APM Workforce Report for Palliative Medicine 2012-2016 Document on behalf of the Workforce Committee of the Association of Palliative Medicine Executive Summary APM Workforce Report for Palliative Medicine 2012-2016 This report has been prepared by the APM Workforce Committee and is based on data provided by the APM Workforce survey 2011, RCP Workforce Census 2011 (Royal College of Physicians) and from the JRCPTB (Joint Royal Colleges Physicians Training Board ) and SAC (Specialty Advisory Committee) Palliative Medicine workforce data produced in 2011 and 2012. For each of the four countries of the United Kingdom & Eire the report aims to: • Review the current number of Consultants in Palliative Medicine working in the NHS, voluntary sector and in academic posts. • Identify the current number of specialty doctors and other non-training grades working in the NHS and the voluntary sector. • Identify the current number of trainees and estimate those entering and completing training over the next five years and in conjunction review the trends in the number of Consultant appointments, vacancy rate and retirements. • Estimate the Consultant workforce required to meet the needs of patients requiring specialist palliative care over the next five years. • Review the factors in the future development of the palliative medicine workforce. • 2011 APM medical workforce survey full data analysis completed and undertaken from November 2011 to April 2012 in obtaining information for UK and Eire on numbers and grades of post-holders, age, gender, ethnicity, hours of working, type of contract, funding, type of clinical service and out of hours working. Overall response rate was 63.6% hence under-reporting of workforce numbers. • RCP workforce census 2011 and SAC workforce data for 2011 and 2012 are included in this report for Consultants and trainees. • Trends in workforce: The high proportion of women trainees (greater than 80% ). The high percentage of doctors working less-than-whole-time (44% for Consultants , 76.5% for SAS doctors and 38% for trainees). • Expansion of Consultant numbers is greater than other medical specialties 9.2% v 5.2%. Vacancy rate has fallen for the 4th successive year and for 2012 is < 8%. Retirement age at 65yrs estimated Consultant numbers for 2011-17 are 4-5/yr then increases to 12/yr from 2017-22. The impact of those Consultants aged < 50 years whose retirement age increases to 67 years. In Eire, currently there are no Consultants over the age of 56 years. • Registrar trainees. Annual expansion fell in 2011 to 5% but increased again to 10% in 2012 to 251 posts despite not replacing significant number of Hewitt- Johnson posts in England. No evidence of unemployment in outcome of CCT holders average 40/year for 2009-2012, though a few are taking up non- consultant posts. Predicted average CCT output 40/year (2011-16). • Estimated Consultant workforce numbers Table 1. Estimated Consultant workforce numbers and fte for each country in UK and Eire compared to current provision (SAC data 2012). Country Population RCP estimate1 Current SAC 2012 data2 Millions Headcount2 fte Headcount fte (2011) Wales 3.10 30 24.8 36 29.80 N Ireland 1.80 16 14.4 18 16.25 Scotland 5.25 53 42.0 47 37.55 England 53.00 526 424.0 404 325.95 UK 62.15 624 505.2 507 408.60 Eire 4.05 34 32.4 30 28.60 Based on 2 full time equivalent (fte) per 250,000 population Consultant Physicians working with patients: The duties, responsibilities and practice of Physicians in Medicine. (4th Ed) revised Royal College of Physicians, 2011.2 With a participation ratio (0.8-0.96) for fte and headcount in each country using SAC 2012 data. Estimated need for UK Consultants = 505 fte (624 headcount). A significant shortfall in England with 326 fte in 2012 compared with an estimated need of 424 fte. The following factors will influence the numbers and development of the workforce: o The increase in workload due to the higher prevalence of cancer, and patients with long-term conditions. o A predicted 20% increase in mortality rates for patients aged 85 years or older. o The high proportion of women trainees (greater than 80%). o The high percentage of doctors working less-than-whole-time (44% for Consultants, 76.5% for SSAS doctors and 38% for trainees). However the number of Consultant posts available may increase due to trainees moving abroad, entering whole-time research or leaving medicine, an increase in the rate of retirement among older consultants, and the impact of the retirement age for those currently younger than 50 years increasing to the age of 67. The most important variable, though, is the creation of new posts (ie expansion in consultant numbers) within the current financial climate. • Workload activity data for Consultants in the specialty of palliative medicine is mainly based on cancer and was undertaken towards the end of the 1990s,and needs to include the increasing workload for cancer and long-term conditions over the last decade. The impact of the need to provide a 7 day /24 hour service. • Other factors Unless there is a significant reduction in medical student numbers over the next decade, there will be an over-supply of doctors, which will have an inevitable impact on a reduction required in the number of trainees for the majority of specialties .The number of medical students is determined centrally .The number of Foundation and ST posts by Deaneries. However, the number of Consultant posts created is dependent on local needs, priorities and funding issues at Trust/Voluntary sector level. • The most important variable in the current financial climate is the creation of new consultant posts and the continued funding of consultant vacancies. Overall there is the potential risk in the next 5 years that there will be an over production of CCT holders in regard to available consultant posts. One of the consequences of this may be the facilitation of recruitment of consultants to regions that are currently under supplied. Recommendations • As a result of a predicted excess in number of CCT holders in the larger medical specialties and a resultant unaffordable number of consultants overall by 2020, and recognising the potential risk of excess CCTs for palliative medicine ; a major piece of work by the specialty is needed on the models of service provision, skill-mix, and the future role of consultants, with an expected requirement to deliver a consultant-led 7 day service. (Shape of the medical workforce: Starting the debate on the future consultant workforce CWFI England February 2012). Dr Stephanie Gomm Chair APM Workforce Committee APM Workforce Report for Palliative Medicine 2012-2016 Document on behalf of the Workforce Committee of the Association of Palliative Medicine 1. Introduction: This report has been prepared by the APM Workforce Committee (see Appendix 1). 2. Aims: For each of the four countries of the United Kingdom & Eire to : 2.1 Review the current number of Consultants in Palliative Medicine working in the NHS, voluntary sector and in academic posts. 2.2 Identify the current number of specialty doctors and other non-training grades working in the NHS and the voluntary sector. 2.3 Identify the current number of trainees and estimate those entering and completing training over the next five years and in conjunction review the trends in the number of Consultant appointments, vacancy rate and retirements. 2.4 Estimate the Consultant workforce required to meet the needs of patients requiring specialist palliative care over the next five years. 2.5 Review the factors in the future development of palliative medicine workforce. 3. Background: 3.1 Needs assessment: Estimates of need for the numbers (fte) Consultants in Palliative Medicine) have been derived from the following sources:- (cid:1) Working for Patients – 5th Edition Consultant Physicians - Palliative Medicine 2011.1 (cid:1) Association of Palliative Medicine Workforce Databases and Annual Reports 2005 -2012. (cid:1) Needs Assessment undertaken by National Council for Palliative Care NCPC Specialist Palliative Care Workforce Survey SPC Longitudinal Survey of English Cancer Networks November 2011 2 (cid:1) For England: the Centre for Workforce Intelligence (CfWI) report 3 July 2011,http://www.cfwi.org.uk/intelligence/in-shape-of-the-medical-workforce- informing-medical-speciality-training-numbers/palliative-medicine. (cid:1) Centre for Workforce Intelligence (CfWI ) Shape of the medical workforce :Starting the debate on the future consultant workforce CWFI England February 2012 4 (cid:1) For Scotland: Re-shaping the medical workforce in Scotland consultation of specialty trainers from 2000 – 2015. 5 (cid:1) For Wales: Sugar Report 2008: Palliative Care Planning Group Report Wales: Report to the Minister for Health and Social Services (June 2008) chaired by Vivienne Sugar and Ilora Finlay’s Implementation of Palliative Care Report (October 2008). 6 (cid:1) RCP Workforce Census reports 2005-2011 7 (cid:1) Data from SAC (JRCPTB) Palliative Medicine 2009-2012 (cid:1) Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives, December 2012.Guidance document published collaboratively with the Association for Palliative Medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie - 4 - Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK. 8 www.apmonline.org/documents/135764105191600.pdf 3.2 Estimate of need: Consultants in palliative medicine Based on various sources a current estimate of the overall number of required Consultants 2 fte per 250,000 population (2011) representing 505 fte working across the UK and for Eire 24 fte (see Table 1). 3.2.1 Estimates of need palliative medicine consultant numbers and fte for each country in UK and Eire. 1,8 The estimated RCP workforce requirements are 2 fte consultants for a population of 250,000 representing 505 fte working across the UK.1 Table 1 demonstrates the continued under provision in England of 326 fte with an estimated need of 424 fte . Both Scotland and Eire have a lesser degree of under provision. Table 1. Estimated Consultant workforce numbers and fte for each country in UK and Eire compared to current provision (SAC data 2012) Country Population RCP estimate3 Current SAC 2012 data2 Millions(2011) Headcount4 fte Headcount fte Wales 3.10 30 24.8 36 29.80 N Ireland 1.80 16 14.4 18 16.25 Scotland 5.25 53 42.0 47 37.55 England 53.00 526 424.0 404 325.95 UK 62.15 624 505.2 507 408.60 Eire 4.05 34 32.4 30 28.60 1 Based on 2 full time equivalent (fte) per 250,000 population Consultant Physicians working with patients: The duties, responsibilities and practice of Physicians in Medicine. (4th Ed) Royal College of Physicians, 2011. 2 Based on the participation ratio (0.8-0.96) for fte and headcount in each country using SAC 2012 data. For Wales the current provision in December 2011 estimates was based on the Sugar report 3 – 0.76 participation rate with a headcount of 38 palliative medicine consultants (total 29 fte). Table 2. Estimated and current provision Consultant workforce numbers and fte for Wales.8 Country Population Headcount No. fte Millions No. (2011) Wales 8 3.1 38.0 29.0 Wales 3.1 36.0 29.8 SAC 2012 Finlay I. Implementation of Palliative Care Report: Palliative care services funding 2008-09, 2009 These estimates of need for Consultant posts have been used by the Departments of Health in England and Wales. These estimates of need will be altered by the future increases in workload that are expected as a result of: - 5 - • An increase in the number of dying patients as a result of the growing population. • The increasing life span of patients with advanced disease requiring longer periods of specialist palliative care. • Increasing referral of patients with non-malignant diseases. • Increasing complexity of medical treatments in advanced disease and increasing co-morbidities. • An increasing role in the supportive care of patients receiving potentially curable therapies for cancer and non-malignant diseases. • Increased patient and carer expectation of medical treatments in advanced disease. • Increases in Palliative Medicine consultant outpatient episodes .6 • Significant changes in commissioning structures and processes which call for high quality clinical engagement between providers and their commissioners. • The centrally led focus on increasing and improving delivery of End of Life care services into the future including a focus on limiting inappropriate admissions to hospital for patients at the end of life, and providing care closer to home. 3.3 The change in shape and size of the medical workforce. This is an extremely important issue affecting workforce planning, in particular the 80% increase in medical student numbers between 1996 and 2007. Currently, the number of medical students who are female at 67%. An increasing number of women and men will wish to work part-time (BMA Survey 2006 of graduates, 21% of females want to work part-time for most of their careers and 48% want to train less than whole time). In addition, the RCP Workforce Group has predicted by various models that by 2021 there will be a significant reduction in training post numbers. The balance of the number of training posts is changing with the recommendation to decrease hospital trainees and increase GP training numbers by 50%. This will have an ultimate impact on the type of doctor undertaking clinics and ward work, i.e., increasing numbers of Consultant and non-training grades undertaking these service roles. Training has also been affected by EWTD rules from August 2009 onwards in regard to the amount of time for training that will be available as a consequence. Other significant impacts changes have been in the length of training eg following the implications of the Tooke Report 2007. The pending publication of the Shape of Training by the Academy of Royal Colleges in 2013 will estimate the need and type of medical workforce for the next 30 years. 3.4 Medical Workforce Planning 3.4.1 England: the Centre for Workforce Intelligence (CfWI) 3 published their report in July 2011, http://www.cfwi.org.uk/intelligence/in-shape-of-the-medical-workforce- informing-medical-speciality-training-numbers/palliative-medicine. This stated: “the forecast growth in palliative medicine CCT holders, together with the potentially slower growth in substantive consultant posts may suggest the number of CCT holders could become too strong. When balancing the progressive ageing population, with higher rates of obesity and a greater number of co-morbidities certainly, the increase in patient activity (2003 – 2009) and the potential withdrawal or non- recurrent funding of the Hewitt & Johnson trainee numbers. The CfWI recommended that no change is made in palliative medicine to either the number of training posts or their current geographical distribution and included the - 6 - recommendation to retain the Hewitt & Johnson posts. We still await the response from the Department of Health and the recommendations of Health Education England. We are monitoring the Deaneries whether the replacement of the Hewitt & Johnson trainee numbers 2007/8 is occurring. From trainees recruited in 2007 – only 4 out of 23 posts continue, 5 lost, 2 with non-recurrent and 12 unstable funding. The consequences for education, training, funding and workforce planning even after amendments to the NHS White Paper in England are still a major concern, in particular the impact of the Learning, Education and Training Boards (LETBs) taking over the role of the SHAs with no commitment to national workforce planning or standards. 3.4.2 Scotland: Re-shaping the medical workforce in Scotland consultation of specialty trainers from 2010 – 2015 4 has indicated that palliative medicine sets a target to reduce training numbers nationally from 16 to 11, however, currently workforce representatives are trying to maintain these at 14. 3.4.3 Wales The medical workforce in Wales following the Sugar Report 2008 6 has recently had significant expansion in consultants posts and is unlikely to significantly increase further or its training capacity. 3.4.4 Northern Ireland: workforce issues are under discussion. 3.4.5 Éire: Expansion in consultant posts is likely to be slow over the coming years. Allied to the fact that none of the consultant body is over 56 years old, this will impact significantly on the availability of consultant posts for trainees who obtain CCST. The RCPI currently has no plans to reduce the numbers of NTNs or trainees in Palliative Medicine. 4. Medical Workforce: 4.1 Current workforce numbers As part of implementation of the APM Strategy 2008 12, an APM Workforce Committee (see Appendix 1) was convened in July 2011 which has undertaken annual electronic workforce questionnaire surveys from 2011 to ascertain for each country in the United Kingdom and Eire the numbers of Consultants, training grades, speciality doctors, other non-raining grades and academic post-holders. For the 2011 survey undertaken from November 2011 to April 2012 obtaining information for UK and Eire on numbers and grade of post-holders, age, gender, ethnicity, hours of working, type of contract, funding, type of clinical service and out of hours working. Overall response rate was 64.6% for APM members (605/936). hence under-reporting of workforce numbers. Grades of palliative medicine doctors by country are shown in Table 2. - 7 - Table 2.Grade of Doctor by Country APM 2011. Grade England Northern Republic Scotland Wales Unknown Totals Ireland of Ireland Associate Specialist 24 1 0 5 3 3 36 66.7% 2.8% 0.0% 13.9% 8.3% 8.3% 5.3% Clinical Assistant 3 0 0 4 0 0 7 42.9% 0.0% 0.0% 57.1% 0.0% 0.0% 1.0% Clinical Lecturer 2 0 0 0 0 1 3 66.7% 0.0% 0.0% 0.0% 0.0% 33.3% 0.4% Consultant 197 8 7 16 20 48 296 66.5% 2.7% 2.4% 5.4% 6.8% 16.2% 44.0% Locum Consultant 13 0 0 2 0 2 17 76.5% 0.0% 0.0% 11.8% 0.0% 11.8% 2.5% GP with Special 3 1 0 0 0 0 4 Interest (GPwSI) 75.0% 25.0% 0.0% 0.0% 0.0% 0.0% 0.6% Lecturer 0 0 0 0 0 1 1 0.0% 0.0% 0.0% 0.0% 0.0% 100% 0.1% Macmillan GP 2 0 0 0 0 0 2 Facilitator 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% Medical Director 30 2 1 3 0 11 47 63.8% 4.3% 2.1% 6.4% 0.0% 23.4% 7.0% Medical Officer 4 2 0 0 0 2 8 50.0% 25.0% 0.0% 0.0% 0.0% 25.0% 1.2% Professor 4 0 0 0 1 1 6 66.7% 0.0% 0.0% 0.0% 16.7% 16.7% 0.9% Reader 3 0 0 0 0 0 3 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% Research Fellow 8 0 0 0 0 1 9 88.9% 0.0% 0.0% 0.0% 0.0% 11.1% 1.3% Senior Lecturer 12 0 0 0 2 1 15 80.0% 0.0% 0.0% 0.0% 13.3% 6.7% 2.2% Specialty Doctor 30 1 0 6 3 6 46 65.2% 2.2% 0.0% 13.0% 6.5% 13.0% 6.8% Staff Grade 11 0 0 2 0 1 14 78.6% 0.0% 0.0% 14.3% 0.0% 7.1% 2.1% Other non-training 11 0 0 2 0 3 16 post 68.8% 0.0% 0.0% 12.5% 0.0% 18.8% 2.4% F1 Post 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% F2 Post 0 0 0 0 0 0 0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% GP Specialty Trainee 1 0 0 0 0 0 1 100% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1% Specialist Registrar 25 0 2 2 1 2 32 78.1% 0.0% 6.3% 6.3% 3.1% 6.3% 4.8% Specialty Reg. (MMC 86 1 0 6 9 2 104 ST3 & above) 82.7% 1.0% 0.0% 5.8% 8.7% 1.9% 15.5% Specialty ST1/ST2 0 0 0 0 0 0 0 Post 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Other training post 5 0 0 0 0 1 6 83.3% 0.0% 0.0% 0.0% 0.0% 16.7% 0.9% Totals 474 16 10 48 39 86 673 70.4% 2.4% 1.5% 7.1% 5.8% 12.8% - 8 - 4.1.2. Consultant medical workforce in Palliative Medicine. RCP Consultant Census 2011: The RCP census 2011 of consultant physicians identified 474 consultants in palliative medicine across the UK; 136 (28.7%) were male and 338 female (71.3%) and overall 44.1% working less than full-time (< FT) compared to 16.6% for all specialties. Consultant numbers were 387 in England, 29 in Wales, 42 in Scotland and 16 in Northern Ireland. (Fig 1.) Fig 1. RCP census 2011: Palliative Medicine Consultant Headcount by Country Table 3. RCP Census 2011 Palliative Medicine Consultant posts by age and gender Females = 71.3% Males = 28.7% - 9 - Table 4. % UK Palliative Medicine Consultant posts by gender and country For UK Consultants, 28.7% male and 71.3% female (Table 4.). In total 63% < 50 years of age. 71% females and 57% males are <50 years of age. Country England Scotland Wales N Ireland UK % Female 72.9 54.8 69.0 81.3 71.3 % Male 27.1 45.2 31.0 18.7 28.7 For UK In total, 44.1% of Consultants working less than full-time (< FT), with 54,2 % females <FT and 15.9% males <FT, compared to all specialties a total of 16.6% working <FT (Tables 5 & 6). Table 5. % Consultant posts by country and type of working hours Country England Scotland Wales N Ireland UK % FT 54.5 63.6 75.0 42.9 55.9 % < FT 45.5 36.4 25.0 57.1 44.1 Table 6.RCP Census 2011 Palliative Medicine Consultant and type of working hours. The annual UK expansion of consultant numbers showed a small increase to 9.5% (compared to 8.8% in 2010, and 17.4% in 2009). This compares to an overall fall in expansion rates for medical specialties from 10.2% in 2009 to 5.2% in 2011. (Figs 1. & 2). Consultant Workforce SAC September 2011 UK The SAC in Palliative Medicine in September 2011 reported UK Consultant numbers as 459 (360.75 fte) and for each country: England 358 (275.1fte), for Scotland 46 (40.8fte), for Wales 37 (28.9 fte) and for Northern Ireland 18 (15.95 fte) see tables 5a & 5b. The consultant vacancy rate was reported as 8.4% for the UK, representing 39 posts (37.1 fte). For Eire there were 29 (27.6 fte) Consultant posts: 26 full time and 3 < full time (APM 2011 data). - 10 -