1. No category

Medical and Dental Workforce
Introduction
HENW‟s macro analysis of the 2014 provider workforce plans from across the North West
highlighted five key themed areas of priority for workforce planning: nursing, medical, urgent
and emergency care, primary care and radiology.
The purpose of this paper is to explore the issues around the medical and dental workforce
in more depth. It identifies in detail the key issues and areas of work that emerge from a
more detailed region-specific analysis, and sets out ways forward and the implications for
HENW‟s work.
Key Story Messages
Health Education North West needs to understand the current context, issues and front-line
situation around the medical and dental workforce and how policy and directives translate in
to what it means in the short, medium and long term for the medical and non-medical
workforce and transformation.
The analysis of the 41 NHS provider plans and wider system has outlined the challenges,
issues and realities for the medical and dental workforce. It has also provided a framework
for what HENW needs to do to plan its way through the 76 specialties through 2015/16 to
ensure more granularity of bottom up medical and dental workforce demand but also the
impact of national allocations at undergraduate and junior doctor levels.
It takes approximately 14 years to train a consultant and ten years to train a GP and HENW
are cognisant of these timescales when planning workforce transformation alongside service
commissioners.
The future medical and dental workforce has historically been planned at a national level.
The process has focused on assessing the number of consultants the system will need
(future demand), in order to determine how many post graduate training posts to create
(future supply). To be able to apply for a consultant post, doctors need to be on the specialist
register. The normal route to entry is via comprehensive training leading to the award of a
Certificate of Completion of Training (CCT). The following paper therefore focuses on how
many postgraduate medical and dental training places ultimately leading to a CCT we will
commission through 2015/16 in the HENW investment plan, financial model and EDCOM
submissions to HEE.
Undergraduate medical workforce planning is often undertaken with an assumption that this
will feed into the local workforce planning processes. However, it generally doesn‟t and this
is a challenge HENW are working to address trying to balance the measure of need,
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Quality education for quality patient care, transforming our workforce
Health Education North West
capitation or weighted capitation, current shortages, consultant numbers, types of workloads
and types of settings.
There is a dichotomy between medical and GP trainees. Predominantly medical trainees
have favoured geographies and there is little evidence from both Goodacre and Knapton
that they migrate north during or on completion of training. GP trainees generally want to
work in the practices they trained in, however these are more city-based than rural.
Providers need to have the capacity to train trainees and a quantum of trainees to have the
opportunity within a given area to make it viable, sustainable and give the breadth, coverage
and exposure to the trainee.
In addition, specialty is affected by the draw of centres, for example:
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Higher trainees within tertiary centres, e.g. cardiology and gastroenterology
More paediatricians in tertiary children‟s hospitals
Specialties in teaching hospital, e.g. plastic, cardiothoracic and neurosurgery
In relation to GP trainees, HENW continue to progress the growth of GP numbers and
expand the wider primary care workforce. We forecast that if our planned training levels are
achieved, then the number of GPs available for employment would be X FTE by 2020, an
increase of X% from the X recorded as being employed in September 2013. This is based
on us achieving X new trainees in 2015 and an average of X new training GP commissions
each year from 2016. We are working with our partners to strengthen our ability to recruit,
retain and attract people back to this vital profession.
Forecasting the future workforce requirements
The fundamental question for HENW is whether this level of future growth (supply) is what
the wider health and care system and current and future patients require (demand).
HENW is committed to ensuring a wider consensus on future requirements is sought with
our 33 Clinical Commissioning Groups‟ (CCGs) service commissioners, NHS and NHS
funded providers, primary care, medical workforce advisory group (MWAG) and learning
from the medical specialty workforce groups led and run by HEE. In addition, we will develop
a shared understanding of the needs of future patients and the impact on the consultant and
wider medical workforce of service transformation and reconfiguration, workforce
transformation and including the implementation of strategies, policies and direction of travel
including:
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considering the life course modelling in the 15 year strategic framework
the intended and unintended consequences of the 5 year forward plan and new
service delivery models
Quality education for quality patient care, transforming our workforce
Health Education North West
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the outputs of the whole system partnership medical and non-medical modelling
collaborative across all 13 LETBs looking at future medical supply models but also
future demand models
analysing, modelling and forecasting the workforce transformation requirements for
the eight North West major service reconfigurations
participating in CfWi medical modelling and deep dive programmes across demand
and supply
horizon scanning future scenarios and modelling solutions using Delphi or similar to
generate quantum demand at a quantitative and qualitative nature
Engaging with the organisations that actually establish and fund consultant and medical
posts including the PGMDE team and heads of schools must be a component for creating
some consensus about the future of the medical and non-medical workforce we are
investing in.
The fact that doctors in postgraduate training also provide significant periods of service while
learning and developing means separating the training posts required to deliver the future
consultant workforce from the numbers needed by employers to deliver today‟s service. This
makes an assessment of the future need more challenging and complex. Reductions in
postgraduate trainee posts or trust-funded posts not only reduce the supply of the future
number of consultants for a particular profession, but can also impact on quality and safe
patient care today.
Adding to this complexity by taking into account the „Shape of training‟ review and policy
challenges, it is clear that we need to develop concrete units of analysis and consensus to
share findings and underpin initiatives and change with intelligence and evidence.
Strategic Context
HEE Strategic Framework 2014-2029
Across England there are 76 different medical specialties covering 94 programmes of
education.
HEE will take forward the „Shape of training‟ review of postgraduate medical education and
training (published 2013) to deliver this for the medical workforce. We will develop a more
flexible workforce that is able to respond to the changing patterns of service and embraces
research and innovation to enable it to adapt to the changing demands of public health,
services and patients.
For England the current projections suggest continued annual 4% growth in medical
consultant numbers until 2020, which resonates with the consultant demand across HENW.
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Quality education for quality patient care, transforming our workforce
Health Education North West
Medical innovation and discovery, from the ancient beginnings of „rational medicine‟ through
the development of antibiotics and organ transplantation to medical imaging and human
genome sequencing have transformed our ability to diagnose and treat disease, saving and
improving the lives of countless patients and their families. Further progress is anticipated in
science and health, which whilst vital is not the prime focus of this report. Instead, we
highlight the extent to which technology and innovation in other fields will increasingly disrupt
the way that patients and staff perceive, understand and manage health and ill-health in the
future.
The current medical model is based largely upon a „diagnose and cure‟ paradigm, which
means the health system can only react when something goes wrong. HEE therefore need
to radically rethink the whole notion of „patient‟ and „professional‟ and the nature of the
relationship between them.
HEE Mandate 2014-15
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HENW needs to ensure for the duration of this mandate that plans are brought forward to
ensure that future medical students graduating in the North West who are competent and
who have completed undergraduate training programmes successfully are supported to
secure full registration at the point of graduation.
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HENW will ensure that 50% of trainees completing foundation level training enter GP
training programmes by 2016.
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HEE have an objective to lead a process to ensure sufficient staff are trained with the
right skills in the right locations to enable healthcare providers to deliver their
commissioning plans. It is often the case that healthcare students have in the past
taken up work close to the areas where their training was undertaken, leading to
workforce imbalances across many areas of the country. Training will need to take
place across the whole of England to reflect the service needs both now and in the
future and HEE should work with LETBs to understand geographical imbalances and
take action to correct them.
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HENW will support the development of the existing workforce
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HENW will deliver competent and capable staff
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HENW will develop a workforce skilled for research and innovation
HEE Business Plan 2014-15
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Oriel - Implementation of medical and dental recruitment for Medical and Dental
Recruitment and Selection Mandate (MDRS) by 31 March 2015
Quality education for quality patient care, transforming our workforce
Health Education North West
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Ensure graduates of UK medical schools achieve full registration
Establish a pilot of the International Postgraduate Medical Training Scheme by 31
January 2015
Work with the medical Royal Colleges that set curricula to support specific perinatal
mental health training being incorporated into the syllabus for doctors in postgraduate
training
Understand the quantum and stock of the medical and dental workforce
Implement processes to commence bottom up workforce planning across the LETBs
NHS Five Year Forward View report from NHS England, Health Education
England, Public Health England, Care Quality Commission, Monitor and Trust
Development Authority
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Building on the earlier work of Monitor looking at the costs of running smaller
hospitals, and on the Royal College of Physicians‟ „Future Hospitals‟ we will work
with those hospitals to examine new models of medical staffing and other initiatives
for care delivery either in hospital or out of hospital.
In partnership with local authority social services departments, and using the
opportunity created by the establishment of the Better Care Fund, we will work with
the NHS locally and the care home sector to develop new shared models of in-reach
support, including medical reviews, medication reviews, and rehab services. In doing
so we will build on the success of models which have been shown to improve quality
of life and reduce hospital bed costs.
Shape of Training
http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training
_FINAL_Report.pdf_53977887.pdf
The publication of the final report from Professor David Greenaway's review of
postgraduate medical training, “Securing the future of excellent patient care: Final
report of the independent review”, follows extensive consultation across the four
countries of the UK. This report sets out a framework for delivering change and for
doing so with minimum disruption to service. It offers an approach which will ensure
doctors are trained to the highest standards and prepared to meet changing patient
needs for many years to come.
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Health Education North West
Units of Analysis
Findings
Analysis of the intelligence has identified the following:
Health Education Northwest Workforce Plans Narratives, Risks, Issues and
Actions:
Geographies
North West
Short-term issues
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Gaps in middle grade rotas across a broad range of medical specialties, see Annex 4
Short, medium and long term consultant vacancies see Annex 4
Understanding the variance between service issues and an actual workforce training
issue.
Understanding the exact number of medical and dental staff linked with: rotas, type of
medical model, locums, out of programme, maternity and sickness and popularity of
specialism.
Struggling to recruit into general practice, emergency medicine, geriatrics, acute
medicine and psychiatry however the latter is improving,
Smaller specialties struggling to recruit include rehab medicine and occupational
medicine.
Hierarchy of specialism and understanding the psychology of choice into medical and
dental specialties is a further piece of work of interest.
Understanding the hidden curriculum and culture within medical specialties.
Understanding the impact of the shape of training – where the focus is on generalist
and how this contrasts with how the specialty views itself and creates an interesting
debate whether generalist is valued less than specialism.
Balancing the demand for certain specialities compared to less glamourous
specialties.
Cumbria and Lancashire (East and West)
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There are hard to fill posts in cardio, ophthalmology, dermatology, care of the elderly,
A&E, special care dentistry and fill the medical training places. The major challenge
is filling our vacant (funded) posts – we made a lot of progress on this last year but
we need to find ways to get jobs filled quicker. Where we continually struggle to fill
posts – particularly junior doctors, where we have no control over the supply of
juniors and we constantly have gaps on rotas.
Quality education for quality patient care, transforming our workforce
Health Education North West
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43 % of the providers medical workforce is aged over 50, with a planned 8 FTE to
retire in the next 12 months
Middle grade vacancies across all directorates
Consultant Haematologists – this is a concern within the region at present as very
few opportunities exist to recruit from within the UK. Recent international recruitment
in this area has proven successful.
National reduction in training grades in several specialities
Number of senior staff who are interims
Consultant vacancies in: Interventional Radiologists, Neuro Radiologists, Neurointerventional Radiologists. Anaesthetists, Urologists, Emergency Department,
Dermatology, Neurology, Haematology, Neuro-Physiology, Oncology, Immunology,
Haematology and Acute Medicine
Middle Grades vacancies in Ophthalmology, Emergency Department, Renal,
Paediatrics, Obstetricians and Gynaecologists, Vascular Surgery and Anaesthetics
Training Grades
The continuing and fluctuating nature of vacancies within Doctors in Training
presents significant challenges in ensuring the ability to maintain services and
balance rotas to ensure compliance with EWTD.
The shift of focus of junior doctors training from the acute sector to GP training and
the inability of the Trust to backfill vacancies with LAT‟s in surgical specialities is
having a major implication for the maintenance of services and compliance with
EWTD. This presents a challenge.
The inability to recruit permanent medical staff, particularly but not exclusively in
remote hospitals, and the subsequent over-reliance on locum agency staff. Small
teams and low activity volumes have further compounded difficulties impacting on:
skills maintenance; training experience for junior staff; quality governance
arrangements and achievement of regulatory and emerging college standards. These
problems directly impact on recruitment and have led to major difficulties in retaining
and recruiting staff with subsequent reliance on locums.
Greater Manchester
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Pressures in the systems through a reduction in junior doctor training numbers –
particularly surgery and pathology, and the difficulty recruiting non-training junior
doctors.
Unfilled Deanery posts on the middle-grade rotation in medical and clinical oncology
having an impact on service delivery
Difficulty recruiting non-training middle-grade doctors across specialties across
patch.
Difficulty recruiting Consultant grade staff in certain specialities including
Anaesthetics and Histopathology
There is also a challenge in recruiting appropriately experienced speciality doctors
within the Prison healthcare system and the subsequent length of times it then takes
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Health Education North West
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to complete the additional mandatory checks in order for them to gain the relevant
clearance.
Many current CCT holders prefer to do agency locum jobs so whenever a vacancy
arises this puts a considerable financial pressure on our services. This leads to
issues with continuity of care and lack of local knowledge (e.g. systems and
processes)
Cheshire and Merseyside
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The risk in developing services further, particularly where expansion is at Consultant
level is the planned reduction of core surgical trainees. Junior Doctor Allocations
often leave gaps in service coverage which have to be filled by expensive agency
and locum staff.
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Vacancies across a range of specialties from consultant, middle grade through to
foundation 1 and 2 in A&E, Emergency Care, Anaesthetics, Radiology, Interventional
Radiology and Psychiatry
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Variance across rural and city centre areas.
Health Education Northwest Workforce Plans Demands:
Demand for medical and dental workforce
HENW providers are forecasting a continued growth for medical and dental workforce over
the next five years continuing the historical trend. Please see Annex 6 for the lists of medical
and dental specialties broken down by uncoupled and run-through specialisms.
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Health Education North West
Total Medical and Dental Staff
16000.0
14000.0
12,110
12,494
12,819
13,167
13,116
13,116
2013
2014 (A)
2014 (SiP)
14,294
14,456
14,502
14,525
14,540
14,554
2014(F)
2015
2016
2017
2018
2019
Full Time Equivalent
12000.0
10000.0
8000.0
6000.0
4000.0
2000.0
0.0
2010
2011
2012
Year
Actual SiP
Forecast SiP
Consultants across the North West
Mirroring the national demand in the consultant workforce, HENW demand follows the same
trajectory against a back-drop of challenging annual cash improvement programmes, QIPP
and tightening financial situations.
Total Consultants (including Directors of Public Health)
7000.0
6000.0
5,593
5,025
5,194
5,967
5,771
5,771
2014 (A)
2014 (SiP)
6,075
6,110
6,132
6,144
6,157
2015
2016
2017
2018
2019
5,364
Full Time Equivalent
5000.0
4000.0
3000.0
2000.0
1000.0
0.0
2010
2011
2012
2013
2014(F)
Year
Actual SiP
Forecast SiP
NW Trainee Grades
The demand for trainee grades increases and then plateaus.
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Health Education North West
Total Trainee Grades
7000.0
6000.0
5,341
5,491
5,497
5,587
5,587
2012
2013
2014 (A)
2014 (SiP)
6,452
6,466
6,468
6,468
6,468
6,468
2014(F)
2015
2016
2017
2018
2019
5,085
Full Time Equivalent
5000.0
4000.0
3000.0
2000.0
1000.0
0.0
2010
2011
Year
Actual SiP
Forecast SiP
Uncoupled Specialties
Providers are forecasting additional demand for the uncoupled specialties including
consultants, similarly the demand for trainees plateaus.
Total Uncoupled' Specialties
3400.0
3300.0
3,302
3,318
2015
2016
2017
2018
2019
3,175
3200.0
3100.0
Full Time Equivalent
3,289
3,312
3,278
3,233
3000.0
3,082
3,082
2014 (A)
2014 (SiP)
2,948
2,902
2900.0
2800.0
2,768
2700.0
2600.0
2500.0
2400.0
2010
2011
2012
2013
2014(F)
Year
Actual SiP
Forecast SiP
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Quality education for quality patient care, transforming our workforce
Health Education North West
Uncoupled' Specialties
Consultants (including Directors of Public Health)
1800.0
1,527
1600.0
1,436
2014 (A)
2014 (SiP)
1,578
1,590
1,594
1,597
2015
2016
2017
2018
2019
1,367
1400.0
1,212
Full Time Equivalent
1,436
1,571
1,250
1,305
1200.0
1000.0
800.0
600.0
400.0
200.0
0.0
2010
2011
2012
2013
2014(F)
Year
Actual SiP
Forecast SiP
Uncoupled' Specialties
Trainee Grades
1380.0
1,358
1,358
1,358
1,358
1,358
1,358
1,358
1,358
2014 (A)
2014 (SiP)
2014(F)
2015
2016
2017
2018
2019
1360.0
1340.0
Full Time Equivalent
1320.0
1,295
1300.0
1280.0
1,269
1260.0
1,251
1,244
1240.0
1220.0
1200.0
1180.0
2010
2011
2012
2013
Year
Actual SiP
Forecast SiP
Run-through specialties
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Quality education for quality patient care, transforming our workforce
Health Education North West
Total Run-through Specialties
3200.0
3,080
3100.0
3,094
3,098
3,100
3,105
2016
2017
2018
2019
3,055
3,043
3,043
2014 (A)
2014 (SiP)
Full Time Equivalent
3000.0
2,927
2900.0
2,842
2800.0
2,738
2,752
2700.0
2600.0
2500.0
2010
2011
2012
2013
2014(F)
2015
Year
Actual SiP
Forecast SiP
Run-through Specialties
Consultants (including Directors of Public Health)
1600.0
1550.0
1,520
1500.0
1,535
1,538
1,540
1,546
2016
2017
2018
2019
1,497
1,486
1,486
2014 (A)
2014 (SiP)
Full Time Equivalent
1,455
1450.0
1,403
1400.0
1,361
1350.0
1,310
1300.0
1250.0
1200.0
1150.0
2010
2011
2012
2013
2014(F)
2015
Year
Actual SiP
Forecast SiP
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Quality education for quality patient care, transforming our workforce
Health Education North West
Run-through Specialties
Trainee Grades
1300.0
1,266
1,266
1,268
1,268
1,268
1,268
1,268
1,268
2014 (A)
2014 (SiP)
2014(F)
2015
2016
2017
2018
2019
Full Time Equivalent
1250.0
1200.0
1,168
1,149
1150.0
1,135
1,112
1100.0
1050.0
1000.0
2010
2011
2012
2013
Year
Actual SiP
Forecast SiP
Core Surgical Trainees
In the North West we are continuing to following the inherited recommendations of the
Medical Workforce Advisory Group and Medical HEEAG to reduce the volume of Core
Surgical Training. The main driver behind the recommendation was the current training
levels of over 600 per year in England were too high for the Higher Specialty Training as the
system only requires 350-400 per year.
Education & Training Commissions for 2015/16
Number of Training Posts
222
Core Surgical Training
Increase / Decrease
Medical and Dental Workforce Solutions
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Consider a 10-15 year planning model for medical and dental workforce, weaving in
the 5 year forward view.
Scope the implications of the proposed new models of 5 year forward view, the
variants it will generate around equipping doctors and healthcare professionals to
deliver a service that is a different model today as today‟s model is unsustainable.
Look at the community facing service and care models and about specialists working
with generalists in primary and community settings to support holistic care of patients
instead of referring them into acute services. General Practitioners should hold the
ring on the care of their patients.
Quality education for quality patient care, transforming our workforce
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Health Education North West
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Work with the Local Workforce and Education Groups (LWEG) to identify areas of
good practice around integrated working in the community and what the priorities
would be for the future. Examples of integrated working across mental health,
diabetes care and respiratory care are three areas where integrated holistic care is
been delivered and best practice around workforce planning, transformation and
education can be identified.
HENW are establishing a programme of work to deep-dive into specialties including general
practice to understand the continuum of posts versus people, training posts versus trust
funded posts, consultant demand versus training demand, middle grade demand across
specialties and the potential solutions needs to mitigate local and regional workforce risks. In
addition, the programme will consider the drivers within the system that cover:
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Strategic direction of travel
Mandate and Business plan deliverables
Five year forward view and new models of integrated care across localities
Shape of Training
Drivers from Royal Colleges
Workforce Development & Future Workforce Solutions
For the purposes of this paper HENW will look to respond to the workforce demand in terms
of timelines as follows:
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Short term – 0 to 2 years
Medium term – 2 to 4 years
Long term – 4 years and longer
The periods relate to the pace at which potential solutions or interventions are applied, and
are meant to be indicative rather than absolute and in each case flexible approaches to
delivery may influence the actual timescale.
Resolving longstanding medical and dental workforce issues cannot be achieved quickly and
needs a long term plan encapsulating the five year forward view to address the issues.
Short term
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Continuing Professional Development
Extended non-medical roles
Nurse and other professional consultants
Review of PAs
Further development of the WRaPT tool to model medical workforce scenarios (see
below)
Quality education for quality patient care, transforming our workforce
Health Education North West
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Continued involvement with the Whole System Partnership Workforce Modelling
Collaborative focusing on medical supply and medical demand
Utilisation of the eWorkforce Tool to collect 5-10 year demand forecasts with
granularity around the medical and dental workforce
Higher Education Institute (HEI) innovation for Emergency and Urgent Care to
transform the medical workforce
LWEG forerunner funds
Additional resources to support 136 Advanced Practitioners
The Workforce Repository and Planning Tool (WRaPT)
 The WRaPT tool is a new web-based tool which enables the analysis of current
and future workforce capacity and capability. The tool has been designed to
capture both workforce and activity data, allowing the modelling of workforce
impact on changes in service activity.
 Phase 1 (March – Sept 2014) of development has included the building of the tool,
the repository of workforce information by a range of providers (13 to date) and the
agreement to test the tool on an urgent care pathway „problem‟ across Central
Lancashire – the output of which have been presented at the Stakeholder Forum in
December.
 Plans for Phase 2 (Sept – March 2015) include widening the workforce data within
the repository from 13 organisations to at least 50% across the breadth of the
health and social care system; embedding primary care workforce planning into
the tool; promoting the tool as the single mechanism for future workforce planning
returns.
 This development is unique nationally, is inclusive of the whole health and social
care system and creates the opportunity to develop workforce planning on a whole
health economy footprint, key to workforce transformation.
Medium term
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Understand the implications of Shape of Training
Alongside existing commissioned roles, the Investment Plan also includes 40
Physician Associates/new roles to better reflect a skill mix responsive to changing
service models
5 year forward system changes
Long Term
Please see Annex 5 for the medical education commissions.
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Quality education for quality patient care, transforming our workforce