Consultant workforce
shortages and solutions:
Now and in the future
1British Medical Association Consultant workforce shortages and solutions: Now and in the future
Consultant workforce shortages and
solutions: Now and in the future
On 22 July 2020 the BMA UK consultants committee hosted a roundtable event with
representatives from medical royal colleges in order to discuss the future of the consultant
workforce in England. The meeting gave particular consideration to short, medium and long-
term stang problems, their causes and potential amelioration strategies. This document
summarises the outcomes from this meeting, is aimed at the Government, employers and
arms-length bodies, and details how we can protect patients, consultants and the NHS from
an emerging consultant workforce crisis.
Acknowledgements
We are grateful for the input of the following medical royal colleges into the development of
this report:
– Faculty of Intensive Medicine
– Royal College of Anaesthetists
– Royal College of Obstetricians and Gynaecologists
– Royal College of Paediatrics and Child Health
– Royal College of Physicians
– Royal College of Psychiatrists
– Royal College of Radiologists
– Royal College of Surgeons of England
2 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Executive summary
Prior to the COVID-19 pandemic the NHS workforce faced a perfect storm of consultants
choosing to retire earlier, a signicant proportion approaching retirement age and a growing
trend of younger doctors walking away from a career in the NHS. COVID-19 added signicant
additional pressure on the workforce with doctors working long hours, in new settings,
sometimes whilst risking their own lives. Now the NHS is facing a growing backlog of unmet
need on top of the existing sta and resource shortages. Every consultant has become more
precious than ever; retention is crucial to the success of any plans for continuing to deliver
safe patient care and catching up with existing and developing backlogs.
Projections of future demand indicate that the NHS needs to respond quickly to address
the workforce crisis, both by increasing supply and improving retention. Vacancies reported
nationally are high and are likely to represent a signicant underestimate. Future consultant
workforce gaps need to be lled by expanding medical student and FP (Foundation
Programme) places now to meet current and future patient demand. At the same time, more
sta/educators and supporting resources are required to deliver the increased educational
workload. The Government is not on track to deliver the commitments set out in the
NHS Long Term Plan.
This report highlights some of the factors driving consultant retention
problems and why retaining and growing the consultant workforce must
be a top priority for the NHS:
The UK has a growing and ageing population
The IFS (Institute for Fiscal Studies) found that ‘meeting the needs of a growing and ageing
population would require hospital activity to increase by a projected almost 40% over the
next 15 years’. The consultant workforce requires considerable further growth to keep up
with this changing pace of demand.
The consultant workforce is ageing, and medical career paths are changing
24% of consultants are over the age of 55, and younger doctors are pursuing dierent career
paths from their older colleagues – including taking breaks in training or leaving clinical work
in the NHS.
Consultants are leaving the medical profession earlier than planned
A recent BMA survey found that 6 out of 10 consultants intend to retire before or at the
age of 60, for reasons heavily linked to job satisfaction, wellbeing, workload, ill health,
bureaucracy and pension taxation rules.
Working in systems under pressure bears a cost to sta
The number of doctors in the UK sits far below that of comparator countries in Europe.
Inadequate stang is leading to rising sickness absence, overworking and burnout, low
morale and poor wellbeing, and doctors reducing their hours or outright leaving the medical
profession.
The role of consultants in care delivery is increasing
There is an increasing expectation, both by the public and the medical royal colleges, of
moving to a system of consultant-delivered care as a way of improving outcomes and
making more ecient use of resources.
Consultant vacancies are likely higher than vacancy data suggests
At the end of June 2020 there were at least 8,278 secondary care FTE (full time equivalent)
medical vacancies (10% of all current recorded NHS vacancies).
However,
persistent
problems with – and varying policies on – how vacancies are advertised and recorded means
vacancy data likely does not reect the true number (and there is consistently a discrepancy
between vacancies that are nationally reported and those captured in census data by the
medical royal colleges).
3British Medical Association Consultant workforce shortages and solutions: Now and in the future
The COVID-19 pandemic highlights the need to grow the consultant workforce
NHS performance measures have been progressively deteriorating over recent years, with
record low performance becoming a monthly norm over the past few winters. COVID-19 has
exacerbated this, creating a huge backlog of non-COVID care, which is likely to grow in the
coming months. To overcome this backlog, reduce NHS waiting lists and waiting times and
restore activity to previous levels, medical workforce numbers – which must include the
consultant workforce – must increase.
Organisations will need to put in place immediate interventions to prevent
erosion of the consultant workforce. Now is a critical time to understand the
factors that motivate the workforce to leave or stay, and respond accordingly.
In the short to medium term, the Government and employers need to:
Reform the pensions taxation system
There are a number of issues with the NHS pension scheme that are forcing doctors to retire
before they would otherwise choose, which need to be addressed.
Clarify and widen ‘retire and return’ arrangements
Trusts should have clear and transparent policies regarding ‘retire and return’ for consultants
and ensure this is communicated to sta. This should of course be facilitated at a local level,
but a national steer would help ensure this is universal.
Address the real terms pay erosion
Consultant pay in England has declined by over 30% in real terms over the last decade.
Addressing this issue will improve retention, as well as make the career more attractive to
new entrants.
Make the most eective use of retired doctors who would like to return to work
Despite many retired doctors being restored to the temporary medical register to support
the COVID response, it has not been possible to provide them all with productive work. Ways
need to be found to harness the skills of this workforce. As a minimum, returners should
receive an induction, have access to a mentor and be able to have open conversations about
how they are able to contribute.This could include taking roles in medical education. There
also needs to be adequate funding in place to employ returning doctors.
Enable consultants to change parts of their role
Job planning conversations should be positive; sta must be listened to if they want to make
changes to their role, including devoting more time to education and training, research,
leadership and management. Employers should support older consultants who wish to
withdraw from certain parts of their role, eg emergency/on-call work to improve retention.
Address the gender pay gap
A primary cause of the gender pay gap in medicine is because of the gender imbalance
across the highest paid positions, grades and specialties. Career pathways and workplace
environments must be designed to encourage retention of female consultants in addition to
addressing issues that may encourage female sta to take on positions in lower-paid roles.
Allow consultants to work exibly, including remotely where possible
Flexible and remote working, and other measures to improve work-life balance, should be
encouraged. Employers should ensure that sta have access to necessary IT hardware,
soware and training to carry out their duties remotely. Consultants should have the right to
work exibly. Employers should ensure sta have suitable equipment to work from home.
Prioritise health and wellbeing of sta
Employers must prioritise doctors’ health and wellbeing and ensure workplace risks are
reduced; this will help to reduce sickness absence.Risk assessments need to be rolled
out and sta need to have adequate access to PPE. Sta who are more at risk of COVID-19,
including BAME sta, need to be better protected. Employers must ensure that sta know
where they can access support if their mental or physical health deteriorates.
4 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Oer sabbatical leave
Sabbatical leave, which is a norm for many modern employers, should be provided.
Employees value sabbaticals as a chance to take time out from a stressful work environment,
an opportunity to acquire new skills and knowledge or to study the operation of other
healthcare systems or organisations. Sabbaticals will retain sta and help them bring new
skills back to their workplaces.
Support sta going through the menopause
Employers should develop a culture where those experiencing physical and/or mental
symptoms can speak openly and access the support they need. Employers should raise
awareness about menopause and provide training for line managers.
Develop a supportive and inclusive workplace culture
Employers need to build a supportive, no-blame culture that values equality and diversity
and addresses bullying, harassment and discrimination. Employers should improve access
to workplace adjustments, invest in OH (occupational health) support and enable sta to
self-refer to OH teams.
Provide opportunities for leadership, training, development and research
Barriers to undertaking research and/or training should be removed and the role of patient-
facing research as part of direct clinical care needs to be recognised. Sta should be
provided with opportunities to develop and become leaders. Workforce shortages should
not prevent consultants from having dened job planned time for this. The opportunity to
develop professionally ensures sta enjoy their role and are motivated to stay.
In the long term, Government and arms-length bodies must urgently take action to ensure
that consultant supply closely matches patient demand.
5British Medical Association Consultant workforce shortages and solutions: Now and in the future
Introduction
Consultant-led clinical teams play a pivotal role in planning and delivering safe patient care.
However, they work in a system under pressure. Whilst numbers are increasing slightly
each year, the overall number of FTE (full time equivalent) consultants continues to grow
by approximately 4% per annum,
1
the demand for consultant care is growing at a faster
rate. This means sta numbers lag behind what is required to undertake consultant activity
within the health service. At the end of June 2020, there were at least 8,278 secondary
care FTE medical vacancies (10% of all current recorded NHS vacancies)
.
2
However, NHS
Digital data does not consider the ‘aspirational gap’; the growing decit between healthcare
expectations and sta required for delivery of that standard of care.
Given the length of time it takes to train a consultant – 12 to 15 years depending on the
specialty – immediate action needs to be taken now to grow the workforce. Delay now
will impact the NHS and its ability to deliver timely access and eective services to
patients in future.
The UK has a growing and ageing population
The drivers for an increased requirement for the consultant workforce are readily apparent.
The UK has a growing and ageing population with a high probability of individual citizens
developing complex comorbidities.
3
The IFS (Institute for Fiscal Studies) found that ‘meeting
the needs of a growing and ageing population would require hospital activity to increase by
a projected almost 40% over the next 15 years’, ie by 2033. If this is correct, the consultant
workforce requires considerable further growth to keep up with the pace of demand.
The consultant workforce itself is ageing and career paths are changing
There are other less apparent factors that drive the need to increase consultant numbers.
A signicant proportion of the workforce is approaching retirement – 24% of consultants
are over the age of 55.
4
There is also a growing trend of younger doctors pursuing dierent
career paths from their older colleagues – including taking breaks in training or leaving
clinical work in the NHS. For example, in 2018, only 37.7% of F2s continueddirectly into core
or specialty training programmes.
5
Consultants are leaving the medical profession earlier
The consultant workforce is not just ageing. Surveys from the BMA and medical royal
colleges have also found that consultants are choosing to retire earlier than planned.
6
This is
for a variety of reasons linked to job satisfaction, wellbeing, workload, ill health, bureaucracy
and pension taxation rules.
7
A recent BMA survey found that 6 out of 10 consultants intend to
retire before or at the age of 60, with important factors in decisions around retirement being
health & wellbeing and pensions. Many of these factors could be resolved by Government
and employers, given sucient political will.
NHS work is seen as increasingly stressful and less adequately rewarded, lacking the
exibility to accommodate older doctors, and therefore less attractive. The Royal College of
Physicians, for example, found that working on-call and the pressures of work were common
drivers in considering retirement.
8
An increasing loss of autonomy in consultant roles can
also act as a powerful disincentive, as does inadequate resourcing.
1 NHS Workforce Statistics – June 2020, NHS Digital (September 2020)
2 NHS Vacancy Statistics England April 2015 – June 2020 Experimental Statistics, NHS Digital (August 2020)
3 National population projections: 2018-based, Oce for National Statistics (October 2019)
4 NHS Workforce Statistics – June 2020, NHS Digital (September 2020)
5 Number of FY2 doctors moving straight into specialty training falls again, British Medical Journal (January 2019)
6 Thousands of NHS hospital consultants intend to quit years before retirement, survey nds, Independent
(January 2019)
7 Pension tax driving half of doctors to retire early, Royal College of Physicians (2020)
8 ‘Later careers – stemming the drain of expertise and skills from the profession’, Royal College of Physicians
(November 2017)
6 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Working in systems under pressure bears a cost to the sta within them
The number of doctors in the UK is far below that of comparator countries in Europe.
9
Rising pressure caused by workforce shortages is resulting in increased sickness absence,
doctors reducing hours or people leaving the profession, adding further burden to the
existing workforce.
10
Inadequate stang means that consultants are oen pressured to
cover rota gaps or even take on the work of more than one doctor.
11
Many consultants work
signicantly beyond their contracted hours in order to ensure patients get the care that they
need; sometimes that work is unrecognised and, frequently, it is unrewarded.
12
Where that is
the case this can cause a loss of goodwill amongst consultant sta, contributing to burnout,
low morale and disengagement with the organisation, and leads to doctors leaving the
medical profession.
13
Consultants may also bear the brunt of systemic pressures. For instance, there is a growing
willingness to assign problems arising from resourcing shortages to consultants to solve.
Consultants are appointed as clinical leaders, of course, but intense pressure on the
secondary care system has the eect of simply deferring issues, appropriate or otherwise,
to the consultant within a team. The worsening NHS performance gures year on year are
evidence of the extraordinary pressure within the system. The expectation for consultants
to manage what is fundamentally a lack of resources becomes unbearable for many.
The good news is that many of these factors could be resolved by Government and
employers, given sucient political will (see solutions set out later in this paper).
The role of consultants in care delivery is increasing
There is also an increasing expectation, both by the public and the medical royal colleges,
of consultant-delivered care. The Benets of Consultant-Delivered Care, a report by the
Academy of Medical Royal Colleges, sets out the case for, and the key benets of, moving
towards a model of consultant-delivered care in the NHS:
14
– Rapid and appropriate decision making
– Improved patient outcomes
– More ecient use of resources
– GP access to the opinion of consultant specialists
– Patient expectation of access to appropriate and skilled clinicians and information
– Benets for the training of junior doctors.
The report concluded that ‘there are real evidence-based benets to moving to a system
of consultant-delivered care. Therefore, viewing the increased numbers of doctors coming
out of training through a purely nancial lens would be a signicantly missed opportunity to
improve the quality of care’.
9 The UK ranks second lowest in the EU with three doctors per 1000 inhabitants (by comparison, Denmark has
4.2, Germany has 4.3, and Austria has 5.2. Doctors, OECD (Organisation for Economic Development) data (2019)
10 The state of medical education and practice in the UK, General Medical Council (December 2019)
11 Focus on physicians: 2018–19 census (UK consultants and higher specialty trainees), Royal College of Physicians
(October 2019)
12 The BMA’s Quarterly Survey of March 2018 reported that 35.2% of doctors very oen worked outside their
regular hours and 17.6% of senior doctors undertook research activities in their own time and 21% undertook
teaching or management activities in their own time. Nearly a third of senior doctors provided pastoral support
and mentoring in their own time, rising to 34.7% of women doctors. Two-thirds of those who had taken on
additional responsibilities reported that they did not receive additional pay for doing so.
13 The state of medical education and practice in the UK, General Medical Council (December 2019)
14 The Benets of Consultant Delivered Care, Academy of Medical Royal Colleges (January 2012)
7British Medical Association Consultant workforce shortages and solutions: Now and in the future
United Kingdom 3 doctors per 1,000 inhabitants
Denmark 4.2 doctors per 1,000 inhabitants
Germany 4.3 doctors per 1,000 inhabitants
Austria 5.2 doctors per 1,000 inhabitants
The number of doctors in the UK is far below
that of comparator countries in Europe
2.5 hospital beds per 1,000 inhabitants
Europe
8 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Changes to the way care is delivered mean additional consultants are required
Recent growth in the consultant workforce has focused on delivering more specialised
consultant services in order to improve patient outcomes. While it is true that focusing
some specialist work in the hands of a smaller number of consultants can improve patient
outcomes, eg by increasing procedure numbers, such changes also drive the development
of more specialised consultant on-call rotas. These rotas increase the contribution of out of
hours working to the overall consultant job plan and help drive the increased requirement
for more appointments.
Medical vacancies are likely higher than reported
Even when posts are advertised, a signicant proportion – close to half – go unlled.
15
At the
end of June 2020 there were at least 8,278 secondary care FTE medical vacancies (10% of
all current recorded NHS vacancies).
However, consultant vacancies are only considered to
exist where a job plan has been approved by an employing trust, and has been advertised but
not lled. In some parts of England, if such posts are re-advertised and remain unlled those
posts are no longer advertised and no longer recorded as vacancies. In other parts of the UK,
varying policies for recording unlled vacancies exist. It is therefore no surprise that there is
a discrepancy between vacancies that are nationally reported and those captured in census
data by the medical royal colleges, which suggest that vacancies are likely to be higher.
16
In
Scotland, the vacancy rate is twice as high as ocial workforce gures indicate.
17
Current NHS service needs and COVID-19 illustrate the need to grow
the workforce
The fact that current workforce numbers and service needs do not match up is abundantly
clear when looking at recent NHS performance gures. In the 2019/20 winter, the NHS
recorded its worst performance ever against multiple key metrics.
18
These performance
measures had been progressively deteriorating over recent years, with record low
performance becoming a monthly norm over the past few winters. Pressure is now so
signicant, even during summer, which usually allowed an opportunity to tackle climbing
waiting lists and improve waiting times, 2019 was the worst summer on record.
To improve NHS performance, and to sustain that performance into the future
commensurate to population requirements, medical workforce numbers, including
consultants, must increase. This is particularly pressing now given the huge backlog of non-
COVID care created as a result of the pandemic, which is only likely to grow in the coming
months. To tackle this backlog, reduce NHS waiting lists and times and restore activity to
previous levels, an extraordinary eort will be necessary over a sustained period of time.
Clinical care continues to be impacted by sta absences, with many sta having to isolate
or shield to protect their own wellbeing. It is now more important than ever to maximise
consultant numbers.
15 ‘RCP publishes census of consultant physicians and higher specialty trainees 2018’, Royal College of Physicians
(October 2019)
16 The Royal College of Anaesthetistscensus indicates there were680 funded consultant posts that were vacant.
However, clinical directors reported that they needed another 374 consultants to meet demand. If there’s a
similar error in all other specialities, then the 8,278 FTE gap is likely to be more like 15,000 FTE.
17 ‘Scotland’s consultant vacancies are double ocial tally, BMA nds’, British Medical Journal (December 2018)
18 December 2019 saw the percentage of patients being admitted, transferred or discharged from A&E within four
hours, reaching an all-time low at 79.8%. The number of patients waiting over 12 hours in corridor trolley beds
also skyrocketed to over 2,800 in January 2020. In February 2020, the proportion of patients on the waiting list
treated within 18 weeks of referral was at its lowest level since September 2008 at 83.2%, and over winter the
waiting list size uctuated between 4.42 and 4.45 million. January 2020’s average treatment wait time of
8.4 weeks (almost 2 months) was the longest monthly wait time on record since April 2008.
At the end
of June 2020
there were at
least 8,278
secondary care
FTE medical
vacancies
(10%of
all current
recorded NHS
vacancies)
9British Medical Association Consultant workforce shortages and solutions: Now and in the future
Timescales and Solutions
As set out above, the consultant workforce needs to grow to address patient need. Moreover,
it is imperative that the NHS retains its existing consultants.
Now is a critical time to understand the factors that motivate the present workforce to leave
or stay and respond accordingly. Health service leaders, including employers, must engage
with consultants proactively to help understand why they choose to leave the NHS. Other
bodies, including the BMA and medical royal colleges, also hold valuable data that may help
inform employers as they develop retention strategies.
This section sets out the dierent solutions needed and divides them into short, medium
and long-term solutions.
Short-term solutions
Short-term solutions should focus on ensuring NHS services are able to respond to patient
demand in the face of subsequent waves of COVID-19 as best as possible. All available and
willing consultants should be recruited and deployed to assist that eort in whatever way
they can contribute; there is no shortage of work for them to undertake.
Make the most eective use of retired doctors who would like to return to work
During the rst peak of the COVID-19 pandemic, 28,000 doctors made themselves available
to return to work, but only a small proportion ofthem were eventually deployed.
19
Many
of the doctors that applied reported encountering diculties when trying to return. While
many sta were restored to the temporary medical register, it has not been possible to
provide all of them with productive work:
20
this is a serious shortcoming. Ways must be found
in order to harness the skills of a willing and available workforce at a time when they are so
obviously needed.
Employers must also provide an eective return to work oer to both attract consultants
and harness the value they bring. Such oers should also include supervision plans to ensure
a smooth return to clinical activity, and detailed consideration must be given to whether an
individual consultant could work on site or remotely. Trusts also need adequate funding to
ensure returning doctors are supported.
While many consultants returning to the workforce will be in an older age group, and may
consequently need to be shielded themselves, this should not preclude the possibility of
them undertaking useful productive work on behalf of the NHS and its patients. Much of this
may well be remote working or using technology to support clinical and other work. Clearly,
secondary care NHS IT facilities need to be adequate in all locations in order to support such
work. Further consideration should be given to developing additional proposals for remote
working to allow this group of sta to be used to their full potential.
Appendix 1 provides examples of work doctors can undertake remotely.
19 Doctors returning to the workforce: guidance for hospitals, Royal College of Physicians (July 2020)
20 Doctors returning to the workforce: guidance for hospitals, Royal College of Physicians (July 2020)
During the
rst peak of
the COVID-19
pandemic,
28,000
doctors made
themselves
available in
response to
COVID-19
10 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Prioritise health and wellbeing
Health systems should use all measures to protect their workforce from the impacts of
infection. NHS Digital reports that 39,911 FTE consultant days were lost due to sickness
absence related to COVID-19 between March and May 2020.
21
The lack of provision of PPE
during the rst wave of COVID-19 put many doctors – and their patients – at risk of serious
illness or even death.
A signicant proportion of doctors who contracted COVID-19, having recovered, are also now
experiencing long-term sequalae of infection, including fatigue, concentration diculties
and physical weakness, delaying their return to work.
22
Evidence also indicates that doctors from BAME backgrounds are more susceptible to severe
and life-threatening COVID-19 infections.
23
Great care needs to be taken to ensure that this
vital group of sta are fully reassured that measures have been put in place to protect their
health, including avoiding unreasonable risk. BAME doctors are more likely to be pressured
to work with inadequate PPE, still be experiencing ongoing health issues following COVID-19
infection and are likely to have taken sick leave.
24
In response to the pandemic, the Royal
College of Psychiatrists developed guidance on risk mitigation for BAME sta.
25
Alongside
immediate action to protect the health of BAME sta, longer term and broader action is
needed to address the deeper causes of inequality within the healthcare system.
Helpfully, trusts are being urged to deploy risk assessments for vulnerable sta, including
those from BAME backgrounds, with organisations being encouraged to prioritise the safety
and wellbeing of the workforce by rolling risk assessments out to all sta.
26
Such systems
are essential not only to protect sta from infections acquired in the workplace but also to
maintain condence.
The mental health of doctors has been a particular focus for the BMA and medical royal
colleges who have engaged with their members to understand the challenges they face at
work.
27
This research highlights concerns about the long-term impacts of COVID-19 on sta
mental health. There is potential for colleagues to experience anxiety, grief, depression,
moral injury and even post-traumatic stress disorder as a result of their experiences. Our
ndings illustrate the variety of challenges that doctors experience and the diversity of
responses that are needed to ensure that they are supported.
28
Supporting sta will be
important in helping them avoid ill health and reducing time away from work.
The NHS People Plan 2020/21 sets a clear expectation for employers to focus on health
and wellbeing, eg through the appointment of wellbeing guardians, providing access to
psychological services and ensuring a healthier workplace. Early implementation of these
measures is essential in order to retain sta condence.
21 13,346 (March 2020), 19,922 (April 2020), and 6,643 (May 2020) – NHS Sickness Absence Rates May 2020,
Provisional Statistics, NHS Digital (September 2020)
22 COVID-19: analysing the impact of coronavirus on doctors, BMA (September 2020)
23 COVID-19: the risk to BAME doctors, BMA (September 2020)
24 The mental health and wellbeing of the medical workforce – now and beyond COVID-19, BMA (May 2020)
25 COVID-19: Guidance on risk mitigation for BAME sta in mental healthcare settings, Royal College of Psychiatrists
(June 2020)
26 People Plan 2020/21, English NHS (July 2020)
27 For example, the BMA runs a regular tracker survey to measure sta wellbeing – COVID-19: analysing the impact
of coronavirus on doctors, BMA (September 2020)
28 The mental health and wellbeing of the medical workforce – now and beyond COVID-19, BMA (May 2020)
NHS Digital
reports that
39,911 FTE
consultant days
were lost due
to sickness
absence related
to COVID-19
between March
and May
11British Medical Association Consultant workforce shortages and solutions: Now and in the future
Box 1: Good practice examples of investing in sta wellbeing:
Invest in facilities
The BMA Fatigue and Facilities charter outlines simple steps that can be taken by trusts
and health boards to improve facilities and reduce fatigue.
Oer opportunities to relax:
“My hospital has set up an all-professions chill-out space. A mess, I suppose, not that
I’ve ever worked in a hospital that has one. It is so nice to have a centrally located space
where sta can relax together.” RCPCH member, May 2020.
29
Oer return to work support:
The RCOG Return to Work Toolkit is a good example of measures designed to support
doctors back into the workplace, aer a period of absence, as a way to retain sta and
reduce attrition.
30
Medium-term solutions
Medium-term solutions encourage existing sta to remain in the workforce rather than
retire, decrease their working hours or leave their current employer to work somewhere else.
Retention of sta is benecial to employers because existing sta know the organisation and
work eectively within it. High sta turnover leads to decreased eciency and productivity,
which, in turn, aects patient care.
31
It is both more costly and time consuming to recruit
a new employee than it is to retain one. The recently released NHS People Plan helpfully
recognises this.
32
Sta retention should not solely focus on those nearing retirement,
although those sta are a large and important group. Rather, eorts should be directed
at consultants across the breadth of their careers: organisationally, all groups are of equal
importance.
Retaining consultants in the workforce is largely dependent on organisations taking active
steps – warm words alone do not suce. Doctors who have taken ‘hard steps’ towards
leaving the profession feel unable to cope with workload, nd it dicult to provide sucient
patient care and experience high levels of burnout and dissatisfaction.
33
Addressing these
issues requires commitment and practical steps by employers.
Appendix 2 sets out principles that should underpin retention policies.
a) Clarify and widen ‘retire and return’ arrangements
Many employers oer “retire and return” arrangements. This involves consultants retiring
from their full or part-time roles and returning to work post-retirement, usually with a
reduction in delivered clinical sessions. They are able to access pension payments and take
up paid employment alongside that. Despite those arrangements being long-established,
there is great variability in how they are interpreted and applied. Such a lack of visibility and
clarity regarding the nature of the oer means that some employees do not seek out or
access such an alternative. Their clinical skills and contribution to the provider’s output are
lost as a result. It is vital that trusts have clear policies in place around ‘retire and return’ and
that these are clearly communicated to consultants.
Appendix 2 includes further information on how employers should develop ‘retire and
return’ policies and areas they need to clarify.
29 Reimagining the future of paediatric care post-COVID-19, Royal College of Paediatrics and Child Health (June 2020)
30 Return to Work Toolkit, Royal College of Obstetricians and Gynaecologists (2020)
31 Reviewing the Benets of Health Workforce Stability, National Centre for Biotechnical Information (December 2010)
32 People Plan 2020/21, English NHS (July 2020)
33 The state of medical education and practice in the UK, General Medical Council (December 2019)
12 British Medical Association Consultant workforce shortages and solutions: Now and in the future
b) Reform the pensions taxation system
The 2020 budget announced signicant pension taxation reforms, which are a welcome
step towards resolving the ongoing crisis. Nevertheless, a number of issues still exist that are
forcing doctors to retire before they would otherwise choose. These must be addressed in
the next budget.
As part of the 2020 reforms, both the threshold and adjusted income limits were raised
by £90,000. This means that individuals with a ‘threshold income’ (net income before tax
excluding pensions) of £200,000 in the 2020/21 tax year and an ‘adjusted income’ (net
income plus pension accrual) below £240,000 will no longer be impacted by the tapered AA
(annual allowance). The AA will begin to taper down for individuals who have an ‘adjusted
income’ above £240,000 (down to a minimum of £4,000).
However, the standard annual allowance remained at £40,000. This means many doctors,
with incomes far below the new threshold income, still face additional tax bills as a result of
exceeding the standard annual allowance. The AA is unsuited for dened benet pension
schemes such as the one oered by the NHS. Even the most modest pay rises in pensionable
pay can therefore result in a tax bill.
The budget also made no change to the LTA (lifetime allowance). Many doctors will still need
to consider taking early retirement as a result of this. For those NHS sta consequently
forced to leave the pension scheme, employer contributions must be recycled.
The sheer complexity of the NHS pension scheme also continues to be an issue for doctors;
their nancial and retirement planning is challenging. It is a contributing factor towards early
retirement, as members are taking a risk adverse approach and leaving the pension scheme
to avoid punitive taxation charges.
Furthermore, those doctors who are members of the 1995 legacy scheme and the
2015 reformed scheme are unable to draw their 1995 pension whilst continuing to pay
contributions into the 2015 scheme. This puts pressure on members in the 1995 scheme
to retire at the age of 60 rather than continuing to work longer.
We also believe that the strict abatement rules that then limit the amount of work doctors
can do when they return to NHS employment aer retirement should be reviewed.
Part-time consultants must not pay pension contributions at the FTE rate either.
Many consultants have received huge additional taxation charges as a result of AA and
LTA breaches. There are sound reasons, however, for oering full employer contributions
to employees who are forced to either leave the NHS pension scheme or face very large
additional tax bills. A large proportion of the likely recipients of additional charges are older
consultants. These older consultants are also at risk of breaching the LTA. For many, they
may be able to choose between staying in employment or retirement. Even where they opt
to retire and return to work, it is likely that the employer would have been able to access a
greater amount of working time from that consultant if they could have been persuaded not
to retire.
When consultants are forced to leave the pension scheme and continue to work, they
are eectively doing the same work when compared to a colleague who has been able to
remain in the scheme but for 20.6% less reward, ie a reduction in the Total Reward Package
equivalent to the value of the employer pension contribution. There is currently no clarity as
to whether this breaches Equal Pay legislation.
Paying the employer contributions to the employee would help to retain valuable
consultants, as full or part-time employees, by removing the nancial disbenet otherwise
incurred when leaving the pension scheme and by avoiding the nancial incentive to retire
and return. Scrapping or increasing the LTA would also remove the huge incentive for senior
consultants to retire earlier than intended.
13British Medical Association Consultant workforce shortages and solutions: Now and in the future
Box 2: Early retirement
A 2019 survey by the Royal College of Physicians
34
found that:
– Nearly half of the 2,800 doctors surveyed decided to retire at a younger age than
previously planned – with eight in ten of those citing pension concerns as one of
the reasons for this decision.
– 62% of senior clinicians said they avoid extra paid work (such as covering for
colleagues), and a quarter have reduced the number of programmed activities
they work.
– One in ve report having stepped down from a leadership role or other role
with extra remuneration.
Similarly, in its annual census of the registered consultant workforce, the Faculty of Intensive
Care Medicine
35
found that 20% of consultants in ICM were planning to leave critical care
ahead of retirement.
A 2019 BMA survey found that more than 6 in every 10 (62%) doctors had retired and
returned, or planned to return, with reduced clinical commitments due to actual or potential
annual allowance taxation charges.
36
c) Allow consultants to work exibly, including remotely, where possible
Enabling doctors to work exibly will help improve work-life balance and sta retention. Full-
time consultant sta have the right to request to work part-time but there is no contractual
right. At various times of life, all doctors may have diculty balancing working lives alongside
other responsibilities. This is disproportionately the case for women who continue to take
on more childcare responsibilities than men. At such times, it may be more practical for
consultant sta to work part-time rather than withdraw from the workforce altogether.
Junior doctors have rightly been given the entitlement to work part-time; this entitlement
should now be extended to the consultant workforce too.
We welcome the commitment in the NHS People Plan to ensure employers are open to all
clinical and non-clinical permanent roles becoming exible. Employers should consider
implementing the RCP toolkit on working exibly to help them make this change.
37
We also welcome the commitment to ensure that sta who are mid-career or approaching
retirement have a career conversation with their employer to discuss any adjustments.
Mirroring changes that have been taking place in primary care throughout 2020, it is vital
that employers ensure sta have access to the necessary IT hardware, soware and training
to carry out their duties remotely. Although secondary care is, in some respects, more
restricted to face-to-face consultations, remote consulting has the potential to open up
opportunities for new innovative ways of working, eg by replacing some outpatient visits
that currently require both patient and clinicians to travel.
At the moment, however, secondary care sta are reporting instances of being unable to
deliver productive clinical work from home as a consequence of inadequate IT equipment.
34 ‘Pension tax driving half of doctors to retire early’, Royal College of Physicians (October 2029)
35 Census, Faculty of Intensive Care Medicine
36 BMA survey (June 2019)
37 Working exibly: A toolkit, Royal College of Physicians (2020)
14 British Medical Association Consultant workforce shortages and solutions: Now and in the future
The ability to conduct such appointments remotely could reduce footfall in outpatient
departments, increase the availability of appointments for patients and enable clinicians to
work in a way that suits them best. Those with disabilities or long-term conditions may also
need specic or additional provision.
The technology to work remotely and eectively is well within our reach but requires
dedicated funding from both employers and national bodies to be fully realised.
Employers should also ensure that sta have the right oce equipment in order to do their
role from home. Those with disabilities may need extra equipment.
Box 3: Covid-19 has accelerated innovation in exible working
A recent report by the RCPCH highlights how Covid-19 has forced services to innovate
rapidly and introduce new forms of working, including home working and remote
consultations.
“In my department, having been told tele clinics could never happen,
people could never work from home, and department teaching and
meetings couldn’t be done remotely, we are now doing all those things
– almost overnight.”
RCPCH member, May 2020
One of the benets of this necessary reconguration is the opportunity for increased
exibility, which can support a better work-life balance, reduce travel time and increase
wellbeing. Going forward post-COVID, employers should continue to build on the
changes we have seen in this period by investing in at-home IT provision for sta and
oering more opportunities for remote and exible working. This will, in turn, support
greater sta retention. As one RCPCH member says:
“I’d like to preserve the little things that make a dierence to our day –
like not having to worry about where to park your car, or whether there
will be something available to eat if you are working late.”
RCPCH member, May 2020
38
d) Enable consultants to change parts of their role
Being a doctor is both physically and mentally demanding. An individual’s age can aect
how well they manage fatigue, stress and cope with dierent working patterns. The BMA’s
fatigue and sleep deprivation report found that older people typically have poorer quality
sleep and are less likely to adapt to shi work, particularly night shi work, without adverse
consequences.
39
As doctors age, they may be able to adapt less quickly and experience higher
stress levels when covering unexpected situations, including those encountered during urgent
and emergency/on-call work. Such work may generate stresses in those consultants – anxious
that they may no longer be able to accomplish those duties with the same facility as they
once did and that their colleagues still exhibit. Those stresses may encourage consultants to
consider retirement, particularly if this is the only available route that would allow the stressors
to be avoided. It seems more sensible to seek solutions that allow the consultant to escape
from a stressor, while maintaining a similar time commitment for their employer. The RCP
have recommended that, past the age of 60, and following discussion with the clinical lead, a
consultant should only opt into on-call work if they wish to.
40
It is vital that this is not perceived
as a weakness. Line managers should understand the normal eects of aging.
38 Reimagining the future of paediatric care post-COVID-19 – a reective report of rapid learning, Royal College of
Paediatrics and Child Health (June 2020)
39 Fatigue and sleep deprivation, BMA (September 2020)
40 Later careers: Stemming the drain of expertise and skills from the profession, Royal College of Physicians (April 2018)
15British Medical Association Consultant workforce shortages and solutions: Now and in the future
Older sta can still contribute to out of hours work within their departments, even where
this work is no longer on-call work. For example, rapid access clinics provide a valuable
contribution to urgent care, while also providing good teaching and clinical mentoring
opportunities, suitable for senior consultants wishing to contribute but not via out of
hours on call. Such a quid-pro-quo may help reassure younger colleagues that older
consultants continue to support the eorts of their departments, particularly where this
is in expectation that younger consultants will be oered similar support later in their
working lives.
41
e) Oer sabbatical Leave
Sabbatical leave should be oered as an incentive for established consultants across all
stages of their careers. Employees value sabbaticals as a chance to take time out from a
stressful work environment, an opportunity to acquire new skills, to study the operation of
other healthcare systems or organisations or to acquire new knowledge. They have been
dicult to access within the NHS for many reasons, including cost and potential loss of
service provision. Organisations oering sabbatical leave, particularly where such oers
are facilitated by active assistance in setting up the sabbatical, may more easily retain sta
who would otherwise have considered leaving. Those returning are also likely to come
back refreshed, with new ideas, perspectives and skills.
41 ‘Academic factors in medical recruitment: evidence to support improvements in medical recruitment
and retention by improving the academic content in medical posts On behalf of Medical Academic Sta
Committee of the British Medical Association’, Research Gate (June 2019)
2020 | 36%
of consultants are women
2009 | 30%
of consultants are women
50%
of medical students
are women
16 British Medical Association Consultant workforce shortages and solutions: Now and in the future
f) Support sta going through menopause
The proportion of NHS doctors who are women has grown every year since 2009 and this
trend is expected to continue. Nearly 4 in every 10 (36%) of consultants were women in
2018 compared with only 3 in every 10 (30%) in 2009.
42
Every specialty group has seen an
increase in the proportion of women; in some specialities, eg psychiatry, there are now more
women than men. Women also make up more than half of all medical students, meaning the
proportion of women in the workforce is likely to grow going forward.
43
The female workforce may face additional challenges around their wellbeing, which
employers need to address. A BMA survey of doctors found that over 90% of respondents
reported that menopause symptoms impacted their working lives and 38% said these
changes were signicant.
44
Over 65% said that the menopause impacts both their physical
and mental health. Worryingly, almost half (48%) of respondents said they had not sought
support and would not feel comfortable discussing their menopausal symptoms with their
managers. This failure to support doctors is leading to doctors stepping down from senior
positions or leaving medicine earlier than intended.
Focus is needed on eective organisational interventions to support employees going
through the menopause. Such measures might include allowing doctors experiencing
these symptoms to work exibly and placing an equal focus on supporting employees
with the mental, as well as the physical, symptoms of menopause. Line managers and sta
undergoing menopause should seek advice from occupational health teams as necessary.
Attention should also be given to developing cultures where those experiencing symptoms
can speak openly and access the support they need. Employers should raise awareness
about menopause and provide training for line managers. Ways should also be explored to
bring sta together in an informal setting to share their thoughts, eg through a “Menopause
Cafe”.
45
g) Address the real terms pay erosion
Over the past 10 years, pay increases for consultant sta have either been subject to a public
sector pay freeze or any oer has been sub-inationary. Consequently, consultant pay in
England has declined in real terms over time. The BMA estimates that a consultant’s average
take-home pay in 2019/20 represents a 31.2% real-terms decline in value from 2008/09,
measuring ination with the RPI (retail prices index). When taken together with multiple
other nancial penalties, such as AA and LTA taxation charges on pension growth, increased
pension contributions and the recent reduction in clinical excellence award spending,
the stark nature of the reduction in consultants’ incomes becomes all too apparent. Pay
cuts have had a damaging eect on consultant morale, spilling over into recruitment and
retention.
h) Develop a supportive and inclusive workplace culture
Creating a supportive and inclusive workplace represents a key aspect of improving sta
retention. Many doctors feel that they are working in a culture of blame that discourages
learning and reection.
46
A change is needed to replace a culture of blame with a culture of
learning. There should also be an emphasis on making the process around job planning and
appraisal as friendly as possible to ensure sta feel valued.
The medical profession and wider NHS workforce are increasingly diverse, but the
experiences of sta and opportunities for development are not equal. Environments that
are diverse and inclusive have greater professional satisfaction among sta and better
outcomes for patients
47
.
42 ‘Narrowing of NHS gender divide but men still the majority in senior roles’, NHS Digital (March 2018)
43 The state of medical education and practice in the UK, General Medical Council (December 2019)
44 Challenging the culture on menopause for working doctors, BMA (2020)
45 Menopause at work, NHS Sta Council (March 2020)
46 Caring, supportive, collaborative? Doctors’ views on working in the NHS, BMA (September 2018 )
47 ‘Diversity in the NHS is everyone’s business’, NHS England (April 2018)
The BMA
estimates that
a consultant’s
average take-
home pay
in 2019/20
represents a
31.2% real-
decline in value
from 2008/09
to 2019/20,
taking into
account the
RPI measure
of ination
17British Medical Association Consultant workforce shortages and solutions: Now and in the future
Unfortunately, bullying and harassment continues to be an issue in healthcare, particularly
for BAME sta.
48
There are signicant costs for organisations resulting from bullying
and harassment; these mainly arise from higher sta turnover and increased sickness
absence.
49
Positive action to tackle discrimination, harassment and victimisation, and the
eective implementation of appropriate policies, must be taken by all employers. We welcome
the emphasis in the NHS People Plan to tackle this issue. The BMA has also produced guidance
for employers to improve equality and diversity in the workplace.
50
Scrupulous care should be
taken to both ensure and, importantly, demonstrate that all sta policies are free from bias of
any kind and will properly protect all sta groups. This is especially important where, as with
COVID-19, there are real threats to life and health for sta.
Up to now, workplaces have paid insucient regard to the realities of living and working
with a disability or health condition. This has, in some instances, made it dicult for those
doctors to work as eectively as they could.
51
This is unwise, as it may lessen the ability of
those sta to deliver their best. Employers could improve access to workplace adjustments,
strengthen OH support (Occupational Health), enable sta to self-refer to OH teams and
raise awareness within the NHS of the essential need to support workers with hidden/
invisible and uctuating disabilities and long-term health conditions. Line managers and
supervisors should also have training and access to advice so they can handle conversations
about disability sensitively, constructively and appropriately.
If unable to work as a result of ill health in their current or any other similar alternative
employment role, the NHS pensions scheme does currently give members the ability
to retire early and take their pension benets without actuarial reduction and with
enhancement. This is known as a tier 2 award. However, if the member subsequently decides
to restart work, they are limited in the amount of money they can earn. If their earnings
exceed the LEL (lower earnings limit) for National Insurance contributions, which is currently
£120 per week for 2020/21 (this equates to £6,240 per annum), they will lose this benet.
This does not take account of uctuating illness/disability and therefore needs to be
reformed so members are not penalised for returning to work when they feel able to do so.
i) Close the gender pay gap
A primary cause of the gender pay gap in medicine is the gender imbalance across the
highest paid positions, grades and specialties. Greater numbers of female consultants
should be reected by a similar increase in women in higher paid roles. Career pathways and
workplace environments must be designed to encourage retention of female consultants, in
addition to addressing issues that may encourage female sta to take on positions in lower-
paid roles.
Female sta still take on a greater proportion of caring responsibilities than their male
counterparts. That may be dicult to accommodate within traditional consultant working
patterns and must be addressed. Flexibility regarding working patterns can be a key
component in maximising participation in the workplace and addressing the career barriers
that develop for women when they have children. Steps should be taken to normalise men
taking an equal role in caring responsibilities; this should include consultants getting access
to enhanced share parental leave.
We are waiting for the publication of the Department of Health and Social Care’s
Independent Review into the Gender Pay Gap in Medicine. It is expected that the review
recommendations will include measures to:
– address the short and long-term career and pay penalties of less than full time doctors
and doctors with caring responsibilities
48 NHS Sta Survey Results, England NHS (2019)
49 ‘The price of fear: Estimating the nancial cost of bullying and harassment to the NHS in England’,
Taylor & Francis Online (October 2018)
50 Are you a good employer?, BMA (September 2020)
51 Disability in the medical profession, BMA (September 2020)
18 British Medical Association Consultant workforce shortages and solutions: Now and in the future
– review pay structures and additional payments, ensuring they are fair and transparent,
and
– ensure senior jobs are accessible to improve retention and greatly increase promotions
amongst women in the medical profession.
j) Provide opportunities for leadership, training, development and research
Consultants, like all sta, value opportunities to innovate and acquire new skills and abilities.
Expanding the range of clinical services that an individual, a department or an organisation
can oer benets both the individual and the provider, particularly if tailored towards
services that have not formerly been oered before. The available training and development
should be widely known, and there should be an expectation for sta to make use of such
oers. Sta should also be supported to undertake leadership training courses, eg those
oered by the BMA and medical royal colleges, and university diplomas and degrees, as well
as certicates from or membership of organisations.
Many consultants would also welcome the opportunity to renew or develop their research
interests.
52
Such activity rewards the individual conducting the research, improves patient
outcomes, rewards the department and the employer through enhanced status – making it
more attractive as a recruiter – and subscribes to the NHS’s stated direction of travel. Clinical
research is critical for understanding, for example, disease trends and risk factors, and
outcomes of public health interventions. Consultant clinicians play a vital role in this regard
which has been highlighted through COVID-19 where the involvement of clinicians has been
crucial to the UK’s public health response.
Barriers to undertaking research include a lack of time and workplace culture. Organisations
are frequently reluctant to oer time not devoted to clinical throughput, yet such a policy
worsens rather than improves the likelihood of consultant sta retention. We also know from
the Keogh Review that having a research-active workforce helps to ensure high standards of
clinical care.
53
There has been an erosion of SPA (supporting professional activities) time overall, which
needs to be addressed. SPAs are dened in the contract as activities that underpin direct
clinical care. These may include participation in training, medical education, continuing
professional development, formal teaching, audit, job planning, appraisal, research, clinical
management and local clinical governance activities. Sucient SPAs, therefore, need to be
included in job plans for the benet of the employer and employee to ensure that the work
of these doctors is underpinned by eective quality control and patient safety standards.
Employers should explore ways to allow clinicians more time to participate in research, do
more to publicise research focused mentoring schemes and provide resource and funding
to promote and celebrate research activity.
54
Long Term Solutions
Over the next 20 years the UK population aged over 65 is expected to grow signicantly,
alongside a general growth in population numbers. An appropriately sized consultant
workforce is both essential to look aer this growing and ageing population and unlikely
to be delivered by current workforce policy as it applies to consultants. It can take up to
15 years to train a doctor to consultant level.
Ensure an appropriate future supply of consultants
From data supplied by Health Education England to the DDRB (doctors’ and dentists’ review
body) in 2017, it was estimated then that 6.8 – 7.7% or 3,400 – 3,756 FTE more consultants were
needed.
55
As set out earlier in this paper, the picture has worsened since then. Despite the recent
52 Research for all: Developing, delivering and driving better research , Royal College of Physicians (August 2020)
53 Review into the quality of care and treatment provided by 14 hospital trusts in England, Professor Sir Bruce
Keogh (July 2013)
54 Research for all: Developing, delivering and driving better research , Royal College of Physicians (August 2020)
55 Review Body on Doctors’ and Dentists’ Remuneration Forty-Seventh Report 2019, p. 78-80 (2019)
A recent
estimate by the
DDRB places
the consultant
undersupply
rate between
6.8 – 7.7% – or
3,400 – 3,756
FTE doctors
19British Medical Association Consultant workforce shortages and solutions: Now and in the future
increase in numbers in some specialties,
56
overall growth within the consultant workforce has
evidently not been keeping pace with demand. Royal college census data indicates current and
anticipated consultant workforce decits across a range of specialty areas.
57
It is vital that the
Government and arms-length bodies urgently take action to ensure appropriate future supply.
Even more worryingly, ONS data suggests population growth of 9% over the next 25 years.
58
Further analysis reveals that this includes a sizeable increase in the proportion of those aged
over 65 – the so-called ‘Baby Boomer’ generation of the 1960s. Healthcare consumption is at
its greatest at the extremes of life; those under the age of one and over the age of 65. In terms
of NHS workforce planning, it is therefore alarming that population projections indicate that
the number of people aged 85 and over will double over the next 20 years, before numbers
begin to return to a more even spread across all age groups in the mid to late-2040s. Prior to
that, however, the proportion of over 65s is set to increase from approximately one in 10, at
present, to one in three or four by the early 2040s. Given this population demographic increase
comes at a stage of peak healthcare usage in these citizens’ lives, it is inconceivable that the
present consultant complement will be adequate to service this need.
It is therefore vital that the Government and arms-length bodies take urgent action to
guarantee safe levels of future consultant supply now and in the decades to come.
To sustainably grow the consultant workforce, medical school, FP and specialty trainee
numbers must be increased.
Medical royal colleges and the BMA have called for additional medical school and FP places. In
2018, the Royal College of Physicians (RCP) estimated that medical schools places would need
to double by 2023/24 in order to meet projected overall doctor supply requirements for the
future.
59,60
The Royal College of Psychiatrists (RCPsych) followed this up in 2019 with a similar
call for the annual medical school intake to rise to 15,000 over the next 10 years.
61
Given the
conrmed medical student intake was 6,800 in 2019/20,
62
an increase of around 7,500 places
would be required take us to an annual cohort of around 14,000-15,000 medical students
per year by the middle of this decade. It is dicult to estimate the full cost of increasing
medical school places. However, based on the data available from the DHSC’s own estimates
in 2017, this amounts to an expenditure of at least £3.45 billion per annum on medical school
placements alone.
63
There is also the issue of recruitment and retention of clinical academics to train future
generations of doctors, but the Medical Schools Council
64
reported a vacancy rate of 3.8%
among senior clinical academics in 2019. A considerable proportion of the foundation
knowledge and clinical skills education occurs in the university setting prior to clinical
placements. The last 10 years, however, has seen a 27% reduction in the senior clinical
academic workforce despite a 25% growth in medical student numbers.
65
Clearly, this
expansion in medical students cannot occur, whilst also still maintaining the UKs world-
leading research status, without an expansion in the clinical academic sector.
56 NHS Workforce Statistics May 2020, NHS Digital (August 2020)
57 RCEM Workforce Recommendations 2018, FCIM In Depth Review of the UK’s Anaesthetic and Intensive Care
Medicine Workforce 2015, RCoA’s The UK’s Anaesthetic Workforce 2019, RCPsych’s Workforce Strategy 2020-23,
RCOG O&G Workforce Report 2018, RCPCH Workforce Brieng 2018, RCR Clinical Radiology Workforce Census
Report 2019, RCP Focus on physicians: 2018–19 census
58 National population projections: 2018-based, Oce for National Statistics (October 2019)
59 Double or quits: calculating how many more medical students we need, Royal College of Physicians (2018)
60 RCP response to ‘Facing the Facts, Shaping the Future: A dra health and care workforce strategy for England to
2027’, Royal College of Physicians (2018)
61 Double the number of medical school places to stop mental health services imploding’, Royal College of
Psychiatrists (2019)
62 Medical and dental intake 2018-19 and 19-20, Oce for Students (January 2020)
63 Expansion of Undergraduate Medical Education, Department of Health and Social Care, (March 2017) – the cost
to put a UK/ EU national through medical school is around £230,000
64 Clinical Academic Survey, Medical Schools Council (2019)
65 Clinical Academics Survey, Medical Schools Council (2019)
20 British Medical Association Consultant workforce shortages and solutions: Now and in the future
The Royal College of Anaesthetists estimates that to keep
up with patient demand whilst counter balancing annual
retirement attrition, the annual anaesthetic consultant CCT
(certicate of completion of training) output must reach
417 per year by 2023-2027.
66
Other medical royal colleges have noted that, in respect of their members,
there are too few trainees within the system to ll all of the posts
anticipated to be required. For example:
Royal College of
Anaesthetists
Royal College of
Psychiatrists
Royal College of
Paediatrics and
Child Health
Royal College of
Obstetricians and
Gynaecologists
The Royal College of Psychiatrists anticipates there
will
only be an additional 200 consultant
psychiatrists
entering the workforce by
2023/24, which is far below the NHS Long Term
Plan requirement of 1,040.
67
The Royal College of Obstetricians and Gynaecologists concurs
with Health Education England’s estimate in its latest workforce
report;
68
that the demand for O&G consultants is expected to be
between
2,336 and 2,490 FTE doctors in 2021.
69
The Royal College of Paediatrics and Child Health (RCPCH)
estimates that
162 specialty training places
have gone unlled between 2018 and2020. The RCPCH
estimates that the demand for paediatric consultants in the
UK outstrips 2017 workforce levels by around
21%. An
increase of approximately 850 FTE consultants above the
2017 workforce is therefore required to meet demand.
21British Medical Association Consultant workforce shortages and solutions: Now and in the future
Royal College
of Emergency
Medicine
Royal College of
Pathologists
Royal College of
Radiologists
In addition, increased resources and sta/educators – including consultants and academics – in medical
schools are also required to deliver the increased education and training workload; otherwise this will
mean another additional pressure on the workforce.
There are also more and more doctors working Less Than Full Time, which makes it increasingly vital that
workforce planning, based on accurate workforce data, is done properly.
The Royal College of Emergency Medicine
70
highlights
that although the EM (emergency medicine) consultant
workforce has grown over recent years (6-8% per year
between 2012-2020), this has
not kept pace with
the demand
and complexity of care required. In 2018,
approximately 26% of advertised consultant posts remained
unlled. The NHS in England also spent
£2.94 billion
on locum and agency sta in 2016/17,
16% of which
(£470 million) was spent in EM.
The Royal College of Pathologists estimates that a
minimum of
288 trainees will be needed to ll all
current and predicted vacancies and retirements in England
only over the next two years. The predicted number of
haematology trainees expected to obtain a CCT in the
whole of the UK is
only 234.
71
A 2018 histopathology
workforce report conrmed that ‘more than three-quarters
of departments reported vacancies for consultants –
78 per cent’.
72
The Royal College of Radiologists states that the current shortfall
of 1,876
radiologists (33%) is forecast to rise to 3,331 (43%) by
2024. Over the past year alone, volumes of computed tomography
(CT) imaging examinations in England have increased by 10% and MRIs
by 8%. This compares with
3% growth in the clinical radiology
workforce
73
.
66 Workforce Data Pack 2018, p. 14, The Royal College of Anaesthetists (March 2018)
67 Next steps for funding mental healthcare in England: A comprehensive settlement that invests in infrastructure, prevention, people
and technology, Royal College of Psychiatrists (September 2020)
68 O&G Workforce Report 2018, Royal College of Obstetricians and Gynaecologists (2019)
69 Maternity Workforce Strategy – Transforming the Maternity Workforce, Health Education England (March 2019)
70 Workforce Recommendations 2018, Royal College of Emergency Medicine (February 2019)
71 The haematology laboratory workforce: challenges and solutions – a meeting pathology demand brieng, Royal College of
Pathologists (2020)
72 Meeting pathology demand: Histopathology workforce census, Royal College of Pathologists (2018)
73 Clinical radiology UK workforce census 2019 report, Royal College of Radiologist (April 2020)
22 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Conclusion
The current consultant workforce is inadequately sized to deliver all of the patient care
required now and into the foreseeable future. There are particular challenges for the NHS
at present, given the COVID-19 outbreak and its impact on NHS capacity and waiting times.
Those challenges have further exacerbated the pre-existing problems with undersupply
of the consultant workforce. Unless there are swi changes to working methods and
organisational culture, it is hard to be condent that the NHS will be able to resolve its
current waiting time diculties.
Without urgent policy intervention at Government level now, there will also be insucient
consultant sta available to the NHS in the future. This will have serious consequences for
the quality of patient care. A wide range of medical specialties report signicant workforce
shortages at a time when population growth and demographic change is highly likely to
place increasing demands on the healthcare system.
Action to implement short, medium and long-term solutions is needed now to increase
consultant numbers and make earnest eorts to retain them. This is the only way we will
meet the expected rising patient need for specialist care. Furthermore, given the long
lead-time to produce fully trained consultants – longer than any other sta group in almost
any other industry – we cannot aord for the expansion of the consultant workforce to be
delayed any further.
Early decisions are needed to avoid a reduction in the quality of NHS care and worsening
patient outcomes. Eective action must be taken now; to do nothing is an unacceptable
alternative. Failing to take action would mean failing British citizens.
23British Medical Association Consultant workforce shortages and solutions: Now and in the future
Appendix 1 – Productive work for sta
not able to work in face-to-face roles
This appendix sets out a number of areas where sta not able to work in face-to-face roles
can be deployed to meet overall demand on the NHS.
Teaching & training
– On-line teaching – trainees, nursing and other sta, sta in other institutions
– Writing webinars, slide presentations, ARCP (Annual Review of Competence Progression),
VC teaching
– On-line appraisals and supporting revalidation
– Virtual procedural supervision
Service improvement
– Local/regional/national protocol development
– How to make my departmental practices more online based
– Guidance for patients with particular conditions
– Referral guidance development
– Guideline development
– Working cooperatively with the IPS (see below)
– Updating local guidelines and documents
– Work with specialty colleges
– Developing relationships with primary care
– Formal management roles
Online working and its facilitation
– OP work online
– New referrals – identify which conditions suitable for electronic review. What are
inclusions/exclusions)
– Follow Up – likely more suitable for non-face to face review as diagnosis is already made
– Review results, dictate letters, order prescriptions, book further investigations and
follow up
– Triage of eRS referrals – review referrals (identify which referrals should be seen
as priority, within X weeks/months etc) and adjust clinic proles to accommodate
emergency referrals when necessary
– Online follow up of inpatient admissions – eg ITU patients (undertake reviews for
other hospitals in local area or more widely), results review, VC liaison with allied health
professionals, medication adjustments
– Review of waiting list across specialty (this has resulted in dramatically cut waiting list
length with patients no longer wanting or needing some surgery)
– Pre-face-to-face review – ie an online review of a patient prior to face-to-face review
– Pre-admission assessment of elective surgery patients by teleclinic, enables faster
assessment on day of surgery. Pre-operative assessment can cover large amounts of
work of standard preop assessment. Major and intermediate surgical elective admissions
could have a teleclinic review by surgeon and anaesthetist
– Virtual multidisciplinary team
Working with Primary care
– Advice line for GPs (local, wider area for specialised services)
– Rapid access to video clinic for GP from surgery so that the patient can have history taken
by consultant with GP providing examination
– Referral advice line – ie provide advice to GPs about which cases/whether to refer a case
or to manage in another way
– Both GP advice line and GP referral advice could be either by phone or by virtual clinic
– Outpatient clinics for primary care – ie review cases at discretion of GP
– Shared care development – pathways for sharing ongoing care between primary and
secondary care
24 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Other Secondary Care Working
– Virtual ward rounds
– Virtual ward round in other healthcare settings eg care home, secure accommodation etc.
– In-hospital advice line for particular service (calls directed to a consultant away from
hospital who is able to give advice. Liaises with on-site colleague who elds cases needing
hands-on care. Can be used to support existing telephone helplines (eg IBD helpline) and
specialist nurses
– Radiology relies heavily on outsourced reporting. Greater access to home reporting
implemented during COVID-19 should be extended to reduce outsourcing costs, support
retention and reduce footfall in the department. Distant review (could be for hospital or
primary care requests where investigation has been done but awaits report) of:
– Specialist blood work and histology
– Cardiological investigation
– Other investigations such as pulmonary function tests
– Imaging
– Shared care development – pathways for sharing ongoing care between primary and
secondary care
– Pre-operative assessment – aim for all forthcoming admissions to improve on the day
throughput (see above)
– Assessment of patients for other trusts
Administration Including Management of Risk
– Audit
– Discharge summaries
– Medication reviews
– CQC preparation
– Safety review inc. review of Datix, root cause analysis etc.
– Future departmental workload/capacity planning
– Future recruitment
– Continued virtual engagement with external duties such as those for specialty and royal
colleges, BMA, GMC, CQC etc.
25British Medical Association Consultant workforce shortages and solutions: Now and in the future
Appendix 2 – Policy Principles for
Trust’s Retention Policy Including
Retire and Return Scheme
Who might be considered a “target group” for retention?
All consultant sta will need to be actively supported to stay in NHS employment if providers
are to retain their existing sta. Employers will need to adopt a range of approaches each
designed to retain dierent groups of consultant medical sta depending on where they are
in their careers. In the later stages of a career alternatives should be oered to encourage
consultants to stay in the workforce and to create circumstances where they will want to
maximise their participation. Earlier in a career some of those considerations will still apply
alongside a range of other policy oers.
General Principles
1. Be clear – tell people you need & want to retain them. It is important that sta feel
valued and supported in their role. No-one will consider staying on with an employer if
they do not feel valued or realise that the employer would like them to remain.
2. Be exible and accommodating – a range of potential oers is likely to have a greater
success rate than a single response. Individual exibility will help too.
3. Don’t penalise – positive persuasion is needed rather than trying to impose barriers to
leaving.
4. Tailor your oer and be inclusive – dierent employees or groups of employees may
prefer dierent things. It is important that employers make a retention oer that is seen
as desirable, useful, and appropriate by the group that is targeted for retention.
5. Ensure you target everyone and at all stages of their career – without a visible,
consistent and clearly expressed policy, employers may lose sta to others who have such
a policy in place. Current retention eorts are largely directed at retaining sta who would
otherwise reduce work commitments as a prelude to retirement. Colleagues at earlier
stages in their careers must also be incentivised to remain.
6. Be timely – once an employee begins to consider or to make preparations to leave then
the opportunity to retain them may have already been lost. Try to prevent that mental
rst step from being taken.
7. Be clear on what local support is available – ensure sta know where they can access
support if their mental or physical health deteriorates.
8. Don’t rely upon sta to work for free – consultants oen work outside of their regular
work hours which damages morale.
26 British Medical Association Consultant workforce shortages and solutions: Now and in the future
Retire and Return
Trusts should have clear and transparent policies regarding retire and return for consultants.
There are several areas where such clarity is needed:
– To whom does this apply? Retire and return should be applied to all consultants, across
all specialty groups. Rather than relying on departmental or even individual oers, trusts
should agree a local policy that applies consistently across the trust and is clearly agged
to all employees. Otherwise there is a risk that the process may be unfairly applied or the
approach is haphazard.
– What is the length of the contract? Many consultants are deterred from seeking retire
and return arrangements because they have only been oered a single year contract
of employment. Such brief and possibly precarious contracts of employment are
unattractive and discouraging, and trusts should oer a longer contract period for those
that desire them.
– What point on the salary scale is oered? Most consultants retire at the top of the
consultant salary scale; however, many employers will only oer retire and return
arrangements that remunerate consultants at the mid-point or even entry point of
the consultant salary scale. This seems inappropriate: employers gain an employee of
immense experience – both of the clinical specialty and the local healthcare system
– that allows that consultant to function at maximal productivity from the point of
engagement. There seems little justication to oer a lower level of remuneration. It is
also a source of frustration that consultants cannot keep the value of their existing CEAs
as it means they have a lower salary than before. Obviously, if oered, they should be
external to any CEA pot for new CEAs.
BMA
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Tavistock Square, London WC1H 9JP
bma.org.uk
© British Medical Association
20200396
BMA 2020
