Staffing of hospitals: future needs, future provision

The government's programme for modernising the United Kingdom's health services has given workforce planning and management a prominence not hitherto observed. The whole subject of workforce planning and the behaviour of labour markets in British health care has been neglected by researchers and is poorly understood. Therefore, although problems can be easily diagnosed, in many cases the solutions have not been identified. This is changing. In September 1998 the aim of securing a quality workforce in the NHS was declared.¹ By April 2000 each employer should have in place training and development plans for most professional staff, as well as an annual workforce plan. Also, each employer should be able to show improvement in retention of all health professional staff. To strengthen research on human resources in the NHS, the Department of Health launched a £2.5m research initiative in December 1998.

Summary points

• Increased numbers of doctors and nurses are required to meet increasing demands in service and management

• Expanded numbers of medical students will not enhance numbers of trained doctors for 6-7 years

• Only limited evidence suggests that quality of care is improved as numbers of cases treated increase

• Larger district general hospitals may be more cost effective in serving the needs of the population, but evidence is lacking

• There is considerable scope for making better use of nursing staff in specialist roles

Workforce factors

Workforce planning has been in place for some time but not within an integrated framework. The Medical Workforce Standing Advisory Committee (the Campbell committee) investigates factors relevant to future needs for doctors in the NHS, and the Specialty Workforce Advisory Group advises on the numbers necessary in training grades to ensure adequate supplies of consultants and general practitioners in England and Wales. For non-medical professions, workforce planning has been, since April 1996, the responsibility of education consortia covering geographical groupings of health authorities and NHS trusts, with overview being provided by the NHS Executive.² It seems that the connection of these bodies to the planning of NHS services is weak. This is a matter of serious concern.

Despite the mechanisms for planning medical manpower, the NHS continues to rely extensively on doctors from overseas. In 1997, 44% of the 7229 doctors obtaining full registration with the General Medical Council received their early training outside the United Kingdom.³ The government has accepted the Campbell committee's recommendation in its third report of a 20% increase in the number of medical students.⁴ The 90% of students who graduate can, however, make little practical contribution for some years, and this will be diminished by a phased increase in the number of students to 2005. It is fair to ask why the situation has now become so critical. Reasons in the hospital service include an accelerating trend of consultants to take early retirement, greater demand for consultants in a consultant delivered (as opposed to a consultant led) service (figure), and higher numbers of women doctors working in hospital specialties, some of whom may choose to work part time or take a career break. In England between 1992 and 1998 the number of women doctors in hospitals rose from 14 110 to 20 210, thus forming 33% of all medical staff in hospitals in 1998.⁵ Within seven years of graduation 20% of women doctors entering hospital specialties may be working on a part time or flexible basis, and another 6% may have interrupted their careers.⁶

Rates of retention of non-medical staff are affected by the general state of labour markets and rates of pay. Dissatisfaction with national pay settlements has led many nurses to leave the NHS and has hindered recruitment. This has been exacerbated by the cuts in places for nurse education made in the mid-1990s and, possibly, by the conversion of nursing to a degree course. In 1997-8, 26 465 new admissions were entered in the register held by the United Kingdom Central Council for Nursing, Midwifery, and Health Visiting, whereas in both 1990-1 and 1991-2 new admissions exceeded 33 000. One sixth of the new nurses in 1997-8 were from outside the United Kingdom.⁷ Six thousand places are to be restored as part of a £50m package to recruit 15 000 extra nurses.

Recent policies affecting medical staffing in hospitals

Two radical changes to medical training have had far reaching consequences for hospital staffing patterns: the implementation of European directives on mutual recognition of specialist qualifications and the new deal limiting working time for trainees. The government accepted the framework on specialist training recommended by a working group chaired by Sir Kenneth Calman in 1993.⁸ To become a consultant, doctors undertaking training in the United Kingdom must obtain a certificate of completion of specialist training, with training programmes being defined by medical royal colleges or faculties and minimum periods of specialist training varying from three to five years. By replacing the two grades of registrar and senior registrar with a single grade of specialist registrar, delays in completing specialist training have been removed. Although the new system was put in place comparatively smoothly, mismatches between the numbers of specialist registrars completing training and vacancies for consultants have delayed progression to consultant status, notably in obstetrics and gynaecology (a difficulty at odds with the restriction applying to the amount of time that doctors may spend in the specialist registrar grade once they have obtained their certificate of completion of specialist training).

The new deal, agreed by a ministerial group in 1990, laid down that by 1 January 1997 doctors in training should not be contracted for more than 72 hours of duty a week, and those with full time contracts should work no more than an average of 56 hours a week.⁹ Implementation of the agreement was largely successful: by 1998 the hours for 85- 90% of junior medical staff were within stipulated limits.¹⁰ To compensate for the reduced availability of trainees to cover clinical duties, funds were released on a continuing basis for additional consultant and staff grade appointments. Between 1993 and 1998 the average annual increase in the numbers of consultants in England (most of whom were newly trained) was 4.9%, compared with 3.0% between 1988 and 1993.⁵

Drivers for the future

Guidance by medical royal colleges

The medical royal colleges and faculties provide advice nationally on required staffing levels for the hospital service and publish their views on optimal service configurations. Research supports indifferently the idea that quality of care is related to the number of cases treated, although that evidence tends to derive narrowly from consideration of operative results in North America.¹¹ College reports, however, tend to return to the need for adequate numbers of cases to allow specialist skills to develop and be maintained.¹² It is also inherently plausible that quality of care is in part influenced by familiarity with the problem. In 1998, a working party from the BMA and the Royal Colleges of Physicians and Surgeons issued a consultation paper,¹³ stimulated by a government white paper, The New NHS, which itself emphasised primary care commissioning, thus influencing pathways for patient care.¹⁴ The working party feared “disinvestment in secondary healthcare services” and identified three types of hospital suitable for acute services for medicine and surgery. These included larger hospital groups serving populations of 450 000-500 000, which, they believed (although evidence was lacking) could be the most cost effective in covering district and regional needs. District hospitals serving populations of 250 000-350 000 would require enough consultants in the main disciplines to free them of all other responsibilities while carrying out emergency duties. Smaller hospitals for populations of 150 000 or less might, if cases were to be managed competently, need to be comparatively overstaffed to ensure ready availability of appropriate skills to deal with emergency problems; alternatively, some small acute hospitals might become community hospitals. Currently, most general hospitals serve a population of under 300 000 (the proportion of hospitals in this category in the West Midlands is 71%), so the recommendations, if accepted, would have profound implications for many hospitals and all specialties.

Guidance by the royal colleges on recognition of training may hinder strategic planning of local services. With accident and emergency medicine, for example, if one of the four “essential” disciplines (general medicine, general surgery, trauma and orthopaedics, and anaesthetics) is removed from the site then the accident and emergency department stands to lose its training recognition.¹³ Furthermore, increased pressure on consultants through greater intensity of clinical and non-clinical activity could significantly impair the attractiveness of these posts.

Nursing strategies

The architects of the new deal considered that efficient deployment of medical staff would be encouraged by maximising the skills of nurses and midwives, although policies on the development of specialist nursing roles had to be formulated locally. Within hospital trusts, therefore, services led by specialist nurses (such as the management of minor injuries) have evolved unsystematically and without a formal system of recognition of specialist or advanced nursing in hospital specialties.Future roles for nurses in developing and leading services will be considered in a national strategy on nursing, midwifery, and health visiting that is due to be published in this year. The strategy will also offer guidance on establishing nurse consultant posts for senior and experienced nurses who might otherwise enter management. Experience from the United States and Europe suggests that there is still greater scope for making better use of nursing staff in specialist roles—for example, in anaesthetic departments and outpatient consultation settings and as surgical assistants.

Government policies on workforce

The government's strategies for alleviating the current crisis in the NHS workforce are more immediately relevant. Success in fulfilling the targets announced in 1998 of 7000 extra doctors over three years and 15 000 extra nurses will depend on attractive, yet affordable, pay settlements being reached each and every year for all professionals in the NHS. But will the entry of extra doctors in the hospital service demand that consultants spend more time on training as well as fully participate in the new clinical governance agenda with its emphasis on audit?¹⁵(Currently consultants with full time contracts are spending on average an extra four hours a week on management, administrative, and professional activities compared with 1989 and two hours less on clinical work.¹⁶) Will these extra doctors enable trusts to implement the European Union's agreement on a staged approach to reducing junior doctors' weekly hours from 56, as now applies, to a statutory 48 hours in 13 years' time?

The government has introduced NHS Direct, a nurse led telephone helpline, and the scheme is being phased in across England. To meet a December 2000 deadline, up to 15 000 nurses may be needed to staff the service.¹⁷ Prepilot evaluations have observed cuts in hospital attendances and admissions. Assuming that these trends can be sustained geographically, workforce planning will become even more important in determining priorities for deploying scarce nursing resources across the community and hospital sectors.

Solutions

Recurring themes in considering hospital staffing are the adequacy, or otherwise, of numbers to give appropriate cover, the best means of deploying staff to give a high quality service, and the wish to preserve local accessibility. The 1998 combined college working party¹³ may be right in wishing to concentrate services in major conurbations, where groups of staff can provide specialty and subspecialty cover in major disciplines while maintaining local access, and better team support may be given in disciplines with increasing volumes of work, such as in general and geriatric medicine. Such principles underlie proposals in Birmingham to focus on fewer main sites, but with associated ambulatory care centres.¹⁸ Opinion is less certain on what to do in places with dispersed populations. These issues are obvious in general paediatrics, where numbers of cases may be too low in smaller hospitals to maintain clinical competence or allow junior staff support and training.

Innovative solutions are required, and much more managerial and research effort is needed. Multidisciplinary teams or nurse specialists alone may not be a solution. Patient focused care, including cross training and multiskilling of different professional groups, has not been comprehensively evaluated in the United Kingdom. New forms of specialist training to equip physicians and surgeons with multispecialty skills may be worth considering.¹³

Can reorganisation and combined focusing of social services and primary care abort problems? To what extent can care at home for elderly people with acute illness be supported cost effectively? What will be the effect of the changing balance between emergency and elective admissions, with emergency patients now occupying two thirds of the staffed beds available,¹⁹ and the drive to better general quality of care? To find innovative answers to these questions the government's new primary care groups and trusts will need to work with hospital trusts. But undoubtedly, the United Kingdom with its current shortage of doctors, nurses, and other professionals is ill placed to support its traditional methods of practice.

Figure.

Ratio of junior doctors to consultants in hospitals at 30 September each year (adapted from Department of Health, Statistical Bulletin, 1996/18, 1999/5)

Figure.

MARY EVANS PICTURE LIBRARY

The Middlesex Hospital, London, in 1831