Future Practice: A Review of the Scottish Medical Workforce
2. DEMAND FOR DOCTORS
11. The starting point for planning the workforce must be what each resident of Scotland needs from the health service:
The public must be involved in defining needs and the delivery systems to meet those needs. A practical framework for public engagement 8 is therefore vital.
12. A wide range of services will be provided by employees, contractors, volunteers, health professionals and support staff. It is they who have the skills to ensure that NHSScotland is able to meet public need. Their contribution must be considered and planned in a balanced way.
13. In many instances who should undertake a given task should no longer always be dictated by 'traditional' professional roles. Increasingly, it is a matter of deciding how the task should be handled within a team. This means that the translation of service need into the demand for doctors is far from straightforward. We need to think about the doctor's role and the roles of others in the wider healthcare team in delivering the service of the future before deciding how many doctors are needed.
14. On considering how the doctor's role can and should evolve and thus the demand for doctors, we need to take into account two inter-related elements:
2.1 How Doctors Work
Patient-centred service delivery has a major impact on how doctors work and the support needed:
acute care services should provide cost effective, 24 hour, 7 day service;
teamwork has an important contribution to make at all levels of care;
intermediate care, through extended general practice provision, has a key role at the primary/secondary service interface; and
managed clinical networks, delivered on a scale usually larger than the responsibility of an NHS Board, have an important role in securing an effective service across Scotland.
How doctors work in the future will be affected by the impact of:
new pay systems which reflect new approaches to the ways in which the contributions of medical staff are recognised;
NHS24 and other similar initiatives;
the changing gender balance in the workforce;
the Working Time Directive (WTD); and
reform of medical education and training.
The move towards specialist-delivered services is inevitable. However, generalist or core skills need to be recognised as desirable for all doctors.
Administrative support linked with robust information services can enable change in service delivery and allow doctors to focus on those tasks more appropriate for their skills.
We need to identify and put in place what has to be done to ensure that doctors are and remain fit for purpose and able to meet changing service needs.
Current developments in training, job design, job planning, appraisal and revalidation will help to clarify professional roles.
The ability and opportunity to engage in personal development will enable doctors to advance their clinical practice. This needs to be flexible and tailored to meet individual need.
Planning needs to provide also for the numbers and training of general practitioners working in enhanced primary care teams and at the interface of primary and secondary care.
Optimum service re-design:
enables maximum use of available resources;
delivers acceptable, local solutions that work;
delivers enhanced services;
redefines the role of service units which may be difficult to sustain in isolation;
is co-ordinated across primary and secondary care; and
must involve the public
15. Services and the patterns of working to deliver them have been changing and will continue to change not only for doctors but for all health professionals. In the future not all services currently provided by doctors will continue to be provided by them. The questions for medical workforce planning are:
what services will doctors be expected to provide in the future;
what types of doctor will be fit for purpose to provide these services; and
what needs to be done to make sure that changes in the role and skills of doctors keep pace with service needs?
We believe that change in the traditional models of service delivery is inevitable if public expectations and Scottish Executive policies for service delivery are to be met and, at the same time, reconciled with a workforce that increasingly will no longer be able to meet the out-of-hours commitment made by doctors and other health professionals in the past. A solution that relies on securing yet more doctors to work much as they have done in the past, looks increasingly untenable.
In essence the supply now and in the future will not meet the demand if we retain current patterns of service delivery. Re-design of the delivery of services is in our view inevitable.
Doctors delivering service
16. New approaches to service delivery will be required and will vary across Scotland. They will alter both the qualitative and quantitative demands for doctors. Here we signal likely and desired changes in service delivery and anticipate their effect on the demand for doctors
17. Local, intermediate and centralised care should be defined. Local service issues will need local solutions. There is no uniform blueprint that can or will be applicable equally everywhere but there are principles that should be applied within the general practice, hospital and community services and for any defined geographical area.
"Travel time increases clinical risk for emergency care, but so can lack of capacity, critical mass or experience in a small unit"
18. Service re-design. It is essential to be clear how services are to be provided and how they are best delivered for both primary and secondary care and in urban and rural situations. There is an urgent need to develop co-ordinated programmes that will deliver accepted and effective service re-design, linked to the development of different models of acute care. Service re-design includes complementary organisational and geographic changes.
Service re-design requires resources; it is not an economy measure. Key aspects are:
the ability to deliver reliable continuity of care in which patients have confidence;
shift, part-time and teamworking are an inevitable consequence of complying with the requirements of the Working Time Directive, and if public expectations of convenience and timely access to services are to be met;
effective team care will become essential;
patient care will benefit from a more effective partnership between all health professionals working within the primary care team. Primary care services both support and are supported by intermediate care and must be linked to appropriate secondary care re-design;
acute care hospital units may need to be reconfigured and the services they provide re-designed. All current acute service configurations (both physical facilities and staffing) need to be reviewed to test their validity and their viability to sustain a high quality 24 hour, 7 days per week service and to remove duplication, which is wasteful of limited resources. 'Cold units' catering for more elective work, caring for the chronically ill or providing ambulatory care should complement the work of acute 'hot units';
the public must be involved in any service re-design. They need to help plan the routes of access to care, to understand and have confidence in them and to see the benefits that will derive from service re-design in terms of access, safety, and of quality of care. Many accept the value of travelling further for care but adequate transport services must be part of new arrangements. This will include air, sea and road support;
it is important to promote and sell:
This is an activity that must be given a high priority; and
19. The political will to lead on change may be influenced by public perceptions, involvement and acceptance of new arrangements. This in turn depends on new arrangements fulfilling public expectations while improving on the quality and safety of current services.
20. Teamwork. There is great scope for the development of teams and of teamwork:
This should be given priority. Their role in advancing service is as effective in secondary and tertiary care as it is in primary care; and in both urban as well as remote and rural parts of Scotland. Where relevant, teams crossing the boundaries of primary and secondary care and extending into social care should be developed. It follows that health professionals may work in more than one team. Clinical leadership, which is not inevitably the doctor's role in any given clinical team, is vital and needs to be identified and developed.
21. The mix of skills required should be assessed carefully to ensure that the team is fit for purpose. The aim should be to make the most effective use of existing and potential skills of team members, not simply to perpetuate within the team, traditional assumptions about roles and inter-professional barriers. This is underpinned by encouraging and developing flexibility in working practices and, where appropriate, transfer of roles. Such skill-mix should be designed to ensure that the team maintains its effectiveness irrespective of the demands of varied and flexible working patterns.
22. The Wanless Report 7 recognised evidence suggesting:
that there is significant, untapped potential for fundamental changes to the mix of staff providing much health care;
changes in skill mix over the past 20 years have added to the cost of health care relating to the increase in proportion of more highly skilled staff within the workforce; and
skill mix changes over the next 20 years may continue to be cost additive with the move to an increasingly consultant-provided service, the reduced reliance on junior doctors for much patient care and the implementation of the Working Time Directive.
In Scotland there are already examples where nurse endoscopists have successfully reduced waiting times. Extended roles for radiographers have done the same.
23. Good practice examples of team-delivered services need to be disseminated. Teams should enable and encompass links with community care, social services and the voluntary sector.
24. The public should be involved in the development and construction of teams thereby ensuring that:
their expectations of quality care are met;
they have greater certainty in what to expect for both acute and chronic care; and that
they understand the roles of different members of the team.
25. Barriers to effective teamworking must be addressed, for example, by clarifying leadership, lines of accountability and clinical responsibility.
26. The development of teams enabling more effective delivery of services and more appropriate opportunities for different health professionals to contribute should be the focus of specific training and service programmes led and co-ordinated nationally but implemented at local level. If this is to be successful, training and experience in teamwork must be seen to be an integral part of training for all heath professions across the continuum of clinical practice:
27. Intermediate care. We define this as lying at the interface of primary and secondary care.
It will have a key role in delivering the service of the future. It is important to explain and secure the support of the public for this new approach to service delivery. Its hallmarks are:
new relationships between primary and secondary care practitioners that ensure that the skills of both are applied to each patient's care in the most effective way;
specific roles for general practitioner/community hospitals providing care more locally and relieving pressure on the secondary sector;
closer working with social care to develop the hospital at home, supporting timely discharge, and prevention of re-admission schemes;
an extended role for general practitioners and an increase in the capacity of primary care; and
improved access from primary care to investigations (e.g. imaging) perhaps through ambulatory care centres.
28. Managed clinical networks. There is great potential to develop and apply this model of care delivery. Managed clinical networks (MCNs) deliver services to areas which are often larger than the responsibilities encompassed by any trust or health board attempting to deliver a similar service in the specialties concerned. This is particularly so where it is difficult to sustain the critical mass of staff to deliver service. Many networks will rely to a significant extent on effective teamwork to deliver service. To take this forward:
Their staffing (both clinical and administrative) and their role in career development and training need also to be identified;
those services which are best delivered through MCNs should be identified and developed to give full effect to the potential for such networks first recognised in the Acute Services Review 9;
the role of networks in enabling more effective delivery of services should be the focus of specific development programmes led and co-ordinated nationally but implemented at local level; and
the advantages of linking employment contracts to networks need to be explored, as a means to provide more equitable access to services for the people of Scotland.
29. Information services. The management of service re-design and the development of managed clinical networks will require:
Electronic patient records will greatly assist this process, as would links with primary care electronic patient records. Those aspects of the Information Management and Technology Strategy for NHSScotland 10 that support service re-design and managed clinical networks should be given high priority.
30. Management and administrative support. Doctors are a highly trained resource but in general do not spend enough time seeing patients or undertaking clinical work. What individual doctors do varies and will often include, for example, managerial and teaching roles as well as direct clinical roles. However, there are administrative and support tasks which others, who have the relevant skills, could better discharge enabling the expensive clinical resource of the doctor to be appropriately deployed. This needs to be understood and taken forward at local level so that it is given practical effect in service delivery and re-design.
Doctors as health professionals
31. Flexible employment opportunities. More flexible employment arrangements would:
ensure a more responsive medical workforce better able to respond to service need;
support recruitment and retention;
meet individual doctor's needs; and
improve career development.
32. Hospital career and training grade structures, including the staff and associate specialist grades, merit review to establish how greater flexibility in employment opportunities can contribute most effectively to the provision of services and the development of the workforce. For example, in the hospital service it is timely to explore:
greater diversity in specialist (consultant) appointments including trained doctors (holding CCSTs 11) who may not wish to hold the responsibilities of a consultant;
short-term service appointments providing constructive experience that doctors in training may wish to take up and which support the expectation of their returning to training later;
expected modernisation of the SHO grade arising from the anticipated report on reform of the grade; and
the role for an earlier award of more general CCSTs.
33. Professional development. It is crucial for the service to invest in the development of all health professionals across the continuum of clinical practice - from entry to pre-registration training until retirement. Equally health professionals need to accept personal responsibility for maintaining their skills and competencies. Many professions are moving rapidly towards re-registration, re-certification or revalidation, usually based on evidence of appraisal and of demonstrating a continuing commitment to personal development. Increasingly there is a demand for flexible working patterns including career breaks and the opportunity to change career direction. These trends drive the need for individually tailored additional educational support that is an important investment in the workforce. If delivered, this in turn will support and enhance recruitment and retention to both primary and secondary care.
34. We believe these trends apply to medicine as they do to other health professions. They are strengthened by the gender shift - the increasing ratio of women in the medical workforce - and moves towards a better quality of life for doctors and their families through, for example, the New Deal on Junior Doctors' Hours and the application of the Working Time Directive.
The gender shift reflects the increasingly dominant selection of women to medical schools: the effects on the service can be seen, for example, in the PRHO and general practice principal grades.
Chart C: Medical PRHO Workforce (Scotland) Gender Shift - %
Chart D: GP Principal Workforce Gender Shift - %
35. Although doctors are responsible for their continuing professional development in partnership with employers, the latter too have obligations to support their workforce. As a consequence of revalidation and appraisal, employers should set out their policies on continuing professional development and the support available to their workforce. This is an integral part of clinical governance. To secure the medical workforce and to enable and support flexibility in career pathways, it will be necessary to provide access to career advice, guidance and counselling throughout the continuum of clinical practice. A more proactive approach to the professional development of doctors is needed. This role could well be led or catalysed by the medical Royal Colleges working with the new NHS Board "NHS Education for Scotland".
36. Role clarity. Changes arising from the Calman reforms 12 of higher specialist training and the expected moves to modernise the SHO grade serve to clarify the role of the trainee and the trainer. They make an increasingly strong distinction between the training and the service role of doctors in training. Job planning, appraisal and revalidation will also bring much greater clarity to the role of individual doctors and their contribution to service outcomes. So will service re-design and teamworking - each bringing more explicit understanding of skill-mix and professional roles within the team. This will assist the planning and delivery of services and also the doctor's ability to manage better his or her own lifestyle and work.
Implications of how doctors work
37. Specialist delivered services. The prime role of the specialist (including the general practitioner) is to deliver medical services. We believe the move towards a specialist-delivered service is driven in part by the need for clarity of role and by the need to deliver quality care underpinned by the new arrangements of clinical governance. It is accelerated by changes in the training of junior doctors which reduce their input to service delivery and by pressures to reduce working hours. In the future specialists will increasingly be part of and may lead a multi-professional team rather than a medical 'firm' or general practice. The move towards a specialist-delivered service needs to be confirmed and a strategy to achieve this agreed with implementation co-ordinated nationally.
38. General practitioners working in enhanced primary care teams. General Practice itself should be recognised as a specialty. General practitioners will need to work more in enhanced primary care teams and at the interface between primary and secondary care. The numbers required will depend on the nature of the service, particularly on how far it will become team-delivered. Rationalisation of service delivery of acute and chronic hospital care will have knock on effects on the interface between secondary and primary care (including intermediate care) and on primary care.
39. Generalism. There is a trend towards increasing specialism to assure skill levels in particular procedures. At the same time, the evidence we received and that from Planning Together show that the core skills of the generalist are highly valued. They are especially important in smaller hospitals providing a wide range of core services and in remote and rural areas. These core skills:
help provide the type of whole-person service envisaged in the future;
bring flexibility necessary to respond to changing demands;
increase the scope for movement between specialisms; and
support recognition of different roles in intermediate care.
It is a widely held view that generalist skills at an appropriate level should be recognised as desirable for all doctors. They need to be supported by training programmes that fit clinicians to this type of service provision. They are also the central tenet of general practice and need to be retained.
More doctors required
40. For all of the reasons stated above we believe more doctors will be needed to deliver both hospital specialist and general practice services. Work is required to identify this additional need for Scotland over the next ten years taking account of changing roles in urban and rural settings and within developing teams. New training requirements to match these changing roles will need to be specified and delivered.
41. Planning the training grades. The purpose of the training grades is to provide fully trained, appropriately skilled specialists. After allowing for likely attrition from medicine or from Scotland, the size of the training grades needs to be geared to the expected requirement for trained doctors in Scotland, Oversupply undermines career planning. Its correction may help better to retain in Scotland those staff trained in Scotland, although this will have to be judged in the context of the dynamics of the UK workforce and continuing cross-border flows. Planning must take into account the movement towards the New Deal/WTD hours limits and an overall diminished service contribution from the training grades. With moves to specialist-delivered service, trainees should not be employed primarily to provide service. This means that the role of non-training grades below specialist level needs to be reconsidered.
Recommendations (how doctors work)
3 Confirm and co-ordinate a strategy to move towards specialist-delivered services.
4 Promote the recognition of generalist skills as desirable for all doctors.
5 Review the hospital career and training grade structures: This is urgent
include the staff and associate specialist grades;
take account of recommendations to modernise the SHO grade;
consider how short-term service appointments can contribute to the provision of services and the development of the workforce; and
consider different models for specialists using listing on the Specialist Register as the basis for identifying a trained doctor.
6 Plan the training grades to satisfy the need for trained doctors, not to provide service.
7 Give service re-design high priority as a co-ordinated, resourced effort covering primary and secondary care:
review all current acute service configurations;
involve patients and public in service re-design; and
promote enhanced services rather than institutions.
8 Identify and pursue opportunities for managed clinical networks:
ensure that their essential features are clear and agreed;
ensure that they are managed;
develop and co-ordinate networks nationally; and
explore the linking of employment contracts to networks.
9 Establish a clear position on intermediate care:This is urgent
10 Give the development of teamwork high priority:
11 Encourage the provision of more flexible opportunities for employment and career development:
12 Address the reallocation of administrative and other tasks currently carried out by doctors, to maximise the use of doctors' clinical skills.