THE WORKFORCE THE BEST CONFIGURATION OF HOSPITAL SERVICES FOR WALES: A REVIEW OF THE EVIDENCE. Michael Ponton, Marcus Longley and Katie Norton

THE BEST CONFIGURATION OF HOSPITAL SERVICES FOR WALES: A REVIEW OF THE EVIDENCE THE WORKFORCE Michael Ponton, Marcus Longley and Katie Norton with assistance from Amy Simpson and Susan Kimani Welsh Institute for Health and Social Care University of Glamorgan April 2012

Contents INTRODUCTION... 3 EXECUTIVE SUMMARY... 3 THE DIRECTION OF TRAVEL... 6 HEALTH POLICY AND THE WORKFORCE... 6 A CASE FOR CHANGE - THE WORKFORCE SCENARIO... 8 THE MEDICAL WORKFORCE... 9 The Future of the Medical Workforce Training Numbers... 9 The Future Consultant Workforce... 9 The Training of Surgeons... 11 The Medical Workforce in Wales... 11 Size of the Medical Workforce... 11 Distribution of the Medical Workforce... 12 Growth in the Medical Workforce... 12 Cost of the Medical Workforce... 12 Current Sickness Absence Rates... 14 Current Turnover... 14 Age Profile and Male/Female... 14 The Future Medical Workforce in Wales... 15 The Increase in Undergraduates Entering UK Medical Schools... 16 Hospital Doctors: NHS Wales... 23 Cost of the Medical Workforce... 25 Amount Spent on NHS Wales Directly Employed Medical Workforce (excludes most GPs)... 25 The likely change in future demand from NHS organisations for new staff... 25 Changes in the Number of Doctors from Different Parts of the World Directly Employed by the NHS... 26 Reductions in the Amount of Time Spent in Work per doctor... 30 FOCUS ON KEY SPECIALTIES RELATED TO FUTURE STRATEGIES... 31 Emergency Medicine... 31 Obstetrics & Gynaecology Consultants in NHS Wales... 36 Profile of the Workforce... 36 Anticipated Supply vs. Demand for new Consultants in O&G... 38 New Paediatric Consultants in NHS Wales... 41 Profile of the Workforce... 42 Anticipated Supply vs. Demand for new Consultants in Paediatrics... 43 Anaesthetics in Wales (excludes Intensive Care Medicine)... 46 Profile of the Workforce... 47 1 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Anticipated Supply vs. Demand for new Consultant Anaesthetists... 48 Psychiatry... 51 General Practice... 52 NURSING AND MIDWIFERY WORKFORCE... 53 Midwifery... 56 HEALTHCARE SCIENCE WORKFORCE... 56 ALLIED HEALTH PROFESSSIONS... 57 ADVANCED PRACTITIONERS... 58 BILBLIOGRAPHY... 59 2 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

INTRODUCTION The purpose of this paper is to explore the workforce issues related to the National case for change and the implementation of the Welsh Government s five year vision for the NHS Wales as described in Together for Health. While the discussion encompasses Nursing and Midwifery, Healthcare Scientists and the Allied Professions, the emphasis is on the medical workforce, the challenges it faces and its status as a key driver for change in the delivery and organisation of health services. EXECUTIVE SUMMARY 1. Together for Health 1 identifies medical staffing pressures as a key driver for reform and therefore the medical workforce is the main focus of this paper. 2. The reshaping and development of the healthcare workforce is fundamental to the successful implementation of the Welsh Government s vision for the NHS in Wales Together for Health 1, and is vital for the future affordability of the NHS. 3. We have an aging workforce and 20% of the medical and dental staff are over 50 years of age. If the NHS is to avoid future skill shortages, it must make the best possible use of its people and their skills. Staff will need to work differently - delivering more of the same through traditional roles and ways of delivering care is not an option. 4. New immigration rules have made overseas recruitment more difficult and the flow of doctors from the EU has also been limited. 5. The future supply and availability of medical staff is crucial to the future range, shape and organisation of health services. While there may be an increase in doctor numbers, there will also have to be a different funding model to accommodate this. The amount of money available to the NHS is unlikely to rise, and the historical rate of year-on-year growth in the workforce will not continue. 6. The current service configuration and hospital network spreads the medical resource very thinly especially at middle grade. This has been compounded by the European Working Time Directive s restrictions on working hours. In 2007 there were 2,748 junior doctors in NHS Wales with a total of 134, 206 hours worked per week. In 2011 the total number of junior doctors had risen to 2,810 but as a result of the introduction of the EWTD 48 hour week the total numbers of hours worked per week had fallen to 126,651. Therefore the average junior doctor now works 2.85 hours less per week or put another way a total of 7,555 less hours are worked every week. 7. The impact of future service models on the numbers and types of medical staff will need to be assessed to determine if they are affordable within current and future financial constraints, and can actually be staffed, given the known future supply of doctors and other professionals. 8. We are experiencing shortages of some medical staff in Wales, as well as difficulties in recruiting doctors in particular hot spots such as West and North Wales. 1 Together for Health - the five-year vision for the NHS in Wales, Welsh Government 3 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

9. The medical, education and training environment in the UK is undergoing significant change. In Wales we are not looking to increase medical school numbers. Indeed there may well be a reduction across the UK going forward. 10. Reduced numbers of training places for medical staff must inevitably lead to redesign of service delivery. 11. Recruitment in Paediatrics has been down for the last 2-3 years. There is no expectation either in Wales or the UK that this situation will be resolved in the short to medium term. This poses particular problems as there are too many paediatric inpatient units and too many medical staff rotas. We are now unable to staff the rotas in a compliant way and this is the immediate problem being faced in three of the health boards and their ability to give proper legal cover to trainees and provide them with the training and education they need. In the current recruitment round there are 11 acceptances for 20 vacancies; this clearly is a pinch point of immediate concern. The GMC survey shows that the workload for Paediatric trainees in Wales is amongst the highest in the UK and we are the lowest and second lowest in the UK for Working Time Directive compliance. The Deanery wishes to reduce the number of training sites for Paediatrics. 12. Core Surgical Training in Wales has been a long-standing problem. There is an oversupply of Core Surgical Trainees who have no hope of progressing through to higher training. This has a knock on effect, to recruitment into these posts, but the service seems to be reliant on their presence. The examination results are poor in Core Surgical Training and our competition ratios going forward into higher training are amongst the highest in the UK. The GMC survey 2 shows Wales as the worst in the UK for overall satisfaction and one of the lowest for adequate experience. The Deanery are reducing the number of Core Surgical Trainees over the next two years with the aim of bringing down competition ratios, improving the quality of the applications and reduce the number of sites that the Core Trainees will be available to work at. However, the Deanery is not reducing the higher training numbers so Wales will be producing the same number of qualified surgeons. 13. Emergency Medicine is a problem UK wide. The GMC are currently undertaking a review of the cover in Emergency Medicine in all departments across the UK. There are particular concerns around the supervision of Foundation Doctors overnight in A&E departments. The Deanery has sought to minimise this in Wales, but there is a need for an urgent review of where training is actually placed as it is spread too thinly across too many departments. Service planning suggests a similar change to trauma centres and more substantive A&Es within each of the Health Boards with different arrangements for cover at the current sites. The GMC survey shows the workload in A&Es in Wales to be the highest in the UK. This does not help recruitment as this will mean that they really are providing service as opposed to being trained. Wales is towards the bottom half in Working Time Directive compliance. This year there are half the number of middle-grade doctors in the appointments process and we have appointed to only 11 out of 20 vacancies. 14. Psychiatry training is another UK wide issue with reduced numbers across the UK, and is particularly prevalent in Wales. The Wales service model is very dated and actually does need a substantive overhaul, which is more imperative than any changes to training from the short to medium term. Again, with this specialty there are too many sites with Junior Doctors unsupervised out of hours. The Deanery will be reviewing these in the coming months and removing Junior Doctors from out-of-hours cover. This will by definition affect service delivery, but is in line with the GMC requirements. Overall satisfaction from the 2 The GMC s 2011 Trainee Survey 4 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

survey is low in Wales and so is adequate experience with poor educational supervision, again all from the GMC survey. 15. Overall with regards to examination results for the specialties of Paediatrics, Surgery and Medicine, we find that after round two of the recruitment programme candidates are poor and that high calibre candidates are not being attracted at that stage to any of the specialties. The poor exam results reflect globally on Wales, as do the higher than average competition ratios for higher training. This has a detrimental effect on recruitment to Wales. Thus, the Deanery is committed to reducing the number of sites on which training occurs with an overall small reduction in number of core trainees across relevant specialties. This should improve our compliance with the working time directive; give us robust rotas, better education supervision and better access to clinical material. More robust rotas mean improved teaching time, which hopefully will also lead to an improvement in our pass rates. 16. The GMC believe that the current Certificate of Completion of Training is not fit for purpose. If this does change then many of the current workforce assumptions will be subject to a complete review. 17. Successfully retaining qualified doctors is key to safeguarding the future supply to NHS Wales. Unless posts are made sufficiently attractive for Welsh-trained doctors to apply for, increasing the number of medical undergraduates and postgraduates is unlikely to translate into additional numbers of middle-grade and Consultant-level doctors. 18. Medical workforce planning has always presented significant challenge because of the long training time associated with training medical staff. The lead-time varies significantly by individual medical specialty. Evidence has shown that the time differs between specialties, and typically varies between 5 years (e.g. Psychiatry specialties) and 8 years (e.g. Paediatrics). This is a critical factor in the development of robust workforce plans and the assessment of the realistic possibility of the medical staff supply pipeline meeting future demand. 19. Over the past two decades the proportion of female graduates has increased and many of these will become mothers during the years of training, i.e. early 20s to late 30s. Each year in Wales, 80-100 doctors in training take maternity leave and 50% of them request less than full time training on return to work. At the current time there are approximately 203 (7.5%) of doctors in training working less than full time. This means that they take longer to complete training programmes and may be working reduced hours in a full time post, which has service implications. A 2010 Deanery research project found that 95% remain in Wales after completion of training. 20. A meaningful discussion on the number of General Practitioners needed in the future and the possible impact that changing to a 4 year training programme will have on the capacity of current practices to train. The real costs of moving to a more community based care system as this is currently impeded by the lack of transferable resources from secondary to primary care. 21. Circa 29% of Nursing and Midwifery staff in Wales are over 50 years of age, and 12% over 55 years. A key risk with any service reconfiguration may be increased attrition. Increased migration of UK trained nurses, and reductions in the recruitment of international nurses, has resulted in a net outflow of nurses from the UK. The ageing workforce poses risk to supply, particularly in community nursing. 5 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

22. A key strategic goal is to realise the maximum potential of nurses, midwives and specialist community public health nurses in order to meet, in partnership with others, the changing health needs of people in Wales. The aim is to develop existing and new roles and flexible career pathways that provide a matrix of opportunities to cross boundaries and participate in clinical practice, education, research, management and/or policy development to enhance care delivery and job satisfaction. 23. Healthcare Scientists and the Allied Professions provide important services that underpin the changes needed in the delivery and organisation of healthcare in Wales. They too face changes in the way they work. Circa 32% of Healthcare Scientists are over 50 years of age, and 17% over 55 years. Circa 22% of the Allied Professionals are over 50 years of age and 21% over 55 years. THE DIRECTION OF TRAVEL Together for Health 2011 is the five-year vision for the NHS in Wales. It is based around community services with patients at the centre, and places prevention, quality and transparency at the heart of healthcare. It outlines the challenges facing the health services and defines the Welsh Government s ambition of putting in place services best suited to Wales but comparable with the best anywhere. The factors driving the need for reform include: A rising elderly population Inequalities in health Increasing numbers of patients with chronic conditions Medical staffing pressures and Some specialist services being spread too thinly Together for Health sets out how the NHS will look in five years time, with primary and community services at the centre of delivery. It emphasises that our collective aim must now be delivery and expresses the belief that we can now make significant improvements over the next five years: Health will be better for everyone; access and patient experience will be better; and better service safety and quality will improve health outcomes. HEALTH POLICY AND THE WORKFORCE Together for Health Together for Health 1 recognises that NHS success depends from first to last on those who work for it, whether directly employed or contracted in primary care. They all have a vital role in creating safe and effective care for those who rely on its services. Most staff are aware that change is necessary. They want to see how change will bring value and benefits to the people they care for. They also need to see how they can contribute to the changes, how their voice will be heard and, importantly, how they will be enabled to work differently in a way they know will bring about better, more quality-focused services to their patients and clients. Staff representatives have an important role to play in leading the change. Effective leadership to bring about this culture change is vital. Staff need to be inspired through knowing they will have a part to play in shaping the change and in seeing early improvements based upon their contribution. Thus the specific actions to implement the vision include building strategic workforce and an organisational development framework that secures the right staff and fully supports and engages them in 6 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

delivering excellent care will be issued by spring 2012, and strengthened partnership arrangements linking the Welsh Government, the NHS and trade unions to support the creation of an NHS people will be proud to work for. Setting the Direction - Primary & Community Services Strategic Delivery Programme 3 The proposed system of care in this Programme will deliver a highly organised model of integrated community services that will act as a bridge between primary care and the acute hospital. This will enable an increasing number of people to be managed effectively in their communities and localities, avoiding unnecessary and often debilitating hospital admissions. This will be dependent on flexible working across professions and organisations to ensure that skills are utilised to maximum effect and that services meet the need of the citizen. Rural Health Plan for Wales The Welsh Government s Rural Health Plan 4 points out that some rural areas indicated difficulties in attracting and retaining appropriately trained staff at all levels and across both health and social care. It is essential that the right skills are accessible in all areas. Workforce planning will need to identify and develop opportunities to overcome barriers and ensure that flexible workforce approaches are adopted and promoted to ensure attractive and flexible work arrangements and training and education schemes are available. Within this, further consideration will also need to be given to harnessing the third sector/community workforce skills available. Developing opportunities for joint workers and other new roles and responsibilities across health and social care will enable a more diverse workforce to develop. There will be a need to take a fresh look at local health needs and align these to the necessary skills and competencies required to meet these across health and social care organisations. Specific emphasis must be given to developing a multi skilled professional and support workforce with generalist skills on the widest practicable basis amongst both health and social care workers. The role of the specialist generalist health worker as an expert within rural communities will be key, whether rural practitioners, nurses or allied health professionals. Further work is already taking place to review the role of the community nurse and their generic role in supporting core nursing needs within local communities. Being clear about core needs and co-ordinating more specialist health needs as and when necessary will be essential to good care in rural communities. Strategic Vision for Maternity Services in Wales 2011 5 Amongst the five key themes for achieving the strategic vision that directly affect the work force are the provision of a range of high quality choices of care as close to home as is safe and sustainable to do so, from midwife to consultant-led services, and the employment of a highly trained workforce able to deliver high quality, safe and effective services. Achieving this vision and its desired results will require a review of the roles of staff providing the current service, to consider opportunities for new and extended roles. It will be essential that workforce data collection and planning for education and training, comply with the current integrated process of workforce, service and financial planning reflecting new models of service provision. Education and training from pre-registration to continuing education must reflect the cultural shift in the philosophy of care, with a focus on the public health agenda, midwives as the first point of contact for women accessing services, together with clinical leadership skills to support appropriate career frameworks for all staff groups. 3 Setting the Direction - Primary & Community Services Strategic Delivery Programme, Welsh Government, 2010 4 Rural Health Plan Improving Integrated Service Delivery Across Wales, Welsh Government, 2009 5 Strategic Vision for Maternity Services in Wales, Welsh Government 2011 7 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

So, to deliver the results we want, it will be essential to plan for the whole maternity services workforce. Workforce planning must be integral to service change and financial planning, and must capture those workforce implications which may need to be addressed at an all Wales or UK level. Welsh Health Standards 6 Welsh Health Standard 24: relates to Workforce Planning and states that organisations and services should work with partners to develop an appropriately constituted and sustainable workforce by: Having effective workforce plans which are integrated with service and financial plans; Meeting the needs of the population served through an appropriate skill mix; Reflecting the demographic profile of its population; Promoting the continuous improvement of services through better ways of working; and enabling the supply of trainees, students, newly qualified staff and new recruits and their development. Welsh Health Standard 26: sets out the requirements regarding workforce training and organisational development. A CASE FOR CHANGE - THE WORKFORCE SCENARIO The Welsh Government s Working Differently Working Together - a workforce & organisational development framework 7 explains that to deliver the vision for NHS laid out Together for Health, it recognises that all staff have a vital role in creating safe and effective care for the people of Wales and in shaping the future of our services. In order to deliver this a strategic workforce and OD framework that secures the right staff and fully supports and engages them in delivering excellent care is essential. The focus of this framework is staff directly employed within the NHS but it is recognised that healthcare is delivered in partnership with other stakeholders and in particular primary care services. The framework has been developed in the context of a number of key workforce drivers for change, including: the Together for Health vision; the current shape of the workforce, age profile, cost, skills base; 1000 Lives culture surveys. It acknowledges that the NHS in Wales is working within a changing environment and in challenging times. The pressures faced by staff are very real and it is therefore all the more important that staff are supported by the very best in employment practices. The framework focuses on those key employment practices and action, which will ensure that NHS Wales has a sound platform from which to deliver the challenges of Together for Heath. NHS Wales organisations will work with staff and trade unions locally to develop a partnership which is based on: An organisational commitment to deliver: Rewarding working environment, life long learning & development, motivating work, supporting staff to deliver the care to patients they believe in, involvement in developing change, change managed well, dignity and respect for all. Staff who are: flexible in their approach to work, supporting and engaged with the vision, committed to safe, effective, efficient working practices etc. 6 Healthcare Standards for Wales: Making the Connections, Designed for Life, Welsh Government 2005 7 Working Differently Working Together - a workforce & organisation development framework, Welsh Government, 2012 8 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Partners who: Share the vision for the NHS in Wales and seek to break down boundaries. Four high level workforce and organisation development objectives have been developed to support the delivery of Together for Health, these are: Objective 1: A fully engaged workforce aligned and committed to the delivery of the Vision for NHS Wales in 2016. This objective sets out the organisation development framework for delivery that underpins the strategy Objective 2: A sustainable and skilled workforce focussed on improving health as well as treating sickness. Objective 3: A redesigned workforce that delivers one system for health and hospitals for the 21 st Century. Objective 4: A workforce that aims at excellence everywhere within available resources. Local organisational plans and programmes will deliver evidence based workforce and organisation development interventions that support change at an organisation wide, department, work group and individual level. THE MEDICAL WORKFORCE The Future of the Medical Workforce Training Numbers In their paper Shape of the medical workforce: informing medical training numbers the Centre for Workforce Intelligence 8 (CfWI) recommend that system wide agreement is reached on the current approach to allocate additional national training numbers (NTNs) beyond the agreed level of 6,500 entry-level posts. This adds to the overall stock of trainees and more Certificate of Completion of Training (CCT) holders than planned. It further recommends that all parties take a single approach in planning the future medical workforce. This will facilitate reconciling the data and a better-shared understanding of current and future risks in the system. The Future Consultant Workforce In its consultative paper for leaders within the healthcare system, Shape of the medical workforce - Starting the debate on the future consultant workforce 9, the Centre for Workforce Intelligence sets out the challenges and opportunities that employers, the medical profession and workforce planners face in relation to the future supply and shape of the consultant workforce. Looking ahead to 2020, the Centre for Workforce Intelligence (CfWI) presents possible future scenarios, the associated risks and opportunities and sets out the need for urgent debate and action. This leadership report sits alongside the CfWI paper Shape of the Medical Workforce: informing medical specialty training numbers 7, which concludes: The system should reduce supply in a range of hospital-based specialties. The current growth in general practice is not strong enough to meet the predicted need. More evidence from service commissioners and employers on service demand would enable the system to make decisions on further specialty-specific changes across the training system. The NHS currently relies on service 8 Centre for Workforce Intelligence (2011), Shape of the medical workforce: informing medical training numbers 9 Shape of the medical workforce - Starting the debate on the future consultant workforce, Centre for Workforce Intelligence, February 2012 9 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

delivery by trainees. A reduction in numbers of trainees would necessitate changes in the way services are delivered. This issue needs to be confronted if we are to continue to invest public money wisely to ensure the efficient supply of the trained doctor workforce. It is vital that an urgent debate now takes place, to reach agreement on what the system should do next. This should include discussion on the interplay between the current trainee workforce and future service requirements, in the context of what is needed to secure high-quality and highly productive care for patients. The Academy of Medical Royal Colleges report The Benefits of Consultant Delivered Care 10, examines the evidence for medical care being delivered by fully trained doctors who have either a Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR) and are thus eligible to be on the GMC Specialist Register i.e. consultant-delivered care. The report does not address the questions of whether care should be delivered by doctors or other clinical groups. The context and driver for the project is a climate in which it is increasingly asserted that the NHS cannot afford to have the number of consultants that current training numbers will deliver. The focus of the report is on the quality, outcomes and productivity of consultant-delivered care. It does not address the question of contractual terms and conditions of consultants, which should be considered separately. This report is set out in two parts. The first part is a summary of the written and oral evidence collected by the Academy of Medical Royal Colleges (the Academy) steering group regarding the benefits and difficulties with a system of consultant-delivered care. The second part comprises an externally commissioned independent review of the literature and commentary on the findings. In summary the paper says: Numerous reviews by expert clinicians have concluded that patients have increased morbidity and mortality when there is a delay in Consultant involvement in their care across a wide range of fields including acute medicine and acute surgery, emergency medicine, trauma, anaesthetics and obstetrics Data from the trainee doctors strike in New Zealand demonstrated consultant care during the strike was associated with faster patient processing and decreased hospital stay The increased mortality among patients treated in hospitals at weekends has been attributed by expert clinicians to decreased consultant involvement in care Studies designed to improve patient care, which have incorporated earlier involvement of consultants, have resulted in better patient outcomes, more efficient use of beds and decreased length of stay. In intensive care similar measures have resulted in better triage and decreased futile care. Overall, the literature shows that there is considerable internationally shared professional knowledge, expert opinion and some secondary evidence on the quality of care delivered by trained secondary care doctors which should contribute to decisions about the shape of the medical workforce. Taking what was received in submissions with the international research there is evidence across a wide range of medical fields that consultants deliver better patient outcomes and improved 10 The Academy of Medical Royal Colleges report The Benefits of Consultant Delivered Care, January 2012 10 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

efficiency of care. While this is not based on Level 1 evidence, the consistency of the association between consultant involvement and improved outcomes across many studies in many specialties is compelling. The Academy believes, therefore, that there are real evidence based benefits from moving to a system of consultantdelivered care. Therefore viewing the increased numbers of doctors coming out of training through a purely financial lens would be a significantly missed opportunity to improve the quality of care. The Academy concludes that the benefits of consultant-delivered care should be available to all patients throughout the week and recommends that work should be undertaken by clinicians and employers to map out the staffing requirements and service implications of implementing a consultant-delivered service throughout the week. The Training of Surgeons The Surgical Forum s Short Life Working Group discussion paper Training Surgeons for Future Service Requirements 11 said that there is increasing concern that surgical training is no longer "fit for purpose". This discussion paper examines some of the issues and makes recommendations for the future. The fundamental premise behind these recommendations is that it is necessary to train surgeons for the requirements of patients and society. A summary of its main points is: It is likely if the present trajectory continues, that in the future holders of a CCT, or those on the specialist register by other routes, may not all obtain traditional "consultant" posts. If society wants Surgical Healthcare to be provided on a consultant delivered basis working in multi-disciplinary teams, then we need to radically review the role and definition of a consultant. A reduction in the number of trainees is likely to stimulate redesign of service delivery to reduce the reliance on doctors "in training" by using non-medical and associated healthcare practitioners. Costs are an important influence in the decision-making process of Government or Trusts in deciding whether or not to justify consultant expansion. Many Trusts have already opted to employ non-recognised Trust grades to deliver simple surgery, thereby circumventing the rigid and restrictive training and employment regulations. Many of these posts are on short-term time-limited contracts. The EWTR will stimulate service reconfiguration of emergency services, particularly in rural areas. In future trainees will require more training after they have gained their CCT particularly if they wish to specialise. Increasing specialisation may have a deleterious effect on the provision of emergency care. The perceived inflexibility of surgical training with a single end point (consultant appointment) is no longer fit for purpose. Not all surgical procedures need to be carried out by a consultant. This has always been the case in the NHS. The Medical Workforce in Wales Size of the Medical Workforce Medical staff account for 8% of the total employed NHS workforce ie excluding primary care. NHS Wales currently employs 5,997 FTE medical staff, (6,799 heads). Consultant staff account for 2,234 FTE (37%), (2,165 heads), training grades account for 3,081 FTE (51%), (3,272 heads) and other grades account for 682 FTE (11%), (1362 heads). 11 Surgical Forum s Short Life" Working Group discussion paper Training Surgeons for Future Service Requirements " initiated by Mr David Tolley 2011 11 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Table 1: The split between Direct Clinical Care (DCC) sessions and Supporting Professional Activity (SPA) sessions has changed over recent years 2004 2010 DCC 9.3 7.9 SPA 2.2 2.5 Total Sessions 11.5 10.4 Distribution of the Medical Workforce Table 2: The organisational distribution of medical staff across Wales Health Board / Trust Population of the Health Board/ Trust Number of Medical & Dental Staff Medical & Dental Staff per 1000 people Number of Consultants Consultants per 1000 people ABMU 502,929 1319 2.62 497 0.99 Aneurin Bevan 560,409 1165 2.08 383 0.68 Betsi Cadwaladr 678,750 1285 1.89 456 0.67 Cardiff & Vale 460,843 1556 3.38 529 1.15 Cwm Taf 290,060 672 2.32 239 0.82 Hywel Dda 374,592 742 1.98 222 0.59 Powys 131,736 42 0.32 14 0.11 Wales 2,999,319 6781 2.26 2340 0.78 The average number of consultants per 1,000 head of population is 0.78; however the table above shows a wide variation across NHS Wales organisations. There are 69 medical specialties in NHS Wales in total. The largest specialties are General Medicine (8%), Anaesthetics (12%), General Surgery (7.5%), T&O (6%), and Paediatrics (7.3%) see appendix 1 for further detail. Growth in the Medical Workforce Overall size of the Hospital Medical and Dental workforce has increased by 49% (1,807 FTE) in the last decade. This is higher than other staff groups, other than the increase in Scientific Therapeutic and Technical which has increased by 59%. Within this overall growth, consultant staff have increased by 836.5 FTE (66%) 735 heads. Cost of the Medical Workforce Although the medical workforce accounts for 8% of total workforce numbers it accounts for 20% of the cost. The total medical pay bill for the 12 months to August 2011 is 472.55 million. Average earnings across all medical grades is 82.6K, with an average cost per consultant of 118K and an average cost of non consultant grades of 60K (excluding on-costs). 12 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

The overall cost is made up of basic pay and variable pay (awards, additional sessions, etc). Variable pay costs account for 24% of consultant total earnings and 27% ( 126m annually) of costs for all medical staff. Of this junior doctor band supplements account for 40m annually. Annual expenditure on all agency/locum staff was 50.14 million. Annual expenditure on medical agency/locum staff was 31.0m for the 2010/11 financial year and is predicted (based on part year costs) to rise to 54.35 million for all staff and 33.8m for medical staff for the 2011/12 financial year. Table 3: Agency analysis at Month 6 2011/12 2010/11 Full Year 2011/12 to M6 ABMU 3.282 m 2.023 m Aneurin Bevan 2.031 m 1.027 m Betsi Cadwaladr 13.351 m 7.083 m Cardiff & Vale 2.67 m 1.296 m Cwm Taf 3.977 m 2.085 m Hywel Dda 5.275 m 3.357 m Powys 0.217 m 0.062 m Public Health 0.017 m 0 m Velindre 0.146 m 0.003 m Welsh Ambulance 0 m 0 m Total 30.966 million 16.936 million Projected to year end 33.872 million Table 4: Current Vacancy Position ABM Aneurin Bevan Betsi Cadwaladr Cardiff & Vale Cwm Taf Hywel Dda Public Health Wales Velindre F1 1 0 0 0 0 1 0 0 2 F2 0 0 0 1 0 1 0 0 2 St Lower 14 1 19 1 16 3 0 0 54 St Higher 15 11 10.8 9 1 3 0 0 49.8 SAS 10 2 41.4 2 15 15 0 0 85.4 Trust Doctors 5 4 5 2 1 5 0 0 22 Consultant 3 7 26 6 6 26 0 0 74 Total 48 25 102.2 21 39 54 0 0 289.2 Est. Vacancy Rate 3.9% 2.7% 9.2% 1.7% 6.3% 8.0% 0.0% 0.0% 4.8% In total 290 vacancies reported in September 2011, circa 4.8%. Lowest vacancy levels are reported in C&V (1.7%) and AB (2.7%) The highest level of vacancies are in SAS grades 85 reported in September of which 41 FTE are in BCUHB and 15 in both CT & HD Organisations with the highest proportion of medical staff vacancies are in BCUHB (9.2%), HD (8.0%), and CT (6.3%). Total 13 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

FTE The overall fill rate for Specialty Training as at August 2011 was 85%. High risk specialties for recruitment were identified as Emergency Medicine, Paediatrics, Medicine (Core Training level 12), plus O&G, Psychiatry. Current Sickness Absence Rates Sickness Absence rates for medical staff is reported as 1.4%, although it is believed that medical staff reporting is generally under reported. Current Turnover Table 5: 12 month Medical and Dental Staff Turnover (excluding Training Grades) 12 month leaver rate Abertawe Bro Morgannwg University LHB 7.23% Aneuring Bevan LHB 5.06% Betsi Cadwaladr University LHB 8.34% Cardiff & Vale 6.37% Cwm Taf LHB 9.37% Hywel Dda LHB 10.13% Powys Teaching LHB 21.43% Public Health Wales 9.84% Velindre NHS Trust 6.06% NHS Wales 7.36% Turnover for Medical & Dental staff varies across NHS Wales from 5.06% in AB to 10.13% in HD and 21.43% in Powys Teaching LHB (NB very low numbers of medical staff in Powys distort this position). Age Profile and Male/Female Figure 1: A Profile of Medical & Dental Staff in Post 1200 Medical & Dental Staff in Post Age Profile & Gender 1000 800 600 400 200 0 Under 25 25 to 29 30 to 34 35 to 39 Male 40 to 44 45 to 49 50 to 54 Female 55 to 59 60 to 64 65 to 69 70 and over 20% of the M&D workforce is over 50, only 25% of these are female. There is a growing feminisation of the workforce. Women account for 34% in the 40-49 age band, 38% on the 30-39 age band, and 61% aged 29 or younger. This is discussed further below. 14 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

The Future Medical Workforce in Wales The Wales Deanery is to commission, quality assure and support the education and training of trainees, hospital doctors, GPs, dentists and DCPs in Wales. This includes the development of innovative models of education and training delivery, building training capacity and leading on postgraduate medical and educational research. The Deanery puts high quality training at the heart of medical careers, from the foundation doctor's first job, through to specialty training on to consultant or general practitioner. Higher specialist training includes access to a fully funded generic curriculum covering topics such as teaching, ethics, law and leadership. The National Leadership and Innovation Agency in Healthcare (NLIAH) was set up in March 2005 as a national, strategic resource to support NHS Wales in the delivery of its plans and strategies, and works with Trusts and LHBs to build organisations that are self improving and have a focus on even better quality and safety of patient care. NLIAH has specialist knowledge, skills and experience in leadership, service improvement, workforce development, governance in health and partnership working and has links within the UK and internationally with world leaders in these fields In their report Supply of and demand for doctors: What might the next few years look like in NHS Wales 13 the Wales Deanery and NLIAH summarise the best intelligence available to begin to answer the question: Is the number of newly-trained doctors available to recruit into NHS Wales likely to increase or decrease over next few years? The paper focuses on identifying broadly how many new doctors NHS Wales is likely to have available to recruit in future. It makes no assumption regarding whether Health Boards/Trusts will eventually choose to employ these doctors (which is a matter for individual NHS organisations to decide in accordance with their Service, Workforce and Financial plans). The medical workforce across the UK has seen dramatic changes over the past 5-10 years, including: A redesigned career pathway as introduced by Modernising Medical Careers. A significant expansion in the number of UK Medical School places. A significant reduction in the number of doctors coming to work in the UK from countries outside the European Economic Area (also known as International Medical Graduates ). Increases and changes to the level and type of demand for healthcare (e.g. increases in the demand for chronic disease care caused by an ageing population). Several years of record investment in the NHS, but there now exists a very different financial environment. NHS organisations strategic planning of their services and workforce (including their medical workforce) is likely to be shaped over the next 5-10 years by several key factors, including: Limited financial resources: NHS Wales could face a potential annual funding gap of 1.3bn 1.9bn by 2014 (as set out in Delivering a Five-Year Service, Workforce and Financial Framework for NHS Wales 14 ). 13 The NLIAH/Wales Deanery s report Supply of and demand for doctors: What might the next few years look like in NHS Wales - A broad overview of key trends likely to influence the future availability of newly-trained doctors in Wales, 2011 15 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

A continuation of the trend of increasing and changing levels of demand for healthcare. Demands from government, regulators and others. Vacancies and recruitment difficulties in a number of medical grades, specialties and geographical areas, but an anticipated oversupply of newly-trained doctors in certain other specialties / grades. NHS executives, clinicians, managers and planners are therefore faced with having to meet increased demand for healthcare but with a limited amount of resources. The traditional approach to meeting increasing demand for medics and/or medical recruitment shortages has been to increase the number of medics an organisation employs. However, due to the financial climate that is likely to exist in the NHS for the next few years, this may not be possible. The effect of doctors working in the independent sector has not been considered in this report, due to the fact that NHS Wales has a small independent sector. However, this may still affect the amount of doctors that NHS Wales has available to employ to some degree. The Increase in Undergraduates Entering UK Medical Schools The number of undergraduates entering UK Medical Schools has risen continually since at least the 1960s (see the chart below). Figure 2: UK medical school intake, 1960 present, by gender 15 However, the pace of this increase visibly accelerated from the late 1990s onwards. This was the result of a decision by the UK government to significantly increase the number of UK Medical School places. This was done both in response to a forecast increase in the number of doctors needed in the UK during 1997-2017 (due to the impact of 14 Delivering a Five-Year Service, Workforce and Financial Strategic Framework for NHS Wales, Welsh Government 2010 15 Webster R, Mellor D, Spavin B. Who are the doctors of tomorrow and what will they do? 9th Conference of the International Medical Workforce Collaborative, Melbourne, November 2005. 16 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

the EWTD etc) and a desire not to see further decreases in the proportion of UK-trained doctors in the UK s medical workforce. The chart below provide a more detailed picture of the growth in Medical School intake during 1998-2009, both in Wales and in the UK as a whole. Figure 3: UK Medical School Intake (1998-2009) The chart above show that: The number of undergraduates in their first year of Medical School in Wales increased by 103% (206 students) between July 1998 and July 2009. All the UK s Home Nations experienced increases in their Medical School intakes during 1998-2009. Wales showed the fastest rate of growth of any of the Home Nations during 1998-2009 (103%). This compared to growth of 73% in England, 40% in Northern Ireland and 5% in Scotland. The growth across the UK as a whole was 60%. Consequently, Wales has increased its share of the UK s Medical undergraduates. As at July 2009, 5% of the UK s first year medical undergraduates were studying in Welsh Medical Schools. This compares to only 3.9% in July 1998. At a UK level, Medical School intake increased dramatically during 2001-2005 (40%). However, it then levelled out and has remained relatively static from 2005 onwards (with growth of only 3% during 2005-2009). The dramatic growth in Welsh Medical School intake during 2001-2005 (46%) was similar to that experienced at a UK level. However, unlike the UK as a whole, intake to Welsh Medical Schools continued to rise significantly during 2005-2009. The number of medical students still at Medical School at the end of their first year is used in this report rather than the number who enrol at the beginning of their first year. This is designed to prevent distortion of the figures caused by any students leaving Medical School shortly after starting their first year. 17 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

It is clear from the above data that there is at least a 10-year trend of year-on-year increases in the number of UK/Welsh medical school undergraduates. If sufficient postgraduate training places are made available to accommodate these increases, this will translate into a corresponding later period (of at least 10-years duration), which would see a year-on-year increase in the number of UK-trained doctors available for the NHS to employ. The table below illustrates broadly how the increases in UK Medical School intakes that took place from 1998/1990 onwards might translate into extra numbers of newly qualified doctors available for recruitment into the NHS. Table 6: Broad indication of how the additional UK Medical School places might translate into doctors available to enter the NHS workforce7. (N.B. (Shaded boxes = the date occurs in past. Therefore, at least some doctors from this cohort should by now already be in the NHS workforce). * Please note: The dates given above are designed only to give a broad sense of timescales, and will not be applicable to all doctors/specialties. They are based on a full-time student completing a traditional 5-year Medical, the 2-year Foundation Programme, then a 6-year Specialty Training programme without repeating a year or taking any time out of programme. Not all doctors will follow this career path, and this will alter the date they can enter each stage. In particular, students undertaking the accelerate 4-year Graduate Entry medical degree at Swansea will graduate a year ahead of a student completing a traditional 5-year medical degree, and so could enter each postgraduate training stage a year earlier than suggested above. The duration of Specialty Training also varies by specialty. The Medical School Intake figure would not translate directly into the number of doctors available to recruit into the NHS. A reduction would take place between the two due to a number of factors (e.g. student/trainee attrition, migration of medical graduates & doctors into/out of Wales, insufficient postgraduate training places to allow the entire cohort to progress directly to the next stage of training, students/doctors taking time out of programme, repeating a year or moving outside the training programme). 18 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

NHS organisations would have seen these extra medical students enter their workforce at Core Specialty Training level (broadly equivalent to the old Senior House Officer grade) from 2004 onwards, and at Higher Specialty Training level (equivalent to a Registrar or Specialist Registrar) from 2006 onwards. Similarly, the extra medical students would have started to complete GP training from 2007 onwards. The additional medical students will have started to be eligible for Consultant posts from around 2016 onwards. Broadly speaking, doctors who entered Medical School during 2000/2001-2004/05 (i.e. during the period of fastest growth in UK Medical School intake), could be expected to enter Core Specialist Training during c.2007-2011+, Higher Specialist Training from 2009-2013+, and Consultant posts from around 2013 onwards. The number of specialties or geographical areas that are currently experiencing recruitment difficulties to Junior Doctor and middle grade-level posts shown in the table below. Table 7: Specialties reported by NHS Wales as being difficult to recruit to in Health Boards /Trusts 2010 Workforce Plans Group A Group (4-6 Welsh Health Boards / Trusts reported recruitment difficulties in 2009/10) No. and names of organisations affected 6 (ABM, AB, BCU, C&V, CwmT, HDda) 6 (ABM, AB, C&V, CwmT, HDda, Powys) 6 (ABM, BCU, C&V, CwmT, HDda, Powys) Speciality Grades affected 16 Also a shortage speciality at UK level (consultant grade) ABM=middle grade (training grades) AB=All grades BCU=Consultants and staff grades C&V=Junior doctors A&E CwmT=Junior Yes doctors and nontraining equivalents HDda=Consultants, Speciality doctors, Core Training Grades (CT2 & CT3) ABM=Consultant (Community Paeds), Junior Doctors AB= middle grades C&V=Junior Doctors CwmT=Higher Training Grades Paediatrics HDda=Consultants, Yes Speciality Doctors, Core Speciality Training Grades (ST1 & FTSTA1 17 ) Powys=Consultants (Community Paeds), Associate Speciallists Mental Health / CAMHS 18 (providing further AB= junior, senior and locum grades BCU=Consultants Yes speciality breakdown C&V=Junior Doctors 19 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Group B Group No. and names of organisations affected (&ABM reports Speciality Doctor shortages in Substance Misuse) 3-4 (C&V, CwmT, HDda, ABM) 4 (BCU, CwmT, HDda, Velindre) 3 (C&V, CwmT, HDda) 3 (ABM, CwmT, HDda) 3 (CwmT, HDda, PHW) 3 (ABM, AB, HDda) 3 (ABM, CwmT, AB) Speciality Grades affected 16 Also a shortage speciality at UK level (consultant grade) not possible from data received could be up to 6 different specialities) T&O Surgery CwmT=Consultants, Speciality Doctors and junior Doctors HDda=Consultants, middle grade, Core training (CT1) Powys=Consultants, Associate Specialities C&V and CwmT=Junior Doctors HDda=Speciality Doctors ABM also notes Junior Doctors in Musco-Skeletal 20 The Best Configuration of Hospital Services for Wales: A Review of the Evidence: Yes Clinical Radiology Consultants No Medicine (more detail of speciality not given in some workforce plans. Most likely refers to general medicine and/or core Medical Training, but also could mean all Medicine specialities) Anaesthetics C&V=Junior Doctors CwmT=Junior Doctors & Speciality Doctors HDda=Speciality Doctors and Core Medical Training (CT1) ABM=registrar, Staff Grades, Junior Doctor CwmT=Consultants (intensivists) HDda=Speciality doctors & Core Training Grades (CT1 level) N/A (specific speciality unclear) Yes Microbiology Consultants Yes Obs and Gynae Oral and Maxillo- Facial Surgery ABM=Junior Doctors AB=SAS Doctors HDda=Speciality Doctors ABM=Junior Doctors CwmT= & AB=Consultants (Maxillo-facial Surgery only) Yes Was in 2008 but removed in Spring 2009

Group C Group No. and names of organisations affected 2 (CwmT, Powys) 2 (ABM, CwmT) 2 (CwmT, HDda) 2 (HDda, AB) 2 (ABM, CwmT) 2 (CwmT, HDda) 2 (CwmT, HDda) 2 (ABM, AB) Speciality Grades affected 16 Also a shortage speciality at UK level (consultant grade) CwmT=Speciality Geriatric Medicine Doctors Powys=Consultants, No Associate Specialists ABM=Junior Doctors GUM/ Sexual Health CwmT=Speciality Yes Doctors Cwm T=Consultants, Palliative Medicine Speciality Doctors HDda=Higher No Training Grade (ST3) Surgery (more detail of speciality not given in some Workforce plans) Most likely to refers to General Surgery, but also could mean all surgical specialities) General Surgery Urology Ophthalmology Pathology / All (Pathology) Disciplines HDda= Speciality Training Grades AB= Middle Grades (but did not specify whether this included training and / or non training grades) ABM=Training Grades (Core & Higher Levels) CwmT=Junior Doctors CwmT=Speciality Doctors & Junior Doctors HDda=Speciality Doctors CwmT=Consultant HDda=Speciality Doctors & Training Grades AB= Middle Grades (not specified whether this includes training and / or non training grades. Also Pathology stated not specified whether this refers to General Pathology or all Pathology Specialities ) ABM notes All (Pathology) Disciplines (Consultant level) N/A (Specific speciality unclear) 21 The Best Configuration of Hospital Services for Wales: A Review of the Evidence: Yes No No No

Group No. and names of organisations affected 2 (CwmT, HDda) 2 (CwmT, HDda) 2 (HDda, BCU) 2 (ABM, HDda) Speciality Grades affected 16 Also a shortage speciality at UK level (consultant grade) CwmT & HDda=Consultants Haematology HDda=Higher Yes Training Grade (ST3 level) Histopathology Consultants Yes Clinical Oncology Old Age Psychiatry HDda=Higher Training Grade (ST3 level) BCU=Consultant ABM=Junior Doctors HDda= Speciality Doctor 1 ABM Vascular Surgery Junior Doctors No 1 HDda Immunology Consultant Yes Group D 1 Specific Training Neurology HDda Grades (ST3, FTSTA) Yes 1 Junior Non Training Neurosurgery ABM Grades No 1 BCU Orhtodontics Consultant Yes 16 Junior Doctors is assumed to refer to doctors in training at Core Specialty Training level 17 FTSTA = Fixed Term Specialty Training Appointments 18 CAMHS = Child & Adolescent Mental Health Services Was in 208 but removed in Spring 2009 Abbreviations used for Health Boards/Trusts: ABM =Abertawe Bro Morgannwg; AB=Aneurin Bevan; BCU=Betsi Cadwaladr; C&V=Cardiff & Vale; CwmT=Cwm Taf; HDda=Hywel Dda; PHW=Public Health Wales The increase in UK-trained doctors produced as a result of UK Medical School expansion therefore does not (at least so far) appear to be translating into sufficient numbers of doctors being appointed to these specialties/areas. This is based on the assumption that Core Specialist Training lasts 2 years, and Higher Specialty Training lasts 4 years. However, these timescales vary between different specialties. Yes The previous increases in the number of doctors employed by the NHS The NHS (both in Wales and the UK) has historically shown an underlying trend of year-on-year growth in its workforce. The UK picture is shown in the chart below. 22 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Figure 4: Total UK NHS Staff 1951-2006 (Full Time Equivalent * FTE ) 8 Sixty years of NHS expenditure and workforce. The medical & dental workforce has seen particularly robust growth during this period (697%) compared to the NHS workforce as a whole (292%). The chart below illustrates the growth in the UK s medical & dental workforce. Figure 5: Medical & Dental staff employed in UK NHS hospitals & community services 1951-2006(FTE) Hospital Doctors: NHS Wales As the chart below shows, the number of hospital doctors employed by NHS Wales increased by 2,800 (115%) during 1990-2009 (FTE). The rate of growth significantly accelerated during 2003-2007, but appears to have slowed considerably between 2007-2009. Given the scale of the potential funding gap that NHS Wales may face during 2010-2015 (as set out in Delivering a Five-Year Service, Workforce and Financial Framework for NHS Wales ), it is unlikely that the next five years will see a continuation of the significant increases in medical staffing that occurred during much of the 2000s. 23 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

N.B. this apparent slowing down only covers 2-3 years worth of data, and so there are insufficient data points to establish whether or not it is a true trend. Figure 6: The number of hospital doctors directly employed by NHS Wales: 1990-2009 Please note: Much of the increase in the Registrar Group and corresponding decrease in the Senior House Officer data lines is due to the converting of posts from one grade to another following the introduction of Modernising Medical Careers The total number of GPs in Wales has also increased over the past few decades, albeit at a slower rate than the number of hospital doctors. The number of GPs in Wales rose by around 20% during 1990-2009 (Headcount)11. The increase in Wales over the period 2000-2009 was 8%. This compares to a rise in England of around28%. Figure 7: GP Headcount by type) in Wales 24 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Cost of the Medical Workforce The amount spent on NHS Wales directly employed (hospital) medical workforce increased by 69% between 2002/03-2007/8. The grade showing the biggest increase in spend during this period was the consultant grade (94% increase). The tables below provide detailed data on medical staffing spend. Equivalent data for GPs (excluding those directly employed by Health Boards or Trusts) is not available. Amount Spent on NHS Wales Directly Employed Medical Workforce (excludes most GPs) NHS Wales has experienced a sustained growth in its medical staffing budgets in recent years, as shown below (source: NHS Wales Annual Accounts). The medical workforce only increased by 35% (FTE) during 2003-2008. These figures suggest that medical staff have generally become more expensive per person to employ. This may be due to the new pay deals introduced during this period, as well as to the increased percentage of consultants in NHS Wales medical workforce. The likely change in future demand from NHS organisations for new staff Key points from the discussion below: From the information submitted by Health Boards and Trusts in their 2010 Workforce Plans, the most likely pattern for NHS Wales overall medical workforce over the next five years is to remain broadly at the 2009 level (or even decrease), before resuming the historical pattern of growth. If this does occur, then an oversupply of new consultant-level doctors ( CCT holders ) would be created in a number of specialties. As discussed above, the NHS shows a strong historical trend of year-on-year increases in the size of its medical workforce. However, the strong growth in NHS Wales directly employed medical workforce seen throughout most of the last decade may have moved to a more a static position. The data from NHS Wales Health Boards/Trusts 2010 Workforce Plans supports this possibility. In their plans (as at March 2010), Health Boards and Trusts anticipated maintaining a relatively static medical workforce during 2010-2016. Across the medical workforce as a whole (i.e. all specialties combined), Health Boards/Trusts anticipated a growth of 64FTE during 2010-2016 (which is equivalent to a 1% growth over this period). This is illustrated in the yellow bars in the chart below (while the blue bars illustrate the historical growth). (Data not available for 2006). 25 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Figure 8: Future medical workforce size anticipated by NHS Wales Health Board/Trusts:(2010-2016) (source: NHS Census [blue] & NHS 2010 Workforce Plans [yellow]) The figures submitted in the 2010 Workforce Plans did not generally take into account either the Service Plans currently being developed by Health Boards/Trusts, nor the staffing implications of responding to the significant potential funding gap outlined in the Welsh Assembly Government s Delivering a Five-Year Service, Workforce and Financial Framework for NHS Wales 15. This Framework noted that NHS Wales could face a potential annual funding gap between 1.3bn and 1.9bn by 2014-15 if steps are not taken now to change the way in which care is delivered. It is possible, therefore, that future demand for staff (including doctors) may decline somewhat over the next few years, before resuming its historical pattern of growth. Having said that, it is worth noting that, unlike some other NHS staff groups, the number of doctors employed by NHS Wales did not fall during the last recession in the early 1990s. If Health Boards/Trusts were to choose to maintain historical rates of growth, then they would need to find the significant additional cost of doing this from other parts of their budget. Pursing this course of action in a climate where organisations may face a 4% year-on-year reduction in annual funding would be extremely challenging. From the above information, the most likely pattern for NHS Wales overall medical workforce over the next five years would be a period where medical staffing numbers either remain broadly at the 2009 level or decrease, before resuming their historical pattern of growth. If this potential future growth does occur, then this would create an oversupply of new consultant-level doctors ( CCT holders ) in a significant number of specialties. Further modelling work is being undertaken to quantify the likely degree of such an oversupply. Work is also underway to model any likely oversupply/undersupply if NHS organisations were to decide that they can maintain historical rates of medical workforce growth in individual specialties. A 4% annual reduction is the most severe scenario considered by Delivering a Five-Year Service, Workforce and Financial Framework for NHS Wales 15. Changes in the Number of Doctors from Different Parts of the World Directly Employed by the NHS Please note: There is very little data available on the rate of migration of doctors into/out of NHS Wales. Migration into/out of NHS England is therefore used as a proxy. Also the discussion below gives data according to from which global region a doctor obtained his/her Primary Medical Qualification (usually the undergraduate medical degree). This is used here as a proxy for which global region a doctor comes from. 26 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

As discussed earlier in this paper, the number of doctors directly employed by NHS England increased by 49% during 1999-2009. The chart below shows that the number of these doctors who obtained their Primary Medical Qualification (PMQ) in each of the following geographical areas increased during this period: i) From within the UK ii) From outside the UK but within the European Economic Area (EEA) iii) From outside the EEA Figure 9: Number of doctors directly employed by NHS England arranged according to the location of their PMQ (source: NHS Information Centre) Although the numbers of doctors in each of these three categories increased during 1999-2009, they did so at different rates (which also varied across time). The chart below shows that, although the number of doctors employed by NHS England who had obtained their PMQ in the UK increased during 1999-2005, the proportion of NHS England s doctors in this category actually fell during this period. In comparison, the proportion who had obtained their PMQ outside the EEA consistently increased. This was a continuation of trend that was also visible during the mid-1990s, and was a major factor that had contributed to the UK government s decision in 1998 to significantly increase the undergraduate intake to UK Medical Schools. Since 2005, however, that trend has reversed. The proportion of NHS England s doctors who obtained their PMQ outside the EEA has fallen, while the proportion who obtained it in the UK has increased. While the proportion of NHS England s doctors who obtained their PMQ outside the EEA decreased during 2005-09, the actual number of these doctors in post still increased slightly during this period. 27 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Figure 10: Percentage of doctors directly employed by NHS England who obtained their primary medical qualification in different geographical areas There are also clear differences between different grades, as shown in the charts below. Key points to note include: i) The number of Consultants who obtained their PMQ in the UK increased every year during 1999-2009. The total increase during this period was 40%. The number of Consultants who obtained their PMQ outside the EEA also increased during this period, although at a faster rate (with a total increase of 133% during 1999-2009). ii) The number of Non-Consultant Career Grade doctors (e.g. Staff Grades, Associate Specialists and Specialty Doctors) who obtained their PMQ in the UK generally increased during 1999-2009. The total increase during this period was 83%. The number of Non-Consultant Career Grade doctors who obtained this qualification outside the EEA also increased at a similar rate during this period (total increase of 84% during 1999-2009). iii) The number of training grade doctors who obtained PMQ in the UK generally increased during 1999-2009 (total increase of 29% during this period). However, the picture of relating to training grade doctors who obtained their PMQ outside the EEA is slightly different. Their numbers increased significantly within NHS England during 2001-2005 (a rise equivalent to 97% of the 1999 staffing level). However, their numbers then decreased during 2005-2009 (a fall equivalent to 35% of the 1999 level). iv) The number of Foundation doctors in NHS England increased significantly during 2005-2009 (a rise equivalent to 217% of the 1999 level, or 166% of the 2005 level). The rate of increase of Foundation doctors from UK Medical Schools during this period (182% of the 2005 level) was greater than the rate of increase in those from Medical Schools outside the EEA (80% of the 2005 level). 28 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Figure 11: Number of doctors directly employed by NHS England who obtained their primary medical qualification in the UK (Scale: up to 30,000) (Headcount) Figure 12: Number of doctors directly employed by NHS England who obtained their primary medical qualification outside the European Economic Area (Scale: up to 16,000) (Headcount) *Includes the House Officer grade 29 The Best Configuration of Hospital Services for Wales: A Review of the Evidence:

Figure 13: Number of doctors directly employed by NHS England who obtained their primary medical qualification outside the UK but within the European Economic Area (Scale: up to 3,000) (Headcount) Reductions in the Amount of Time Spent in Work per doctor Although the number of doctors in the workforce has increased over recent years, not all the additional doctors produced can be used to treat additional numbers of patients. Many of the additional doctors trained have been required to: i) Compensate for the reduction in the number of hours that many doctors work following the implementation of the European Working Time Directive ( EWTD ). ii) Mitigate the effect of changing working patterns amongst many doctors, most notably an increase in less than full time working. iii) The impact of the European Working Time Directive on the number of staff required. The EWTD came into effect in the UK in 1998, limiting the number of hours that UK workers (including doctors) can work. While the Directive applied to Consultants and other career grade doctors from the outset, its effect on training grade doctors was phased in more gradually, coming into full effect in 2009. Although there are some exceptions, the EWTD has generally reduced the number of hours worked by doctors in the UK to around 48 hours per week. It is clear that, prior to the EWTD, many doctors were working far in excess of 48 hours per week. Therefore, a significant reduction in the number of hours that many doctors work took place between 1998-2009. The number of additional doctors required to compensate for the effects of EWTD is unclear. It is not possible to calculate the number of hours/sessions worked by existing doctors prior to EWTD that were no longer able to be worked by those individuals (and so needed to be worked by additional numbers of new doctors). This is primarily due to the way workforce statistics have historically been recorded. iv. The impact of doctors changing working patterns on the number of staff required. 30 The Best Configuration of Hospital Services for Wales: A Review of the Evidence: