need for more staff.

    22. Ideally, workforce planning should be at least equally concerned with recommending mechanisms for meeting demand by implementing best practice not only in redesigning services but also in the effective deployment and rewarding of NHS staff to maximise their contribution to direct patient care. It will often, given lead times for adjusting the numbers of professional staff, be more effective to change working patterns at least in the interim. Such changes as do occur do so in isolation from workforce planning. For example, the new GP contract is practice-based and it provides resources to deliver primary care rather than linking payments to doctors. This leaves practices free to make better use of the available workforce – not only satisfying the requirements of a new generation of doctors wishing to work part-time or as salaried doctors but also making better use of other professionally trained staff. The workforce implications of this have yet to be evaluated.

    23. On the hospitals side too, system reform has implications for workforce planning. If there is to be a competitive environment on the provider side, there needs to be spare capacity. It seems curious to talk of spare capacity in the context of an apparent overall shortfall in doctor numbers – to say nothing of the relative position in individual specialties. The mismatch between doctor numbers and demand will be exacerbated by system reform aimed at delivering choice of provider other than under three scenarios:
    • A substantial influx of doctors from outside the UK on a temporary basis.
    • A radically different contractual relationship between provider organisations and professional staff.
    • Providers prepared to offer choice on the basis of substantially different models of care involving different staff mix.
    24. Allied to system reform are the issues of changes to medical training (Modernising Medical Careers) and the service needs of NHS providers. The latter, particularly Foundation Trusts, will increasingly wish to plan their own workforces to meet service requirements and will seek to influence the future shape of training programmes. This has the potential to undermine effective workforce planning, unless taken into account by planners.

    Governance
    25. For the medical workforce as a whole there has been a dramatic increase in non-clinical workload with management and administrative duties, teaching and training taking up an increasing share of available time. By way of example, time spent on management by whole time consultants increased by over 4 hours per week between 1989 and 1998, helping to increase average total hours of work (excluding emergency recalls) from 48.3 to 51.3 hours per week. In consequence the time available for clinical work has declined by around 2 hours (6%) per week. The Wanless review identified two competing trends in workforce growth - information and communication technology (ICT) investment which might significantly reduce the amount of time medical and nursing staff had to spend on administration, freeing up more time for patient care and the amount of time spent on clinical governance which would have the opposite effect. For its financial projections, the review assumed that 10 per cent of professional staff time would be devoted to clinical governance.

    How doctors make career choices
    26. The way in which doctors make career choices is an important issue affecting recruitment into both the profession itself and individual sectors and specialties. The BMA hs studied the career progression of a cohort over 500 doctors who graduated in 1995. (Go to reference 10 here). The results of the study have been hugely informative. The findings from the tenth and final year of the study are summarised in Box 1.

    27. These suggest that a medical career no longer follows a traditional pattern for a significant proportion of doctors. Workforce planning will need to take greater account of this in future. This will be particularly true of planning at the micro level.

    Findings from 10th (2005) report of BMA cohort study
    While three-quarters of cohort doctors are currently satisfied with practising medicine, a fifth report a lukewarm desire to practise medicine and the remainder have little or no desire to practise medicine. A key factor in the morale and motivation of cohort doctors is achieving an acceptable work-life balance.

    The proportion of cohort doctors working in general practice continues to increase, with a third of cohort doctors working as general practitioners (GPs) in the past year. Around a quarter of cohort GPs worked as full-time principals, with the remainder working in part-time principal or non-principal posts.

    One in five cohort GPs worked as a locum. Flexibility is one of the key reasons given for cohort doctors working as locums in both general practice and and hospital medicine.

    The numbers of cohort doctors choosing to specialise in radiology, anaesthetics and pathology or pursue a career in academic medicine have increased over the nine-year period. In contrast, the proportions planning a career in general medicine or surgery have more than halved since graduation in 1995.

    In the past year, 15 per cent of cohort doctors had changed their choice of career and one of the key factors influencing this change is ‘hours of work and working conditions’.

    A third of the cohort plan to practise medicine overseas in the future, either on a temporary or permanent basis. The main reasons centre on increased experience and improved standards of living.

    Many cohort doctors suggest that the real impact of the European Working Time Directive (EWTD) has not made the working lives of junior doctors any easier. Many doctors complain that although the number of hours worked may have been reduced, other important aspects of their job have suffered, including training and patient care.

    Three-quarters of the cohort are either currently working less than fulltime or would like to do so in the future. Since 2001, the proportion of cohort doctors working part-time has more than doubled, from 13 per cent in 2001 to 30 per cent in 2004. Despite the increase in the number of flexible trainees over the past four years, a third report difficulties in working less than fulltime.

    For two in every five cohort doctors, the reality of a career in medicine is very different from that envisaged at graduation in 1995. Many cohort doctors admit that they were unprepared for the reality of life as a doctor.

    The career choices of cohort doctors vary somewhat according to gender. Females are more likely to choose a career in general practice, while males are more likely to choose a career in hospital medicine or research/academic medicine. Female cohort doctors are more likely to be undecided about their futurecareer options.

    Conclusions and recommendations
    • Medical workforce planning needs to be an ongoing process and whilst this is theoretically the position, changes in demand are affected more radically by short term changes in NHS delivery systems than has hitherto been recognised by planners. One solution is clearly to avoid making the sorts of change which exacerbate the position without first evaluating the impact.
    • This is not however, an option where such changes are prompted by technological or medical advance and more account needs to be taken of these forces in workforce planning than is currently the case.
    • Skill mix change offers a potential solution to some of the problems likely to be faced by workforce planners in the future. It is not, however, a universal
    • panacea and should be carefully evaluated for both its cost and effectiveness before being introduced.
    • Workforce planners should concern themselves with recommending change as much as with predicting it and this is especially true of designing incentives for encouraging recruitment, retention and changes in working practices.
    • The need for a strong and effective regulatory environment should be tempered by recognition of its impact on the resources available for patient care.
    • The way in which doctors make career choices is an important issue affecting recruitment into both the profession itself and individual sectors and specialties and should be taken into account in workforce planning. It is particualrly important in the context of training requirements, where any mismatch has costly unemployment consequences.
    • Sitting across the whole planning process is the issue of resource constraints. We have identified the service needs of NHS providers as a major variable in the process but overall resource constraints also impact on providers’ capacity to employ or contract with NHS staff.
    • The difficulty with which some doectors obtain posts at varying points in their careers is symptomatic both of the impact of funding pressures and poor workforce planning at the micro level. Recent problems in the medical workforce at SHO level testify to this.
    References:
    1. Planning the Medical Workforce, Medical Workforce Standing Advisory Committee: Third Report, December 1997, p3.
    2. Brian Jarman, Simon Gault, Bernadette Alves, Amy Hider, Susan Dolan, Adrian Cook, Brian Hurwitz, and Lisa I Iezzoni. Explaining differences in English hospital death rates using routinely collected data. BMJ, Jun 1999; 318: 1515 – 1520.
    3. The NHS Plan: A plan for investment, a plan for reform Cm 4818-I (London: Department of Health, July 2000).
    4. Universities and Colleges Admissions Service (UCAS) Statistics 2005. http://www.ucas.ac.uk.
    5. Securing Our Future Health: Taking A Long-Term View: Final reprort. Derek Wanless. London, H M Treasury. April 2002.
    6. Securing Our Future Health: Taking A Long-Term View: Interim report. Derek Wanless. London, H M Treasury. November 2001.
    7. Laurant M; Reeves D; Braspenning J; Grol R; Sibbald B; Substitution of doctors by nurses in primary care (Cochrane Review) 2004.
    8. Survey of medical students' finances in 2004 - 2005: Report. BMA Health Policy and Economic Research Unit. London. British Medical Association. December 2005.
    9. Mercer Human Resource Consulting. New GMS Contract: GP Retirement Intentions: research conducted on behalf of the NHS Confederation and the BMA. December 2002.
    10. BMA cohort study of 1995 medical graduates. Tenth report June 2005.
    For further information, please contact our Parliamentary Unit:
    Address: BMA House, Tavistock Square, London WC1H 9JP
    Email: parliamentaryunit@bma.org.uk
    Fax: 020 7383 6830

    © British Medical Association 2008

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