RCoA/ GAT Trainee Survey on Workforce Planning

Transcription

1 RCoA/ GAT Trainee Survey on Workforce Planning The Department of Health (DH) workforce strategy document A High Quality Workforce 1 paved the way for the establishment of the Centre for Workforce Intelligence (CfWI) to act as the national workforce planning and development resource for the health and social care system 2. The CfWI was launched in July In February 2012, the CfWI published Shape of the Medical Workforce: Starting the debate on the future consultant workforce 3. Arising from their previous 2011 report Shape of the Medical Workforce: informing medical specialty training numbers 4, the CfWI suggested that to meet future medical needs, intake to General Practice would need to be increased to the detriment of trainee numbers in hospital- based specialties. This reduction, along with changes in service delivery and utilisation, would impact on the future consultant workforce. Due to the long nature of medical training the future consultants of 2020 are already in their final years of medical school or early years of postgraduate training. Decisions therefore need to be taken years in advance to avoid over or undersupply. The 2012 report outlined, using data obtained from mathematical modelling, the likely outcome of 7 scenarios upon the consultant workforce. These are outlined below: Potential models for the future workforce configuration Scenario Overview Scenario 1 Business as usual No changes are made to the current patterns of recruitment and deployment of trainees and doctors. Trends continue as at present Scenario 2 Shift to General Practice There is a shift from hospital specialty training posts to General Practice to achieve a target 50:50 ratio Scenario 3 Change in retirement age Retirement fixed at 60 years of age Scenario 4 Set level of demand The size of the consultant workforce is set using the Royal College demand criteria Scenario 5 Training consolidation period A consolidation period is introduced during CCT Scenario 6 Consultant- present service Employers move to a service where a consultant is in the vicinity at all times with accountability and responsibility for patient outcomes Scenario 7 Graded career structure A multi- level career structure is introduced with recognises different levels of expertise, competence and intensity of work Table reproduced from Van Besouw JP. Anaesthesia News, Sept 2012 These models incorporated existing workforce data (e.g. Office for National Statistics, NHS Information Centre for Health and Social Care) to generate a supply and demand model for the consultant workforce as a whole. Individual scenarios, generated after a consultation exercise with major health service stakeholders, were then applied to the model.

2 The projected results for scenario 1 suggest that if no changes occur in recruitment or consultant working practices, there will be an increase in the consultant headcount by 60% to over 60,000 doctors by This represents an oversupply of trained doctors against the projected demand. These projections are worrying for trainees looking to join the consultant workforce in the next decade. The Presidents of the Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) have responded to the report with concerns over the validity of some of the tabled scenarios 5,6. All scenarios, if enacted, are likely to affect current trainees more than our senior colleagues. GAT and the RCoA trainee committees therefore conducted a membership survey both to gauge trainee and junior consultant opinion about these potential changes, and to raise awareness of the report s potential implications. Aims: The survey aimed to examine four primary questions: 1. What are the respondents views on the seven modelled scenarios? 2. Does our membership agree with the CfWI proposal that change is necessary? 3. Which potential ramifications of the scenarios would be considered acceptable? 4. Which of the proposed alterations to consultant practices would our membership consider acceptable? Secondary issues we wished to investigate were: 1. What influences respondents choice of post CCT employment? 2. Do the respondents intend to gain a CCT in the current climate? Methods: The survey was conducted over a period of 3 weeks (26 th October to 16 th November 2012). It was aimed at current trainees and those who received their CCT within five years of the survey date. It was actively publicised to gain a maximal response (AAGBI e- newsletters, the RCoA The Gas trainee newsletter, AAGBI Trainee Network Links, the RCoA e- portfolio and anaesthesia school administrators). The survey was conducted using Surveymonkey and was produced with administrative support from staff at the Association of Anaesthetists of Great Britain and Ireland. As the CfWI report outlined seven options for change, our questions were tailored to these. Ranking of the options was chosen to allow respondents to demonstrate those that were the most and least acceptable, and hence reduce gaps in the data. Results:

3 2165 individuals took part in the survey with 1796 complete responses obtained. Of those respondents who supplied their grade there were: 1741 trainees, 325 consultants and 94 were made up of locum consultants, specialty doctors and fellows. Baseline data from the RCoA show 4870 registered trainees, giving a 35% response rate. It is harder to numerate for those post CCT. The RCoA has recommended 2577 doctors for a CCT since This would suggest a response rate of 15% but we know that not all post- CCT doctors continue to practice in the UK; therefore, this probably represents an underestimate. Each region of anaesthesia was well represented within the total number of survey respondents (figure 1) trainees provided their stage of training. 331 were in the first two core training years (CT1-2), 27 were in core training year 3 (CT3), 1279 were in specialty training (ST3-7) and 86 were in the old specialist registrar grade (SpR). A small number did not fit any category e.g. Maternity leave, OOPE. West of Scotland School of Wessex School Anaesthesia of Anaesthesia Welsh School of Anaesthesia Warwickshire School of Anaesthesia Tayside School of Anaesthesia Stoke on Trent School of Anaesthesia St George's School of Anaesthesia South West School of Anaesthesia South East Scotland School of South Eastern School Anaesthesia of Anaesthesia ShefKield & South Yorkshire School of Oxford Anaesthesia School of Anaesthesia Nottingham & East Midlands School of Northern Anaesthesia Ireland School of Northern School of Anaesthesia & ICM North West School of Anaesthesia North & N.E. of Scotland School of Mersey Anaesthesia School of Anaesthesia Leeds & Bradford School of KSS School Anaesthesia of Anaesthesia Imperial School of Anaesthesia East Midlands Healthcare Workforce East Coast Deanery School of Anaesthesia Central London School of Anaesthesia Bristol School of Anaesthesia Birmingham School of Anaesthesia Barts & the London School of Anglia School Anaesthesia of Anaesthesia Figure 1: Responses by primary school of anaesthesia (n = 2165) Responses to the primary questions:

4 1. What are our memberships views on the seven modelled scenarios? The seven scenarios were ranked in order of acceptability complete responses were submitted. Free text comments revealed that some trainees thought all the options were unacceptable. Despite evidence that maintaining the status quo (scenario 1) will become unfeasible, it was the most popular option (mean ranking 2.81) whilst the implementation of a graded career structure (scenario 7) was the least popular (mean ranking 5.98) (figure 2). )*+,-./0"!"1"C64/,+44"-4"646-9" )*+,-./0"%"1")+5"9+@+9"0B"3+A-,3" )*+,-./0"$"1"?7-,=+"/,".+;.+A+,5"-=+" )*+,-./0"'"1"?0,4695-,51>.+4+,5"4+.@/*+" )*+,-./0"&"1"<.-/,/,="*0,409/3-;0,">+./03" )*+,-./0"#"1")7/8"50"2+,+.-9":.-*;*+" )*+,-./0"("1"2.-3+3"*-.++."45.6*56.+"!" #" $" %" &" '" (" Figure 2: Mean ranking of CfWI scenarios based on all responses (lower number represents higher ranking) 2. Which potential ramifications of the scenarios would be considered acceptable? In addition to the ranking exercise, all trainees were asked how willing they would be to accept the changes necessary for the CfWI scenarios to be implemented. The statements they were asked to comment on were: Statement 1 Statement 2 Statement 3 Statement 4 I would consider changing specialty to meet national service reconfiguration demands for more GP trainees (scenario 2) I would consider changing specialty, if the alternative was being unemployed (scenario 2) I would consider enforced retirement at 60 to reduce consultant salary costs (Scenario 3) I would accept a period out of training rotation at mid- registrar level purely for service provision (Scenario 5)

5 Statement 5 Statement 6 Statement 7 I would support a reduction in available National Training Numbers (NTNs) to reduce the oversupply of CCT holders (Scenario 6) I would accept the formation of a tiered consultant grade, without salary or career progression, over a ten year period (Scenario 7) I would support a reduction in national medical school intake to reduce overall trainee numbers in the long- term '$!!" '#!!" '!!!" &!!" %!!" $!!" #!!"!" ()*+,-"./"01" ()*+,-"./"*2/34" /96-+." :+;/<=-4" >-?<-6-+." 1-<3/4"/5."/;".<*3+3+," >-45=-"@A@B" A3-<-4" (/+B58.*+." 0<*4-" >-45=-"C-43=*8" D=)//8"3+.*E-" Figure 3: Respondents acceptance of CfWI proposals (n = 1585). = strongly agree, = agree, = no opinion, = disagree, = strongly disagree. The most obviously unpopular options were: Changing specialty (Statement 1,CfWI Scenario 2) with 1451 (91% of respondents) scoring as disagree or strongly disagree Formation of a tiered consultant grade (Statement 6, CfWI Scenario 7) with 1270 (80 %) scoring as disagree or strongly disagree Only one option was universally popular reducing the numbers at medical school (Statement 7). The Shape of Training review 7, currently being conducted, will specifically look at the transition from undergraduate to foundation doctor. The point of this question was to canvas opinion on whether workforce planning in medicine should begin at an undergraduate level trainees (80%) agreed or strongly agreed that this concept was a potential solution to the problem of excess trained doctors. 3. Which of the proposed alterations to consultant practices would our membership consider acceptable? We asked respondents to rank the acceptability of some alternative ways of working at consultant level beyond the current New Consultant Contract (2003) 8. Creating resident on- call sessions ranked the highest for acceptability (mean 1.72), whilst

6 altering the consultant job plan to have neither pay nor career progression ranked lowest (mean 4.83 and 4.59 respectively). HI!")-"!JIJ:" 8A/"0+6/"</*+-86/28" ()"3+-//-"*-).-/001)2"45-)6"7"8)"9:" ()"*+,"*-).-/001)2"!" #" $" %" &" '" Figure 4: Alternatives to current consultant working practices. Mean ranking by respondents (1 = most acceptable, 6 = least acceptable) (n=1866) Secondary questions: 1. What influences respondents choice of post CCT employment? Consultants responding to the survey were asked to rate factors in order of importance when choosing post CCT employment, including post availability and on- call commitments. The rating scale ran from 1 (strong influence) to 5 (no influence). The factors, in order of preference, that were rated most influential were: % rated either 1 or 2 Post availability 88 Area on anaesthesia/ sub- specialisation 78 Location 91 Department 82 Future opportunities. 79 Geographical location appeared to be a strong influence in choosing where to apply for consultancy and on further questioning, 226 out of 323 (70%) had not moved on completion of training.

7 %#!" %!!" $#!" $!!" #!"!" &'()"*+*,-*.,-,)/" 012*"'3"*4*2()52(,*"6"(7." (829,*-)/" :*-*1/" ;'9*<'4" Figure 5: Factors in determining post- CCT employment (n=314). ). = no influence, = little influence, = some influence, = influence, = strong influence. 2. What are respondents intentions towards the gaining of a CCT in the current climate? Less than fulltime (LTFT) working is becoming more common amongst trainee doctors. The CfWI intends to explore how this trend will continue into the future consultant workforce. Our data provides an insight into the current thinking amongst anaesthetists trainees responded to the questions about LTFT working. 185 (10.8%) were working less than full time. 5 out of 115 non- trainees (4.8%) completing this section of the survey worked less than full time. More than 90% (168 out of 185) of NTN- holding LTFT trainees were working at 60% of the full time equivalent (FTE). The non- training grade responders were all working at 70% or more of the FTE. 13.5% of trainee respondents (both fulltime and LTFT, 230 out of 1709) expressed a desire to work less than fulltime post- CCT. This is higher than the proportion that is currently training less than fulltime. Similarly, 10.6% (12 out of 113) post- CCT respondents answered that they would like to work LTFT in the future. =7>.21"'3":&0(" With anxiety surrounding the dearth of consultant appointments, 105 out of 185 LTFT trainees (57%) have considered increasing to fulltime training to finish training and gain the CCT more quickly. Conversely, approximately the same proportion (55%) of full time trainees (839 of 1529 respondents) have considered reducing their working commitments to delay completion of &'()"*+*,-*.,-,)/" 012*"'3"*4*2()52(,*"6"(7."(829,*-)/" :*-*1/" C7)712"'88'1)74,<2(" D4"E*--"9'>>,)>24)(" C7)712"'88'1)74,<2(" D4"E*--"9'>>,)>24)("

8 The CfWI state that it is unlikely that the status quo of transition from trainee to consultant will be maintained, and that compromises by current and future trainees will have to be made. We presented six examples of compromise and asked respondents to rate each one in order to gauge which ones they considered most acceptable: '#!!" '!!!" &!!" %!!" $!!" #!!"!" (")*+,-"./01"/"2*3."45"67"5*58 291:1991-"3+;8321<4/,.7" (")*+,-"./01"/"2*3."45"67"5*58 291:1991-"=1*=9/2>4</,",*</?*5" (")*+,-"<*534-19"/"2196/515." <*53+,./5.",1C1," (")*+,-"<*534-19"/"?618,464.1-" (")*+,-"<*534-19"/"?618,464.1-" (")*+,-"<*534-19",1/C45=".>1"EFG" H164=9/?*5I"294C/.1"31<.*9" )4.>"=**-"29*321<.3"*:"/" <*53+,./5."2*3." 1C15"4:".>1"162,*7615."*2?*53" /D19)/9-3")191"+5<,1/9" )*9045=J"4:"/"=9/-1-"</9119" 3.9+<.+91"/3"-13<94;1-"45"G<15/94*" K")191".*";1"45.9*-+<1-" Figure 6: Respondents rating of acceptability of compromise examples in order to gain future post- CCT employment (n=1866). = strongly agree, = agree, = no opinion, = disagree, = strongly disagree. 37% indicated they would be willing to work within a different anaesthetic subspecialty (choosing either strongly agree or agree ) and 36% would relocate within the UK out of 1866 (79%) responded that if a graded consultant structure were to be introduced (scenario 7), they would consider emigration or leaving the NHS (either agree or strongly agree ). 60% of respondents would accept a time- limited non- consultant post with good prospects of a consultant post afterwards, however 2/3 (64%) disagreed with taking up a time- limited non- consultant post where the options for advancement were unclear and 72% rated taking up a permanent non- consultant post as unacceptable ( disagree or strongly disagree ). Free text: 431 doctors utilised the free text facility within the survey. The majority expressed deep concern over the reported proposals for changing Consultant employment and working practices. Examples included: This is all sounding very bleak

9 It is difficult to rank options when none of them are very attractive The massive changes within the NHS in the past 24 months have led me to accept a consultant post overseas This survey does not inspire me to have pride in my job! It just makes me very angry These changes are very damaging to morale amongst trainees in the NHS This survey has made me seriously depressed. The best idea was to cut back medical students. There are far too many I m planning to leave anaesthesia due to this upheaval Rock and a hard place comes to mind The UK will lose out. Anyone able to emigrate will do so The last question (about compromise solutions) is pointless. It would be better to just choose a mode of execution Conclusion: Trainee and newly appointed consultant anaesthetists are concerned about future employment. Despite the evidence put forward by the CfWI for the need for change the main scenarios put forward (4-7) were deemed unpalatable by the majority of survey respondents. Business as usual was considered to be the most acceptable solution, despite the unlikely scenario of the previous decades consultant workforce expansion continuing. The second most popular choice was to set the level of demand by using Royal College guidelines. The high ranking of this choice is difficult to understand, but may be due to the report stressing it would find solutions for current trainees 3. However, scenario 4 details the deployment of trainees in alternative service delivery models, such as using excess trainees in a trained doctor- delivered service ; in other words, trainees becoming permanent non- consultant career grades. Setting the retirement age at 60 was considered the third most acceptable choice; however, as previously pointed out, this is unlikely under current employment law. The worrying scenario is naturally number 7. The graded career structure has the potential to irreparably damage the medical service. Over generations, junior doctors have worked diligently through long, anti- social hours in order to progress to the consultant grade, where respect and a salary commensurate with their standing were expected. Grading consultants, whereby those newly appointed would no longer be able to achieve the same position as those of longer standing, has to be considered as potentially damaging. Firstly, trainee satisfaction may take a significant hit, and as the survey has shown, nearly three- quarters of trainees have said they would consider emigrating if scenario 7 were enacted. Secondly, it would serve to split the consultant workforce into factions, reducing cohesion and the teamwork so often espoused for optimum patient care. Creating tiers of seniority runs a risk of removing the unified consultant voice that has often called for reason in the face of NHS political changes. With the Shape of Training Review s interim report due in April of this year, it seems appropriate to include alterations to medical student numbers as a possible choice.

10 If the future workforce planning concerns of the medical profession could be mitigated to some extent by reducing medical school intake rather than creating a breed of unemployed expert professionals, trained at the tax- payers expense, then this should be considered as an option. 80% of respondents agreed or strongly agreed with this position. The survey has highlighted the anxiety faced by the reduction in available consultant posts. 57% of LTFT respondents reported that they have considered returning to work fulltime to secure a post, yet conversely, almost the same proportion of fulltime trainees reported that they would consider delaying their CCT for the same reason. Confusion seems to exist over what is the right course of action for trainees gaining their CCT over the upcoming years. The most acceptable compromise to respondents in altering the way they would practice in the future was opting for a consultant- delivered service with resident on- call sessions. Within the free text comments, several themes emerged. The first is that many trainees, despite the efforts of the RCoA and AAGBI, were unaware of the debate surrounding the evolution of the consultant role. Many were angry or fearful of the proposed options with the most negative comments being directed towards scenario 7, depicting a tiered consultant structure. A small minority were unwilling to accept that changes were likely and others did not engage with our efforts to gauge what would be the least bad or best compromise option. This group remained critical of the scenarios being presented in the same way as by the CfWI. 3 It should be noted that these are possibilities put forward by a single, non- medical organisation and scenario 7 may not actually come to fruition. However, with the NHS Efficiency Challenge calling for significant cost- savings, it is unlikely that the medical profession will escape unscathed. References: 1. Department of Health. A High Quality Workforce: NHS Next Stage Review; 2008: WCL. Department of Health: Procurement of Centre for Workforce Intelligence; 2010 [accessed 4 Feb 2013]. Available from: c- l.com/articles/ / WCL/How_we_can/Case_studies/Department_of_Health.aspx 3. Centre for Workforce Intelligence. Shape of the Medical Workforce: starting the debate on the future of the consultant workforce; 2012 [accessed 4 Feb 2013]. Available from: report- shape- of- the- medical- workforce 4. Centre for Workforce Intelligence. Shape of the medical workforce: informing medical specialty training numbers; 2011 [accessed 4 Feb 2013]. Available from: shape Van Besouw JP. Workforce planning: the issues. Anaesthesia News. 2012; 302:

11 Harrop- Griffiths W. Is a consultant- delivered anaesthesia service feasible or desirable? British Journal of Anaesthesia. 2012; 109: Shape of Training Review. Call for ideas and evidence; 2012 [accessed 4 Feb 2013]. Available from: nd_evidence_pub_0001.pdf_ pdf 8. National Audit Office. Pay Modernisation: A New Contract for NHS Consultants in England. London: The Stationary Office; 2007: 1-9.