Evidence submitted by the Royal College
of Anaesthetists (WP 11)
The Royal College of Anaesthetists welcomes
the opportunity to contribute to this inquiry. As a service speciality,
the anaesthetic workforce is critical to the delivery of anaesthesia,
critical and pain management in today's NHS.
Anaesthetists undertake a much wider role than
simply providing anaesthesia: they also form the majority of doctors
working in critical care and pain management. Because of this
variety of practice, medical staff trained as, or training to
be anaesthetists, contribute to the care of 65-70% of hospitalised
patients.
Current Workforce Situation (February 2006 data)
— Anaesthesia is the largest single
hospital specialty with approximately 2,800 SHO's, 2,062 SpR's,
1,200 SAS Grades and 5,300 Consultants (including approximately
250 locums).
— About 400 anaesthetists enter SpR
training each year and so a significant number of SHO's never
progress to SpR training.
— About 160 retirement vacancies occur
each year, and there is likely to be a bulge of retirements in
March 2006 and March 2007.
— Net increase of about 240 CCT holders
to become consultants per annum.
— Every four to five years we increase
the consultant anaesthetic workforce by 1,000.
Future Projections
Our currently used projection estimates that:
— 8,500 whole time equivalent consultants
would be required to support a consultant delivered service.
— This means that with current expansion
we will have attained 8,500 consultants in about 2,019.
— At that stage we will only need sufficient
trainees to fill retirement vacancies, which would be increased
to approximately 200 per year or 50% of our current SpR numbers.
— But estimates from DOH and our College
show that the average consultant only works for 0.7-0.8 of a whole
time equivalent during their whole career.
— This means that we will need approximately
11,000 anaesthetists to deliver a specialist based service, which
at current expansion rates and using UK trained anaesthetists,
would be attained in 2030.
The way in which anaesthetists contribute to
clinical care can be summarised as providing elective and emergency
anaesthetic services for:
— Acute medical admissions units
— Acute and Chronic Pain Management
— Specialist surgical services eg Neuro,
Cardiac, Paediatric Surgery
The range of activities is sufficiently wide
and specialised that in many instances, there are sub-specialty
on-call rotas and limitations in the possibilities of daytime
cross-cover.
Elective services—current situation
Anaesthesia in the UK is currently very safe,
with a very low morbidity and mortality. The quality delivered
is excellent and we would not be prepared to see this diminished
in any way. As trainees complete their training, although competition
in some parts of the UK is increasing, it is rare to find one
who does not get appointed to a consultant post within a reasonable
time. This would tend to suggest that there is still an unfulfilled
need for consultant anaesthetists. It is difficult to get an exact
estimate of vacant posts because many Trusts do not advertise
until they think there are suitable applicants or indeed prefer,
because of financial constraints, to leave them unfilled. Hospital
Training Visits do however, continue to reveal significant areas
of service which are regularly covered by trainees. Although this
is possibly good for their experience, it can seriously limit
their advancement of new skills. The use of trainees for service
purposes to the detriment of their training continues to worry
the College. On the other hand, what level of service commitment
is appropriate for trainees at various stages of their Specialist
Registrar training is something that needs further discussion.
In addition there has been a very strong growth in SAS grade doctors,
(sometimes to cover out-of-hours rotas) as a result of the reduction
in junior doctors from EWTD implementation.
If they continue to play a major part in out-of-hours
work, the opportunity for in-hours training of junior anaesthetists
will decrease as their working hours are further reduced and will
reach critical levels if the European working time directive continues
to be strictly implemented. In contrast, the consultant workload
is increasing at an alarming rate, partly because of sheer volume
and also because of covering relatively inexperienced trainees
both within and out-of-hours. This unpredictable rise in clinical
commitment is currently causing considerable stress in the older
consultants, resulting in early retirement.
The specialty also uses non-consultant career
grade doctors as to provide service (often by plugging unpopular
gaps) and as a result, they can feel misused and recruitment is
poor. Training is often minimal, supervision is nominal and few
people are interested in their career progression. It is crucial
that we increase the status of doctors in this role and be inclusive
and use all those involved with anaesthesia, critical care and
pain management to their best ability. It is however our stated
policy that all trainee and NCCG staff must be responsible to
a named consultant.
Non-Medically Qualified Anaesthesia Practitioners
As a Speciality, we are also faced with considerable
challenges to traditional work patterns and have been asked to
look at non-medical roles within anaesthesia. Many of the more
senior anaesthetists in the UK have had considerable experience
of working in such systems, both in Europe, Scandinavia and North
America but it is by no means a straightforward solution.
The Royal College of Anaesthetists and the Association
of Anaesthetists have been actively involved in developing and
piloting the training of Anaesthesia Practitioners to work as
part of the anaesthetic team, providing an alternative workforce
opportunity in some hospitals. The Royal College of Anaesthetists
has produced the following statement on Skill-Mix within Anaesthesia:
"Council of the Royal College of Anaesthetists
supports the concept of the anaesthetic team and the development
of non-medical roles within it. Council further supports the concept
of medically-led delivery of anaesthesia, critical care and pain
management, in order that the current low levels of morbidity
and mortality in our speciality can be maintained."
EMERGENCY SERVICES—CURRENT
SITUATION
Anaesthesia offers a wide range of out-of-hours
emergency services, both in general anaesthesia, obstetrics, intensive
care and a wide range of specialist rotas covering neurosurgery,
cardiac surgery and paediatric anaesthesia and intensive care.
As a result of the combination of greater demand, reduced junior
doctors hours and no rationalisation of the out-of-hours service,
many trainees and trained specialists spend a significant proportion
of their work covering these rotas, increasingly on a full shift
basis.
If all the out of hours work was to be done
by consultants, every emergency anaesthetic service would require
far more consultant staff than are currently available. For example,
obstetric anaesthetic cover on a 24-hour basis by Consultants
would require approximately 2,200 consultants, or almost one third
of the consultant workforce. In Critical Care a similar problem
emerges in that approximately 2,500 Consultants are required to
provide 24 hour cover throughout the country. Conversely, removing
medically provided obstetric cover altogether would free up a
considerable number of consultants and alleviate the in theatre
anaesthetic workforce problem.
With the current numbers of anaesthetists, we
are so dependent on trainees that the Royal College of Anaesthetists
has calculated that we would have to rationalise the use of approximately
100-150 acute hospitals in order to maintain a safe service. ie
one-third of all those hospitals in the United Kingdom who currently
have trainees covering out-of-hours rotas would have to have no
night time operating or anaesthetic cover.
Staffing emergency rotas will always be a problem
because of the quality, risk management and safety aspects which
apply. The emergency workload inevitably diminishes daytime availability
of both trainees and Consultants. We have found from experience,
and this is supported by our trainees, that the ideal training
rota is a one-in-eight with prospective cover, which provides
one period of on call and four days work together with a day off
after the night on-call, per week. Rotas, which are any more frequent
than this, are detrimental to both service and training. Shifts
are unpopular, produce difficulties with training and adversely
affect continuity and "seeing a patient through" the
whole treatment episode.
The number of on-call rotas, which are provided
in any single hospital, is a major source of difficulty since
they have to be divided into the total staff available. Those,
which reflect sub-specialist practice, have a high dependency
on consultant attendance. In many people's opinion, it is only
a matter of time before Consultants being resident on call is
the norm rather than the exception (unless of course Consultants
start to work in shifts, with the European working time directive
applying to everyone). Certainly this is already happening in
intensive care medicine, where, with the introduction of Modernising
Medical Careers, increasing numbers of inexperienced doctors will
be rotated through intensive care units to obtain basic experience
and "tick competency boxes". Many are not anaesthetists
and therefore do not possess the necessary skills to allow distant
consultant supervision out of hours. As a result we will need
to have large numbers of consultants on-call and living in. On
the plus side, if senior staff are involved in on-call rotas,
it is usually possible to remove one or two tiers of junior staff
as a result, thereby increasing training opportunities.
TERMS OF
REFERENCE
How effectively workforce planning, including
clinical and managerial staff, has been undertaken, and how it
should be done in the future?
Anaesthesia, including intensive care medicine
and pain management, regularly contributes data to and takes part
in the Department of Health's Workforce review team's analysis.
Our data is drawn from census information, initially gathered
on an annual basis and now every three years with a 100% return
rate from our census questionnaires across all hospitals in the
UK. The problem with workforce predictions relates to the inevitable
assumptions which are necessary and which constantly change. Some
of these are outlined above. Other examples include:
— It still takes seven years to train
an anaesthetist and given that we have to start planning to reduce
numbers about five years ahead, how far in advance should this
process commence in order achieve the correct balance by 2019
or 2030? This will depend on how fast consultant anaesthetists
take on out of hours work and also, in turn, when consultant surgeons
do the same as increasing numbers do now, the demand may well
fall.
— But as outlined above, in order to
provide 24 hour consultant cover in obstetrics would itself require
2,200 WTE consultants and so it only needs a decision to provide,
for example, an anaesthetist on every acute care team, to further
distort the figures.
— Almost every new initiative, however,
will require more, rather than less anaesthetists.
— How many consultants, either male
or female, will want to work full time for the whole of their
anaesthetic careers?
— Will the changes in gender balance
of medical graduates produce significant changes in anaesthetic
recruitment and retention?
— How many will follow other interests,
management, teaching, training, Deanery work, etc?
— Will future trainees put location
in advance of their career preferences and therefore sustain competition
in some parts of the UK and on-going shortages in others?
— Will a consultant job be for life
in the future?
There will also always be significant uncertainties
such as:
— How many posts are agreed but not
advertised for financial reasons.
— How will alterations in service delivery
and the introduction of ISTC's etc, alter the workload.
— How will alterations in surgical,
radiological and pharmacological techniques affect the demand
for anaesthesia.
— How will increasing demand for acute
and critical care affect the demand for intensivists?
— Possible political decisions to provide
less care because of affordability; this is most likely to affect
Critical Care.
— How much further will our speciality
expand? Some believe that by 2020 the only 24 hour acute "physicians"
in hospitals will be anaesthetists or Emergency and Acute Medicine
physicians.
In considering future demand, how should the effects
of the following be taken into account
Recent policy announcements, including Commissioning
a patient-led NHS
Anaesthesia is increasingly involved in areas
of healthcare outside our traditional role. If patients are to
be offered more choice and more locally delivered care, this will
increase demand not only on workforce, but also to ensure the
continuing competence and clinical governance of specialists,
if their practice is increasingly remote from major hospital departments.
Technological change
This constantly affects anaesthesia, but the
benefits are in patient safety and quality of care, rather than
on workforce needs.
An ageing population
The expectation of patients to receive treatment
despite significant co-morbidity makes enormous demands on anaesthetists,
both in terms of increasing numbers of cases but also in pre-and
post anaesthetic assessment and recovery and also on high dependency
and critical care facilities.
The increasing use of private providers of services
If this is transferred activity, then the actual
demand on anaesthetic services should not be great, but if it
is additionally, then this has obvious workforce implications.
Efficiency gains occur from undertaking operating lists rather
than isolated cases, distributed in different locations.
How will the ability to meet demands be affected
by:
Financial constraints
As we have outlined, many Trusts have unappointed
anaesthetic posts and rely heavily on trainees to deliver service
work from an early stage. On current estimates, in Consultant
"PA terms", the weekly service contribution of anaesthetic
SHOs is 2 PAs, and of SpRs, 3-4 PAs.
The European Working Time Directive
This has had a major impact which is largely
being addressed by full shift working. Of major concern is that
this Directive applies to all doctors, not just trainees, and
career grade staff are increasingly working unmonitored hours
well in excess of EWTD.
Increasing international competition for staff
This certainly occurs in anaesthesia and 50%
of current anaesthetic SHOs have not received their primary medical
training in the UK. However anaesthesia is an easily internationally
transferable skill and many UK anaesthetists have worked in Europe
and further afield and continue to do so.
Early retirement
Anaesthesia is an acute and high risk speciality,
which many find very stressful. Very few anaesthetists, particularly
with the high demand for out of hours work, are anticipating working
beyond 60, and the average retirement age at present is around
58.
To what extent can and should the demand be met,
for both clinical and managerial staff, by:
Changing the roles and improving the skills of
existing staff
The question of introducing non-medical roles
has already been covered. One could ask whether the aspiration
of a Consultant delivered service is crucial to future workforce
predictions in terms of trainee numbers? In fact the current situation
is unsustainable. There are two choices:
— If we continue to use the same number
of trainees to deliver service work, but don't create consultant
posts for them to take up, we will overproduce by 240 CCT holders
each year.
— If on the other hand, service work
which trainees undertake is transferred to career grade posts,
then expansion in the number of such posts is essential.
Better Retention
Many anaesthetists leave the service for very
simple reasons. Job planning is very insensitive to the changing
demands of age, gender and external responsibilities. Key reasons
for leaving are frustration with the system, boredom (being asked
to do the same work day after day), on-call commitment (a major
problem), managerial interference and not being allowed to do
what they are good at and take a pride in. Anaesthetists like
any other employee deserve to feel satisfied, feeling valued and
competent with a reasonable work/life balance, which if necessary
allows flexible and part-time working
The Recruitment Of New Staff In England
We have already considered non-medical roles
Other possibilities include:
Offering SAS grade staff additional training.
This would have to be done with temporary, additional training
numbers as many of them have entered the SAS grade having failed
to obtain a national training number and thus fulfil a normal
training programme. We have to ask what the future holds for the
SAS grades at present. It is essential that they be considered
a vital and integral part of the anaesthetic medical workforce,
they must have a clear career pathway (Choice and Opportunity)
and their training could perhaps be linked to flexible programmes
to allow re-entry at an appropriate time.
Flexible trainees. Anaesthesia has always been
relatively popular with women and others with domestic commitments
and we always have a significant number of flexible trainees.
Many Medical Schools are recruiting more than 70% female undergraduates.
At present, having elected to "go flexible" part of
the way through their registrar training, SpR's have to embark
upon a very long training programme simply to fulfil the prescribed,
pro rata time commitment. Although this may be solved with the
advent of competency based training, there is still a need to
be able to offer trainees a more expeditious route to a consultant
post or alternative style of employment which does not carry the
connotations of `failed doctor'. Like all specialities anaesthesia
needs to recruit pragmatically for the following reasons:
— The 2006 Medical school intake is
more than 70% female.
— Anaesthesia is and should be a family
friendly speciality.
— Work/Life balance issues are increasingly
important to today's doctors.
— However, training programmes cannot
be infinitely flexible if they are to be fair to everyone and
new ways of training need to be explored.
International recruitment.
Overseas trainees. For many years the Health
Service has relied upon overseas trainees coming to fill vacancies
in the UK. This has occurred because of a shortage of our own
trainees and also because of the natural desires of doctors from
other countries to come and work in the UK. Everyone has the right
to be part of an international mobile medical workforce. However,
although it is comparatively easy for an overseas trainee to come
to the UK for training, either by obtaining PLAB and then applying
for a job, and subsequently limited registration, or on a sponsored
programme through ODTS, the difficulty of getting on a recognised
training programme is another matter altogether. As a result many
overseas trainees end up disillusioned and feeling used and abused
which is not what we should be trying to achieve.
Trained overseas doctors. At the present time
there are significant initiatives to attract trained doctors to
come to work in the UK from European or other countries. It is
recognised that the training will not necessarily be compatible
with immediately appointment to a consultant post in the UK and
so it is intended that they should come and spend one or two years
"acclimatising" to the British system. The assumption
is that they will then perhaps work here for a few years before
returning to their home country but we do not have evidence that
this will be so. It is quite likely that those who come will apply
for consultant posts and obtain them in the UK; particularly those
who have a right of entry to the specialist register as EU nationals
anyway.
European Regulations on Interchangeable Speciality
Recognition. EU enlargement has and will continue to introduce
large numbers of trained anaesthetists into the European labour
market and this has the potential to distort workforce planning,
in both the immediate and the long term
How should planning be undertaken?
To what extent should it centralised or decentralised?
National planning is essential, and we have
found that combining our data collection with the Department of
Health has been very valuable in keeping a regular and current
view of workforce requirements. New initiatives or commitments
made centrally can have profound consequences on workforce requirements
and proper consultation is essential before politically sensitive
commitments are made to the public. Public expectation is a major
workforce driver, which can significantly distort longer term
planning, for example, the provision of 24 hour consultant cover
in obstetrics or critical care.
How Is Flexibility To Be Ensured?
By continuous monitoring of issues, which affect
either workforce demand, duration of training or patterns of working.
These must include the effect of lifting the absolute ceiling
on training time with the introduction of competency based training,
and continually assessing the whole time equivalent correction
factor; that currently used is 0.82. Is this applicable to all
specialities or should it be individually adjusted? In anaesthesia,
we estimate this should more accurately be 0.7 over a whole career.
We need to know what the intentions of Trusts,
Hospitals and PCTs are about the future development of services
and then work out the workforce implications in an informed way.
What Examples Of Good Practice Can Be Found In
England And Elsewhere?
We have outlined the process undertaken within
anaesthesia and critical care by the Royal College of Anaesthetists
and the Department of Heath's Workforce Review Team.
Dr Peter Simpson
President, Royal College of Anaethetistis
13 February 2006
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