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Workforce planning in medicine is far from being an exact science, with some claiming that the phrase is a classic example of an oxymoron. A recent publication from the Centre for Workforce Intelligence (CfWI) declares that there are too many people in medical training at present, and has prophesied an uncertain future for those entering specialty training: many may struggle to find consultant posts [1]. The CfWI's confidence in its assertions is admirable, but there exists a complex mix of medical, financial, political and social factors that together will militate against reliance on the prognostications of even the most estimable of workforce think tanks. The following are just a few of the current issues, all of which may have substantial – and at different times opposing or synergistic – effects on the demand for trained doctors: changes to the National Health Service (NHS) pension scheme; revalidation; increasing calls for 24/7 consultant-delivered care; the implications of the Health and Social Care Act [2]; and, perhaps most significant of all these, the current and future pressures on the NHS budget. Add to this rich mix the feminisation of medicine, trends in what are and are not attractive specialties, and the changing attitudes to work-life balance of Generations X, Y and Z, and you have a recipe for profound incalculability. With this as a backdrop, what chances do those charged with workforce planning in anaesthesia have of matching the need for anaesthetists with the supply of those coming off the Certificate of Completion of Training (CCT) production line, with even a loose degree of accuracy?

The work done by anaesthetists is changing as the role moves from simple deliverer of unconsciousness and analgesia to that of peri-operative physician, including: pre-operative assessment and optimisation; acute and chronic pain management; peri-operative critical care; resuscitation and transfer; theatre systems management; education; and research. As the population ages and its need for healthcare intervention escalates, the work of anaesthetists increases in breadth and complexity, and the demand for a larger and more highly trained anaesthetic workforce inexorably mounts. Workforce estimates that result in a plateauing of the need for anaesthetic numbers are almost certainly inaccurate.

What questions should be answered when making plans for the anaesthetic workforce of the future? We would argue that they should include at least:

  • How many people per year will need care from anaesthetists, and what level and complexity of care will they need?
  • What are the effects of an ageing population, new therapeutic interventions, more preventative care and better non-surgical treatments?
  • Which service configurations provide the best quality care: small numbers of large, acute hospitals; large numbers of smaller, local units; and/or an increasing proportion of care delivered in the independent (private) sector?
  • Who should provide anaesthetic care – consultants, trainees, staff grades, associate specialists, specialty doctors or physician's assistants (anaesthesia) (PA(A)s) – and in what proportions?

The number of patients and the complexity of their care

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

Epidemiologists and demographic experts tell us with justifiable confidence that although the population of the UK may not grow significantly, its average age will increase. An ageing population will place greater demands on the NHS, both in terms of the numbers of patients requiring surgical and other invasive interventions, and in the complexity of the care required, given that advancing age is associated with an increasing prevalence of co-morbidity. Professional bodies such as the Association of Anaesthetists of Great Britain & Ireland (AAGBI) are well placed to comment on the likely future clinical developments and on the changes necessary to provide the increasingly high-quality outcomes that will reasonably be demanded. It is the anaesthetists themselves, whether they are primarily clinicians, managers, researchers or innovators, who are best placed to map out the future direction of the specialty and the demands that this direction will place on the numbers of anaesthetists needed. Technological developments in surgery have led prognosticators to talk of the decreased need for anaesthesia on many occasions in the last 20 years, and yet the amount of work that anaesthetists are asked to do inexorably mounts. One department [3] has experienced a 52% increase in the total number of daytime theatre sessions delivered between 1999 and 2009, achieved with a 50% expansion in anaesthetic staff. Emergency admissions increased by 12% between 2004/05 and 2008/09, with 40% of this increase caused by the ageing population [4]. Thus, in the last decade, the need for anaesthetic care has grown considerably, and there is no reason to suppose that the next 10 years will be any different.

Service reconfiguration

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

Centralisation of acute care is an attractive clinical and organisational concept. Proportionately fewer doctors would be needed to provide resident, out-of-hours cover in medical specialties that are clinically active around the clock if there were fewer, larger sites delivering acute care. This is a simple and logical strategy but is one that is fraught with political difficulties. Closing hospitals may be attractive to those responsible for managing the NHS but is almost always unacceptable to the communities surrounding the doomed hospitals. So far, the English Strategic Health Authorities (SHAs) do not appear to have grasped the nettle of reconfiguration with any real determination, with the possible recent exception of NHS North West London [5]. One is tempted to speculate that this failure to grasp nettles may have been because the SHAs were answerable to the Department of Health, which is in turn answerable to the Government, which is answerable ultimately to the electorate, many of whom live near the self-same doomed, local hospitals whose closure they will inevitably and vigorously oppose. Health is politics and politics is health. It is a difficult conundrum to resolve, and exercises politicians in the whole of the UK, the Republic of Ireland and in many other countries

The Health and Social Care Act 2012 [2] envisages that a larger proportion of NHS elective surgical care will be delivered in the private sector, and independent sector providers are more than keen to make this vision a reality. Who is going to provide anaesthetic services for these organisations as their proportion of elective NHS surgery grows? It is likely that most consultant anaesthetists in the NHS have little extra capacity to cover NHS work in the independent sector, particularly with current trends for an increasing proportion of their contracted time to be devoted to delivering direct clinical care in NHS trusts. Increasing pension contributions and decreasing pension values may lead some consultants to retire early from the NHS and transfer to the independent sector. Although this ‘grey migration’ may put experienced clinicians in the independent sector, the salaries they will expect might not be readily affordable. Trainees seeking consultant posts may fulfil this need if NHS jobs are hard to come by. Anaesthetists from overseas may fill these gaps if the remuneration offered in the private sector is unattractive to UK doctors but relatively generous for those from the lower-income countries of Europe. The workforce response to the changes driven by the Health and Social Care Act is just another unknown in the complex calculation.

Who provides care?

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

Another important factor in the workforce riddle is the question of who delivers anaesthetic care. The CfWI document states that consultant-delivered care is faster and is associated with better patient outcomes [1]. This is endorsed by a recent publication by the Academy of Medical Royal Colleges, The Benefits of Consultant-delivered Care [6], which details the following key benefits: (i) rapid and appropriate decision-making; (ii) improved outcomes; (iii) more efficient use of resources; (iv) matching patients’ expectations of access to appropriate and skilled clinicians and information; and (v) improved training of junior doctors.

The determination that consultant-delivered care, as opposed to trained doctor-delivered care, is ideal may be primarily political, in that there is resistance within the medical profession to the creation of a sub-consultant or other non-consultant-but-fully-trained grade, but the suggestion that medical care should be delivered primarily by trained doctors is attractive. However, what little evidence is available on the practice of PA(A)s suggests that they too can deliver safe and effective care under appropriate supervision [7]. The exact future model of care delivery is difficult to ascertain, but with limited financial resources, a static number of specialty doctors, decreasing numbers of anaesthetic trainees and a still very small PA(A) workforce, it is difficult to imagine that it will change significantly in the medium term.

A shift to general practice

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

The Department of Health's White Paper, Equity and Excellence: Liberating the NHS, states that care should be moved closer to home [8]. The CfWI report recommends that, to support this, England increases the number of general practitioner (GP) training posts from 2700 to 3250 per annum (a 17% increase) within four years [1]. This will result in an effective diversion of trainees from hospital medicine to general practice, achieved by decreasing national training numbers and core training opportunities in hospital-based specialties. The vision that an enhanced GP workforce will serve to decrease the number of hospital admissions and allow a significant reduction in the number of hospital consultants is an attractive one, but great care should be exercised to resist the temptation to spread the decrease evenly across all hospital specialties. Better primary care may reduce the burden on consultant physicians. However, few anaesthetics are given for conditions that will be eradicated by larger GP numbers.

The current dilemma

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

In 2011, the number of people who completed UK anaesthetic training (approx 370) [9] was more than the number of consultant posts advertised [10, 11]. Severe financial pressures upon the NHS are restricting trusts’ capacity to increase – or even maintain – service delivery. Although ‘efficiencies’ are being identified in the rationalisation of operating theatre usage, and increases in delivery of direct clinical care resulting from enforced reductions in the amount of supporting professional activity that consultants can perform within their contract, there is a limit to the time for which these efficiencies can delay the appointment of more consultants. The gaps left by a relative shortage of consultants can, on the face of it at least, be filled by extending the unsupervised clinical commitment of trainees, but with an almost inevitable detriment to the quality of training [12]. Unfortunately, the number of consultant posts advertised is being taken as a surrogate measure of current requirements, and training numbers are being reduced proportionately. In our opinion, this is a folly that will create a problem for both the specialty of anaesthesia and the NHS as a whole.

It is important that those making workforce predications take account of the effect that their statements have on recruitment and retention. A recent example of the difficulties caused has been seen recently in Scotland, where rumours of poor local job prospects may have been a factor in the decision taken by 25% of those obtaining a CCT in anaesthesia in Scotland in 2012 to leave the country to seek work elsewhere. Not everyone is willing to wait around when job prospects are uncertain. In fact, 28 consultant posts have been advertised in Scotland, not all of which are currently filled. Furthermore, for the first time in a number of years, Scotland failed to fill its 3rd-year specialist trainee (ST3) posts in 2012 and there is a 40% reduction in ST3 applications to Scotland for 2013 (AAGBI Scottish Standing Committee Minutes; unpublished). This parallels the situation that occurred in obstetrics and gynaecology in 2000 [13], and 10 years earlier in histopathology [14], where an apparent lack of consultant posts led to these specialties’ becoming a less popular career choice.

The dilemma we face is whether: (i) to train the number of anaesthetists that is likely to be needed to deliver the projected increased volume of care, on a consultant – or at least trained-doctor – basis; (ii) to train the number necessary simply to fulfil current NHS vacancy rates; or (iii) to cut numbers of trainees to cater for a world in which improved primary care makes hospital-based care less necessary. If we cut recruitment, we will be likely to face a future shortage. Pressure will then be placed on anaesthetists to stay ‘at the coalface’ and not to develop leadership, management and academic roles. As a result, we will be less available to innovate and develop more efficient and safer services that deliver better care. We will undoubtedly be expected to work for longer: newer consultants already face the prospect of working to the age of 68. However, will we be able to function fully in our acute specialty all the way to the new age of retirement? Canadian anaesthesiologists aged 65 or older have almost twice as many settled medicolegal claims against them compared with those aged < 51 years, particularly in relation to events occurring at night and at the weekend [15]. With fewer trainees, consultants and other trained doctors will inevitably have to provide more emergency, i.e. out-of-hours, care. This could lead to short-term cuts in elective services and even greater pressure on a contracted, ageing workforce. The risk in continuing to recruit at current levels relates to the short-term oversupply of trained doctors. This may create an additional downward pressure on salaries and a greater drive towards a grade into which trained anaesthetists could fit but whose terms and conditions of working are not as good as those rightly enjoyed by current consultants. There are risks in either direction.

We believe that recruitment into UK anaesthesia should be increased to meet the projected future needs of the population in 2020. The demands for a 24/7 consultant-delivered service will only become ever louder, and rightly so; it is what the public deserves, what the commissioners want and what the politicians will have to deliver. In addition to this, it is only with larger numbers that the specialty of anaesthesia will be able not only to meet the inevitable extra demands upon it, but also to develop in the direction that we feel it should follow: towards peri-operative medicine as a specialty that provides much broader and more holistic care and benefits for patients than the simple provision of unconsciousness and analgesia [16]. Greater numbers will also allow us to accommodate the increased feminisation that we believe benefits overall care, the increased demands for the matching of work and lifestyle that accompany an expansion in less-than-full-time working, and a likely expanding independent sector.

Workforce planning in medicine is far from being an exact science. It is beset by too many known unknowns and as yet unknown unknowns. There is risk in cutting training numbers, risk in freezing training numbers and risk in increasing training numbers. However, we would argue that in an NHS that has not seen a sustained decrease in the demand for anaesthetists’ skills in its 65-year existence, in a climate in which care is likely to be demanded on a round-the-clock basis, and in a specialty that has ambitions to extend the patient care benefits it delivers, now is not the time to contract. However, what do we know?

Competing interests

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References

NR is a member of AAGBI Council and WHG is President of the AAGBI. The views expressed in this Editorial are the personal views of the authors. No other competing interests or external funding declared.

References

  1. Top of page
  2. The number of patients and the complexity of their care
  3. Service reconfiguration
  4. Who provides care?
  5. A shift to general practice
  6. The current dilemma
  7. Competing interests
  8. References