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Future Practice: A Review of the Scottish Medical Workforce

1. PICTURING THE FUTURE

1. It takes time to develop a doctor: from entry to medical school to trained specialist ⁴. For instance, the minimum for some specialties is 9 years but much longer for others. It also takes significant time to bring about change in attitudes to clinical care and how it is delivered. That is why we need to set out a view of the future health service for Scotland now. It means striving to understand how services might look at least 10 years ahead and the roles that doctors are likely to play.

2. We have assumed the continuation of a publicly funded and managed service, providing comprehensive care. That excludes the option of managing pressures by withdrawing completely from difficult areas of service delivery and means that any change has to be justified in terms of its priority within the financial envelope of public funds.

Some factors, which will affect the future shape of the health service, are external and beyond the control of government or the service itself. Trends in demography and disease suggest that in the future:

• the level of chronic disease requiring health care will increase;

• the population of Scotland is projected to fall by 1% over the next twenty years whereas that of England is projected to rise by 8% over the same period;

• the proportion of older people in the population will continue to increase and in rural and remote areas will be higher than in the general population (see charts A and B);

Chart A: Scottish Population Projection % by Age

Chart B: Highland and Western Isles Population Projection % by Age

• the working population from which health care staff is recruited will form a progressively smaller proportion of the population;

• more women are working than ever before. In 2000, 48.1% of all those employed in Scotland were women ⁶; and

• the urban drift of population will mean that the pool of health care staff is itself increasingly urban-based.

4. It is likely that the public of the future will expect:

• a more informed and informative service from all members of the health team;

• speed and convenience of access comparable to general commercial services - including 24 hour, 7 day access to acute care services;

• more care delivered in community settings and tailored to meet individual need;

• advice and assistance in healthy living and the management of chronic disease; and

• greater specialisation and greater medical input to deliver medical advances.

Health staff, in line with social trends and to comply with legal requirements, will increasingly expect:

• reasonable working hours and patterns of work that match with family commitments and a changing lifestyle outside the working environment; and

• a clear, secure and flexible framework for career progression in which to work and develop professional skills.

6. Medical and technical advances will continue. They can take some time to translate from the laboratory to clinical practice, but they do have dramatic effects on the service in a timescale which is short by comparison with the time it takes to train a doctor. It is likely that, over a horizon of 10 years or more:

• new specialised skills will be introduced;

• the need for some medical skills will disappear;

• other skills which are currently highly specialised, relatively unimportant or unforeseen will become standard or widely required;

• the developing electronic world will mean communication of information between clinicians will be immediate;

• new investigative and operative techniques such as digital imaging will be widely available and enable remote assessment and intervention; and

• there will be new ways of accessing and delivering education reflecting the changing nature of educational technology and its application to clinical practice.

Recent examples of medical and technical advance have resulted in the decrease in peptic ulcer surgery, the substitution of laparoscopic for some open surgery procedures, thrombolysis for myocardial infarction, the rapid growth in coronary artery bypass surgery and the emergence of gene therapy.

7. Our National Health and the various policies which amplify and develop its messages, take account of these factors and set the direction of a modern health service. Thus our picture of services in 10 years' time includes the following:

• a shared understanding with the community about how the health service can help people maintain healthy lives and cope with illness, and of the priorities that apply for individuals and for the service as a whole;

• a community and primary care focus on promoting and improving health;

• 24 hour, 7 day access to acute services;

• managed access to timely elective secondary care;

• services provided by a team and identified with a team - not an institution nor an individual;

• advice and care given in all cases by a health care professional who has the skills to perform that function and to recognise when other team members need to be involved; and

• medical care delivered primarily by doctors who are trained specialists (consultants or general practitioners).

8. This picture of the future has been in our minds as we have written this Report. It is, of course, a speculation, but we think it is a reasonable basis for a long-term view. It sits well with many planning assumptions applied by the Scottish Executive Health Department (SEHD). However, we feel that SEHD policy is not informed by a long-term view. Following the lead of the Wanless report ⁷, that should be addressed. It will mean engaging with key partners, including those outside the health service, such as local authorities and universities.

9. A suitable approach could be to take a small number of health conditions and describe how in, say 2012, patients in urban and rural parts of Scotland could expect each condition to be addressed. There will be a need to look at the services provided and the roles of the various health professionals and others in the "care team".

10. We are conscious that we need to plan starting from where we are today and to take account of Scotland's particular needs. In many ways these are different from the rest of the UK. It is evident that we must plan to secure Scotland's workforce taking these differences into account. Some of the parameters that illustrate the differences are in Table 1. We were conscious of them as we considered the options for planning for the future.

Table 1: Comparative Parameters

* Life expectancy figures are for the period 1997 - 99;

** Excludes the intake to St Andrews University which has been included within the intake to English clinical medical schools;

*** Planned target intake is 772. Actual intake may be higher than the planned intake.

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