Workforce planning must not be an afterthought if surgeons are to provide high quality care and deliver savings. The Royal College of Surgeons’ council lead for workforce Robert Greatorex looks at how to make informed decisions.
As the NHS reforms unfold it becomes increasingly obvious that effective workforce planning and development will be crucial for supporting the rapidly changing environment in healthcare provision.
In light of the £20bn efficiency savings expected by 2015 and the shift towards a service that will be driven by market competition, we need to be prepared for significant changes in staffing and service configuration. The NHS has not given adequate priority to the process of planning strategically to ensure that workforce issues are identified and addressed flexibly in a timely manner.
Training surgeons is a long term investment that requires structured learning and experiential practice. The long time-lapse between planning and delivery compounds the challenges of matching supply and demand.
During my career as a consultant general surgeon I have witnessed a recurring phenomenon of massive swings of surgical provision in the NHS. There was either a shortfall of skilled surgeons available to respond to the needs of the patient population, or a significant surplus unable to secure an appropriate post.
There is no doubt that national planning for the delivery of surgical care is a complex undertaking with many variables, and as such we will never get the balance exactly right. But we can certainly reduce the steep imbalances and uneven distribution of skills by adopting a strategic and integrated approach to workforce development.
If we are to provide high quality care under the pressures of the current fiscal environment, workforce planning cannot be an afterthought.
To make informed decisions on the surgical workforce, reliable data is essential. Unfortunately, in many areas of clinical practice even basic data, vital for accurate forecasting and planning, is missing. Available sources of information are disparate and of variable accuracy. Data is plagued by different formats and terminology and focus on different regions or subspecialties, covering different time frames.
In England, the electronic staff record has been the primary source of information for the Department of Health. This system has been developed for payroll use and lacks the sophistication necessary to capture the complexity and variability of the medical workforce.
Although the number of consultants identified by the ESR is in most areas accurate, the quality of data for other grades is unreliable. Moreover, the ESR does not contain in-depth information on clinicians’ activity, such as sub-specialisation or working hours.
The Royal College of Surgeons of England, in collaboration with the surgical associations, has undertaken a long term project of collecting workforce information directly from the profession.
In 2010 the college launched the first workforce survey for surgeons who practice in England, Wales and Northern Ireland across all surgical specialties. We feel this is the only way to get robust and coherent data that will provide a clear understanding of surgeons’ working practices and the services they deliver.
Our first call for information from the surgical profession resulted in a 60 per cent response rate, and a summary of the results is available from the RCS website.
More than two thirds of consultants who responded to the survey indicated they work more than the 10 programmed activities recommended for the job plan of a full time consultant (see figure 1, above). In the majority of these responses, consultants worked longer hours than their employment contract required, and exceeded the 48 hour limit of the European working time directive. Less than 31 per cent of respondents, a strikingly low percentage, said they are free from elective duties while covering on-call responsibilities (figure 2, above). This means that the vast majority of surgeons are expected to carry out elective operating lists when they should be available to deal with emergencies. As a result, emergency services are frequently compromised and this is a particularly worrying trend for specialties with a high emergency workload, such as general surgery and trauma and orthopaedics.
These figures are indicative of the current pressures placed upon the service to meet the needs of the patient population in the face of ever tighter NHS purse strings. There is clearly a growing demand for secondary surgical care, and in response surgeons are routinely called to work in overstretched rotas.
Supporting professional activities, a contractual arrangement aimed to allow surgeons to monitor and improve their own standards of practice, is often the first target for cuts in the consultant contract.
However, lack of adequate time devoted to training, audit, appraisal, continuing professional development and research for new techniques and services will inevitably have critical consequences for the long term maintenance of service quality.
The increasing need for surgical care is unlikely to be reversed in the near future. According to the Office for National Statistics the pensionable population will increase by 3 per cent a year until 2036. This portion of the population places the greatest demand on healthcare services for both elective and emergency care. The increase in life expectancy in the UK in recent decades has introduced longevity as a known variable and area of pressure.
Moreover, based on good practice and European mean workforce figures, most of the surgical specialty associations recommend more consultants per head of population. If the population continues to increase as predicted - and current projections by the ONS point to a 6 per cent increase in the next 10 years - then these recommendations are at risk of becoming entirely aspirational.
The challenge of planning the healthcare workforce is compounded by cultural changes that mean a younger generation of clinicians is actively seeking a better work-life balance and opting to work part-time. Although only 9.3 per cent of respondents to the survey described themselves as working part time, almost 40 per cent of consultants who currently work full time expressed the wish to work less at some point in their career (figure 3, above).
On the same theme, female participation in the consultant workforce is still low, averaging 7.1 per cent for all surgical specialties (figure 4, above). In contrast, more than two thirds of UK medical graduates are women. There is no long term data on the impact this could potentially have on the medical workforce, or more specifically the surgical workforce.
A strategic approach to workforce planning has never been more relevant than in this time of fundamental structural change. The very basis of surgical provision remains, as ever, high standards of surgical practice and surgeons’ own commitment to high-quality patient care.
As healthcare reform is implemented, we must ensure that the primary aim remains to improved service outcomes, while bureaucracy and administrative costs are appropriately contained.
The dismantling of strategic health authorities and the emergence of local skills networks of NHS providers present as many risks as opportunities. Skills networks will be assigned the complex task of commissioning, overseeing and delivering education and training. This can only succeed if the professions are involved from the outset in the commissioning and organisation of services.
The 2010 report is a starting point for capturing the full profile of the surgical workforce in all specialties.
Although further work will follow to ensure consistency, depth of data and improved response rates, we hope the report will serve as a step towards building an effective dialogue among decision makers and informing policy for flexible, integrated and transparent workforce planning.