Reshaping the Medical Workforce in Scotland - 2012 and Beyond

COMMENTS ON SCOTTISH GOVERNMENT - HEALTH WORKFORCE DIRECTORATE
RESHAPING THE MEDICAL WORKFORCE IN SCOTLAND – 2012 AND BEYOND

1. The Royal College of Physicians of Edinburgh (the College) welcomes the opportunity to contribute to the debate on future trainee numbers.  Many of our Fellows and Members will be contributing via their local specialty lead and this response is intended to reflect wider College concerns about the process and the impact of making incorrect assumptions on patient care, the quality of training and the professional attraction of consultant posts in Scotland.
2. The College accepts the need to plan for Scottish workforce requirements but urges close integration with equivalent workforce teams across the UK; the mobility of trainees and trained doctors makes planning for Scotland’s needs in isolation a most unwise approach.
3. The College recognises the financial pressures facing Health Boards and accepts that in the short term there may be little expansion in consultant numbers to address service needs.  However, in the medium to longer term, the demand for additional medical input resulting from demographic and therapeutic changes will require expansion and the lead time to deliver this for medical staff is long.  For example, endoscopy screening and rising alcohol related disease will require more gastroenterologists, and particularly liver specialists, and there will be increased demand for medical oncologists due to rising incidence of cancer generally and the impact of new and ever more complex therapy.
4. The College is also concerned that current financial pressures may encourage salary savings from reduced trainee numbers being diverted away from medical budgets before the debate on the balance of trainee/trained doctors is concluded.  It is critical that the overall medical support available to the NHS in Scotland is maintained.
5. The College feels it is essential to see the detail of the employers’ vision of the role and remit of the “speciality doctor” to be clear whether the changing balance of consultant/specialty doctor can sustain a safe clinical service.  The potential role of the “speciality doctor” might not be applicable to some disciplines and where the role might be considered, the remit could vary between specialty.  Although they might be capable of independent practice, specialty doctors with CCT may offer little in terms of financial savings.  Lower level speciality doctors will still be limited in their roles and require consultant supervision.
6. The College accepts that the figures offered for medicine acknowledge data difficulties and has a number of general comments, grouped as follows:
   1. Inaccuracy of ISD base data for the medical specialties
   2. Contribution of the specialties to the Acute Medical take
   3. The “bulge”
   4. Retirement and Vacancy factors
   5. Correction Factor
   6. Attrition Rates
   7. CMT numbers

Inaccuracy of ISD Base Data for the Medical Specialties

1. Specialty leads will comment individually on this point but the College is concerned that, in addition to the recognition of miscoding consultants to specialty, there are some fundamental differences between the ISD payroll-based data and staff in post.  Examples include:

• consultant numbers in clinical neurophysiology are incorrect; 9.8 plus 1 vacancy against the consultation figure of 4.  Similarly, there are 3 rather than 2 training posts.
• consultant numbers in medical oncology are incorrect with 29 consultants in post rather than the 12 listed in the consultation document.  27% of those posts are academic and 55% work less than full time, resulting in a lower contribution to the NHS than might be expected from the raw data.
• training programme establishment numbers are felt to be underestimated in rheumatology by 4 with the recommended establishment being 17 to take account of 2 retirals annually and a correction factor of 1.4.  It is thought that the inaccuracy in these figures originates from previous inaccuracies carried forward from 2009/10.

Also, the College seeks confirmation of the status of academic sessions within the SWISS payroll data as this may be the source of further inaccuracies, particularly in wte data for consultants.

Contribution of the Specialties to the Acute Medical take

1. The College welcomes the shift of emphasis from head count to wte given the likely increase in numbers seeking to work less than full time and the split working for many consultants between their specialty and acute medical admissions.  It is critical, for the accuracy of future planning, that correct data is available on the wte available to support the acute medical take given that this is delivered by consultants and trainees in both acute medicine and a large number of medical specialties; planning for neither acute medicine itself nor those required to undertake training in General Internal Medicine can be accurate until this is accomplished.  Similarly, the impact on specialty time will be underestimated for many trainees with knock on effects to service provision; renal medicine is particularly worried given the proposal to reduce established training posts.
2.  The proposed trainee numbers indicate a reduction of 22 posts in the establishments of the specialities that generally contribute to acute medical units.  RCPE is undertaking a study over the autumn of the current staffing approaches in acute medical units across Scotland and would be ideally placed to contribute to improving the quality of specialty data.

Is the “bulge” of trainees real?

1. The College welcomes the recognition by the Workforce Directorate that the “glidepath” for the changes in trainee numbers in many specialties needs adjustments and that, where there is doubt, the government intends to err on the side of “oversupply”.  However, a broad brush approach based on flawed national data could leave some clinical services in jeopardy, and specialist advice is essential.  There is no hard evidence that the expected “bulge” of trainees (certainly in the medical specialties) will now materialise as illustrated by recent NES and JRCPTB surveys, where Scottish CMT trainees continue to move into other specialities including General Practice, radiology and the laboratory specialities, moving south into training posts in England or take time out overseas.  This, combined with the major uncertainty about retirement numbers, makes it reckless to reduce training numbers significantly until the future position is clear.

Retirement and Vacancy Factors

1. The College notes that that the modelling has not taken account of a possible increase in retirement rates and strongly urges the national planners to undertake some sensitivity analysis, based on specialty specific feedback given the potential for significant disruption to patient care and the quality of training if these assumptions are incorrect.  For example, many consultants in gastroenterology are in their mid to late fifties and plans to reduce trainee numbers must be sufficiently flexible to cope with firmer retirement plans in 12 months’ time.  Also, the retirement rate in medical oncology does not include those retiring from academic posts and therefore requires adjustment, suggested as 1 annually.
2. The College understands that the base ISD data is on consultants in post and takes no account of the current vacancy factors.  In the medical specialities alone, according to the most recent ISD data, there are currently 41 vacant posts, 12 of which have been vacant for over 6 months.  This is felt particularly in regions with recruitment challenges eg the North of Scotland and our more rural areas.  The College recommends that modelling is based on established posts rather than staff in post.

Correction Factor

1. The College welcomes the specialty-specific approach to the correction factor for gender and work-life balance as there are clear gender preferences within the medical specialities. However, this is not a female only issue with many male trainees expressing a preference for working less than full time, particularly if full time means a 11-12 PA contract (currently medical consultants work on average 11.4 PAs)
2. The College has assumed that in calculating the PA contribution of consultants the workforce model is referring to the totality of PAs and not just the directly clinical sessions; it is not clear within the consultation document.  Also, an increasing number of medical specialities (across the UK) are now female dominated and to which a higher correction factor should be applied.  The latest census data across the UK illustrates that 46.5% of higher trainees in medicine are now female and in addition to the list provided in the consultation document, dermatology, medical oncology, GUM, haematology and rheumatology are among the larger specialties showing a clear female preference with the smaller specialities of allergy and audio-vestibular medicine, following suit.  The College would not support a delay in application of the correction factor purely on the grounds that there is no current evidence of reduced participation, as vacancy levels and quality standards may have stimulated participation levels through job planning to protect clinical services.
3. There is direct conflict between the assumptions of decreased participation through reducing PAs due to less than full time working and increasing participation via a higher DCC:SPA ratio.  The College continues to challenge the 9:1 contract position, arguing that all consultants participate in medical education and clinical supervision and this alone, when added to individual responsibility for maintaining professional competence through CPD and, in time, revalidation makes a nonsense of a 9:1 contract split.  The College is particularly concerned about the professional development of less than full time consultants if the SPA element of consultant time is to be limited in this way.  The current vacancy factor illustrates that market forces are not influencing applications to some areas of Scotland, and contractual limitations will add to this pressure.  In a recent letter to the Scottish Government, the CMO, Chair of HIS and Chair of the Scottish Academy sought active support for the wider work of consultants in support of education, patient safety and clinical service development.  This must be resolved if planning assumptions based on participation rates are to be meaningful.
4. The College warns that a seemingly small increase in PAs worked translates into significant additional posts if consultants are expected to reduce their participation; in turn this will influence trainee numbers.  The 0.2 PA increase between 2009 and 2011 becomes almost 100 extra posts across Scotland if average PAs are expected to drop to 10 PAs.

Attrition Rates

1. The temporary attrition from trainee programmes both delays CCT dates and causes significant operational problems when LATs are difficult to recruit.  Planning assumptions should take account of predictable vacancy factors due to OOPE trends (including time out for academic study, given the strength of academic training in some specialities in Scotland) and career breaks.  Rota gaps should be addressed either through the numbers of training posts offered or initiatives like the Medical Training Initiative (MTI) which places high quality candidates from overseas for up to 2 years in training positions across the UK.
2. The College welcomes the recognition that the impact of attrition rates will be specialty-specific and that those with local knowledge have been asked to confirm current assumptions.  For example, in medical oncology the attrition rate should be higher (possibly as high as 10% due to trainees leaving or experiencing difficulties in progressing) and there is a current ”bulge” of trainees taking on average 7.5 years to complete their CCT. 
3. The impact of any future policy decisions by medical specialities to withdraw from acute take rotas to focus on specialty work should be recognised as an “attrition equivalent” for acute medicine and feature in future models. 
4. The College would be keen to see the evidence that suggests that moving overseas may become more difficult.  At a recent meeting with the President of the Australasian College of Physicians, it was very clear that both Australia and New Zealand continue to be under- doctored and are actively recruiting young physicians.  A recent JRCPTB survey of Deaneries across the UK indicates that, of almost 500 recent CCT holders, over 80% were in permanent or locum consultant posts with 6% moving overseas or out of medicine altogether – none were unemployed.
5. The global mobility of trained doctors and the UK mobility of trainees make it essential that Scottish planning takes account of workforce plans across the UK.  To plan, based on Scotland’s needs only, is short-sighted and the adoption of unattractive terms and conditions (ie 9:1 contracts) is unwise where competition for the best available candidates remains high.

CMT Numbers

1. Finally, although not considered by the consultation document – the College believes that CMT numbers in Scotland must be modelled carefully to ensure numbers are adequate to feed through into the 76 trainee posts proposed for medical specialities from ST3 onwards. A significant proportion of CMT trainees continue to move into non-medical specialities eg general practice and radiology, and the recent pattern of trainees taking time out before or after CMT to work overseas will influence competition ratios which are themselves steadily declining for CMT. 
2. A recent study in Scotland, tracking the progress of CMT trainees, has demonstrated that 63% have moved into ST3 posts in a medical specialty, 9% have left medicine for other Scottish specialties and a further 9% have left Scotland.  This illustrates all too clearly the importance of maintaining CMT numbers and of UK workforce planning.