Comments on Shape of Medical Workforce: Starting the debate on the future
consultant workforce, Centre for Workforce Intelligence, February 2012.
AJ Mifsud, on behalf of British Infection Association Council
A debate over the size and shape of the medical workforce in the future is long
overdue, and in this respect, this document is timely and welcome. However, we
have deep concerns over many of the assumptions made, and the proposed
scenarios, which in themselves are limited and are not mutually exclusive. The British
Infection Association represents both medical microbiologists and infectious disease
physicians, and whilst many concerns are shared by both specialties, some are more
relevant to one or the other.
The authors of this document make a number of observations and assumptions
regarding the current and future funding levels of the health service, as well as the
future pattern of clinical service delivery, and they have modelled the impact of a
variety of scenarios on staffing and budget. They project that in all scenarios
developed, there will be an excess of new CCT-holding specialists over demand, or a
substantial increase in salary costs, or both. While we recognise this range of
possible outcomes, we also recognise that there is an increasing demand for health
services, as described in a recent survey undertaken by the Royal College of
Physicians. Future investment is recognised to be a significant concern by 4,642
consultants out of 8788 recently polled by the RCP (March 2012, source: RCP
President’s Bulletin, March 15th, 2012). Other major concerns recognised by the RCP
poll included: clinical staff shortages (by 4,387) and increased workload in acute
medicine (by 2,352). It would therefore be helpful if the modelling included
productivity measures, to take changing demand and workload into account.
The importance of a consultant-led (and largely delivered) service in delivering highquality care and improving patient outcomes is discussed, but the consultants of the
future need to be adequately trained with appropriate exposure to clinical problems,
and decision-making opportunities, throughout their training. The future of infection
specialist training is currently under review, with the Colleges of Physicians and
Pathologists coming together to determine an appropriate training curriculum.
Current medical microbiology service provision (including out-of hours working)
outside major teaching units is predominantly consultant delivered. Both medical
microbiology and infectious disease services provide 7 day working with 24 hour
availability. We do not endorse the artificial distinction between the two specialties as
described in Annex 1 (participation in acute or general medical rotas is an integral
part of most, but not all, Infectious Disease physicians’ duties).
At various points in the document, changes in skill mix, with duties currently
undertaken by medically-qualified staff being undertaken by others. Skill mix is not
always the money saving option it first appears to be. In the past few years there has
been an increase in the number of consultations with nurse specialists, undertaking
roles formerly carried out by doctors. Many consultants in infection find themselves
spending longer on explanations and providing more support than previously. We
have to be careful that skill mix does not hide work being shifted from one area of
practice to another.
It is also important to note the limitations of workforce requirements predictions.
However the models are only as good as what is known at the time - technical
advances can radically change requirements in a short space of time. A good
example is the development of medical and percutaneous treatments for CHD which
has reduced the requirement for cardiothoracic surgery. We need to allow for, (and
make it easier for trainees and those who have completed training) to move between
related specialities. It has been suggested before that microbiology, infectious
diseases and communicable disease control could share a common training pathway
and this may be one way of solving this problem within the infection specialties.
Despite the descriptions provided in Chapters 2 and 4, it is difficult to understand the
rationale behind selection of these scenarios and their true impact. Specific
comments follow:
Scenario 1: This assumes that supply of trainees will determine consultant staffing
levels. Historically, this has not been the case in medical microbiology and virology,
where, over the years, there have been protracted periods of substantial trainee over
supply, followed by considerable shortage. In any case, this mode of service planning
appears to place the cart before the horse, as trainee numbers should follow
anticipated consultant vacancies not the converse. It would have been helpful if the
authors had attempted to determine the numbers of ‘excess’ available specialists
should the assumed expansion in consultant numbers not materialise.
Scenario 2: A shift from hospital to GP training posts may be a welcome idea, as long
as it is accompanied by planning to where these GPs are to end up (US experience
says they are unlikely to want to work in underserved areas). However, this should
also be critically dependent on specialist consultant manpower projections as well as
the feasibility of potential transfer of certain services into primary care. In terms of
workforce planning numbers, this scenario is similar to Scenario 1 in that it assumes
that consultant and GP numbers will be determined by the supply of CCT holders, a
methodology that we believe is flawed. It is also important to note that the future of
infection specialties lies firmly in secondary care.
Scenario 3: In the current political climate in which delays in retirement age to 65 if
not beyond are being imposed across the board, it is puzzling why the authors chose
to model a reduction in retirement age. It can only be assumed that this scenario was
devised to describe the maximum likely impact of a substantial increase in early
retirements in the event of changes to working conditions and pensions legislation.
The proposal could also selectively disadvantage women as they are likely to have
accrued smaller pension rights by the age of 60.
Scenario 4: This suggests that projected supply of CCT holders will also be greater
than demand as recommended by the Royal Colleges. It is suspected that the
excess supply will differ by specialty, and therefore some subdivision into broad
specialty groupings will be essential. We are also aware that current variation is
supply differ by specialty, and by region.
Scenario 5: The rationale for suggesting this scenario is unclear. It implies a latent
significant demand for a post broadly equivalent to ‘staff grade’. In the context of the
proposed ‘consultant delivered’ service, the nature of work done by such individuals
is unclear. It is also unclear why this consolidation year has been picked at ST4/5
level (when, depending on speciality, many trainees will have already achieved the
large majority of competencies required for award of CCT) rather than, for example,
immediately after Foundation years, or between core medical / surgical training and
higher specialist training.
Scenario 6: While there appears to be widespread acknowledgement that consultantdelivered service will improve quality of care, it would be ideal if some attempt were
made to quantify these assumed benefits. The flaw in this approach is the belief that
admitting consultants alone can make the difference; presumably they will need the
back-up of support specialities at a level approaching that present during the working
day to deal promptly and effectively with seriously ill patients.
Scenario 7: The use of the description ‘graded career structure’, can at best be
described as disingenuous. It describes the retention of current salary levels for
existing consultants, with lower salary levels for new appointees, with no opportunity
for career progression. The modelling should also include the impact on productivity
and the probable adverse effect on quality of service s a direct result of the ensuing
demoralisation. It is also noted that within this scenario, further reductions in
minimum training durations are proposed. This will inevitably lead to reduction in
standards and professional societies cannot condone this proposed blanket
approach.
Many of the recommendations for further work, as described in Para 5.4, are
important. However, as the British health service continues to be a National Health
Service, with the current trend towards decision making on consultant and trainee
numbers being devolved increasingly to individual Trust level, further work is
necessary to establish two-way linkage between consultant numbers and
consequently on trainee requirements.
In particular, the recommendations that the role of the consultant in the direct delivery
of service is reviewed urgently should be welcome, as this will then underpin the
projections for trainee requirements. The opening of a debate around the role of the
trained specialist should also be welcomed, but there must be clarity over the
minimum training requirements for these post-holders, as maintenance of standards
is an absolute requirement. Any review must consider which specialties may be
suited to the development of such posts. It is likely that this would not apply to the
specialties of infection: microbiology, virology or infectious diseases.
Throughout this document there are multiple allusions to contentious topics. These
include the contribution to service delivery undertaken by trainees; by doctors who
are not specialists or in training; by doctors who are not consultants but are qualified
as specialists; and finally by consultants. The opportunity to model the impact on staff
availability, costs, productivity as well as on quality of care of various combinations of
service delivery by these staff groups has not been taken. Without this data, it will be
impossible to truly review the future shape of the medical workforce in this country.
This document provides a base for discussion and recommendations for further work
which are important. There must be clarity over minimum training requirements for all
medical careers, and the Colleges and professional societies should ensure that
maintenance of quality standards is safeguarded. Some of the scenario proposals
show a lack of understanding of the detail required to make sound manpower
projections. Trainee numbers in all specialties (including Primary Care) should be
based on sound manpower projections, based on realistic retirement ages, and
numbers of staff required to fulfil clinical expectations. Scenario 7 remains a deeply
concerning course of action, which would have a profound demoralising effect on the
medical workforce. Affecting the rights of existing consultants will lead to increased
demoralisation.