Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

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Matter for debate

Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?* D.W. Harkin a,*,e, J.D. Beard b,f, C.P. Shearman c,e,f, M.G. Wyatt d,f a

Belfast Vascular Centre, Royal Victoria Hospital Belfast, Belfast, United Kingdom Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom c Department of Vascular Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom d The Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom b

article info

abstract

Article history:

Background: Vascular surgery became a new independent surgical specialty in the United

Received 13 August 2015

Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a

Received in revised form

“shortage of vascular surgeons in the United Kingdom?”

22 October 2015

Materials and methods: We used data derived from the “Vascular Surgery United Kingdom

Accepted 29 October 2015

Workforce Survey 2014”, NHS Employers Electronic Staff Records (ESR), and the National

Available online xxx

Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements.

Keywords:

Results: We estimate there are approximately 458 Consultant Vascular Surgeons for the

Vascular surgery

current UK population of 63 million, or 1 per 137,000 population. In several UK Regions

Endovascular

there are a large number of relatively small teams (3 or less) of vascular surgeons working

Workforce planning

in separate NHS Trusts in close geographical proximity. In developed countries, both the

Training

number and complexity of vascular surgery procedures (open and endovascular) per capita

United Kingdom

population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical workpatterns with respect to gender, working-life-balance and 7-day services. Conclusions: We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services. Crown Copyright © 2015 Published by Elsevier Ltd. All rights reserved.

*

Presented at Annual General Meeting of Vascular Society of Great Britain & Ireland in, 2014. * Corresponding author. Belfast Vascular Centre, Royal Victoria Hospital, Belfast Health & Social Care Trust, Belfast, United Kingdom. Tel.: þ44 2890635936. E-mail address: [email protected] (D.W. Harkin). e On behalf of the Specialty Advisory Committee for Vascular Surgery, Joint Committee on Surgical Training, Royal College of Surgeons, London, United Kingdom. f On behalf of the Vascular Society of Great Britain and Ireland, Royal College of Surgeons, London, United Kingdom. http://dx.doi.org/10.1016/j.surge.2015.10.004 1479-666X/Crown Copyright © 2015 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Harkin DW, et al., Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.10.004

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Introduction Vascular Surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013.1 In many European countries vascular surgery has been an independent specialty for several years.2 Vascular Surgeons manage a vast array of conditions affecting the body's vascular system, including the arteries, veins, and lymphatics. In developed countries, both the number and complexity of vascular surgery procedures per capita population is increasing,3,5 and concerns have been raised in the United States,6,7 France,8 and the UK9,10 that this demand cannot be met without a significant expansion in numbers of vascular surgeons. We have recently characterized the current Consultant Vascular Surgery workforce in the UK.11 Here we describe the current and predict the future Consultant Vascular Surgeon workforce needed across the UK. We anticipate that these data will provide valuable information for Vascular Surgery workforce planning in the UK, and perhaps in Europe and similar healthcare systems abroad.

Estimation of Vascular Surgeon Workforce in UK To arrive at an estimate of the current Vascular Surgeon Workforce in the UK and allow prediction of future workforce requirements we scrutinized data derived from the Vascular Surgery United Kingdom Workforce Survey (VSUKWS) 201411, National Health Service (NHS) Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeonlevel public report.12 The VSKUWS 201411, reported the views of 352 Consultant Vascular Surgeons, practicing in the UK. NHS Electronic Staff Records (ESR) represents an employer record of the physician workforce in the UK. The National Vascular Registry (NVR),12 records and reports on outcome activity data for vascular surgeons practicing in the UK (a legal requirement in England). VSUKWS 201411, surveyed 450 Members of the Vascular Society GB&I (VSGBI) based within the UK, and received 352 surveys (78% response rate) completed by Consultant Vascular Surgeons currently practicing in 95 NHS Hospital Trusts covering every Postgraduate Medical Training region in the UK (England, Scotland, Wales, and Northern Ireland). Respondents described themselves as Vascular Surgeons: none identified themselves as a General Surgeon. However, not all practicing Vascular Surgeons in the UK are members of the VSGBI. Therefore, other sources of information were considered. The National Health Service (NHS) collates data on consultant workforce primarily from Electronic Staff Records (ESR). Unfortunately, as a new specialty there is no historical data for Vascular Surgery, as previously a sub-specialty of General Surgery (pre-2013) even specialist Vascular Surgeons would have been coded as General Surgeons on these records. Therefore, we felt ESR data was currently unreliable and could not be used for further analysis. Without reliable data from employers we looked to other sources of information. The National Vascular Registry (NVR) “2013 Report on Surgical Outcomes Consultant-level

Statistics”12 records that 458 surgeons in UK were conducting Abdominal Aortic Aneurysm (AAA) repair. With a UK population circa 63 million, this suggests that currently the ratio of vascular surgeons to capita population is 1 per 137,000. The VSGBI recommends a minimum of 1 vascular surgeon per 150,000, and for large tertiary centres, due to added complexity of case load, 1 per 100,000 population.10 Many consider AAA repair to be an index procedure for a specialist vascular surgeon, and an essential skill for a Vascular Generalist equipped to manage un-selected Vascular Surgery Emergencies. Using this definition we felt the NVR data provided the most robust current estimate of vascular surgeons currently practicing in the UK, and these numbers are used in future predictions. We considered the ratio of consultant vascular surgeons, per capita population, across the UK. The Office for National Statistics gives the population for the Nations of the UK as of mid-2010 to be as follows: Scotland, 5.3 million; Wales, 3 million; Northern Ireland, 1.8 million; England, 52.6 million.13 To determine whether there are sufficient numbers of Consultant Vascular Surgeons to deliver a safe level of Vascular Surgery Service across the respective UK Nations, we carried out weighted-capitation transformation based on assumed ideal numbers of consultant vascular surgeons' per capita population, as follows: 1 per 150,000 as VSGB (minimum number)10; 1 per 137,000 as number registered by NVR (surgeons conducting AAA repair); 1 per 100,000 as VSGBI (number for tertiary centres).10 Suggesting, in the UK we need between 418 and 627 Vascular Surgeons, Table 1.

Analysis of Regional Distribution of vascular surgeons in UK The NVR12 records 111 NHS Trusts in the UK as registered to perform major vascular surgery (Aneurysm Repair or AAA). As expected the greatest numbers are seen in London, the West Midlands, and the North West. There is significant variation between regions in the number of NHS Trusts with registered vascular surgeons, Fig. 1. From our analysis there is significant regional variation in the distribution of inpatient vascular services across the UK. In part this variation can be explained by population density. Based on available data, if we accept the VSGBI minimum numbers to deliver a safe service, there would appear to be significant under-provision of Consultant Vascular Surgeons in the UK, and this is most acute in Scotland, Wales, and Northern Ireland. It is also clear that in some regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in quite close geographical proximity to each other, Figs. 1 and 2. This is most acute in the East of England, North West, South Central, South West, and all of the home-nations (Scotland, Wales, and Northern Ireland). The effect of team volume on outcome in respect to major vascular surgery interventions is now established, with the large higher volume teams producing better outcomes for the majority of their patients who undergo complex arterial vascular surgery procedures.14 From our survey there are still a significant minority (17.1%) of working in teams of 3, or less.

Please cite this article in press as: Harkin DW, et al., Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.10.004

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Table 1 e Estimation of vascular surgeons per capita population by UK region. Weighted capitation 1 per 150,000a 1 per 137,000b 1 per 100,000c a b c

Scotland

Wales

Northern Ireland

England

Greater London

Total

35 39 53

20 22 30

12 13 18

351 384 526

55 61 83

418 458 627

1 per 150,000 as POVS (minimum recommended number). 1 per 137,000 as number registered by NVR (surgeons in UK conducting AAA repair). 1 per 100,000 as POVS (number for tertiary centres).

Changes to surgical training mean that there has been an overall reduction in surgical trainees national and an overall reduction in hours worked per individual trainee in order to achieve compliance with the EWTD.15,16 Many major arterial procedures, in particular complex or revision open surgery and complex endovascular surgery, require two experienced surgeons within the team. With a reduction in the number and experience of trainees dual-consultant operating is likely to increase further and to facilitate this it is likely that some complex inpatient vascular surgery services may need to relocate to larger centres with larger teams. Therefore, using survey data from the UKVSWFS we assessed the effect of team size on vascular surgery service delivered. Whilst the average team was composed of between 5 and 6 (range 2e10) Vascular Surgeons, 17% of Vascular Surgeons are working in small teams of 3, or less. From our

survey11 it is clear that Small Teams (3, or less) provide less comprehensive vascular surgery service within their Hospital Trust, as compared to either a Medium Team (4e7) or a large Team (8 or more). These differences are perhaps most acute in respect to the 24/7 provision of a CePOD Emergency Theatre, access to Vascular Imaging, and availability of Interventional Radiology cover, Table 2. The VSGBI has advised reconfiguration of vascular services to a smaller number of NHS Trusts with larger teams (6 or greater) of vascular surgeons.10

UK factors impacting on future demand Many UK vascular surgeons consider the current numbers nationally to be inadequate, and with predicted expansion in population and demand for vascular surgery services this

Fig. 1 e Regional Distribution of Vascular Surgery Services in United Kingdom. Data derived from NVR12 and reflects practice in 2012 with the regional number of Surgeons, Surgeons*(Surgeons performing AAA), and NHS Trusts with registered vascular surgeons. Please cite this article in press as: Harkin DW, et al., Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.10.004

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Fig. 2 e Geographical Distribution of Vascular Surgery Services in United Kingdom. Data derived from NVR12 and reflects practice in 2012 with the regional number of Surgeons*(Surgeons performing AAA), and NHS Trusts with registered vascular surgeons. could create a “perfect storm” in respect to lack of provision of vascular surgery services in the United Kingdom.4e9,11 The population of the UK is projected to increase by 4.9 million over the next 10 years from 62.3 million at mid-2010 to 67.2 million at mid-2020, an annual average rate of growth of 0.8 per cent. It is projected that the UK population will be 73.2 million at mid-2035, a total increase of 10.9 million over the next 25 years.13 As the UK population becomes more aged so too would we expect an increase in the burden of age-related conditions, such as vascular disease. The population of the UK is aging with median age increasing from 35.4 years to 39.7 years, and the percentage aged over 65 years increasing from

15 to 17 percent, from 1985 to 2010. The fastest population increases have been seen in the “oldest old” (those aged 85 and over), with the number increasing from 0.7 to 1.4 million, from 1985 to 2010, and this group is predicted to reach 3.5 million (5% of population) by 2035.17 Many believe that with an increasing and increasingly aged population that demand cannot be met without a significant expansion in numbers of vascular surgeons. From our VSUKWFS11 up to one-fifth of the workforce are above the age of 55 and would be expected to retire within 10 years, and concerning 44% indicated they were considering early retirement, so this number could be considerably higher.

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Table 2 e Effect of team size on level of emergency vascular surgery service. Hospital emergency resource

Team size Small Medium Large

Specialist vascular surgery beds (n ¼ 323) On-call for vascular surgery only (n ¼ 323) 24/7 vascular surgery cover (n ¼ 327) 24/7 vascular imaging (CT/MRI) (n ¼ 321) 24/7 CePOD emergency theatre (n ¼ 322) 24/7 interventional radiology cover (n ¼ 325)

pValue

44.4*

90

94.5

0.01

60.4*

87

83.6

0.05

50*

95.8

100

0.01

83.3*

96.8

95.9

0.05

78.2*

89.9

97.3

0.05

20.4*

70.7

75.7

0.001

Data represents percentage. Teams (number vascular surgeons in hospital): Small (3, or less), Medium (4e7), Large (8, or more). * Small as compared to large team.

From our survey it is clear that most current practicing consultant vascular surgeons are men but given that more than 50% of medical students currently enrolled in United Kingdom Medical Schools are women, the imbalance between male and female vascular surgeons is likely to change. This gender imbalance is not unique to vascular surgery, but seen across a range of surgical specialties and indeed to a lesser degree in the total NHS Consultant Workforce.15,16,18 As we move towards gender re-balancing of the workforce, we may predict that there will be an increase in part-time working. With these changes in the workforce we need to plan for an increase in part-time working, career-breaks (including entitled maternity leave), and to create a more family-friendly work pattern.18 Currently a majority of consultants are contracted to work more than the recommended standard 10 PA (session) Consultant Contract.11 Both the NHS Employers and Professional Associations have indicated that they would aspire to bring current job-plans down to 10 PAs or below, a level which is considered safe and sustainable. The Consultant Workforce in currently non-compliant with the EWTD.15,16 Obviously, some additional efficiency may reduce PAs without resort to new-job creation, but this workload cannot wholly be replaced with efficiency alone and will require workforce expansion. Furthermore, NHS England's National Medical Director has recently set out a plan to adopt seven day services across the NHS, starting with urgent care services and supporting diagnostics. This was prompted by evidence that compared to

the standard working week on weekend days there was a significant detrimental effect in respect to mortality rates, patient experience, the length of hospital stays and readmission rates.19 However, it is clear that a move to scheduled working at the weekend will require an expansion in workforce numbers. From our survey11 it is clear that the vast majority (over 90%) of Consultant Vascular Surgeons perform the major index Vascular Surgery procedures, the outcomes of which are recorded by the NVR,11,12 and could be considered vascular surgery Generalist. Endovascular surgery is increasing year-onyear in respect to the number and range of procedures. Whilst endovascular surgery is firmly established, it is clear that it will take time for the full transition to an Endovascular Specialist. Complex Endovascular and Open Vascular Surgery requires’ very significant resources in respect to equipment and skilled personnel. This combined with the volumeoutcome effect and the proactive commissioning of these complex services would suggest these interventions in future will be carried out at a relatively small number of superspecialist Vascular Surgery units across the UK. This may in the future produce Vascular Surgery Specialists in a range of sub-specialty areas such as Vascular Medicine, Endovascular Surgery, Open Thoraco-abdominal Aortic Surgery, and Venous Therapy. Therefore we have made the following predictions. From the VSUKWS,11 overall, 93% currently worked full-time, Interestingly, on sub-set analysis female surgeons, who currently represent only 8% of the overall workforce, and are more likely to work part-time, (16% Female versus 7% Male, p < 0.05). The standard full-time NHS Consultant contract recommends a total of 10 Programmed Activities (PA), or sessions (typically 4 h, morning or afternoon), but currently 88% work more sessions, average 12 (range 6e16) PAs, and 60.3% estimate they worked >50 h per week. First, the population in the UK will grow. Second, we shall move towards a gender-balanced (50:50) workforce, and part-time working will increase proportionately, perhaps to 11.5% (average of gender %). Third, to approach compliance with the European Working Time Directive (EWTD) consultant job-plans will reduce from the average 12 PA (circa 5496 PAs), towards the recommended average 10 PA (circa 4580 PAs), leaving a shortfall of circa 916 PA (or 92 Surgeons) of workload to be replaced. Fourth, 7-day services will increase and to provide additional scheduled day-time work (0800e1700 h) on Saturday and Sunday, in premium time (circa 6 PAs) as currently contracted, would require an additional 2748 PAs (or 275 Surgeons) workload to be replaced, Table 3.

Table 3 e Estimation of Numbers of Vascular Surgeons needed per Capita Population in UK. Weighted capitation 1 per 150,000a 1 per 137,000b 1 per 100,000c a b c

Baseline Population expansion (þ36) Gender Re-balance (þ53) 10PA contract (þ92) 7-day Working (þ275) 418 458 627

454 494 663

507 547 716

599 639 808

874 914 1083

1 per 150,000 as POVS (minimum recommended number). 1 per 137,000 as number registered by NVR (surgeons in UK conducting AAA repair). 1 per 100,000 as POVS (number for tertiary centres).

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Worldwide factors impacting on future demand Vascular surgery is a new surgical specialty in the UK but is well established as an independent specialty in several countries within Europe,2 and in North America,6 Australia, and Asia. In developed countries, both the number and complexity of vascular surgery procedures per capita population is increasing year-on-year.4,6e8 Fowkes et al., in their analysis of reported global trends noted a significant increase in the prevalence of peripheral arterial disease over the decade ending 2010.3 In the United States America (USA) the Healthcare Cost and Utilization Project Nationwide Inpatient Sample has demonstrates a net increase in vascular surgery procedures and based on these trends they have predicted inpatient vascular surgery workload to increase (compared to 2008) by 18% by 2015, 34% by 2020, and 72% by 2030.6,7 In the USA in 2008, it was reported that the estimated ratio of Vascular Surgeons per capita population of approximately 1 per 108,000 population.6,7 France, a close European Neighbor, by comparison to the UK has a similar population size, demographic, and socio-economic status. In France in 2011 it was reported that there were 611 active vascular surgeons for a population of circa 65 million, giving them an estimated ratio of Vascular Surgeon per capita population of approximately 1 per 107,000 population.8 They too recognized a substantial increase in vascular surgery procedures per capita population and predict a 61% increase in major vascular surgery interventions by the year 2030. Combined with the effect of an increasing and increasingly aged population, they predicted they would need a 30% increase in numbers of vascular surgeons.8 Obviously there are significant differences between the healthcare systems in these comparator countries, which make direct comparison difficult, but despite their obvious concerns both countries have significantly greater numbers of vascular surgeons per capita population than the UK. In many developed countries were vascular surgery exists as an independent specialty the number of Consultant Vascular Surgeons per capita is considerably higher than in the UK and closer to 1 per 100,000 population.6e8

Conclusions We estimate that currently for the UK population of circa 63 million there are approximately 458 consultant vascular surgeons, which equates to 1 specialist vascular surgeon per 137,000 population. The number of vascular surgeons per head capita in many other countries is significantly higher and that combined with robust evidence suggesting increasing demand for vascular surgery interventions would suggest we need a significant expansion in our vascular surgery workforce. Reconfiguration of vascular surgery services is likely to increase the number of large teams in high volume units delivering urgent or emergency inpatient vascular surgery services. Whilst the level of service provision will ultimately be based on governmental healthcare policy in this area, it is undoubtedly clear that we need to plan for a significant expansion in the Consultant Vascular Surgeon Workforce over the short- and medium-term. We will need to

train and appoint sufficient numbers of new Consultant Vascular Surgeons in the United Kingdom over the next 10 years to maintain the status quo.

references

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Please cite this article in press as: Harkin DW, et al., Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.10.004