Policy responses and statements

Name of organisation:
Scottish Government - NHS Workforce Planning & Development
Name of policy document:
Reshaping the Medical Workforce in Scotland - Consultation on Specialty Training Numbers from 2011 to 2015
Deadline for response:
31 August 2010

Background: The Scottish Government has circulated this consultation for comments.

This paper sets out the consultation process for agreeing establishment numbers for specialty training posts in programmes leading to CCT or equivalent in Scotland for the period 2011-2015. The changes to trainee numbers, and consequent increases in the number of trained doctors will help to address the projected over-supply of doctors between now and 2014 – the Scottish Government's modelling indicates that Scotland will produce surpluses of around 1500 hospital and community specialty doctors and 900 GPs over the period to 2014, based on expected retirement rates among existing staff and the numbers of junior doctors expected to complete their training programmes. Rebalancing the proportions of trainees and trained doctors will ultimately deliver the improvements in patient care which are at the heart of the reshaping project.

Consultation will be an annual process, with scope for adjustment of numbers in response to changes of circumstance but after the consultation in 2009 it was agreed that the Scottish Government should set out a proposal over a longer timeframe than agreeing intake numbers on an annual basis.

At the end of the consultation period, a small group from the Reshaping Medical Workforce Project Board will be asked to collate responses and bring any suggestions for change to the Project Board for approval. The final Project Board approval of training intakes for 2011 will be needed by October 2010 so that recommendations can be made to the Cabinet Secretary in time for her decision in November. However, the paper that is signed off by the Project Board will give service and deaneries a clear target for managing changes in training establishments over the five year period, subject always to annual Ministerial decisions on overall intake numbers. Consultation in 2011 and 2012 should be able to focus only on areas where there is new evidence.

CONSULTATION EXERCISE RESPONSE SHEET

ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH

RESPONSE TO

RESHAPING THE MEDICAL WORKFORCE IN SCOTLAND - CONSULTATION ON SPECIALTY TRAINING NUMBERS FROM 2011 TO 2015

SUMMARY OF KEY POINTS

  • The baseline data at specialty level is subject to serious challenge and provides a poor platform for modelling on such a critical issue. It fails to take account of the complex and variable balance of acute medicine and other specialties for many trainees and consultants.
  • Workforce planning based on replacement and 1% growth averages across all specialties will result in an underestimate of trainee posts and consequent service pressures.
  • The multiplier applied to current data to address demographic change is inadequate for many medical specialties.
  • Service gaps resulting from a reduction in trainees and changing working practices for consultants will impact on both in-patient and out-patient care.
  • Consultants continue to provide cost-effective care; not all service gaps can be filled effectively by specialty doctors or nurse practitioners.
  • Workforce planning in Scotland must not be undertaken in isolation; trainee numbers must be co-ordinated across the UK.
  • The introduction of a sub-consultant grade for CCT holders, or the perception of same, will result in trainees leaving Scotland either for higher specialty training or at the end of their training. The consequent recruitment crisis will be particularly damaging for remote and rural parts of Scotland.

INTRODUCTION

  1. The College welcomes the opportunity to comment on the consultation process for agreeing numbers and the first tranche of data that may underpin early projections. However, it has not been possible to review each medical sub-specialty in detail, given the short timescale over the main holiday period. The College has illustrated some points by reference to the specialty of gastroenterology, in particular, to draw attention to the inaccuracies within the baseline data and the process of data compilation. The College is concerned that the Cabinet Secretary will be asked to take critical decisions on medical training numbers in Scotland based on inaccurate data and contested assumptions.

  2. Comments are referenced against the consultation questions and paragraphs in the consultation document.

Question 1: Do you have any comments on the assumptions used under the following headlines when applied to your specialty?

Estimating Retirements

  1. The College cautions that estimating future retiral rates may be more difficult than suggested in the consultation with the unknown impact of the introduction of revalidation, the perspectives of a growing female consultant cohort, increased work intensity due to service pressures, the loss of trainee posts and the introduction of the clinical leadership and excellence awards (para 8).

  2. The College is very concerned about the wording of this paragraph and the implication that retiring doctors may not be replaced at consultant level. This is at odds with previous policy statements about a consultant delivered workforce. Scotland will become less attractive to trainees if, at the end of training, they may be offered specialty doctor rather than consultant posts (para 9).

  3. The College is concerned that the quality of care for patients will be damaged if the future workforce model is dominated by replacement through retirements only and with minimal growth despite the reduction already planned in training numbers. Whilst some service pressures can be relieved by advanced nurse practitioners and multi-disciplinary teams, high level diagnostic or procedural skills within many of the medical specialties cannot be delivered by these means. There will thus not always be cheaper alternatives available. The College believes that many policy developments and service ambitions (eg the quality strategy and extended hours working) along with enhanced training responsibilities and the regulatory requirements of revalidation cannot be delivered without an increase in the consultant workforce, however unpalatable a message this may be at a time of financial pressure.

Correcting for gender shift and changes in working patterns

  1. The College strongly believes that the correction factor as used in the modelling for gender change and work-life balance is both inadequate and over simplistic. Preferences are indeed gender specific and this extends to trainee physicians; at its most extreme, cardiology is male dominated (90%) and palliative medicine female dominated (65%). The College believes an average correction factor of 1.6 should be used with 1.8 for all those specialties clearly favoured by female trainees and/or those seeking less than full- time posts. The College believes that female preferences are not restricted to paediatrics, obstetrics and gynaecology and pathology as included in the consultation document (para 11).
  2. The College understands that the most recently published data indicates that across the UK the average female entry to medical school is around 60%. However, it would be helpful to understand this data better as there is also evidence of significant differences between medical schools. Can the Workforce Planning Unit provide data for Scotland, Northern Ireland and the North of England?
  3. The assumption of a 40 hour working week for all consultants may be premature, as many will be working extended working days to cover the gaps left by the loss of trainee posts and for clinical quality and patient safety reasons. Recent surveys have demonstrated significant concern about the impact on service quality and patient safety of the 48 hour working week and rotas that have no capacity to absorb vacancies resulting from recruitment failures or short term absence. In addition, a recent Audit Scotland Report shows significant reliance on locum doctors both at trainee and consultant level with Scotland spending over £27m in 2008-9 on agency locums.

Estimating net effects of migration

  1. Whilst the College agrees with the principle of setting trainee numbers at a level consistent with future need, we have reservations about this need being based solely on the medical workforce requirements in Scotland (para 4). The College urges the Scottish Government Health department to work closely with colleagues across the UK over trainee numbers, both for overall training capacity and specialty split. This is for several reasons:
  • Scotland’s national reputation as an educator of doctors (see comments on migration below).
  • To ensure annual variations by specialty can be accommodated better across the UK.
  • To avoid a training market developing that disadvantages Scotland, particularly the more rural areas and the teaching centres in Aberdeen and Inverness.
  • To cope with any changes in trainee numbers in England as a result of local devolution of planning following implementation of the White Paper

  1. The College is concerned about the parochialism within the rationale on migration. Scotland has long benefited from its reputation as a world class centre for medical education, attracting high calibre medical teachers and forging links with health systems overseas (para 12). The College believes that to risk this would not be in the interests of the country or Scottish patients. Similarly, the acknowledged recruitment difficulties in the North of Scotland are unlikely to be helped by an under-supply of Scottish trainees. Current ISD figures show a 3% vacancy factor across Scotland, almost half of which is over 6 months old. Grampian is significantly higher on both measures. The accuracy and applicability of workforce models must take account of local needs – a “one model fits all” across Scotland may not deliver fully.

  2. The evidence underpinning the “push/pull” arguments is not clear. Scottish trainees have moved to England for good quality posts. Many graduates of Scottish Medical Schools will have originally travelled from England to study and are therefore returning home. The nature and strength of the “pull” factor into England is not well understood and may have changed little by the expansion of English medical schools and/or the relative availability of posts in England. Similarly the “push” factor resulting from increased competition for consultant posts in Scotland may well remain and any proposals (or even perceptions of proposals) for sub consultant grade posts will further encourage moves out of Scotland.

  3. Taking gastroenterology as an example of an expanding medical specialty, over the past 5 years 30 trainees have attained their CCT in Scotland. Over this period there have been 35 consultant posts in Scotland. One third of these, almost exclusively DGH posts, have gone to trainees from outside Scotland (often outside the UK), while 5 of the Scottish trainees have taken teaching hospital posts in England and 2 have taken academic posts. The lesson is that training only the exact number of doctors that Scotland will require is likely to damage recruitment, particularly in rural DGHs.

Question 2: Do you have any comments on the recommended intake numbers for your specialty?

  1. The College is concerned that the document leaves each specialty to make their own case for other than a 1% growth. This is of crucial importance to each specialty, yet this document has been issued over the summer vacation period with a short response time. There is a real risk that individual specialties will either not appreciate the importance of what they are being asked, or that they will have insufficient time to answer the question.

  2. The College welcomes annual consultation on the actual numbers and agrees that a longer time frame is required given the lead times for change. However, the College believes the national picture would be more accurate and representative of need if built from the hospital/specialty level (ie a “bottom-up” rather than a “top-down” approach) (para 2).

  3. The College seeks clarification on the definition of career grade doctors. Does this include consultants and specialty doctors and is there a process under development to determine how budgets released as trainees achieve CCTs will be reallocated between these grades? (para 6).

  4. The College agrees that estimating future growth is a more exacting task but we should not apologise for equalling the WHO European averages, particularly given Scotland’s health record. The budget constraints facing the public sector are real, but the consultation paper has determined that the 4-5% growth rates that result from the current trainee numbers is unrealistic rather than unneeded in terms of service demand. The College strongly believes that likely changes to the working patterns of many hospital consultants, coupled with the under-estimated multiplier in many specialties has not been taken into consideration in planning for a 2% headcount growth rate (paras 14-18).

  5. It is critical that, before trainees posts are reduced, a systematic sensitivity analysis is completed to quantify the risk of serious service disruption (in the short and long term) resulting from inaccuracies in the data and modelling assumptions. The Cabinet Secretary must be fully informed of the risks to patient care if (as the College believes) the balance of trainee posts and consultant capacity is miscalculated.

  6. Paras 19-22: The College applauds the agreed “growth” in acute medicine consultant posts but would like to understand better the factors which have influenced the Health Board projections in all medical specialties, particularly as replacement rather than growth is the major determinant in the current model (paras 19-22). It is unclear how Health Boards have taken account of the drivers of service need, including patient demand, the effects of an ageing population, the working time regulations, the focus on health inequalities, and remote and rural challenges, all of which may have specialty-specific outcomes.

  7. The consultation document is silent on the particular needs/impact of academic medicine, either in relation to their contribution to service delivery or the impact of trainees following an academic career pathway.

Acceptable Evidence to drive a change in numbers

  1. The College has questioned the accuracy of the baseline data on specialty split in the medical specialties and on which future projections are based. The data in the table are said to be taken from the Physicians Annual Census (2008), but comparison of the two reveals marked differences. For example, consultant rheumatology posts number 43 in the Physicians’ Census but only 15 in this document, leading to an absurd projection for target trainee numbers in rheumatology. Whether the result of simple transcription errors or inaccurate ISD coding, it is essential that all such errors are corrected prior to policy decisions.

  2. A particular complication in medical specialties is the option to accredit in more than one specialty, an option favoured by the NHS to support acute receiving and by many trainees. For example, trainees in acute (internal) medicine may opt to train solely in this specialty or combined with general (internal) medicine or one of the other medical specialties (see JRCPTB website). This must be factored into workforce planning assumptions.

  3. Deriving projections for 2011-2015 on figures from 2008 without any correction factor for growth in the interim period will lead to further errors. For example, the number of gastroenterologists in the UK has grown from 818 at the time of the 2008 census to 1,078 by 2010. This data must be reviewed before proposals are submitted to the Cabinet Secretary for approval.

  4. Absent from the list of factors that would prompt change is evidence that the multiplier/corrective factor for participation rates is wrong, and the College calls for a review of the standard application of a factor of 1.4 across all but 3 key specialties.

  5. The impact of the 48 hour working week on training quality and patient care has not been considered within the 1% p.a. growth factor estimated as being the maximum affordable in the next 4-5 years.

Question 3: The paper proposes moving from national control over the number of NTNs to setting a target number for the number of whole time equivalents in programme for each programme. What are your views on this proposal?

  1. The College, mindful of the gender shift in the physicianly specialties, is fully supportive of this move to facilitate less than full time training. However, some budgetary flexibility will be required to manage the timing differences for those who opt to train part-time or change in mid-programme to part-time training. Similarly, some national co-ordination will be required to ensure equality of opportunity to train part- time across Scotland. This could become a very positive signal to trainees about the value to staying or moving to Scotland to train.

Question 4: Do you have any other comments you would like to make?

Implementation of the Programme

  1. The College acknowledges the transition difficulties and welcomes a phased approach as CCTs create vacancies and supports the statement in para 5 that numbers will default to the higher estimate when there is uncertainty. The College hopes this position can be maintained in the face of budget pressures.

  2. The consultation document is silent on contingency plans for the current cohort of trainees and the next 5 years of medical graduates should training numbers in Scotland be reduced radically. The impact of such planning on the career choices of highly capable young doctors should not be underestimated.

Completed responses should be returned to:
James.Falconer@scotland.gsi.gov.uk by no later than 31 August 2010

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[30 August 2010]
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