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Medical manpower short again: A view from a teaching district
Public Health (1986), 100, 140-143
Medical Manpower Short Again" A View from a Teaching District A. M. B. G o l d i n g District MedicalOfficer
Camberwell Health Authority, King's College Hospital, Denmark Hill, London SE5 9RS
Introduction
The Fourth Report from the Social Services Committee of the House of Commons for the 1980-81 Session 1 was concerned with Medical Manpower and made a number of recommendations, including the need to increase the ratio of consultants to junior staff. The Government's response to the report 2 supported many of their recommendations. But the latest Fifth Report of the Social Services Committee 3, with Mrs Renee Short again in the chair, has expressed its concern that so little has happened in response to the earlier report; in particular, their view that there should be a one to one ratio of consultants to trainees had not been implemented. It would seem that most Health Authorities have agreed with the Minister 'the targets (set by the Short Committee) were never more than a recommendation and a broad indication. Those recommendations came to be seen to be pretty unrealistic almost straight away. With the wisdom of hindsight they look as though they have been plucked out of the air'. However, the reports are important in drawing attention to the serious underlying problems and, even though the recommendations have proved unacceptable, it is still necessary to re-examine the issues to see how they can be put right. General
A medical manpower policy is essential if we are to make the best use of skilled medical staff but it is important to remember the strengths of the present system as well as its shortcomings. If a doctor wishes to specialise in a hospital based specialty he (or she) will need to compete for a series of posts - SHO, Registrar, Senior Registrar and ultimately Consultant. The very high standing of British Medicine undoubtedly owes much to this competition, which not unnaturally, is greatest in the most popular specialties. A justifiable criticism made in the Short Report 1 is that the most popular specialties have too many trainees competing for too few Consultant posts. However, if the competitive nature of thi½ process were to be eliminated completely then it is likely that the standards would fall. Certainly there is evidence that in other countries the less competitive Consultant posts are not up to the general standard in this country although Teaching Centres (where there js more competition) may be excellent. The Short Report also suggests that patients would be better treated by a Consultant than a Senior Registrar or Registrar but it is by no means self evident that translating a © The Societyof CommunityMedicine, 1986
Medical Manpower
141
Senior Registrar to a Consultant post will improve the standard of care given. At registrar level it is important to winnow out of the system the least satisfactory registrars and remove the least satisfactory posts. The Government in its response to the Short Report 2 commented that almost 50% of posts at both SHO and Registrar level were filled by overseas-born medical graduates. 'The number of overseas graduates is falling while the number of UK graduates is rising so the net effect of these changes will be that some posts in outlying hospitals and in shortage specialties, and those which offer less than good training facilities, will be increasingly difficult to fill. British graduates will wish to ensure that posts they obtain will be useful in furthering their career.' It is in this context that most would agree that the service load carried by trainees in posts not providing satisfactory training will have to be borne by career grade doctors. We also accept the need to regularise 'the terms and conditions of those individuals who have been in training posts for many years without prospects of becoming Consultants '4 (para. 29).
The Teaching Hospital The Teaching Hospitals have a special contribution to make and this has long been recognised. In 1974 the undergraduate Teaching Hospitals lost their direct access to the DHSS and came under the Regional Health Authorities. At that time there was much discussion on whether the London Teaching Hospitals should form a Central London Region or be part of the Thames Regions. The decision not to create a separate Central London Region was based primarily on the belief that the Teaching Hospitals have an important role in influencing the service provided throughout the Thames Regions - by joint Consultant Appointments, by admitting particularly complex problems beyond the capacity of the ordinary hospital, developing Specialist Multidistrict Units and postgraduate training. One of the great strengths of British Medicine is the close links between the academic units in the Medical Schools and the service pressures so that many of the Specialist units which have developed in the Teaching Hospitals have done so in response to service needs. The list of approved multiregional and multidistrict specialties in the teaching hospitals is evidence of this. To be recognised by the Regions they have to be reasonably large e.g. costing over £100,000 a year as well as attracting a substantial proportion of patients from outside their local district. There are very many developments within these teaching hospitals which do not yet qualify for recognition. Like any small high risk business, some will fall by the wayside but others will develop into approved multidistrict specialties. The reason they flourish is due to the interplay between academic environment and service need. The multidistrict specialist units are a focus for new developments. The emphasis in this paper is on postgraduate training but postgraduates in training are also responsible for teaching medical students who need the stimulating atmosphere of a University Hospital although they also benefit from periods in non-teaching hospitals which can provide a different kind of experience usually intellectually less demanding (as measured for example by publications in learned journals). For a teaching hospital to function properly it needs Consultants of high calibre capable of fostering research, and not so overburdened by routine duties that they do not have the energy to develop new ideas and are able to teach both within the .hospital and to colleagues outside. It also needs Trainees, especially Senior Registrars and Registrars, who will be fired with the enthusiasm of their colleagues and their chiefs to try
142
A. M. B. Golding
to develop new and better forms of treatment. In most specialties the pattern in the Teaching Hospital is of a Consultant led service rather than a Consultant based service, with the Consultant taking ultimate responsibility for the standard of care provided by the Junior Staff. The medical student of today will be in practice forty years from now and it is important that he or she has the capacity to cope with the major changes which will occur during that time. The postgraduate training programme and the appointment of Consultant Staff must encourage this dynamism. Any coherent medical staffing policy must use standards which could be applied nationally without critically impairing the training of doctors or the National Health Service. It is hardly surprising 4 (para. 30) that the system of providing a Consultant based service (at Huntingdon) led to higher basic staffing costs and to a more onerous work pattern for Consultants. It is important 4 (para. 43) 'thahMedical Manpower data systems be improved at R e g i o n a l l e v e l ' , and (para. 44) that R H A ' s should assess the need for~training programmes both specialist and 'general clinical' and draw up plans for introducing them. Also (para. 46) that the Government should take steps to establish a more integrated manpower planning system for hospital and family practice medical staff, both centrally and at local level. One of the major problems is the number of trainees in various specialties who are unlikely to achieve consultant status. These are in two separate groups. The first group consists of trainees of high calibre in specialties like General Surgery where significant numbers of good candidates are unlikely to achieve consultant posts in that specialty. It is important that they are counselled earlier in their careers so that they can choose a similar but less popular specialty. At present many of them are wasting their talents and it is clearly quite wrong that some of the ablest doctors should be placed in this position. The second group consists of those people in training grades who are unlikely to achieve consultant status because they have been in post for a long period and many have failed to achieve the higher qualifications needed. Todd et al. 4 in a recent article in the British Medical Journal used as a criterion those Registrars who had been in post for six years or longer, and there were more than a thousand. There are a further 3,161 doctors who have been in the SHO grade for three years or longer. Some of these will be overseas doctors intending to return to their country of origin but, even making allowance for that, it would seem that there are going to be at least a thousand or, more probably over two thousand, such doctors unlikely to make further progress in a hospital career who wish to remain in this country. One solution is that a sub-consultant grade should be established for these doctors. Part of any solution to the problem of surplus trainees who are unlikely to make the consultant grade must be to reduce the number of training posts. In the main this reduction should be by replacing them with consultant posts, particularly in specialties like General Surgery where there are plenty of good candidates available, taking care to remove the least satisfactory training posts. But there is also a need to assess carefully those doctors who are unlikely to make the "consultant grade in their current specialty with a view to giving them a sub-consultant post unless they can be offered a suitable alternative career in some other hospital specialty or in General Practice. The worst problem is in General Surgery. For example, in September 1984 there were 947 consultant posts in General Surgery in Engiand and Wales 5 with, "on average, 31 retirements annually. There had been no net increase in Consultant posts in the previous
Medical Manpower
143
five years and if this continues the 176 Senior Registrar posts are more than are needed. By contrast, Radiology with 940 Consultants needs the 230 Senior Registrar posts to fill vacancies because the specialty has been expanding by 26 extra Consultant posts each year. At Registrar level in Radiology the 241 posts is little more than the number of Senior Registrar posts but in General Surgery there are 668 Registrars - 3.7 for every Senior Registrar post. However, there will be serious problems in Radiology if the number of new posts is curtailed. The policy for specialties like General Surgery should be: (1) to replace some Registrar/Senior Registrar posts by Consultant appointments; (2) identify posts specifically for doctors who are not intending to become Consultants in the specialty in this country, such as overseas doctors who intend returning to their own country, those intending to transfer to allied specialties, doctors seconded from the Armed Services etc. As far as less popular specialties are concerned the situation has already changed over the last five or ten years and they a.re~now beginning to have sufficient recruits to fill the vacant posts. However, the balance is still somewhat precarious. For example i n E N T there is nationally a need for additional Senior Registrar posts. It is therefore imperative to look at each specialty separately to see what the particular needs are. One of the key ways in which this whole system can be effectively monitored is by receiving annual reports on each Registrar in training. These reports would go to a central point, presumably in each Region. They would identify the name of the Registrar and the specialty, the number of years he or she has been in a Registrar post, and the views of the present Consultant on the Registrar's suitability for continuing in that post for a further period. One problem of the Short Report is that it would involve appointing more (expensive) Consultants at a time when other categories of staff are being cut back and there is as yet no evidence that the changes proposed would provide a cheaper service - although if it were to reduce the numbers of patients admitted to hospital or reduce lengths of stay, the service might be better and cheaper. The number of doctors needed for General Practice is difficult to estimate, principally because there is still no age at which they have to retire but an integrated medical manpower system incorporating general practice is urgently needed and should be developed in each Region within parameters set nationally.
References 1. Fourth Report from the Social Services Committee 1980-81 session, vol. 1. London: HMSO.
Reprinted 1983. ('The Short Report'). 2. Government Response to the Fourth Report from the Social Services Committee 1980-81 session. London: HMSO. Cmnd 8479. 3. Fifth Report from the Social Services Committee 1984-85 session. London: HMSO. June 1985.
4. Todd, G., O'Brien, M. & Gooding, D. (1985). Career Structure - the Modern Doctor's Dilemma. British Medical Journal, 291,755. 5. Health trends (1985). No. 3, vol. 17 (August), p. 46, 47. London: DHSS.
Medical Manpower Short Again" A View from a Teaching District A. M. B. G o l d i n g District MedicalOfficer
Camberwell Health Authority, King's College Hospital, Denmark Hill, London SE5 9RS
Introduction
The Fourth Report from the Social Services Committee of the House of Commons for the 1980-81 Session 1 was concerned with Medical Manpower and made a number of recommendations, including the need to increase the ratio of consultants to junior staff. The Government's response to the report 2 supported many of their recommendations. But the latest Fifth Report of the Social Services Committee 3, with Mrs Renee Short again in the chair, has expressed its concern that so little has happened in response to the earlier report; in particular, their view that there should be a one to one ratio of consultants to trainees had not been implemented. It would seem that most Health Authorities have agreed with the Minister 'the targets (set by the Short Committee) were never more than a recommendation and a broad indication. Those recommendations came to be seen to be pretty unrealistic almost straight away. With the wisdom of hindsight they look as though they have been plucked out of the air'. However, the reports are important in drawing attention to the serious underlying problems and, even though the recommendations have proved unacceptable, it is still necessary to re-examine the issues to see how they can be put right. General
A medical manpower policy is essential if we are to make the best use of skilled medical staff but it is important to remember the strengths of the present system as well as its shortcomings. If a doctor wishes to specialise in a hospital based specialty he (or she) will need to compete for a series of posts - SHO, Registrar, Senior Registrar and ultimately Consultant. The very high standing of British Medicine undoubtedly owes much to this competition, which not unnaturally, is greatest in the most popular specialties. A justifiable criticism made in the Short Report 1 is that the most popular specialties have too many trainees competing for too few Consultant posts. However, if the competitive nature of thi½ process were to be eliminated completely then it is likely that the standards would fall. Certainly there is evidence that in other countries the less competitive Consultant posts are not up to the general standard in this country although Teaching Centres (where there js more competition) may be excellent. The Short Report also suggests that patients would be better treated by a Consultant than a Senior Registrar or Registrar but it is by no means self evident that translating a © The Societyof CommunityMedicine, 1986
Medical Manpower
141
Senior Registrar to a Consultant post will improve the standard of care given. At registrar level it is important to winnow out of the system the least satisfactory registrars and remove the least satisfactory posts. The Government in its response to the Short Report 2 commented that almost 50% of posts at both SHO and Registrar level were filled by overseas-born medical graduates. 'The number of overseas graduates is falling while the number of UK graduates is rising so the net effect of these changes will be that some posts in outlying hospitals and in shortage specialties, and those which offer less than good training facilities, will be increasingly difficult to fill. British graduates will wish to ensure that posts they obtain will be useful in furthering their career.' It is in this context that most would agree that the service load carried by trainees in posts not providing satisfactory training will have to be borne by career grade doctors. We also accept the need to regularise 'the terms and conditions of those individuals who have been in training posts for many years without prospects of becoming Consultants '4 (para. 29).
The Teaching Hospital The Teaching Hospitals have a special contribution to make and this has long been recognised. In 1974 the undergraduate Teaching Hospitals lost their direct access to the DHSS and came under the Regional Health Authorities. At that time there was much discussion on whether the London Teaching Hospitals should form a Central London Region or be part of the Thames Regions. The decision not to create a separate Central London Region was based primarily on the belief that the Teaching Hospitals have an important role in influencing the service provided throughout the Thames Regions - by joint Consultant Appointments, by admitting particularly complex problems beyond the capacity of the ordinary hospital, developing Specialist Multidistrict Units and postgraduate training. One of the great strengths of British Medicine is the close links between the academic units in the Medical Schools and the service pressures so that many of the Specialist units which have developed in the Teaching Hospitals have done so in response to service needs. The list of approved multiregional and multidistrict specialties in the teaching hospitals is evidence of this. To be recognised by the Regions they have to be reasonably large e.g. costing over £100,000 a year as well as attracting a substantial proportion of patients from outside their local district. There are very many developments within these teaching hospitals which do not yet qualify for recognition. Like any small high risk business, some will fall by the wayside but others will develop into approved multidistrict specialties. The reason they flourish is due to the interplay between academic environment and service need. The multidistrict specialist units are a focus for new developments. The emphasis in this paper is on postgraduate training but postgraduates in training are also responsible for teaching medical students who need the stimulating atmosphere of a University Hospital although they also benefit from periods in non-teaching hospitals which can provide a different kind of experience usually intellectually less demanding (as measured for example by publications in learned journals). For a teaching hospital to function properly it needs Consultants of high calibre capable of fostering research, and not so overburdened by routine duties that they do not have the energy to develop new ideas and are able to teach both within the .hospital and to colleagues outside. It also needs Trainees, especially Senior Registrars and Registrars, who will be fired with the enthusiasm of their colleagues and their chiefs to try
142
A. M. B. Golding
to develop new and better forms of treatment. In most specialties the pattern in the Teaching Hospital is of a Consultant led service rather than a Consultant based service, with the Consultant taking ultimate responsibility for the standard of care provided by the Junior Staff. The medical student of today will be in practice forty years from now and it is important that he or she has the capacity to cope with the major changes which will occur during that time. The postgraduate training programme and the appointment of Consultant Staff must encourage this dynamism. Any coherent medical staffing policy must use standards which could be applied nationally without critically impairing the training of doctors or the National Health Service. It is hardly surprising 4 (para. 30) that the system of providing a Consultant based service (at Huntingdon) led to higher basic staffing costs and to a more onerous work pattern for Consultants. It is important 4 (para. 43) 'thahMedical Manpower data systems be improved at R e g i o n a l l e v e l ' , and (para. 44) that R H A ' s should assess the need for~training programmes both specialist and 'general clinical' and draw up plans for introducing them. Also (para. 46) that the Government should take steps to establish a more integrated manpower planning system for hospital and family practice medical staff, both centrally and at local level. One of the major problems is the number of trainees in various specialties who are unlikely to achieve consultant status. These are in two separate groups. The first group consists of trainees of high calibre in specialties like General Surgery where significant numbers of good candidates are unlikely to achieve consultant posts in that specialty. It is important that they are counselled earlier in their careers so that they can choose a similar but less popular specialty. At present many of them are wasting their talents and it is clearly quite wrong that some of the ablest doctors should be placed in this position. The second group consists of those people in training grades who are unlikely to achieve consultant status because they have been in post for a long period and many have failed to achieve the higher qualifications needed. Todd et al. 4 in a recent article in the British Medical Journal used as a criterion those Registrars who had been in post for six years or longer, and there were more than a thousand. There are a further 3,161 doctors who have been in the SHO grade for three years or longer. Some of these will be overseas doctors intending to return to their country of origin but, even making allowance for that, it would seem that there are going to be at least a thousand or, more probably over two thousand, such doctors unlikely to make further progress in a hospital career who wish to remain in this country. One solution is that a sub-consultant grade should be established for these doctors. Part of any solution to the problem of surplus trainees who are unlikely to make the consultant grade must be to reduce the number of training posts. In the main this reduction should be by replacing them with consultant posts, particularly in specialties like General Surgery where there are plenty of good candidates available, taking care to remove the least satisfactory training posts. But there is also a need to assess carefully those doctors who are unlikely to make the "consultant grade in their current specialty with a view to giving them a sub-consultant post unless they can be offered a suitable alternative career in some other hospital specialty or in General Practice. The worst problem is in General Surgery. For example, in September 1984 there were 947 consultant posts in General Surgery in Engiand and Wales 5 with, "on average, 31 retirements annually. There had been no net increase in Consultant posts in the previous
Medical Manpower
143
five years and if this continues the 176 Senior Registrar posts are more than are needed. By contrast, Radiology with 940 Consultants needs the 230 Senior Registrar posts to fill vacancies because the specialty has been expanding by 26 extra Consultant posts each year. At Registrar level in Radiology the 241 posts is little more than the number of Senior Registrar posts but in General Surgery there are 668 Registrars - 3.7 for every Senior Registrar post. However, there will be serious problems in Radiology if the number of new posts is curtailed. The policy for specialties like General Surgery should be: (1) to replace some Registrar/Senior Registrar posts by Consultant appointments; (2) identify posts specifically for doctors who are not intending to become Consultants in the specialty in this country, such as overseas doctors who intend returning to their own country, those intending to transfer to allied specialties, doctors seconded from the Armed Services etc. As far as less popular specialties are concerned the situation has already changed over the last five or ten years and they a.re~now beginning to have sufficient recruits to fill the vacant posts. However, the balance is still somewhat precarious. For example i n E N T there is nationally a need for additional Senior Registrar posts. It is therefore imperative to look at each specialty separately to see what the particular needs are. One of the key ways in which this whole system can be effectively monitored is by receiving annual reports on each Registrar in training. These reports would go to a central point, presumably in each Region. They would identify the name of the Registrar and the specialty, the number of years he or she has been in a Registrar post, and the views of the present Consultant on the Registrar's suitability for continuing in that post for a further period. One problem of the Short Report is that it would involve appointing more (expensive) Consultants at a time when other categories of staff are being cut back and there is as yet no evidence that the changes proposed would provide a cheaper service - although if it were to reduce the numbers of patients admitted to hospital or reduce lengths of stay, the service might be better and cheaper. The number of doctors needed for General Practice is difficult to estimate, principally because there is still no age at which they have to retire but an integrated medical manpower system incorporating general practice is urgently needed and should be developed in each Region within parameters set nationally.
References 1. Fourth Report from the Social Services Committee 1980-81 session, vol. 1. London: HMSO.
Reprinted 1983. ('The Short Report'). 2. Government Response to the Fourth Report from the Social Services Committee 1980-81 session. London: HMSO. Cmnd 8479. 3. Fifth Report from the Social Services Committee 1984-85 session. London: HMSO. June 1985.
4. Todd, G., O'Brien, M. & Gooding, D. (1985). Career Structure - the Modern Doctor's Dilemma. British Medical Journal, 291,755. 5. Health trends (1985). No. 3, vol. 17 (August), p. 46, 47. London: DHSS.