Planning a consultant delivered NHS

A crisis in the global healthcare workforce is currently looming.1 In Europe, the problem is so great that the Belgian European Union presidency made “investing in Europe’s health workforce of tomorrow” the subject of their ministerial conference recently held in Brussels. That conference, following on from an EU green paper,2 showed that EU countries have very different perspectives on the needs of their workforces, but they all face similar problems—an ageing population; increasing public expectations; an increasing proportion of women (who are more likely to work part time) in the workforce; increasing worker mobility; and, most importantly, limited finances. The history of workforce planning in the NHS shows how difficult planning can be for an individual country and that seemingly well made plans can soon become inadequate with changes in policy and finances⇓.3

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The NHS has traditionally relied on junior doctors to deliver most acute services, and, until recently, many of these doctors had been trained abroad. Between 1992 and 2003, 42% of doctors entering the NHS workforce came from overseas, with most being international medical graduates.4 In the late 1990s, the number of places at medical school increased so that the UK could become self sufficient with respect to its workforce. To create space for the additional “homegrown” doctors, in 2006 legislation was changed to limit the number of international medical graduates working in the United Kingdom.5 This change, together with the painful rationalisation of training places (Medical Training Application Service; MTAS) that occurred around the same time,6 meant that many international medical graduates subsequently left the UK. The exact numbers and pattern of migration were not monitored and the loss was seen most acutely in hospitals in less popular parts of the country. Such hospitals have struggled the most to recruit doctors ever since.

The available medical workforce is, obviously, a product of the number of doctors and the hours that they can work, and changes to working time regulation have substantially reduced working hours over the past decade. The “new deal” for junior doctors came into full force in 2003, and, although it allowed doctors to work up to 56 hours a week, it imposed severe financial disincentives for trusts where doctors worked for longer than 48 hours. The full implementation of the European Working Time Directive in 2009, and more importantly the SiMAP (Sindicato de Medicos de Asistencia Publica—a Spanish primary healthcare organisation) and Jaeger rulings,7 then removed much of the remaining flexibility hospitals had in the way their doctors worked (box). Although the current UK government has declared an interest in revisiting the European Working Time Directive legislation, any changes will take years to get through the EU legislative process.

Thus, despite more junior doctors being produced by the UK since 2000, the availability of doctors for hospital patient care has not increased, and out of hours care continues to be delivered largely by junior doctors. In 2001, the average junior doctor had 67 patients under his or her care at night, and by 2009 this figure was still 63.8 Furthermore, the pressure on hospitals is worsening, with hospital admissions having increased by 19% during the past five years, and the UK continues to have fewer doctors per head of the population than most other EU countries.

The NHS is only too aware of the need for better workforce planning. The Centre for Workforce Intelligence was established in July 2010 to facilitate this and has already produced a set of recommendations for specialty training numbers in England.9 These predictions use data from the NHS Information Centre on current doctor numbers and use weighted capitation to look at the distribution of specialists across different regions. They show that by increasing the number of consultants to mirror the output of specialist trainees the slow transition towards a consultant delivered service, which is undoubtedly better for patient care and training of doctors,10 can continue.

This is a large and uncertain proviso. The number of hospital consultants has expanded at 4-5% each year during the past 15 years and would need to continue to expand at around 6% a year to ensure that all specialist trainees will be employed in the NHS as consultants. Even in a helpful financial climate this seems unlikely, and the financial winter that the NHS faces will mean that job numbers will be frozen by many trusts. This illustrates the major problem with workforce planning in the UK—no matter how good national planning is, adequate local finances are essential to delivering it.

The prospects for employment for trainees in the larger medical specialties are therefore unclear. Although an oversupply will be good news for regions of the country that struggle to recruit staff, it remains to be seen whether fully trained doctors will migrate around the UK or move abroad. Increased tightening of accreditation criteria for trainees during the past few years has removed the flexibility for doctors to move between specialties, which had been relatively common 15-20 years ago when a particular specialty became oversupplied. Some cynics say that oversupply of trained doctors in the UK was always intended and will open the door to a subconsultant grade. The King’s Fund has included such a workforce in its predictions of the future NHS workforce,3 and such posts are already present in some hospitals.

The UK needs to move away from a trainee delivered service, but this will take many years to achieve. In the interim, reversing the SiMAP and Jaeger rulings, renegotiating the new deal, relaxing immigration rules, and enhancing mobility between specialties will all give the NHS more flexibility to cope with its ever increasing demands. However, the healthcare crisis is global, and the NHS must be mindful of the impact of such changes on other healthcare economies.