BMA EVIDENCE TO DATE

  The BMA submitted preliminary written evidence in June 1998 and further evidence which expanded upon and updated it, was produced in September 1998. It provided information about the Association's current concerns and addressed in particular, the issues of numbers of doctors, overall medical workforce strategy, general practice recruitment and retention, workforce planning machinery and consultant expansion.

FURTHER EVIDENCE

  This supplementary memorandum provides additional information on workforce shortages, supply/wastage and skill mix.

  There are considerable problems with motivation and with recruitment and retention in some branches of medicine. In addition, the numbers of doctors practising in the NHS are insufficient for the activity expected of them and that this situation is likely to continue in the future. This shortage manifests itself in lengthening hours of work for many doctors and/or increased intensity of work for others. This in turn contributes to a progressive decline in morale and motivation which itself militates against the productivity gains necessary to meet demand for medical services. In short there is a vicious circule. Even when investment in new technology permits productivity gains which would ordinarily enable some additional pressures to be met without increasing intensity of work, these prove insufficient to keep up with the pace of increase of demand—itself fuelled by expectations. We set out below the evidence to support these contentions and examine the merits of "solutions" advanced from time to time to resolve the dilemma. Such solutions include the substitution of non-medical staff for doctors ("skill mix") and shifting treatment to less labour intensive settings.

THE DILEMMA

  Each year a total of 1,800 doctors retire on normal age grounds from the two main medical branches of the NHS—the hospital service and general practice. If ill-health retirements, deaths in service and retirement from other branches of medicine are included the total is nearer 2,000. Simply replacing these doctors takes around 45 per cent of the output of UK medical schools. At the same time, there has been an increase in demand for NHS care and treatment. Over the past four years, inpatient/day case activity has increased by 4.2 per cent pa, new outpatients by 4.8 per cent pa and GP consultations by 2.7 per cent pa. Some of this demand can be met from increased productivity but it would be unreasonable to expect this to exceed 1 per cent per annum on anything other than a very short term basis. Thus, in the absence of any structural change, as many as a further 2,000 doctors are needed each year to meet this new demand. This means that, in effect, some 80 per cent of the output of UK medical schools is already spoken for by replacing retiring doctors and meeting increased demand for care. This is before any account is taken of complicating factors. Some of these are as follows:

—  The majority (over 50 per cent) of new graduates are women and will over a professional lifetime supply less full time hours of work than those they are replacing;

—  The demotivating effect of medicine as a career means that many doctors will choose to reduce their commitment, retire early, or othewise leave the workforce;

—  The Working Time Directive and the ordinary pace of social change will ensure that long working hours will be increasingly unacceptable and more doctors will be needed to meet basic service commitments (an estimated 4,000 extra consultants needed to implement the Calman and New Deal reforms);

—  Changing attitudes in society generally to working patterns/intensity will be reflected in the medical workforce.

  This clearly raises the question of exactly how many doctors are going to need in the future to meet the expected continuing rise in demand and to allow for the factors outlined above. This is difficult to quantify, however. The Campbell report recommendation of an extra 1,000 doctors a year should help, however these doctors will take a number of years to come "on-stream" and will do nothing during the next 5-10 years to address the factors outlined above. The number of doctors needed to meet future demand also depends to an extent and the level of service society wants and how much the country can afford. It is worth noting that compared with other European countries, we would appear to be woefully under doctored with 1.8 doctors per thousand population compared with 2.9 in France, 3.4 in Germany and 5.5 in Italy.

  The overall shortage of doctors in the UK means that at any one time there will be competition for those the system produces. However, the nature of medical training is such that change cannot be instantaneous. Thus we have shortages of applicants for posts in general practice and psychiatry combined with over supply of trained doctors for consultant posts in obstetrics and gynaecology. In the recent past there has been a shortage of anaesthetists. There is therefore a clear need for sensible workforce planning which brings into equilibrium posts for fully trained doctors and the supply of candidates to fill these even in the context of an overall shortage.

  Short term and pragmatic thinking often works against the mechanisms which do exist. Thus trusts needing service posts advertise non-standard career and training grade posts. The NHSE was recently provided by the BMA's junior doctors' committee with a list of 191 such posts advertised in the BMJ between November 1997 and May 1998. The Department has recently issued a circular The Recruitment of Doctors and Dentists in Training (HSC 1998-229) which seeks to regularise the situation by stressing to Trusts that hospital posts which are not in a recognised training grade and which do not have both educational approval and approval by the relevant postgraduate dean cannot by designated a training placement or programme. This guidance is intended to ensure that all training opportunities to which trainees are recruited in the NHS are of an acceptable standard and accord with workforce planning requirements where these apply. It would be helpful if the Health Committee could reinforce in its report, the importance of Trusts complying with this guidance.

 THE IMPACT OF THE PRIVATE FINANCE INITIATIVE

  The BMA remains concerned about the impact of the Private Finance Initiative on the NHS and is of the view that it is an affordable long term strategy for increasing capital investment in the health service.

  We have not had an opportunity to make an analysis of the more detailed documentation such as business cases which has recently become available, however, generally our concerns about the PFI can be summarised as follows:

—  We remain concerned over the question of bed numbers and the presumption in the planning of PFI hospitals that there will be increased throughput and a reduction in bed numbers;

—  The long term nature of PFI agreements and the assumption implicit in them that there will be continued demand for the services of a particular hospital, effectively pre-empts the revenue decisions to be made by local health authorities and PCGs, for the foreseeable future;

—  There has been a reduction in the amont of capital available to the NHS because of the assumption made by government that PFI is the only feasible route for funding large capital projects.

  Our concerns about the potential implications for workforce planning are, firstly, that hospitals built under the PFI are paid for from revenue rather than capital spending, PFI funding is effectively hypothecated and resource constraints will therefore have to manifest themselves elsewhere, possibly through productivity improvements which may lead to staff reductions. Assumptions made about reduced bed numbers in PFI hospitals may also lead to unplanned changes in workforce configuration. Secondly, there is potential for the non-NHS bodies who own PFI hospitals to become employers of what were previously NHS staff. Assurances have been given that "clinical" staff will remain NHS employees, however, guidance has yet to be published.

SUPPLY/WASTAGE

  An analysis of the evidence on supply and wastage indicates the following:

EARLY CAREER

Permanent loss of manpower

  The proportion of doctors leaving medicine as a career in the first five years after graduation is small (no more than 1 per cent) 123 and is probably not preventable, other than through better career guidance before entering medical school.

  A slightly larger proportion of medical graduates (approximately 3 per cent) choose to work in another country. The main reasons for this are to attain better working conditions and/or lifestyle, followed by domestic reasons such as accompanying a spouse4. A country that is particularly seductive is Australia where doctors can work a maximum of 16 hours over the 40-hour working week and are paid at an overtime rate of four times the basic.

Temporary loss of manpower

  A temporary break from working in medicine in the United Kingdom is a popular option among doctors in the years following graduation. The BMA cohort study has tracked these workforce flows among a representative sample of five hundred doctors who graduated from UK medical schools in 1995. In the three years since the doctors graduated approximately 30 per cent have left the workforce at some point.

  The majority of doctors who leave the UK workforce during the early years of their career do so to work overseas, typically for a period of between six months and two years. Favourite destinations are Australia and New Zealand, although many still opt to work for non-government organisations in developing countries.

  A smaller proportion leave the workforce for other reasons, these include:

—  Study—this is usually related to medicine, for example postgraduate courses in tropical medicine or sports medicine;

—  To have a break from work;

—  Maternity leave;

—  Other domestic reasons—for example to care for elderly parents;

—  To pursue other interests—examples from the BMA cohort study included competing in international sporting events and renovating a house;

—  Illness—this is typically stress-related.

  Doctors are motivated to leave the workforce temporarily by both positive and negative factors. Positive factors include the desire to broaden experience, to see another health care system, the love of travel and to seek personal development. Negative factors include wanting to escape unsatisfactory working conditions, work-related stress, and illness.

  Wastage that is due to positive reasons is not only unavoidable but also desirable. Doctors who undertake overseas work, for example, have been found to return to the NHS with "enhanced, clinical, organisational and managerial skills"6. Doctors who volunteer to work in developing countries are also making an essential contribution to the international community. It should also be noted that in terms of manpower their absence is largely offset by the reciprocity of overseas medical graduates working temporarily in the United Kingdom.

  Wastage that is due to negative factors, however, is avoidable and can be reduced through improvement of working conditions and through providing better support in the early years of the medical career. Wastage due to work-related stress is an area in need of urgent attention, not just to prevent loss to the NHS, but to prevent the suffering caused to the individuals and their families. Recent research by the Health Policy and Economic Research Unit7 found that the vast majority of work-related stress experienced by junior doctors could be avoided through improvements to staffing levels and arrangements for cover.

Mid career

  There is evidence that the pattern for temporary departure from the workforce seen in the years following graduation continues throughout the medical career, albeit for different reasons (ie more for research opportunities and family reasons, less for backpacking). Again, where this is undertaken for positive reasons it should be encouraged. Properly organised and funded sabbaticals, for example, result in greater productivity over the long run by providing for continuing education and professional development; and by rejuvenating the individual and preventing "bunrnout".

  Women now make up over half of medical graduates. This will result in an increase in both temporary departures from the workforce and part time working. For example, a cohort study of 1977 qualifiers found that in 1995 nearly half of the women were working part-time8. Research by Isobel Allen9 has revealed that the majority of women doctors who have children return to work in medicine. However, in the context of the overall medical workforce shortage outlined above, more should be done to encourage their return to work. The barriers to this include:

—  Few opportunities exist for flexible training and those that do are mostly supernumerary and are therefore not considered to have the same status as full-time posts (Allen 1994);

—  "Part-time" posts in medicine usually have the equivalent hours to full-time jobs in other occupations (ibid);

—  Even fewer opportunities exist for retraining, for example for those doctors wishing to return to medicine after a break of more than two years;

—  Doctors continue to work very long hours. In a survey of senior house officers 60 per cent reported working more than 56 hours a week and 15 per cent reported working more than 80 hours a week. 10 A recent, but as yet unpublished, study of consultant workload is expected to show that the intensity, volume and complexity of the work of NHS consultants has risen since 1990 and has risen more steeply than that of other professionals11;

—  Inadequate staffing often results in doctors having to cover the work of colleagues at very short notice. This can cause severe problems for doctors with families12;

—  Many types of child-care arrangements are not appropriate for doctors who do not work 9 to 5 and are rarely able to leave work when the shift finishes;

—  Working practices do not allow for family emergencies, for example a child's illness13.

  Within medicine, the introduction of flexible working arrangements has been found to lead to increased career satisfaction without decreasing productivity or skill level14. Other benefits include improved morale, reduced absenteeism and employer cost reductions. The benefits of flexible working practices extend beyond the NHS to society as a whole. Recent research by the ESRC has found that not only do long working hours have detrimental consequences for health and wellbeing of the individual, but parents who work long hours are less likely to see their children and are less likely to supervise their progress at school15.

  It should also be accepted that career trajectories, of both men and women, have changed significantly over the last two decades. These changes can be seen in the wider labour market and have been linked to such things as changes in the family (later marriages, more divorces) and in the general standard of living. Both men and women not only want a richer professional life, but they want to combine their professional life with family and other pursuits.

  Other commentators have observed a decline in the "public service ethos". This has been evidenced by a number of attitudinal surveys; the most recent carried out by Mori for the Adam Smith Institute16. What this means is that doctors in future will be less prepared to sacrifice themselves or their families to service requirements. It will also mean that traditional market motivators such as pay will be increasingly important in manpower planning.

Late career

  The DOH has submitted evidence to the Doctors' and Dentists' Review Body that the proportion of consultants taking early retirement has increased over the last ten years. Wastage at this end of the medical career can be reduced through more flexible working arrangements that enable doctors to continue to contribute their valuable skills to the NHS in a reduced or different capacity.

SKILL MIX

  Changes to the skill mix between health professionals is often mooted as a solution to some of the workforce problems current in the NHS, ie, shortage of doctors, poor motivation of nurses. Evidence as to the real potential of changes in skill mix to address these issues is still limited however.

  Skill mix initiatives are underway throughout the NHS mainly centred on the doctor/nurse roles—both in primary care (PCAPs nurse led pilots and nurse prescribing) and in secondary care (development of advanced nurse specialists/consultants and others relating to the delegating of traditional junior doctor type work).

Recognised potential benefits to the medical profession

  enhances continuity and quality of patient care in that it can lead to better communication and improved multi professional team working. A nurse practitioners study (S Thames) found them to be safe and valued service to selected patients)

  relieves doctors of mundane tasks (admin and routine). Many of the early initiatives in skill mix were centred on transferring/sharing repetitive tasks of junior doctors work.

Issues raised by skill mix initiatives

  contested professional boundaries. Although the profession welcomes such initiatives, there are concerns about demarcation between medical and non-medical work.—ie what traditional medical tasks can be carried out safely without medical input. One example of this relates to nurse prescribing where concern has been expressed that despite dedicated nurse training, such nurses would not hold the body of knowledge to be able to identify rare illnesses if presented during consultations.

  Concerns about loss of practical training opportunities (de-skilling) are also raised, as doctors need to ensure basic skills are rehearsed (ie venflons) in a climate of increasing focus on professional competence and clinical governance. Nurses are also concerned that undertaking new roles may leave little time to dedicate to their existing roles.

  Skills transfer/substitution/specialisation threatens, in nursing, a very limited pool of nursing manpower which is currently experiencing severe shortage of qualified nursing staff thus merely creating another manpower crisis in another profession.

  Development of advanced specialist roles for other health professionals have an impact on issues of accountability (clinical and financial), competence and professional responsibility which require greater clarification as doctors and nurses may have different views of their new roles and the range and limitations of their clinical discretion. Currently, doctors are ultimately clinically responsible for the care provided for their patients as they owe them a duty of care, which may contrast with what a nurse may consider his/her professional accountability. In the case of GPs they, as employers, have additional responsibilities. Issues such as statutory registration for PAMs etc would also need clarification. Widespread skill mix would have important implications for training.

  Evaluations of skill mix initiatives have yet to provide substantial evidence that they release substantial levels of doctors time to make an impact on the demand for medical manpower—although it is thought that skill mix offers potential savings and efficiencies, there is little available evidence to demonstrate this. It is commonly known that a reduction in workload does not necessarily correlate to reduced hours of work (Read and Graves 1994). Such initiatives may reduce the level of intensity at which a doctor works and increase their job satisfaction without necessarily having a major impact on hours of work (challenging practice).

  Skill mix as a means of cost containment needs to be further examined and evidence provided. Does employing less skilled staff (cheaper resources) compromise the quality of patient care?

  Ultimately we would concur with the view of the Medical Workforce Standing Advisory Committee(3rd report—Dec 1997) that "we do not believe that skills mix changes will do a great deal to ameliorate the growth in the demand for doctors. It may however, enable other health care needs to be met".

 CHANGING THE SETTING OF CARE

  It has been contended that health care is unnecessarily "medicalised" and that much of the care offered in the relatively labour intensive setting of hospitals could be shifted into primary care and community based settings. There is little evidence, however, to suggest that this is a cheaper option, particularly as primary care is already under resourced.

TRAINING LEVY FOR DOCTORS IN PRIVATE PRACTICE

  During the oral evidence session the BMA's Chairman of Council was asked whether, when staff working in the NHS and fully trained by the NHS transfer to the private sector, there should be a levy paid towards the cost of their training. The Chairman of Council undertook to consider this issue further.

  On the question of whether doctors who mix private and NHS work should be liable for some payment towards their training, if we consider medical training as being divided into the two distinct sections of undergraduate and post graduate training, the same considerations vis a vis repayment for public funding should apply to undergraduate training as would to any undergraduate course. It should be noted that medical students already finish their courses with, on average, twice the debt of their contemporaries on other undergraduate courses (£7,697 compared with £3,88317). With regard to postgraduate training, doctors work in the training grades, where private practice is not a contractual option, for a number of years, and are usually in their mid thirties before gaining a consultant post. We believe that doctors are discharging their obligation to the NHS during this, often arduous, period of work as a junior doctor and that payment of a levy would not be appropriate, particularly as the vast majority of doctors continue to work predominantly or wholly in the NHS and receive only a small proportion of their income from non NHS work.

  With regard to doctors working wholly outside the NHS, a recently published survey of 1977 medical graduates found that 2.2 per cent of respondents were working in "non-public sector" medicine in the UK18. Of these, some will be working in areas such as private sector occupational health which, it could be argued, make a beneficial contribution to the wider public health. Others will be working in industry, along with other, non medical, researchers for whom the question of repayment of public funds spent on their training has not been raised. On the basis of this, we do not believe that there is a sufficient number of doctors employed wholly in the private sector for the question of the payment of a levy to be an issue.

SOLUTIONS TO THE CURRENT PROBLEMS OF SUPPLY IN THE MEDICAL WORKFORCE

  Since submitting its original evidence, the BMA has launched its "stop the exodus" campaign. The solutions it has put forward to the current problems in supply are:

—  Improved working conditions;

—  Support for flexible working;

—  Better pay;

—  Realistic workforce planning and consultant expansion;

—  More student exposure to general practice;

—  Better access to education for GP retainees.

  Ensuring that there is a comprehensive, confidential occupational health service available to all NHS staff would also be a useful source of support for staff and which could aid retention. The BMA has recently produced a charter for occupational health services in the NHS, a copy of which is appended.

January 1999

 REFERENCES

  1  Health Policy and Economic Research Unit. The workforce dynamics of recent medical graduates. London : British Medical Association. 1998.

  2  Richards P, McManus C, Allen I. British Doctors are not disappearing. BMJ 1997; 314 : 1567-68.

  3  Allen I. Doctors and their careers : A new generation. London: Policy Studies Institute. 1992.

  4  Health Policy and Economic Research Unit. The workforce dynamics of recent medical graduates. London : British Medical Association. 1998.

  5  Health Policy and Economic Research Unit. The workforce dynamics of recent medical graduates. London : British Medical Association. 1998.

  6  Banatvala N, and Macklow-Smith A. Bringing it back to Blighty. BMJ 1997; Classified suppl:31 May 1997.

  7  Health Policy and Economic Research Unit. Work related stress among junior doctors. London : British Medical Association. 1998.

  8  Davidson J, Lamber T, Goldacre M. Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977 : postal questionnaire survey. BMJ 1998; 317:1429-31.

  9  Allen I. Doctors and their careers : A new generation. London : Policy Studies Institute. 1992.

  10  HPERU. Stress among junior doctors: A report from the BMA cohort study of 1995 medical graduates. London: BMA. 1998.

  11  Timmins N. NHS Consultants are now roking "harder and longer". Financial Times. January 7, 1999.

  12  Ibid.

  13  Ibid.

  14  Reider M J, Hanmer S J, and Haslan R H. Age and gender-related differences in clinical productivity among Canadian paediatricians. Paediatrics. 1990 : 85 : 144-9.

  15  Economics and Social Research Council. Work Now. Pay Later! Social Sciences. Issue 40.October 1998.

  16  Pirie M, Worcester R. The Millennial Generation. London : Adam Smith Institute. 1998.

  17  Barclays student survey. 1998.

  18  Davidson J, Lamber T, Goldacre M. Op cit.