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Workforce planning : briefing note for the Annual Representative Meeting

June 2002

Workforce planning
This briefing has two aims. One is to inform debate at the ARM by outlining recent government proposals in the area of workforce planning. The other is to draw out areas of possible concern for the BMA. These include increasing the general practice workforce, service needs and maintaining standards in medical education and training; and self-reliance in workforce planning.

NHS Plan
The NHS Plan, published in 2000, sets out two objectives for the NHS workforce:

1. Greatly expand the number of staff

2. Redesign jobs

Specifically, the plan promised 7,500 more consultants, 2,000 more GPs, 1,000 more medical places and 20,000 extra nurses over four years.

The annual NHS workforce census for September 2001 showed that the government had met its target for nurse recruitment. Between 2000 and 2001 the number of consultants had increased by 1,360 (5.9%). The number of GPs had risen by 139 (0.5%). The whole-time equivalent (wte) increase in consultants was 870 (4.2%). The wte increase in GPs was 18 (0.1%). 1 2

Wanless report
The Health Trends Review Team developed a workforce model for the final version of the Wanless report. 3 This compared the demand for doctors with planned supply (assuming current levels of productivity) the implementation of the European Working Time Directive and a decline in average length of stay in line with that set out in the National Beds Inquiry. This model predicts a substantial gap between demand and supply emerging before the end of this decade and reaching 25,000 wte after 20 years. Between 2005 and 2010, the demand for doctors could increase by nearly one third while the supply rises by only 10 per cent.

Clinical academic staff
Medical schools face serious difficulties filling senior vacancies. This is at a time when the NHS Plan has increased the number of medical students. The problem has been exacerbated by the results of the recent Research Assessment Exercise (RAE) which has led to cuts in funding and redundancies as a consequence. The criteria used by the RAE do not value teaching contribution or research that is directed at improving patient care.

So far there has not been a policy response from the government.

A health service of all the talents
In June 1999, in response to the Health Select Committees Inquiry on Future NHS Staffing the government announced a major review of workforce planning in the NHS. In April 2000, having received the report of the review team, the Department of Health published the consultation document 'A health service of all the talents: developing the NHS workforce'. The report emphasised the importance of the following in future workforce planning arrangements:
- Workforce planning based on the needs of patients not of professionals
- Teamworking across professional and organisational boundaries
- Modernising education and training to ensure that staff are equipped with the skills they need
- Developing new flexible careers for all staff
- Expanding the workforce to meet future demands.

New workforce planning arrangements
'A health service of all the talents' proposed new arrangements for workforce planning that were established in April 2001. Workforce Development Confederations were introduced to replace education consortia and Local Medical Workforce Advisory Boards (LMWAGS). Workforce Development Confederations will bring together NHS and non-NHS employers to plan the whole healthcare workforce. They are also expected to work closely with local higher education institutions to develop innovative approaches to education and training.

At national level workforce planning is now the responsibility of the National Workforce Development Board. The board is supported by Care Group Workforce Teams that focus on the workforce requirements of different care groups. The Specialty Workforce Advisory Group (SWAG) has been replaced by the Workforce Numbers Advisory Board which will make recommendations on the numbers of undergraduate and postgraduate training commissions needed in each staff group each year. The new planning arrangements are illustrated in figure 1.

SHO modernisation
Following recommendations from 'A health service of all the talents', the government made a commitment in the NHS Plan that it would modernise the SHO grade. The following proposals were included in an early draft from the working group.

In future the number of SHO posts or ‘foundation programmes’ will be limited, possibly by allocation of national training numbers as occurs now with the SpR grade. The total number will be based on the needs of the service. Recruitment to the foundation programmes will take place during the PRHO year. Instead of the current system of ‘clearing’ where graduates are guaranteed a post, recruitment will be based on a devolved selection process.

The foundation programmes will be time-capped so that doctors cannot remain on the programme when it is completed. Exit from the grade will be limited to:
- A Higher Specialist Training programme or a GP registrar appointment
- Entry to a different foundation programme
- Research
- Entry to a service grade
- Alternative employment
- Leaving the UK

There will be a limited number of time-capped individual programmes. These will be tailored to the individual needs of, for example, returners or those changing career direction.

The service grade will have a clearly defined career path linked to education and training and CPD. There will be opportunities to re-enter training from the service grade.

Shortening SpR training
The Royal College of Paediatrics recently published its own proposals for the future of postgraduate training in the specialty. Anticipating the results of the SHO modernisation report the college also sees junior doctors spending more time in service grades between periods of postgraduate training, proposing that, for example, those selecting new SpRs will be invited to consider giving more weight to experience and good performance in staff posts. Provided a doctor can fulfil the minimum entry requirements, a period of service in a staff grade post might be considered favourably in the competition for a place on an SpR training scheme (though it is recognised that under current rules the time spent in staff grade posts could not be counted towards total training time). 4

Controversially, they also propose shortening SpR training to three years. At this time doctors will be awarded a CCST and will be appointed to a specialist paediatrician post. The individual will have full clinical responsibility but availability of senior support when needed. This would be followed by competitive entry to further training in a paediatric speciality if desired (see figure 2).

The college acknowledges that the disadvantages of this proposal are that the new structure would lead to a sub or junior consultant grade and that transition from the present system would be difficult to handle.

The Postgraduate Medical Education and Training Board (PMETB)
The PMETB will replace the Specialist Training Authority and the Joint Committee on Postgraduate Training for General Practice. Its duty will be to supervise all postgraduate medical education. It will set standards for training and attest to the satisfactory completion of training by individual doctors.

The consultation document on the PMETB proposes a board of 25 members (including chair) with an equal split (12/12) between medical representation and lay/NHS interests. The chair of the Board could be a lay person. In addition there will be observers form UK health departments. The Board will be accountable to the Secretary of State for Health.

The PMETB is expected to be self-financing. Individual doctors will be asked to bear the cost of the Board by paying a certification fee and possibly by the levy of registration fees.

Importing teams of surgeons from overseas to cut waiting lists
In May of this year the Department of Health wrote to all DHSC directors asking them to identify a substantial number of sites that could use overseas clinical teams to supplement capacity and to make significant, and sustained, inroads into long waiting times. Although early attempts to bring overseas teams to the UK have been unsuccessful, Alan Milburn, the Secretary of State for Health, has indicated that the use of overseas surgical teams would become a permanent part of the NHS strategy for reducing maximum waiting times to three months by 2008.

The European Working Time Directive
The EWTD (93/104/EEC) was enacted into UK law in 1998 as a measure protecting the health and safety of workers under Article 138 of the EC Treaty. The directive already applies to consultants, NCCGs and RMOs working in the private sector. Doctors in training were excluded from the original directive. However, a transition period timetable has now been agreed:

August 2004 Interim 58-hour maximum working week. Rest and break requirements also become legally enforceable from this date.
August 2007 Interim 56-hour maximum working week.
August 2009 Deadline for 48-hour maximum working week. This may exceptionally be extended by another three years at an interim of 52 hours, with 48 hours then coming in 2012.

According to Paul Thorpe of the BMA’s junior doctors committee, implementing the EWTD is the most important item on the workforce agenda. 5 It will require serious reappraisal of service delivery patterns, as well as a reconsideration of how junior doctors can complete their training within the limits of the directive. Countries such as Australia are able to train doctors and deliver high quality patient care within a 48-hour week and therefore may be a source of ideas. Training in the UK has traditionally been based on ‘time–served’ and a move to an effective competency based system is probably overdue.

Discussion
Reform is needed in all the areas set out above. Doctors are facing numerous blockages in their careers due to a failure of workforce planning and ill-managed postgraduate training. There are also a number of helpful suggestions from the government. The central funding of SpRs, for example, is to be welcomed. The second purpose of this briefing, however, is to highlight areas of potential concern for the profession which may be considered appropriate for debate at the Annual Representative Meeting. We have identified three of these as follows:

1. The need to increase the general practitioner workforce
In response to the NHS Plan the BMA general practitioners committee and the Royal College of General Practitioners published a 'Position statement on the general practitioner workforce'. 6 This paper calculated that implementing the initiatives of the NHS Plan, such as audit, appraisal, national service frameworks and intermediate care, would require the equivalent of a 30 per cent increase in the GP workforce.

In 1998 recruitment to general practice was at a fifteen-year low 7, although then there has been a slow improvement. For example, between 2000 and 2001 the number of GP registrars increased from 664 to 731 (10%). Although in recent years medical school graduates have preferred to enter the hospital specialties, there is a trend for women, in particular, to move into general practice to achieve a better balance between work and family life. 8 However, in an attempt to achieve this work-life balance, many women and men are working part-time. This trend is reflected in the workforce census figures so that whereas the headcount increase of GPs in the last year was 139, the whole-time equivalent was only 18.

When considering how to improve recruitment to general practice the attractions of the specialty should not be overlooked. These include excellent training and support, teamwork, a sense of being valued by colleagues, and more control over hours of work and an improved quality of life. 9 One way of improving recruitment may therefore be to increase exposure to general practice during undergraduate training. This could be facilitated by establishing education and research networks that include primary care centres. Many medical schools already have substantial exposure to general practice in the undergraduate curriculum. One such school is Leicester-Warwick where medical students learn alongside other health professionals and with the involvement of members of the community. This innovative approach has resulted in an increased number of students wishing to enter general practice as well as an expressed desire among students to stay in the local community. 10

The proposed new GP contract contains many radical proposals aimed at increasing resources for primary care, controlling workload and improving career opportunities in general practice. If final agreement is reached and if, crucially, appropriate resources are made available to fund the contract, there is the opportunity to significantly raise the profile and popularity of general practice as a career choice.

Researchers at the centre for health economics at York University estimated that minor self-limiting conditions account for 72 million consultations per year. This indicates that there is also a role for educating patients about the help that can be provided by other members of the healthcare team, such as pharmacists and nurse practitioners. Good teamwork can also help to manage workload and improve the job satisfaction of all members of the primary healthcare team. 11

2. Service needs and maintaining standards in medical education and training
In the policy documents outlined above the government makes a number of statements suggesting that in future, for doctors in the hospital specialties, completion of training cannot be guaranteed and the attainment of independent practice via consultant status will be available to a select few.

For example, 'A health service of all the talents' proposes that serious consideration should also be given to establishing a specialist grade which would be staffed by fully trained doctors who would work alongside, but not under, the clinical supervision of consultants and be appropriately remunerated. Elsewhere the document describes a consultant delivered service in which significantly more care is delivered by fully-trained staff with support from those in training and other staff who have chosen not to progress to consultant status.

The proportion of junior doctors who will choose to become NCCGs may well fall very short of that needed to deliver the latter model. The BMA cohort study of 1995 medical graduates seventh report (doctors surveyed six years after graduation) found that only two per cent wanted to become a non-consultant career grade doctor. 12

The proposals for SHO modernisation suggest that doctors could enter a service grade after completion of the foundation programme (and presumably before if they have been unsuccessful in being recruited). The assumption that it would be acceptable for junior doctors to extend their training to incorporate a service grade between SHO and SpR level ignores the fact that by the time doctors complete SHO training they are in their late twenties. Many have families and mortgages and peers who have reached the top of their careers in other fields.

The SHO modernisation working group is adamant that to ensure free flows into training, it will be important that the service grades are not seen as a career ‘dead end’... transfer into the service grade should be recognised as an acceptable career move with opportunities to shift back into training with no stigma attached.

However increasing competition for training places will create a breeding ground for prejudice in the selection process. This can currently be seen with the artificial competition for NTNs. Selection criteria for SpRs are becoming increasingly obscure and unrelated to competency (for example a completed PhD and eight publications). One only need look at the current absence of female doctors and doctors from an ethnic minority in the competitive specialities to predict that the plans for the modernisation of the SHO grade will result in a two-tiered career structure.

Another future scenario that is alluded to in recent policy documents is an increasing role for service imperatives to drive medical education and training. A key recommendation from 'A health service of all the talents' is that service needs are taken into account before accreditation of training posts is removed. Similarly the key objective of the establishment of the PMETB is to give the NHS direct influence over the education and training of doctors. According to the consultation document on the PMETB, as its primary customer will be the NHS, NHS interests and priorities will be properly reflected in the Board’s activity and outlook.

The plans for the modernisation of the SHO grade propose that the number of foundation programmes will also be based on the needs of the service. No doubt employers will be trusted to ensure sufficient training places are available for UK graduates, just as they were trusted to meet the new deal, expand the consultant grade and establish SpR posts.

The PMETB will take over the role of the royal colleges and to a certain extent the GMC:

Specific registration of all doctors seeking to work in the NHS as an independent specialist (ie consultant) or as a general practitioner will be required, and the Board will also set the standards required for entry to the Specialist and General Practitioner Registers. The Board would therefore control the post-registration training routes leading to independent practice as a specialist or a general practitioner. The consultation document proposes that the Board will be able to invoke temporary or permanent suspension from the Specialist Register.

The PMETB will be accountable to the Secretary of State for Health. (This is in contrast to the GMC, the competent authority for basic medical education, which is accountable to Parliament.) This further increases the influence of the prevailing government. This should give rise to serious concerns given the track-record of the way short-term political interests have distorted clinical priorities in the NHS.

3. Self-reliance
Plans to use teams of surgeons from overseas to treat NHS patients runs counter to the primary tenet of workforce planning in the UK which is self-reliance. According to the Medical Workforce Standing Advisory Committee training overseas doctors in the UK has mutual benefits: the UK benefits from this through the contribution these doctors make, through contributing to improving health overseas, and in the longer term, through cultural and diplomatic links. 13

However the committee warns of the dangers of abandoning self-reliance. These include exposing the UK to uncertainties in supply, making overseas countries reluctant to send doctors to train in the UK because of the high risk they may not return, and depriving countries in need of essential medical skills.

In addition, the recruitment of surgical teams from overseas to work in the UK may detract from the investment that is needed in the UK medical workforce. The resources that will be consumed by this scheme could be used instead to increase the number of consultant and SpR posts. This will further limit the career opportunities for those junior doctors who are ready to complete their training but unable to so because of the shortage of NTNs.

Other potential issues for concern include:
- Protocols and clinical governance
- Continuity of care
- Public confidence in the NHS

The assumption that importing teams of specialists will have an immediate impact on waiting lists also fails to recognise other factors involved such as lack of availability of nursing staff, poor management of theatre time and ‘bed-blocking’. It is estimated that as demand in hospitals exceeds 82 per cent of capacity, elective surgery will be cancelled inline with fluctuations in emergency admissions. Temporarily increasing the number of surgeons will not address this problem.

1 Hospital, Public Health medicine and Community Health Services Medical and Dental staff in England: 1991-2001. Bulletin 2002/4.
2 Statistics for General Medical Practitioners in England: 1991-2001.
3 Securing our Future Health: Taking a Long Term View. London: H M Treasury April 2002.
4 The Royal College of Paediatrics and Child Health. The Next Ten Years. Educating paediatricians for new roles in the 21st century. January 2002.
5 Thorpe P. The challenges of the Directive for existing working patterns. Presentation at Towards a 48-hour week. European Working Time Directive one day conference. Thursday 16 May 2002. Royal College of Obstetricians and Gynaecologists.
6 General Practitioners Committee and the Royal College of General Practitioners. Position statement on the general practitioner workforce. London: BMA; 2000.
7 The Joint Committee on Postgraduate Training for General Practice, Annual Report 1998/99.
8 Health Policy and Economic Research Unit. BMA cohort study of 1995 medical graduates. Seventh Report. London: BMA; 2002.
9 Health Policy and Economic Research Unit. BMA cohort study of 1995 medical graduates. Seventh Report. London: BMA; 2002.
10 Lennox A. Presentation given at the IPPR Lecture on Healthy Communities. Tuesday 22 January 2002. One Great George Street, London.
11 Health Policy and Economic Research Unit. Teamwork in primary care. London: BMA; (Date).
12 Health Policy and Economic Research Unit. BMA cohort study of 1995 medical graduates. Seventh Report. London: BMA; 2002.
13 Medical Workforce Standing Advisory Committee. Planning the Medical Workforce. December 1997.