As a guide, the document is set out in the following divisions. Some of the themes that have been identified may overlap several divisions.
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1 MEDICAL SPECIALTY WORKFORCE FACTSHEET MEDICAL ONCOLOGY This document sets out factors that will be considered when assessing the supply and requirement of the future medical workforce. The first section of the fact sheet focuses on the future requirement of the specialty; the second section focuses on the current supply. This information will form part of the body of evidence used to advise recommendations of future medical training numbers. At this stage it does not present conclusions or recommendations. This is a live document that represents work in progress; it will be updated on an ongoing basis as information is located and made available to the CfWI. The CfWI will welcome relevant contributions to the content or interpretation of information within the medical specialty workforce fact sheets. As a guide, the document is set out in the following divisions. Some of the themes that have been identified may overlap several divisions. Considerations for future requirements Current Status of Specialty s Requirement Demographics Health and Lifestyle Prevalence and estimated future incidence of factors that affect requirement Changes in practice which may affect level of service Finished Consultant Episodes (FCEs) and Outpatient Attendances Weighted Capitation Historical and forecast supply Existing Workforce Consultant projections Geographic distribution Recruitment to further medical training Related healthcare workforce CfWI August
2 CONSIDERATIONS FOR FUTURE REQUIREMENTS Current Status of Specialty s Requirement Demand for trained specialists in is increasing. The major drivers of this rise in demand include the ageing population and consequently the rise of incidents of cancer in the country. Chemotherapy is also being used to treat a wider variety of cancer; the delivery of which has increased by 60% in four years (National Chemotherapy Advisory Group). The 2008 Cancer Reform Strategy (CRS) states that the number of new drugs licensed for use in different cancers is likely to grow considerably over the next decade. The Royal College of Physicians (RCP) have also reported that treatment options for patients with common cancers have increased substantially in recent years, which has led to a significantly greater workload for Medical Oncologists, thus demanding a greater workforce requirement. The World Health Organisation (WHO) has recognised that the proportion of people aged over 60 years is growing faster than any other age group. This ageing population suggests that cancer rates will increase in years to come as cancer is more prevalent in the elderly. An increasing cancer rate acts as a demand driver for specialists to treat the cancer patients. It is forecast that by 2015, the estimated requirement of 300 consultants, to deliver comprehensive care to all, will be reached (source: The Royal College of Physicians (RCP), Consultant Physicians Working with Patients 4th edition, 2007). The College predicts that due to the increase in treatment options now available for patients with common cancers the actual requirement for consultants is closer to 400. Vacancies and Locum staff The three-month vacancy rate for consultants is 0.5% on average for the whole of England (Information Census Vacancy Survey, 2008). According to the NHS Information Centre s IView database (March 2010), locum staff account for 2% of the total consultant workforce in. CfWI August
3 Demographics Figure 1 (below) shows growth of the population from 2010 up to 2031 by age band as predicted by the ONS. It indicates that the greatest growth of the population is in the over 60s. The bold lines indicate the level of the population in Figure 1: 2031 population estimate and Indication of age and gender of the population which relies most heavily on Figure 1 indicates the age and gender of the population which relies most heavily on. The blue area is the male age range whereas the pink area is the female age range which requires the most significant portion of services. A grey area indicates a section of the population which does not typically present for care or have interventions delivered by this specialty. Figure 1 also indicates that the older adult and elderly population are most reliant on and will drive the requirement for those services. Figure 2: Demographic Summary all ages % 0.79% -0.01% 0.43% 0.01% 0.5% 2.03% 0.74% Time/years 2031 Figure 2 displays the relative population percentage growth per year, broken down by age group, highlighting the variable rates over time and age. In the age group which accounts for the most significant proportion of care required is generally the elderly adult population (over 60s). The average growth of the elderly adult population is about 2%. CfWI August
4 Health and Lifestyle Table 1 shows the trends in lifestyle behaviours for a select set of behaviours which are indicators to the possible health requirement for Medical Oncology. Lifestyle Influences Table 1: Trends in lifestyle behaviours for a select number of behaviours Lifestyle behaviour Smoking % Drinking (adult males) % (-) (-) (-) 28 Drinking (adult females) % (-) (-) (-) 19 Binge drinking (adult males) % Binge drinking (adult females) % Obesity (children) % Obesity (adult males) % Obesity (adult females) % Source: DoH Health Profile for England, published March 2010 (-) Indicates no available data The table indicates that smoking in adults has been decreasing in recent years. Drinking in adults has fluctuated since 2000 with a high of 31% in 2006 for men (20% in 2006 for women) and a low of 24% in 2005 (13% in 2005 for women). There is no evidence to suggest that drinking will not stay between these extremes in the near future. Binge drinking for males in 2008 (21%) is at the same level it was in 2000 after peaking in 2007 at 25%. In females, however, the recent trend is a decreasing one although it is still higher in 2008 (14%) than it was in 2005 (8%). Obesity in children is on the decline and may drop below 10% by 2012 if the recent trend holds. Obesity in adults, however, is still rising although there is an indication that it may be flattening out. CfWI August
5 Tobacco smoke Figure 3: Smoking trends, Great Britain by sex Smoking is the largest cause of premature death in England. Smoking is seen as a factor towards lung cancer, coronary heart disease and chronic obstructive pulmonary disease (COPD). Cancer Research UK reports that in 2008, approximately 10 million adults smoked cigarettes in Britain (23% of men and 21% of women). Although the smoking prevalence has been gradually declining since the early 1970s, the proportion of current cigarette smokers (22%) has not changed significantly in recent years (Figure 3). Men were more likely than women to have given up smoking cigarettes (34 per cent compared with 30 per cent) (Office for National Statistics, 2009). Figure 4: Prevalence of cigarette smoking by age, persons aged 16 and over, Great Britain In Great Britain, one third of people in the age group are recorded as smokers and this group has highest rate of smoking. The prevalence of smoking is going down with age, with 13% of people aged 60 and over recorded as smokers (Figure 4). CfWI August
6 Various legislation measurements were launched to reduce smoking: Smoking Kills a White Paper on tobacco (DoH, 1998); Choosing Health: Making healthier choices easier (DoH, 2004); a target to reduce smoking rates among adults to 21% or less and among manual groups to 26% or less by 2010 was set in the Cancer Plan in 2000 and then was repeated in the Public Service Agreement in 2004; a comprehensive ban on smoking in all enclosed public places was introduced in England from July Every year, there are 78 attempts to quit smoking for every 100 smokers (counting multiple attempts by the same individual). Creating universally accessible, effective smoking cessation services and widely publicising their utility is an NHS priority. There are a range of possible intervention techniques, both pharmaceutical (nicotine replacement therapy, bupropion and varenicline) and behavioural (group therapy, face-to-face or telephone counselling), with varied staffing configurations. It can be assumed that prevalence of smoking will be decreasing or at least remaining constant. The use of oral contraceptives and hormone replacement therapy have been shown to increase the risk of developing cancer in women. Alcohol consumption increases cancer risk especially among smokers. A high fibre, low fat diet with plenty of fruit reduces the risk of cancer. Physical activity reduces the risk of cancer. Obesity, and being overweight, increases the risk of developing cancer. Exposure to significant levels of sunlight increases the risk of skin cancer. CfWI August
7 Prevalence and estimated future incidence of factors that affect requirement Table 2: UK estimates of total cancer prevalence Cancer Type UK 2008 estimates 1 Breast (female) Large bowel Prostate Lung Other All cancers (based on diagnoses applied to 2008 population; Thames Cancer Registry, 2008) Source: Cancer Research UK According to Cancer Research UK: Overall, it is estimated that there are now 2 million cancer survivors in the UK, or approximately 3.3% of the population of the UK 1. This figure is rising at an estimated 3.2% per year, with the single cancer that contributes most to this total being breast cancer, with an estimated 550,000 women alive who have had a diagnosis of breast cancer. Overall, 10% of the total UK population over the age of 65 years is now a cancer survivor. These latest estimates are much higher than previous forecasts of cancer prevalence. This is mainly because incidence has been rising whilst the death rates have continued to fall, leading to better survival. This trend is expected to continue over the coming years as a result of a number of factors, including an ageing population, earlier detection of cancer and continued improvements in treatment. The rate of new cases of lung cancer is decreasing, however the total number of cases is increasing due to the aging population. Breast cancer incidence rates in the UK have increased by 5% over the past 10 years. 80% of breast cancer cases are diagnosed in women over 50. Bowel cancer incidence rates have remained relatively stable over the past 10 years. 80% of bowel cancer is diagnosed in people over 60. More than 50% of all prostate cancer cases are diagnosed in men over 70. Increased use of Prostate Specific Antigen (PSA) testing has increased the rate of survival from prostate cancer, so more men are living with prostate cancer. CfWI August
8 Figure 5: Number of new cases and rates, by age and sex, all malignant neoplasms (excluding non-melanoma skin cancer), UK, 2007 (Cancer Research UK) Figure 5 shows that the aginig population accounts for the vast majority of the number of new cases of malignant neoplasms in the UK. It is estimated that more than one in three people will develop some form of cancer during their lifetime. This compares to an estimated risk of 1 in 27 for people aged up to 50 years. (Cancer Research, UK) Breast cancer accounts for nearly half (46%) of all cancers diagnosed in UK women aged years. Figure 6: Age-standardised (European) incidence rates, all cancers excluding non-melanoma skin cancer, by sex, UK, If current cancer incidence rates remain the same, by 2025 there will be an additional 100,000 cases of cancer diagnosed each year as a result of the ageing population (Cancer Research UK). CfWI August
9 Changes in practice which may affect level of service Royal College of Physicians consultant physicians working with patients (4th ed) This report describes recent changes to the service: Referral of patients with suspected cancer is usually initiated in primary care by the patient s GP. Waiting-time targets have been set to ensure that the time from referral to diagnosis to treatment is as short as possible, and further action will be taken over the next five years to reduce waiting times for all modalities of treatment. Patients are now referred to experts in the relevant tumour type, initial referral is often to a cancer surgeon or physician, and all suspected and proved cases of cancer are discussed within a MDT to ensure that a treatment plan is developed appropriate to a patient s needs. Systemic treatment is delivered under the care of medical (and clinical) oncologists. Future changes are also outlined: Meetings of the MDT take place within local hospitals or cancer units for common tumour types; however, less common types of tumour are centralised within a cancer centre, so that there is a critical volume of patients and staff to allow delivery of the highest possible standard of care. No cancer unit can function in isolation, and all units are part of one of the 34 cancer networks within the UK (each network serves a population of between one million and three million). Within each network, tumour site-specific boards cover all tumour types to ensure a coordinated approach to the organisation of services and delivery of care and to ensure equity of access for patients. Over the next decade, the new National Cancer Intelligence Network will monitor these processes in relation to performance and patient experience. Within the cancer strategy, focus is increasingly on new models of care, with an emphasis on centralising wherever necessary to improve outcomes eg for complex treatment delivery but with the principle that care should be delivered locally, whenever that is consistent with good-quality care, in order to maximise convenience for the patient. Regarding inpatient care for cancer, significant opportunities exist to move some services from inpatient to ambulatory care, and the Cancer Services Collaborative Partnership and Cancer Action Team are developing a programme of work on inpatient management to support such local implementation and changes in models of care. In all cases, care must conform with national standards eg the Improving Outcomes Guidance (IOG)3 and should be integrated fully with other services within the cancer network. These changes can be delivered only with strong commissioning and with primary care trusts (PCTs) supported by cancer networks to ensure that the NHS delivers value for money while funding world-class cancer services. The new cancer strategy will: support workforce development and training conduct good-quality horizon scanning increase support for research CfWI August
10 continue working in partnership with stakeholders provide national leadership and support publish annual reports. The focus is not only on delivery of care for established cancer but also on prevention of cancer, as more than half of all cancers could be prevented by lifestyle changes and, for some cancers, interventions (secondary prevention) may afford further opportunities to prevent development of the disease. Such strategies may include immunisation against cervical cancer, increased screening for breast and bowel cancer, and increased regulation of tobacco. The report outlines service developments to deliver improved patient care: Coordination of care for patients with cancer through regular meetings of the MDT has improved patient access to oncological care and the timeliness of delivery. Medical oncology continues to develop MDTs for all tumour sites. Cancer medicine and systemic treatment are undergoing rapid change with the development of multiple diagnostic tools and treatment modalities. The assessment and introduction of this new technology has, for the most part, been led by medical oncology, with an emphasis on audit and research. The National Institute for Health and Clinical Excellence (NICE) issues guidance on the use of not only drugs but also new technologies. Service provision in cancer centres and cancer units is described as follows: Most medical oncologists will be based in a cancer centre and will provide a number of direct clinical care PAs in a peripheral cancer unit within their network. For some, the principal site of activity and, as a consequence, inpatient admitting rights and responsibilities is within the cancer unit of a DGH, and they will visit their cancer centre for a limited number of PAs relating to audit, research and CPD. If the secondary site is a cancer unit, arrangements must be made for local consultant cover (eg by a haematologist or a general physician), with appropriate protocols for the care of oncological emergencies and the attending medical oncologist acting in an advisory role. The workforce requirements for the specialty are outlined: In 2000, the College recommended a figure of 1.25 WTE medical oncologists per 200, ,000 population. This requires about 250 WTE, which equates to a total of about 300 medical oncologists in the UK. In November 2000, there were 138 medical oncologists in the UK; this figure increased to 229 in September There is, therefore, still a substantial shortfall against the figure of 300 medical oncologists recommended in Treatment options for patients with common cancers have increased substantially in the past three years, which has led to a significantly greater workload for medical oncologists. It is likely, therefore, that the predicted workforce requirement for medical oncology in the UK is actually a minimum of 400 posts. CfWI August
11 Department of Health two week wait Government policy in 2010 gave patients the right to an appointment for suspected cancer in urgent cases within two weeks of referral by their GP. FCEs, Outpatient Attendances Figure 7: FCE per year for Finished consultant episodes per year for medical oncology Source: The NHS Information Centre, Hospital Episode Statistics for England. Inpatient statistics, Finished Consultant Episodes (FCEs) The chart shows Finished Consultant Episode (FCE) data for Medical Oncology over three years up to It is assumed that the recording and definition of FCEs in this speciality has not changed significantly over this time period, and therefore the rise in FCEs indicates an increase of activity in the speciality. It should be noted that the data in the chart does not represent all the activity in this speciality; outpatient data is not covered, which makes up a significant proportion of the service. Year starting Potential sources of data include historic outpatient attendance data that may highlight changing demand within the speciality. However, verification that the data is appropriate for an analysis should be sought from a member of the speciality. CfWI August
12 Weighted Capitation Table 3: Table of 6 scenarios for each SHA based on weighted capitation for the possible requirements of junior doctors SHA Ratio of Actual : Weighted Capitation Move All to Average Value Move All to Median Value Move All to Min Move All to 2nd Min Move All to 2nd Max Move All to Max North East North West Yorkshire & The Humber East Midlands West Midlands East of England London 2.83 max max max max max max South East Coast 0.34 min min min min min min South Central South West Total % change -1.0% -5.2% -34.9% -18.8% 34.8% 100.6% The table above displays six scenarios based on weighted capitation (WCAP) alone for the possible requirements of junior doctors in Medical Oncology. Column 2 is the ratio of the actual capitation to the calculated theoretical capitation. Columns 3-8 are the scenarios where all except the most under capitated and the most over-capitated are moved to the mean, median, least, 2 nd least, 2 nd most and most capitated levels respectively. The values in the 2 nd row are the mean, median, least capitated, 2 nd least capitated, the 2 nd most and most capitated respectively. This analysis reveals that change in requirements range from an increase of 34.8% (2 nd most capitated) to a decrease of 18.8% (2 nd least capitated) on average when only weighted capitation is considered for. CfWI August
13 HISTORICAL AND FORECAST SUPPLY The supply of the medical workforce and forecast of consultant medical oncologists are shown in Figures 8a-b. The Figures are based upon the latest data available (SAS data only dates back to 2005). Figures 8a-b: (a) Workforce supply (FTE), and (b) Workforce supply (HC) 800 Cumulative historical workforce supply (HC) and future consultant projections Cumulative historical workforce supply (FTE) and future consultant projections SAS SAS 500 All Trainees 500 All Trainees HC Consultants HC (historic) FTE Consultants FTE (historic) Consultants HC (forecast) Consultants FTE (forecast) Year Year The chart above shows an expansion in the workforce since 1997, at an increasing rate of change during the past five years, and the supply of consultants is forecast to increase during the next decade. Trainee grade doctors (which are defined as those in the F2, SHO and registrar groups) account for approximately half the workforce in total. The data indicate that there has been an increase of 81 FTE consultants between 2004 and 2008, which is 30% of the workforce in CFWI modelling suggests that the supply of consultants over the next ten years is forecast to increase to 316 FTE in 2018 (446 headcount), an average increase of 4.7% annually, based upon the following assumptions: CfWI August
14 an average of 4 retirements per year over the next 10 years, 50% of current trainees are delayed in completing their training by three years, there is no international recruit per annum, one young leaver (non-retirements) and no returners per annum, there is no conversions of staff grade or associate specialist posts to consultant posts per annum, there is a wastage rate amongst registrars of 1%. In the past, the accuracy of WRT s projections in this specialty have been true to within 6.3%, based upon records predictions made in 2005 for CfWI August
15 Existing Workforce Supply According to the 2009 IC census there are 254 FTE (283 headcount) consultants, while Electronic Staff Records (ESR) from September 2009 show 225 FTE (240 headcount). This is a difference of 13% in comparison to census records. The latest available data records 230 FTE consultants (245 headcount) (extracted via iview from ESR, March 2010). The age profile of the current consultant workforce as at September 2009 is shown in Figures 9a-b. Figures 9a-b: (a) Age profile (FTE) and, (b) Age profile (Headcount) consultants FTE Consultant age profile (FTE) - Headcount Consultant age profile (Headcount) - Under Age bracket (years) and over Under Age bracket (years) and over Figures 9a-b show a plentiful supply of younger staff with only a small number of consultants working beyond typical retirement age. The IC three-month vacancy rate for all general medicine consultants is 0.7% as of March 2008 (the latest available data); the three-month vacancy rate for consultants is marginally lower at 0.5%. CfWI August
16 Geographic Distribution Tables 4a and b below show the geographic distribution of doctors and trainees in absolute values and in relation to the weighted capitation of each Strategic Health Authority (SHA) (a definition of weighted capitation is given below*). Tables 4a-b: (a) Number of doctors minus the weighted capitation, (b) Actual number of doctors, by grade and SHA for Number of doctors minus the weighted capitation, shown for by SHA - Based on latest data available as at April 2010 Actual number of doctors by grade and SHA, shown for - Based on latest data available as at April 2010 Table a Table b SHA Weighted Capitation Junior doctors Staff grade Specialty Doctor Associate specialist Consultant Junior doctors Staff grade Specialty Doctor Associate specialist Consultant North East 5.9% North West 15.2% Yorkshire & The Humber 10.8% East Midlands 8.6% West Midlands 11.2% East of England 10.2% London 14.1% South East Coast 7.6% South Central 6.6% South West 9.8% Total 100% CfWI August
17 Tables 4 a and b suggest that, out of the ten SHAs, NHS London is over-capitated for both consultants and junior doctors, i.e. it has a greater proportion of England s doctors than if provision were to follow weighted capitation. This indicates a significantly skewed geographical distribution of the workforce. It can be seen that junior doctors are also skewed slightly towards Yorkshire and The Humber SHA. *The Department of Health uses a weighted capitation formula (WCAP) to distribute resources to primary care trusts (PCTS) based on the relative health needs of each PCT s catchment area. If qualified doctors and trainees were equitably distributed according to the formula, all other columns in tables 3a would be zero. Values greater than zero indicate that the SHA has more doctors and trainees than would be included by WCAP; values less than zero indicate evidenced room for growth of the workforce. CfWI August
18 Recruitment 2009 The level of recruitment to further medical training is shown in Table 5. The table illustrates the situation at point of entry in The data corresponds to posts openly advertised but not those training posts secured by run-through trainees. Table 5: 2009 Specialty Recruitment for at ST3 (as of October 2009) Deanery Available Posts Accepted Posts Fill Rate East Midlands % East of England Kent, Surrey and Sussex London 3 0 0% Mersey % North West % Northern 1 0 0% Oxford Peninsula Severn West Midlands The table shows that there is an uneven distribution geographically, with London, Yorkshire and the Humber and Northern deaneries filling none of their available posts. The North West shows a fill rate of 700% even though there was only one post, which is due to students deferring the year. The current number of available posts does not correspond with geographic distribution, as London is hugely overcapitated compared to other areas, although still has the largest increase in commissioned training posts. The West Midlands is under-capitated both with junior and consultant doctors and this does not reflect the choice of zero additional posts for the area. In CfWI s view, the degree to which the current number of available posts are filled together with geographic distribution are essential factors in evaluating the requirement for additional posts. Wessex Yorkshire and the Humber 2 0 0% Total % CfWI August
19 Related Healthcare Workforce Medical oncologists form part of an MDT with surgeons, specialist physicians, clinical oncologists, radiologists, pathologists, clinical nurse specialists, research practitioners and other professions allied to medicine (PAMs). They work closely with local support services in the hospital, including physiotherapy, occupational therapy, district nursing and hospice teams. Integration with palliative care services is vital in the provision of appropriate care. CfWI August
20 REFERENCES Cancer Research UK ( Department of Health, Smoking kills a white paper on tobacco. Available at: DH_ Department of Health, Cancer plan. Available at: Department of Health, Choosing Health: Making healthy choices easier. Available at: DH_ Doll, R. and Fau, P.J., Epidemiology of Cancer, in Oxford Textbook of MedicineD. Warrell, et al., Editors. 2003, OUP. Forman, D., et al., Cancer prevalence in the UK: results from the EUROPREVAL study. Ann Oncol, (4): p ( Health Survey for England 2006 (2008), Available at Maddams J, Moller H and Devane C., Cancer prevalence in the UK, 2008 Thames Cancer Registry and Macmillan Cancer Support, 2008 ( Royal College of Physicians. Consultant Physicians Working with Patients 4th Edition (2008) ( The NHS Information Centre Vacancy Survey (2008) The NHS Information Centre, Hospital Episode Statistics for England. Inpatient statistics, Available at: CfWI August
21 OTHER SOURCES Cancer Reform Strategy (CRS) Choosing Health White Paper (2004) Department of Health (2010) Foresight (2007) National Audit Office (2008) National Chemotherapy Advisory Group NHS Information Centre (2010) Office of National Statistics Quality Care for All (June 2008) The World Health Organisation (WHO) Workforce Review Team CfWI August
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