Health Education England: Call for evidence for review of strategic framework on workforce planning

Submission from the Royal College of Anaesthetists to the Call for Evidence for the HEE strategic framework for workforce planning

About the Royal College of Anaesthetists

The Royal College of Anaesthetists (RCoA)^[1] is the third largest medical royal college by UK membership. With a combined membership of over 24,000 fellows and members, we represent the three specialties of anaesthesia, intensive care and pain medicine.

16% of all hospital consultants are anaesthetists, making anaesthesia the single largest hospital specialty in the UK. Anaesthetists of all grades play a critical role in the care of two-thirds of hospital patients. Anaesthetists also play a leading role in the delivery of perioperative care services.

The specialty of anaesthesia has been and continues to be essential to the management of the COVID-19 pandemic in hospitals and in addressing the elective care backlog. With COVID-19 becoming an endemic disease and the danger of new variants, it’s critical that any workforce planning for the NHS includes anaesthetic services. We hope that the evidence provided in this submission will be useful and we would be happy to discuss any specific aspects with relevant colleagues.

For queries about this submission, please contact Elena Fabbrani, Policy Manager, efabbrani@rcoa.ac.uk.

Category 1- Demographics and Disease

Long Term Conditions and multiple-morbidities       

An ageing population and increasing burden of complex multi-morbidities are driving demand for healthcare services. There will be an additional 8.2 million people aged 65 and over in the UK by 2068[1]. At the same time, advances in medicine, including less invasive surgical techniques, have led to an increase in the number of older patients living longer with complex diseases and better tolerating the stresses of surgery. NHS Digital has calculated a 2.8% average annual growth over the last twenty years in Finished Consultant Episodes (continuous period of care under one hospital consultant)[2]. In addition, the elective surgery backlog from the pandemic and predicted annual winter pressures caused by conditions including endemic COVID-19 and flu will put unprecedented strain on the NHS and surgical services and will continue to do so for years to come.

Workforce demographics

An ageing anaesthetic workforce - The latest Medical Workforce Census by the RCoA[3] shows an ageing of the anaesthetic workforce. More consultants are now working beyond the age of 60 years, up from 5 per cent in 2015 to 7 per cent in 2020. The 50 plus age group is now 39 per cent of the workforce, compared with 31 per cent in 2007.

Like all other professions, doctors are subject to a decline in physiological and cognitive abilities brought on by the ageing process. Anaesthesia is a highly technical specialty, requiring good hand-eye co-ordination, eye-sight and hearing. However, there is variation in the ageing process between individuals, with some requiring considerable adjustments and others requiring fewer. In other words a one size fits all approach to adjusting clinical practice for older anaesthetists is not the solution to making the most of what senior clinicians can offer.

One aspect of clinical practice which is particularly challenging for the ageing anaesthetist is the requirement to be on call. Quality and duration of sleep worsen with age. Being on-call further disrupts sleep, even when not called out, and there is a decrease in the capacity to adapt to shift work with increasing age. In older workers cognitive performance may be more impaired during night work but they may be less aware of their degree of impairment[4], which could have an impact on patient safety.

Additional resources: Age and the Anaesthetist - A report of a working party of the AAGBI, endorsed by the Royal College of Anaesthetists

Category 2 - Public, People who need care and support, Patient and Carer Expectations

• Expectations of the health and social care system as a whole
• Quality and safety of care
• Expectations of the staff that work within social care and health (e.g., skills, values, behaviours)

Patients expect timely care by well trained health and care professionals. Professionals expect the government to step in with necessary resources to enable the delivery of high quality care. Healthcare staff also expect more autonomy as to how the care is delivered and to whom it is prioritised.

People who need care and support/patient  involvement, empowerment and shared decision making

The ability to facilitate a true shared decision making is not yet a skill of the majority of healthcare workers. The GMC have recently confirmed the need for Shared Decision Making (SDM) in the context of consent for surgical procedures and it is recognised that a SDM process not only improves patient satisfaction with their care and reduces regret postoperatively but also reduces the number of patients wishing to have surgery once they are fully informed of the potential risks and realistic benefits to them. There is a need for some professionals to be more generically aware of aspects of different specialties to allow them to lead SDM conversations and for specialist trained professionals to be able to work and communicate more effectively together to facilitate such discussions. It may require new roles such as ‘perioperative care physicians’ who have a more generic overview of the whole surgical pathway than any specialty has currently. It will also require new skills for the vast majority of professionals involved in the perioperative pathways and a new culture of cross-silo working.

Category 3 - Socio-economic and Environmental Factors

• Health inequalities
• Social determinants of health (e.g. housing)
• Climate Change
• Greenhouse emissions and pollution

These are all factors that increase poor health in the population and therefore lead to greater surgical disease burden in the form of cancer surgery and medical disease burden particularly respiratory disease.  The fact that COVID-19 will become an endemic disease in the UK population is going to drive the demand for the health and social care workforce, and in particular ITU services, further as we have seen that covid deaths and ITU admissions have been greater in areas with the highest indices of deprivation.

COVID-19 reporting by the Intensive Care National Audit and Research Centre (ICNARC) confirms that the majority of critically ill patients confirmed with COVID-19 fall within the upper quintiles for the Index of Multiple Deprivation.[1] 

Patients with confirmed COVID-19 (from ICNARC COVID-19 report August 2021)

 

• The economy and public funding/finances
• Labour market

The UK Government has to commit to training more nurses and doctors and reduce the reliance on importing trained workers from poorer nations with detrimental consequences to those countries. 

It will also ensure long-term sustainability of its medical workforce.

The pandemic has exposed existing workforce shortages and the need for comprehensive workforce planning as a critical component of future-proofing the NHS for future pandemics. Space, equipment and facilities are important, but without the staff to fill them the NHS will not be able to make full use of these resources.

A stronger, larger workforce would ensure that NHS hospitals could better sustain the increased workload during pandemics without a detrimental impact on the business as usual activity and the wellbeing of staff.

In particular, there needs to be investment in a larger and more flexible workforce – this should include anaesthetists and intensivists, but very importantly nurses, particularly critical care nurses, the shortage of which has limited the expansion plans of many departments during surges.

The UK has one of the lowest critical care bed to population ratios in Western Europe. When the pandemic hit, a great deal of time and effort was spent reorganising wards and operating theatres to cope with the influx of COVID-19 patients requiring intensive care, leading to the suspension of or reduction in the delivery of elective care even for urgent and time-critical treatments such as cancer.  

Critical care capacity should be a key priority for building back an NHS that can cope with future pandemics and surges, for example through the  expansion of postoperative care units and the adoption of the enhanced care model to improve patient flow, support operative scheduling and release capacity within critical care for the patients who need it most.

Category 4 - Staff and Student/Trainee Expectations

 

• Expectations of working life and careers e.g. flexible working, work related stress and
        burnout, tackling bullying and harassment, time to care, wellbeing, reward,
        progression and career development, retirement plans, carer and dependent
        responsibilities
• Culture
• Workforce recovery post pandemic
• Generational preferences

 

The Royal College of Anaesthetists’ Anaesthesia – fit for the future campaign is exploring what the anaesthetic workforce needs to deliver the best possible care in the aftermath of COVID-19 and beyond. As part of this, we wanted to know whether the anaesthetic workforce is planning to stay working within the NHS and what might influence those plans.

We have commissioned a rapid evidence review on the factors affecting retention and surveyed 815 of our members, across all grades and stages of career, responded to a survey in June 2021. Below is a summary of the findings from the evidence review and survey and the full reports are enclosed with this submission.

Key findings from evidence review

The key things influencing whether anaesthetists and others stay in their roles are:

• individual-level factors such as mental wellbeing and burnout; physical issues associated with aging; the extent to which professionals felt valued and satisfied with their work; and family commitments and other priorities
• role-related factors such as workload and working requirements, including working on call; plus perceived autonomy in the role
• organisational/team-related factors such as organisational climate; leadership; communication; team morale; and supportive relationships
• system-level factors such as perceived bureaucracy; issues related to income and pensions; and concerns about litigation or risks

Key finding from the survey

Intentions to leave/retire (trainees/SAS in training)

1 in 4 Anaesthetists in training planned to leave the NHS within 5 years, either to work in another country, in private practice or to leave entirely:

• 18% planned to work in anaesthesia in another country permanently after completing their training
• 5% planned to leave the NHS and work only in private practice within 5 years of completing training
• 6% planned to leave the NHS entirely within the next 5 years
• Only 54% said that they planned to work in the NHS for the rest of their career
• 30% said they were considering working on a less than full time basis after they complete their training

Intentions to leave/retire (consultants/SAS not in training)

• 1 in 4 (25%) Consultants and 1 in 5 (20%) SAS Anaesthetists planned to leave the NHS within 5 years
• 1 in 10 SAS Anaesthetists and Consultant Anaesthetists were currently working less than full time and at least 2 in 10 were considering working less than full time within the next 5 years.
• This could mean that around one third of the anaesthetic workforce may be working less than full time within 5 years. This is particularly useful to know as the Census has no data on LTFT working for consultants and SAS not in training.
• The majority of SAS Anaesthetists said they planned to retire in their early 60s whereas half of the Consultant Anaesthetists said they planned to retire by 60 (The Census 2020 reports that the 50 plus age group is now 39% of the workforce)

Intentions to return (retired/returners)

• the majority did not want to return to working as an Anaesthetist (38%)
• 14% had returned to working as an Anaesthetist during the COVID-19 pandemic. Some did not plan to stay on (9%) and some would consider continuing after the pandemic ended (5%)
• 22% said they had successfully applied to return to work on a less than full time basis and 9% said that they would consider returning to work on a less than full time basis in future
• 2% had been unsuccessful in applying to return to work on a less than full time basis. They said that this was due to lack of flexibility from managers over job plans and too much administrative bureaucracy

Extent to which COVID-19 pandemic changed career intentions

 

Of those who said that COVID-19 had made them less inclined to stay in the NHS, the main reasons were, in order of how commonly they were mentioned:

• feeling underappreciated or as though they were working in a hostile environment
• feeling unsupported
• feeling overworked and burnt out emotionally and physically
• feeling underpaid
• feeling isolated from family and friends
• difficult work experiences and trauma at work, including covering intensive care units
• feeling that training opportunities had been poor, curriculum changes were not well managed or that they had not been able to keep up with training requirements due to job pressures (amongst those in training)

Why do people retire or leave early?

Anaesthetists who had retired or recently returned after retiring said that the main reasons that they left were:

• not feeling valued or well supported, including relationships with colleagues and managers (42%)
• wanting to pursue leisure interests and spend time with family (36%)
• concerns about taxes or pensions (36%)
• bureaucracy and leadership issues (35%)
• improving mental wellbeing, reducing stress or burnout (25%)
• could not sustain workload or being on-call (25%)
• lack of flexibility, reduced hours, breaks or leave (19%)
• lack of autonomy and respect (16%) after retiring said that the main reasons that they left were

What would influence people to stay longer?

People with different roles said that similar things would encourage them to stay working in the NHS for longer or return after retiring:

• being able to work flexibly and less than full time to have better work / life balance
• reduced or no on-call work (this was not stated as an issue in training)
• contract flexibility
• being able to adjust clinical practice or the environment to account for physical changes with age
• having supportive colleagues and managers that are respectful and appreciative
• advice about pay, pension and taxation issues

Factors affecting retention for anaesthetic trainees

We asked Anaesthetists in training and Anaesthetists planning to return to training within the next two years what would improve their experience as trainees.

The most commonly mentioned things were:

• better work-life balance (51%)
• increase in training places so there is less competition in the application process (45%)
• flexibility to pursue other interests (42%)
• less bureaucracy and paperwork when rotating to different jobs, including less paperwork associated with workplace based assessments (30%)
• adequate notice of rotas to support planning (25%)
• practical support, such as being able to use the lockers, rest facilities and catering available to permanent staff (21%)

The need for flexibility and adjustments

We asked consultants and SAS anaesthetists if they thought that they would be able to carry on with their current workload and job plan as they got older:

• 61% of consultants and SAS grade anaesthetists thought their workload was sustainable with some adjustments
• 30% of consultants said their workload was not at all sustainable as they got older

When applying a filter to respondents aged 50+ 80% responded that they have not had a conversation about retirement and career plans (20% chose non applicable, therefore of those who responded to the question none have had a conversation about retirement). This is despite the NHS People Plan’s recommendation:

“Employers should ensure that staff who are mid-career (aged around 40 years) and those approaching retirement (aged 55 years and over) have a career conversation with their line manager, HR and occupational health.”

 

Category 5 - Science, Digital, Data and Technology (Including Genomics)

• Artificial Intelligence
• Robotics
• Automation
• Digital Health Technologies (e.g., Telemedicine, Smartphone Apps, sensors and wearables, virtual and augmented reality)

Technological advances will no doubt continue to revolutionise healthcare. Although we do not have any empirical evidence at this stage for how these drivers will affect anaesthetic services and the healthcare workforce, anecdotal experience to date in other areas, such as radiology and surgery, has shown that whilst the efficiency and accuracy of care has improved considerably, it has not shown a demonstrable reduction in workforce numbers; instead, what we have witnessed is a form of labour arbitrage, with staff moving to areas where workforce gaps are most acutely felt, rather than leaving healthcare or being made redundant.

Category 6 - Service Models and Pandemic Recovery

Pandemic recovery (elective care and waiting lists) and resilience (e.g. surge demand capacity)

The Royal College of Anaesthetists has published a report identifying 10 lessons the UK healthcare system can learn from the pandemic. Effective workforce planning and investment, staff wellbeing, and increased critical care capacity remain vital to the recovery of the NHS.

The risk of new COVID-19 variants coinciding with annual winter pressures and recurring peaks of infection from flu and respiratory diseases threatens to overwhelm healthcare services.  If critical care is once again pushed beyond capacity, this will jeopardise the NHS recovery. Our report outlines how the NHS must be better prepared for potential additional COVID-19 surges, with consideration of supply of PPE, pandemic skills maintenance, and the need for staff to be protected from burnout and given the opportunity to recover. The report also highlights the importance of innovation and new ways of delivering care, including the expansion of perioperative and enhanced care to optimise surgical activity.

Over the next few years, the biggest challenge for the healthcare service will be to tackle the backlog in planned surgery built up prior to and during the pandemic. With data from the College census showing at least one consultant vacancy in 90 per cent of all anaesthetic departments, we argue that any recovery plans must be underpinned by an investment in staff and long-term workforce planning.

The RCoA’s 10 lessons learnt from the pandemic:

1. the wellbeing of NHS staff is paramount
2. staff shortages must not persist, now is the time to invest in workforce
3. we need increased critical care capacity across the UK
4. appropriate and timely supply of PPE is key
5. perioperative care has a critical role to play in the NHS recovery and beyond
6. we should maintain pandemic skills
7. collaboration and information sharing are critical for a successful pandemic response
8. local decision-making works
9. the healthcare system must be better prepared for future pandemics
10. there is huge potential for digital innovations

Please see enclosed the full report here: 10 lessons learnt from COVID-10 – focus on anaesthesia and Intensive Care.

• Current and future service models 
• Integration  
• Working across boundaries

To recover in a reasonable time from the pandemic, the NHS will need to operate elective services at around 120-130% of pre-pandemic levels, while continuing to battle Covid and work in a Covid-secure way.  There is a recognition that this will not be achievable or sustainable unless there are radical changes to how the NHS delivers services.

Perioperative care – the integrated care of patients before, during, and after an operation – should be used as an exemplar for the kind of system change that is envisioned in the current NHS reforms and that is needed for the elective recovery.

 In terms of the impact on workforce demand, this model of working requires staff to work together in cohesive, multidisciplinary teams. Evidence from the Centre for Perioperative Care shows that good multidisciplinary working can have a transformative impact on NHS elective care efficiency, including by speeding access to surgery, improving clinical outcomes (such as reducing complications) and reducing time spent in hospital.

At the moment, key barriers stand in the way of good multidisciplinary working across the NHS, including lack of IT systems, lack of staff education, and lack of buy in from senior leadership and management.  HEE should prioritise the training and development of the multidisciplinary perioperative team to help overcome some of those barriers.

Demand and supply gaps over the next 15 years

Current workforce trends for the specialty of anaesthesia

Data collected through the latest RCoA Medical Workforce Census 2020[1] paints a worrying downward trend for the UK anaesthetic workforce:

• The mean growth rate for consultant anaesthetists across the UK, 2007-2020 is now at 2.1% per year, less than the 2.3% growth rate per year, 2007-2015 noted in the last College census
• More than 90% of anaesthetic departments in the UK have at least one unfilled consultant post
• A comparison of previous censuses with the latest 2020 census shows that the funded workforce gap in consultant anaesthetists has been steadily increasing across the UK from 4.4% in 2015 to 8% in 2020, and that the aspirational gap (the number of anaesthetists required to deliver the service sustainably) is currently at 12%
• There were 680 funded but unfilled consultant posts at the time of completing the latest census
• The anaesthetic workforce is ageing. The number of consultants who now work beyond 60 and approaching retirement is up from 5% in 2015 to 7% in 2020.
• Specialty and Associate Specialist (SAS) and Trust doctor numbers are unchanged compared to the 2015 Census, despite increased demand and their key role in delivery of anaesthetic services and, in many instances, supporting anaesthetic rota gaps

The growth rate of the consultant workforce and ability of anaesthetic departments to recruit anaesthetists to meet local demands are directly dependent and limited by the supply of new anaesthetists coming through specialist training. At the time of completing the census, there were approximately 4,000 training grade anaesthetists who should reach Certificate of Completion of Training (CCT) and be able to enter the GMC specialist register over the next 5 years. However, demand is growing at a faster pace leading to a predicted increasing workforce gap over the coming years. The effect of anaesthetists in training abandoning a career in anaesthesia must also be taken into consideration. An analysis by the RCoA Workforce Strategy Committee in 2014-2016 shows that the attrition rate for anaesthetist in training has been in the order of 25%[2].

Anaesthetic workforce requirements to meet demand

In 2015 the Centre for Workforce Intelligence (CfWI) reported an unmet need of 15% for anaesthetics and 25% for ICM. Modelling predicted that both specialties were likely to grow at 4.7% per year and without action demand would outstrip supply[1]. Our latest census reveals that the specialty has grown at a much slower rate than predicted by CfWI. Yet Health Education England has seen its budget fall from £5.3bn in 2013/14 to £4.2bn in 2019/20. This not only affects the number of training places available, but the quality of training and the level of support available for doctors in training.

The RCoA has commissioned York Health Economics Consortium to carry out an up to date demand and supply analysis for the anaesthetic workforce over the coming 20 years, based on the RCoA Census 2020 and the CfWI report 2015. A summary of the findings is offered below and we are enclosing the full report as supporting documentation to this submission. 

Data and information drawn from the 2020 workforce census and 2015 Centre for Workforce Intelligence (CfWI) modelling have been used to estimate a baseline and to forecast future anaesthetist demand and supply over 20 years.  This analysis estimates that, in the base case, the size of the anaesthetic workforce would need to rise from 10,710 FTE to 15,044 FTE from 2020 to 2040 in order to meet demand for anaesthetic services. Without considering the current growth and trajectory of supply, this is equivalent to 216.7 FTE per year on average from 2020 to 2040. 

This type of workforce modelling will be critical to identify where early intervention will be required, with consideration of the length of medical training, to allow the NHS to continue to provide the best care for a growing and ageing population and deliver the objectives of the Long-Term Plan^[1]. 

Anaesthesia Associates workforce

The 2015 RCoA census was the first to consider non-medically qualified anaesthesia practitioners. The role was introduced in the UK in 2004 and they were known as Physicians Assistants in Anaesthesia PA(A)s. The 2015 census reported that there were 323 PA(A)s across the UK. However, data from the Association of Physicians’ Assistants in Anaesthesia and the University of Birmingham, showed that there were 165 trained PA(A)s. The overestimate was probably a result of a lack of familiarity with the role and title, and clinical directors may have included advanced critical care practitioners and nurse practitioners. In 2019, PA(A)s formally changed their title to anaesthesia associates (AAs), recognising their role within the anaesthesia team and also within medical associate professions. In the same year, statutory regulation for AAs was approved and will be the responsibility of the GMC to regulate from 2021. The 2020 census showed that there were 173 Anaesthesia Associates in the UK (Figure 13). This is fewer than the 205 who have qualified through the University of Birmingham.

Specialty and associate specialist doctors (SAS) and trust doctor workforce

The data from the 2020 census showed that the total number of SAS and trust doctors had changed little in five years (Figure 7). In 2015, the SAS and trust doctor made up 21.6% of the anaesthesia workforce. In 2020, that figure is relatively unchanged at 21.1%, despite an increase in service demand, which is likely to continue to grow, and an increase in workforce gaps. Some 72% of SAS doctors were contracted to work more than 10 PAs, compared to 62% of consultants.

Ambitions for the health and social care system

In 15 years' time, what one key thing do you hope to be able to say the social care and health system has achieved for people who need care and support, patients and the population served?

For the NHS to remain the pride of a nation, able to deliver high quality care for all.

For health inequalities to be addressed and for patients, especially those at high risk and affected by long term conditions and multiple morbidities, to have better surgical outcomes through the adoption across the NHS of perioperative care pathways to optimise and prepare patients as much as possible ahead of surgery.

In 15 years' time, what one key thing do you hope to be able to say the health and social care system has achieved for its workforce, including students and trainees?

A sustainable and long term approach to the planning and funding of the NHS workforce, where the funding envelope follows the requirements for funding training rather than the NHS having to depend on short term settlements and trying to fix workforce gaps with limited resources or relying on importing healthcare workers from overseas as a knee-jerk response to plug chronic shortages. We hope this review and all the evidence submitted will persuade the Government to accept the amendments which will be proposed to the Health and Care Bill with regards to workforce planning and for projections to be published at least every two years across the whole of the health and social care workforce and acted on by the Secretary of State.

[1] https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf

[1] CfWI. In-depth review of the anaesthetics and intensive care medicine workforce. February 2015  

[1] RCoA. Medical Workforce Census Report 2020

[2] RCoA. Workforce Data Pack 2018. March 2018

[1] ICNARC report on COVID-19 in critical care: England, Wales and Northern Ireland 27 August 2021

[1] Office for National Statistics. Overview of the UK population: August 2019.   

[2] NHS Digital. Hospital Admitted Patient Care and Adult Critical Care Activity 2018-19. September 2019

[3] RCoA. Medical Workforce Census Report 2020. November 2020.

[4] Anaesthesia News Special Issue. Age and the anaesthetist. August 2016

[1] www.rcoa.ac.uk