Securing Future Practice: Shaping the New Medical Workforce for Scotland
3 SETTING THE SCENE
'Looking at services from a patient's point of view underpins everything we are seeking to do in the health service. Patients are concerned about: quality of care; treatment at the right time and in the right place; being treated with dignity and respect; having their say in decision making; having their feedback taken into account; and getting clear explanations at every stage.
All this amounts to a massive cultural change in the health service compared to the first fifty years of its history.' Partnership for Care: Scotland's Heath White Paper, The Scottish Executive 2003 |
1. It is just over a year since the Scottish Executive accepted the proposals set out in the report Future Practice7 and determined how they should be advanced 8. This review focuses specifically on the medical workforce and how it could be shaped in the future to meet the needs of NHSScotland. It is timely to do so.
2. This is a period of change for our health service. The drivers pressing that change are known, accepted and recognised across the United Kingdom and in many developed countries. Yet the circumstances in Scotland are often different.
3. The aim of NHSScotland is to assure the best care for patients and families. How we deliver service is already changing and will continue to change. For a patient that is likely to mean new and improved means of relating to his or her local service; for staff different ways of working. Doctors will still continue to provide a pivotal role in delivering care but inevitably and increasingly they will work more closely with other health professions and staff in integrated multi-disciplinary teams.
4. Training a doctor takes time: basic medical education ordinarily lasts six years; postgraduate training to become a general practitioner or specialist a further three to seven years or longer; and thereafter professional development is life-long. The outcome of this training must be the right numbers of 'fit-for-purpose' doctors where and when they are needed. That is a challenge now, but there is already a shortage of doctors across the United Kingdom and there are increasing difficulties in delivering clinical services in Scotland. More importantly it is also a challenge to consider now how to safeguard our services for the future. That is at the heart of this Review: we look at both the immediate challenges facing our medical workforce as well as those that we will face some 10 to 15 years from now.
5. Some of the factors that will affect the medical workforce in the future are difficult or impossible to influence: others can be modified; but all must be recognised. We consider many here because they provide an important context that will influence clinical practice and the capacity to recruit to and sustain the service now and in the future. They include:
demography;
the health of the Scots;
the number of doctors we need;
two policy statements from Government:
- Partnership for Care: Scotland's Health White Paper; and
- Modernising Medical Careers.
the Working Time Regulations;
the new consultant and general practitioner contracts;
increased public expectations of high standards of care provided as locally as possible;
staff who seek an improved work-life balance;
the advance of medicine and technology;
the 'gender shift' in the medical workforce;
the contribution of overseas doctors; and
the recommendations of Future Practice.
6. Demography The key messages about Scotland's population have been set out in the Annual report of the Registrar General for Scotland. 9 They are clear:
Our population is falling - from 5.05 million in 2002 to a projected 4.82 million in 2031. It is projected to fall below 5 million in 2009. This is a proportionately higher fall than that projected for any other European country. While a modest net 'outward migration' of 1,000 per annum is expected, since 1997 there has been a natural decrease in the population (an excess of deaths over births). To put this in context most countries (including other countries within the UK) are projected to increase in population over this period as future levels of inward migration offset projected declines caused by natural change.
Figure 1
Projected Population Change in EU Countries 2000-2020
Source: Eurostat 'European Social Statistics, Demography 2001 Edition'
* GAD Websitehttp://www.gad.gov.uk
Our birth rate is falling - the number of births fell to 51,270 in 2002, the lowest ever recorded. If this recent decline continues, it will ultimately have a significant impact on the future level of our working age population. The evidence is stark:
- the population under 1 year is now lower than for any other single age up to 60;
- smaller numbers of children than parents mean decreases in the number of parents in the next generation, contributing to the continued population decline.
Our population is getting older - and is projected to continue ageing:
- half the population is now over 39, which is four years older than the1991 equivalent;
- the number of children under 16 is projected to fall by 20% by 2027; while
- the number of people of pensionable age is projected to increase by 25% in 2007.
Figure 2
The Projected percentage Change in Age Structure of Scoland's Population 2001-2026
Source: General Register Office for Scotland
Figure 3
Estimated and Projected Age Structure for Scotland 1911-2031
Source: General Register Office for Scotland
Figure 4
Expectation of Life at Birth in EU Countries Estimate at 1999
Source: General Register Office for Scotland
*GAD Websitehttp://www.gad.cov.uk
Migration - there is net 'outward migration' of population from Scotland and, although it is currently much smaller than in the 1960s, it is likely to continue around this level ( see Figure 5). Continued migration within Scotland will also have a large impact on population distribution ( see Figure 6).
Figure 5
Net Migration and Natural Change Scotland 1951-2002
Source: General Register office for Scotland
The combination of falling birth rate and outward migration is unique within the UK.
Figure 6
Projected Percentage Population Change by NHS Board Area Scotland 2002-2018
Source: General Register Office for Scotland
Scotland is now a 'very low fertility country'. 10 This contributes to natural population decline and population ageing and suggests an unstable future for our population with implications for the economy, for society and for the NHS workforce:
- an ageing population has a major impact on health and community care as the elderly are amongst the highest users of services. Patterns of disease prevalence will change, for example cancer will increase as it is more common among the elderly;
- a shrinking labour market will make it more challenging to recruit the NHS workforce, including the medical workforce. Change in the workforce we know today and how it provides care is inevitable; and
- remote to central migration within Scotland will make it more difficult to sustain some remote and rural communities and their healthcare.
'The most important policy issue facing European governments over the next fifty years is how to cope with their ageing populations. . . . For Scotland the future is now. . . . Its population is ageing faster and dying quicker than any other industrialised nation.' The Scottish Report - Scotland the Grave, Ralph Industrial Advisers Ltd., April 2003 |
7. The health of Scots The principal purpose for developing and sustaining the medical workforce is to improve the health of the people of Scotland. The challenges to health are recognised and, while there has been improvement, Scotland lags behind the rest of the UK and most other European countries. There is an unacceptable health gap between the richest and poorest communities.
8. The number of trained doctors we need There is as yet no authoritative analysis of the various pressures on the NHS in Scotland, both now and in the future, to inform a workforce plan for doctors (or indeed the whole workforce) and to understand better the interplay between their supply and demand for their services. Further, our workforce does not exist in isolation; it is part of a wider and much larger UK and international workforce. This makes the challenge of securing doctors for NHSScotland even more complex: less easy to anticipate; less easy to plan.
9. The Treasury commissioned a review to examine the long-term trends affecting the health service in the UK and to provide a convincing guide to what we may expect in 2022 (The Wanless Review). 11 Based on modelling developed by the Department of Health, Wanless predicted that, as a consequence of increased activity, there would be a substantial increase in the demand for health care workers: over the 20 year period he considered, at least two thirds more doctors and up to a third more nurses would be needed. His model assumes current levels of workforce productivity and that doctors' hours will fall to 48 hours in line with the Working Time Regulations. He goes on to say that
'Assuming that the existing ambitious plans for expanding the skilled workforce are achieved and that estimates of reduction in length of stay from the National Beds Inquiry are delivered, then without any other action the model projects a small short fall of nurses by 2020 but a larger shortfall, around 25,000 of doctors, especially GPs.' 12
There is a caveat. The intelligence on which these predictions are based was limited to England and is not sensitive to further differences in Scotland. Building on his work Wanless recommends that a separate analysis be taken forward for each devolved administration.
10. Preliminary consideration of workforce requirements in Scotland reported in Future Practice recognised that even with limited service and professional reforms there is a need to increase the recruitment of doctors.
'Much more work would need to be done to provide a sound basis for projections over the next 10 - 20 years for the medical workforce overall and the split between different categories of doctor. This work is urgent.' |
11. A separate review of certain aspects underpinning the provision of basic medical education in our medical schools has been commissioned 13 ('the Calman Review'). In particular this Review is examining the arrangements for access to undergraduate medical education in Scotland and the number of student places that we may require. We recognise that these arrangements for basic medical education will inform and influence the development of the medical workforce.
12. Scotland already has more doctors per head of population than the rest of the UK ( see Table 1) and numbers are continuing to grow ( see Figure 7).
Table 1
OECD Doctors per 100,000 Population (as at 2001)
| Doctors per 100,000 population |
France | 330 |
Germany | 330 |
Netherlands | 330 |
Spain (as at 2000) | 330 |
Greece | 440 |
Ireland | 240 |
UK (as at 2000) | 200 |
Scotland (as at 2002) | 260 |
Source: OECD Health Data 2003;Note: 1) The criteria for assessing numbers of doctors can vary across countries 2) Data for Scotland are not separately identifiable from the OECD UK numbers.
Data provided here are supplied by ISD Scotland.Figure 7
Doctors per 100,000 population (headcount)
Source: ISD Scotland
13. Elsewhere we identify the different pressures on our medical workforce now and in the future and what may be done to contain them. However, we are certain that:
The challenge is to ensure that this will happen.
14. Partnership for Care: Scotland's Health White Paper was published in March 2003. This sets out the vision to improve the health of Scots, and the direction of travel and plans for the further development of our health service. Patients are at the centre: in a partnership with staff and Government to deliver quality national standards of care. The key drivers for change are:
a service more responsive to patient needs;
support and empowerment of front line staff, especially clinicians, building on multi-professional healthcare teams working together in new ways to deliver integrated services around the needs of their patients - a greater emphasis on systems of care rather than separately managed institutions;
a strong emphasis on partnership and service redesign looking at the pathway of care from a patient's point of view;
concentrating some inpatient and specialist care in fewer centres to get the best and safest clinical services;
a central role for primary care teams working with hospital services - for example in Managed Clinical Networks;
a commitment to ensure that the highest clinical standards are achieved underpinned by rigorous and independent quality assurance systems; and
a strategic role for the centre in delivering coherent workforce development planning - assuring its size and shape, and that it has the right skills and is 'fit-for-purpose'.
15.
Modernising Medical Careers In the spring of 2003 the four UK Health Ministers launched
Modernising Medical Careers14 (MMC) an important statement by the Government in response to consultation on
Unfinished Business: Proposals for Reform of the Senior House Officer Grade.
15 Earlier this year further development of this policy was set out by the four UK Health Departments in the document
The Next Steps.
16 Ministers are committed to turning these principles into practice as part of the programme of change and improvement within the NHS leading to the development of a new structure for postgraduate medical training geared to meet current pressure and changing demands. The key principles underpinning this policy are:
the end product should be a well trained and accredited hospital doctor or general practitioner able to deliver the care and treatment patients need and prepared to work in multi-professional settings;
all postgraduate training should be organised in structured programmes and delivered to clear, consistent and assured UK-wide standards encompassing:
- a new two-year Foundation Programme subsuming the current Pre-Registration House Officer year followed by new seamless specialist and general practice training programmes leading to the award of a Certificate of Completion of Training (CCT) and delivered in a streamlined training grade structure to support that process;
- programmes broadly-based at first, leading to greater specialisation as appropriate;
- explicit career pathways and explicit career goals;
- training which is trainee-centred reflecting a variety of career choices and, where relevant, individual need;
- opportunities for trainees to change career direction to meet service and individual needs with the minimum of duplication and retraining;
- strong educational management underpinned by skilled trainers with the capacity to provide sound counselling and career advice;
- the needs of academia; and
- providing for overseas doctors.
an increasingly competency-based approach applying to both trainees and to career doctors supported through continuing professional development;
new arrangements for the non-consultant career grades to support better their professional development and, where appropriate, their re-entry to training; and
increased diversity within the consultant grade - not all will require the skills and training to provide more complex and specialist treatment.
This is a huge task. We have given initial consideration to how MMC policy could be implemented in Scotland. We recognise that this responsibility will fall to the National Workforce Committee and the Group established under its aegis to ensure effective delivery of MMC in Scotland. There are particular short-term challenges:
to increase consultant and general practitioner numbers - essential to increase capacity and improve service delivery;
to provide new arrangements for the non-consultant career grades; and
to commission a new system of postgraduate training where the focus is on outputs and on moving doctors efficiently through the system based on their accredited progress in acquiring competences. This will include:
- new Foundation Programmes; and thereafter
- subject to the approval of the new Postgraduate Medical Education and Training Board (PMETB) and the needs of particular specialties, new streamlined progressive programmes delivering trained doctors; and
- reforming the SHO, specialist registrar and general practice training grades.
16. The Working Time Regulations This UK legislation 17 expresses European Union Directives concerned with workers' heath and safety and the organisation of working time. Member States are required to ensure that workers enjoy an average working week of not more than 48 hours. A transitional period of five years from 1st August 2004 has been laid down for training grade doctors. By 2009 the ceiling will be 48 hours weekly. Compliance with these Regulations has profound implications for:
the delivery of health services, especially in the hospital sector because doctors in training contribute so much to out-of-hours cover; and for
meeting the standards required by the new training arrangements.
17. In parallel with this the 'New Deal for Junior Doctors' is already limiting the hours worked by doctors in training. Together with the working time regulations they are powerful drivers for change, for service redesign and for reform of the medical career structure. Responding to such pressure will require investment. To date there has been some progress. However, the New Deal for Junior Doctors compliance figures at February 2003 showed an overall compliance rate of only 53%. 18,19
18.
The new consultant and general practitioner contracts Recent agreement on both consultant and general practitioner contracts will influence the development of the medical workforce:
The new consultant contract will support better relationships between managers and clinicians. As a time-based contract, it will provide greater flexibility of working patterns, which will allow consultants to plan their work more effectively and enhance their contribution to clinical care. It also embraces non-clinical roles, such as management, training and supervision.
Equally the new general practitioner contract will transform the way services are delivered in the community by focusing on the practice team and not only on the individual GP. It will reward GPs according to the quality of care they provide and thus improve the provision of care to patients. It will enable GPs to control better their workload and will support more flexible career options, with increased opportunity to undertake shorter-term salaried posts. GPs will also be encouraged to deliver a wider range of services providing the opportunity for them to pursue special interests.
Both contracts should support more effective career pathways enabling individual doctors to embrace both primary and secondary care. Their impact on medical workforce development and morale in Scotland will depend upon the time it will take for doctors and managers to make full and appropriate use of the flexibility offered. The implementation of new contracts elsewhere in the UK may also play a role in future workforce development as doctors make their career choices within the wider UK market.
Agenda for Change, which sets out new pay systems for staff other than medical staff, will support the development of new professional roles and teamwork.
19. Other factors that will shape the development of the medical workforce These are well known, even if their impact is not always understood or quantifiable:
increased public and patient expectations of high standards of health care wherever it is delivered;
staff who expect to work sensible hours, and whose work patterns will sit more easily with family and life-style commitments;
the inevitable advance of medicine and technology and its impact on clinical practice requiring a workforce with the capacity to adapt to change; and
the gender shift which is resulting in increasingly larger numbers of women entering medicine ( see Table 2). Some of the reasons for this are now clearer and reflect the age and stage of personal development at which we select for medicine - a time when young women can perform better than young men. The resultant effect on the medical workforce can be predicted. As the gender shift becomes increasingly established this will necessarily increase expectations for different patterns of work and career. The service must respond to this.
The medical workforce of the future will be predominantly female. |
20.
Overseas doctors The contribution of overseas doctors to the medical workforce in Scotland is significant but differs across the grades (
see Table 3).
Table 2
Gender Balance (Scotland 2002)
| % Male | % Female |
Student (intake) | 40 | 60 |
PRHO | 47 | 53 |
SHO | 52 | 48 |
Registrar Group | 59 | 41 |
GP Registrar | 36 | 64 |
NCCG | 35 | 65 |
GP | 61 | 39 |
Consultant | 75 | 25 |
Table 3
| Total 30/9/2002 | Country of qualification % |
Scotland | Other UK | Other EEA | Rest of the World |
Consultant | 3303 | 68 | 22 | 3 | 7 |
NCCG | 790 | 54 | 11 | 3 | 32 |
Registrar Group | 1494 | 57 | 17 | 7 | 20 |
SHO | 2458 | 66 | 8 | 4 | 22 |
PRHO | 803 | 92 | 2 | 3 | 3 |
All GPs | 3882 | 82 | 13 | 2 | 3 |
GP Registrar | 284 | 65 | 15 | 15 | 5 |
21. Future Practice The recommendations of this Report conditioned our remit. We noted the 10 key messages and the single conclusion set out in the Report. They focus on the medical workforce and remain valid today. They can be found in Annex C.
22. These then are the some of the factors that we have had in mind as we considered how best to advise on the shape and structure of the Scottish medical workforce. They and others will be examined further within our Report. It is, however, true to say that they also informed much of the advice we received from individuals and expert groups and frequently conditioned debate in the focus group discussions convened by the Working Group which provided much of the evidence we considered.
Shaping the New Medical Workforce for Scotland In the next four sections we explore the factors that will bear on our recommendations to reform the medical workforce: What kind of service do we need to staff? What kinds of doctor do we need? How do we provide for education, training and career development? How do we secure the workforce?
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