Scottish Government

Future Practice: A Review of the Scottish Medical Workforce

2.3 Understanding the demand for doctors

60. This section considers the numbers of doctors that we believe the workforce planning system is going to have to supply. It looks at:

• the current position;

• expected pressures on numbers;

• the effect of the changing role of the doctor (from sections 2.1 and 2.2); and

• how these combine in the short, medium and long term.

Current position

61. There are currently around 12,500 doctors ¹⁷ working in the NHSScotland disposed as follows:

Chart G: Medical Workforce Profile

62. Comparison with the NHS in England shows that Scotland is relatively well provided for doctors (see also Section 1, Table 1):

Table 2: Comparisons of Numbers of Doctors

Comparisons with other health systems outside the UK, which are so different, make commentary difficult. Simple comparison of staffing statistics would be misleading.

63. However, the current position in Scotland is not static and particular difficulties in certain specialties and locations appear to us to be symptoms of a system which is under strain. New and now foreseeable pressures will cause the situation to worsen. Positive action is required to secure the future supply of suitable doctors.

The effect of the changing role of doctors - qualitative demand

64. The effects outlined in sections 2.1 and 2.2 suggest that the supply of doctors should accommodate:

• teamworking and flexibility;

• shorter working hours and shift work;

• functioning in networks;

• intermediate care and the changing role of the GP;

• a better focus on role clarity and what doctors do;

• more flexible career opportunities and career paths;

• a greater emphasis and time spent on continuing professional development;

• specialist-delivered services;

• a clear distinction between time in training and time in service provision;

• generalist skills for specialists, and specialists for the generalist approach; and

• special stressors in the labour market, particularly in remote and rural areas.

Expected pressures on numbers - quantitative demand

65. Achieving policy objectives to reduce waiting times in primary and secondary care is in our view mainly a question of capacity. Efficiencies from, for example, service re-design, an increasing role for teamwork and better uses of IT will certainly make their contribution. But the key factor is the availability of clinical contact time.

66. Waiting times are a strong pressure to maintain and increase the numbers of doctors providing clinical services in the short term. In the medium and long-term the need to sustain and improve access to services will continue this pressure.

67. Action on working hours is currently the biggest single pressure and a powerful stimulus for change. There are several strands:

• Doctors in the training grades. The core purpose of junior doctors' posts is training; this was confirmed by the Calman reforms, will be reinforced by the expected reforms to modernise the SHO grade and is underpinned by clinical governance provisions.

The New Deal on Junior Doctors' Hours and working conditions includes contractual limits on hours. Their contracts provide premium rates of pay for trainee doctors in the PRHO, SHO and specialist registrar grades where New Deal standards are not met. The limits are:

• 56 hours of 'actual work' for PRHOs from August 2001; and

• 56 hours of 'actual work' for SHOs and specialist registrars from August 2003.

In addition the Working Time Directive (WTD) will now have effect on all doctors in training from August 2004:

• an average of 58 hours of work for each seven days; all duty hours where resident in hospital will be considered as actual work.

• 11 hours continuous rest in every 24 (This goes beyond the New Deal provisions for rest); and

• an average 48 hours to be achieved by 2009.

• All other salaried doctors. The Working Time Directive applies now to all other doctors in salaried employment where the limit is an average of 48 hours. The implications of the Directive were part of negotiations on the consultants' contract. The WTD also applies to doctors in so-called "SHO" posts which do not have training approval - their individual option to waive the 48 hour limit may be removed from 2003; and

• General practitioners who are independent contractors to NHSScotland are responsible for their own and their employees' working arrangements but the standards in the Directive will no doubt influence their expectations in negotiations on the GPs' contract.

70. Responding to pressures on working hours. Although doctors are able to make an increasingly important clinical contribution as they progress through training grade posts, the prime purpose of their clinical involvement while in these posts must be to develop their expertise and experience through training. Their routine contribution to service delivery will reduce substantially as the Working Time Directive takes effect and as service is squeezed between training time and the limits on hours.

71. The compliance process for PRHOs is still working through the system, and it is too early to quantify its effects. However, it is important to learn from this experience to anticipate the implications for SHO and specialist registrar compliance. Where PRHO compliance has been achieved by displacing service delivery onto SHOs that will have to be addressed as SHOs themselves are required to comply with working hours requirements from August 2003 and the managed, programme-based approach to training which we expect to be introduced.

72. Hence:

• at local level, it is clearly vital, given the timescales involved, that medical managers plan for SHO and specialist registrar compliance, and that they do so on the assumption that there will be a time-limited programme-based training system for SHOs. They need to consider and plan for:

  • increased numbers of doctors (although not necessarily trainees);

  • service re-design; and

  • skillmix and role transfer where appropriate.

    as complementary tools for achieving compliance;

• at national level it is essential to establish the impact on the numbers of fully-trained specialists (including GPs) required in the short and long term and the way their provision is to be assured; and

• at UK level, clarity on the proposed programme to modernise the SHO grade is needed urgently.

73. Although we cannot quantify the position at present, it seems clear to us that in the short to medium term, the system is unlikely to be able to deliver sufficient additional specialists to meet service commitments currently met by doctors in training and by consultants working beyond 48 hours. This suggests that the role for doctors providing service who are not fully trained specialists and who are not in training posts should be considered urgently. This means, in effect, devising posts and/or a grade that would be valued for the experience provided at that level and which would be acceptable as part of a doctor's career progression. In order to meet clinical governance requirements the duties would have to be ones for which the individual could demonstrate a sufficient level of competence.

74. Shortage specialties need to be recognised and the numbers of doctors required to meet requirements in the short and medium-term specified. There are current problems and the factors that lead to shortage may mean that different measures are needed to increase and secure the supply of different specialties, to improve recruitment and retention and to ensure the most effective use of the resources that we have. The specialties of radiology, pathology, and psychiatry are currently recognised as having problems of shortage throughout the UK. But there will be other specialties where there are shortages or where the small numbers involved or the effects of geography mean that the career decisions of individuals can lead to severe difficulties in maintaining service delivery.

75. Local hotspots should be recognised and addressed urgently both locally and at national level. The handling of particular problems should be resolved within the context of longer-term objectives for service planning. On the one hand, there may be a need to train or recruit a doctor with a particular set of skills to suit the local situation: on the other hand the apparent demand to deal with a particular hotspot may be better resolved by management changes such as service re-design.

76. The pressures on doctor numbers we have identified may be summarised in graphic form as follows:

Chart H: Pressures on doctor numbers

Forecasting demand

77. Against this background, a range of three possible scenarios has been considered. These scenarios are based on the following assumptions which should be seen as illustrative.

Low Growth

• Consultant staffing grows by 2.1% per annum in line with the long term trend during the 1980s and 1990s.

• The ratio of junior doctors to consultants is assumed to remain constant at 1.38.

• The number of GPs is assumed to grow by 1% per annum. This is slightly above the long term trend of 0.9%.

• The number of doctors in other grades is assumed to remain constant at just over 7% of the total medical workforce.

Medium Growth

• Consultant staffing grows by 2.8% per annum, in line with the trend observed during the 1990s.

• The ratio of junior doctors to consultants is assumed to remain constant at 1.38.

• The number of GPs is assumed to grow by 1.5% a year. This is relatively high by previous standards.

• The number of doctors in other grades is assumed to remain constant at just over 7% of the total medical workforce.

High Growth

• Consultant staffing grows by 3.4% per annum, in line with the trend observed during the second half of the 1990s.

• The ratio of junior doctors to consultants is assumed to remain constant at 1.38.

• The number of GPs is assumed to grow by 2.0% a year. This is very high by previous standards.

• The number of doctors in other grades is assumed to remain constant at just over 7% of the total medical workforce.

78. These scenarios produce the following projections of total medical staffing levels (Table 3 and Chart I):

Table 3: Projections of Total Medical Staffing (Scotland) in 2010 and 2020

Chart I: Projections of Medical Staffing (WTE) Under Different Growth Scenarios

79. There are a few points to consider about these projections:

• All of the scenarios assume an overall average growth rate in medical staffing over the next 20 years which is higher than the average growth rate of the past 20 years. We need to consider if this is a realistic range.

• The projections assume uniform growth rates throughout the next 20 years. It might be argued that growth rates would be higher during the next 10 years - reflecting a perception in Wanless and elsewhere that standards of healthcare in the UK have fallen behind other countries and therefore significant investment is now needed to catch up. Whether such high growth rates would continue over the following 10 years may be more questionable.

• The projections are quite sensitive to the assumptions made about growth rates and about the ratio of doctors in training grades to consultants. In all of the scenarios it has been assumed that the ratio of doctors in training grades to consultants remains constant at its current ratio of around 1.38. Because doctors in training grades account for over one third of all medical staff, even small changes in this ratio have significant effect on overall staff numbers.

• Changes in working methods are a potentially important influence on staffing numbers over the period covered by the projections. Some of these changes will tend to increase the number of doctors required (e.g. implementation of the Working Time Directive), while other changes will tend to reduce numbers (e.g. the adoption of more efficient methods of working through substitution of medical by non-medical staff). At present, it is difficult to judge what allowance should be built into projections to reflect these factors.

• International data have been used to suggest that the UK is 'under-doctored' compared with other EU countries. The most recent OECD figures indicate that many EU countries have around 3 doctors per 1,000 population, while the UK figure is about 1.9. Scotland, however, has a significantly higher figure than the UK as a whole, at 2.4 per 1,000 population. This is still below most EU countries, but the difference is not nearly as great as for the UK as a whole. Such comparisons need to be treated with caution. Apart from concerns about the statistical quality of the data used in these comparisons, the figures do not tell us anything about relative healthcare needs of the population living in different countries.

• No attempt has been made here to convert the projections of medical staffing into estimates of the changes required in numbers of medical students. This introduces an additional range of complexities which will require more detailed modelling. The impact on student numbers in Scottish medical schools will be influenced by assumptions made about where medical graduates choose to work, by the scope for meeting demand through doctors from EU and other countries coming to work in Scotland, etc. Nevertheless, the projections in Chart I clearly imply a substantial expansion in the number of students in medical schools. This implication must be viewed in the broader UK and labour market context. Student intake to the Scottish institutions is an important element in the supply equation for NHSScotland.

• The projections set out in Chart I should be seen very much as an initial and largely illustrative set of figures. Much more work would need to be done to provide a sounder basis for projections of the trends in medical staff numbers overall, and the split between different categories over the next 10-20 years.

Summary - short, medium and long-term demand

80. We have not been able in the time and with the information available to quantify the effects we have identified. There is an urgent need to do so, at least to the extent of establishing working assumptions that can be improved as information develops. But we feel that even with the service and professional reforms we recommend there will still be a need to increase the recruitment of doctors. There is an urgent need to determine quantitatively and qualitatively how that is best achieved.