GASTROENTEROLOGY WORKFORCE REPORT, Dec 13 (May 2014 update)

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1 GASTROENTEROLOGY WORKFORCE REPORT, Dec 13 (May 2014 update) Chris Romaya & Melanie Lockett Key points There are 1289 UK gastroenterologists, a 2.7% expansion from The average expansion for the last 10 years has been 5.0%/year (range: 2.3% 7.1%). The RCP document Consultant physicians working for patients in 2011 predicted that we need 6 whole time equivalent (WTE) consultants in gastroenterology (with GIM) all working 11.5 PAs per week per 250,000 population. For the current UK population of 63,181,775 (2011 national census) this is a total of 1516 WTE, or an additional 227 WTE. If we assume that the number of less than whole time (LTWT) consultants (anyone working <10PAs) will stay at 11% and they will work 7 PAs on average this gives a total of 1584 consultants (295 more). If the proportion of LTWT consultants rises to 30% (as it is predicted to do due to increased feminisation of the workforce) then 1718 consultants would be required (429 more). Trainees have been enrolled to fill posts based on 6.5% expansion over the next 6 years, or 576 new posts, plus the predicted 170 retirement posts (746 posts in total). In the last 4 years 4 NTNs have been lost in England, but 1 has been gained in Scotland & 2 in Northern Ireland, so overall there has been a loss of 1 NTN in the UK. ~100 CCTs in excess of retirements are predicted each year for the next 5 years (mean training time 6 years). 130 substantive posts were advertised in the last year, but 36% were not filled, especially in the north of the UK. The number of trainees >6 months post CCT (78) is 6% lower than the previous year. There are several drivers for Gastroenterology expansion: flexible sigmoidoscopy screening, 7 day working, management of UGI bleeding, increasing hepatology burden and an aging population (who are high users of gastroenterology services) will increase the number of gastroenterologists needed. However in this austere financial climate Trusts may choose to meet this service demand by a reduction in GIM commitment of the specialty. Changes to the NHS pension scheme in 2015 may link usual retirement age (currently 60 for most) to State Pension age (increasing to 66 in ). If this occurs there will be a 6 year retirement vacuum leading to an excess of CCT holders over jobs in 13 years when protection arrangements cease.

2 Consultant gastroenterologists There are currently (at ) 1289 substantive gastroenterology consultants in the UK, an increase of 2.7% from In addition on the there were 31 locum consultants (28 in England, 2 in Northern Ireland, 1 in Scotland and 0 in Wales). 23 of these posts were filled by UK CCT holders, 1 by an Irish CCT holder and 7 by doctors trained abroad. The individuals had been in post ranging from 1 month to 6 years. The 24 UK & Irish CCT holders working as locum consultants are counted as trainees for the purposes of this report. The 7 locum consultants from overseas are not included further in this report. Table 1: Number of consultants in different parts of the UK 30/9/5 30/9/6 30/9/7 30/9/8 30/9/9 30/9/10 30/9/11 30/9/12 30/09/13 01/05/14 England Wales Scotland Northern Ireland Total Consultant expansion Table 2: Annual expansion (%) of consultants in different parts of the UK by year 30/9/5 30/9/6 30/9/7 30/9/8 30/9/9 30/9/10 30/9/11 30/9/12 30/09/13 01/05/14 England Wales Scotland Northern Ireland Total

3 Figure 1: Annual expansion (%) of UK consultants by year n5 sio a n 4 x p e % Year Over the last 10 years the mean annual % expansion has been 5.0 % per year (Table 2 & figure 1). Expansion was running at 6 7% until 2005, dropped to 2.3 % in 2006 and 3.9% in It increased to 6.9% in 2010, attributable to financially supported recruitment driven by national bowel cancer screening and other political targets e.g. the '18 week pathway'. It dropped to 3.5 & 3.4% in 2011 & 2012 as NHS resources were reduced during the UK recession, but increased to 5.4% in 2013 attributable to financially supported recruitment driven by bowel scope, as well as Trusts expanding Gastroenterology services as they move towards 7 day working. 47 substantive consultant posts were advertised in 2013 but not filled. If all advertised posts had been filled there would have been a 9.3% consultant expansion in Fig 2: Graph of predicted WTE consultant expansion at 3%, 5% and 7%

4 The RCP document Consultant physicians working for patients in 2011 predicted that we need 6 whole time equivalent (WTE) consultants in Gastroenterology (with GIM) all working 11.5 PAs per week per 250,000 population. For the current UK population of 63,181,775 (office for national statistics (ONS) population census 2011) this is a total of 1516 WTE, or an additional 227 WTE. With consultant expansion at 7% this would take 2 3 years to achieve, with consultant expansion at 5% 3 4 years, and with consultant expansion at 3% it would take 5 6 years to achieve. If we assume that the number of less than whole time (LTWT) consultants (anyone working <10PAs) will remain at 11%, and they will work 7 PAs on average, this gives a total of 1584 consultants or 295 more new consultants over and above retirement replacements. This would be achievable in 3 4 years if expansion is at 7%, 4 5 years if expansion is at 5% and 7 years if expansion is at 3% (figure 2). If we assume that the number of LTWT consultants working 7 PAs on average increases to 30% (as the proportion of females and number of returning retired consultants increases) this would mean we would need a total of 1718 consultants or 429 more. This would be achievable in 4 5 years if expansion is at 7%, 5 6 years if expansion is at 5% and 9 10 years if expansion is at 3%. The ONS predicts that the UK population will increase to 68.0 million by This would require 1632 WTEs (343 more) or 1705 with 11% LTWT (416 more) or 1849 with 30% LTWT (560 more). The number of training posts has been set to a level that produces an average output of 100 CCT holders per year in excess of retirements over the next 6 years. This is sufficient to enable an average consultant expansion rate of 7% over the next 6 years. There are 687 specialist registrars in training, approximately 35% of whom are female. There are likely to be approximately 170 retirements over the next 7 years leaving 517 trainees to take up new posts. If the average training time continues at 6 years, then there are sufficient trainees already in place to meet a 5.8% per year expansion target. If expansion is

5 less than this then the number of CCT holders will rise. Since 2011 there have been further drivers to expand gastroenterology services (including Bowel scope & 7 day consultant present care) which are not included in the RCP predicted figures. Gender On (83%) of substantive gastroenterology consultants were male, and 209 (17%) female. The proportion of female gastroenterology consultants has increased compared to 2012 (15% female, 85% male). Across all medical specialties 32.1% consultants are female (RCP census 2012). Figure 3 illustrates the percentage of female consultants in different age ranges. 27% of year olds are female compared to 7% of year olds. Fig 3: Age/gender distribution of consultants: age groups & percentage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 34 & younger & older unknown Age range (years) Female Male

6 35% of trainee gastroenterologists are female (47% of trainees in all medical specialties are female). In % of people accepted for medical school, 62% of Foundation programme trainees and 49% of specialty trainees were female. The RCP predicts that the number of female doctors will outnumber men sometime between 2017 and Age of consultants Figure 4 shows the age & sex distribution of substantive consultant Gastroenterologists in the UK. The majority of the consultants are within the age group. Retirements There have been 12 substantive consultants who have vacated their posts between 1 st Oct 2012 and 30 th Sept have retired (1 has gone on to take up a management role post retirement), 2 have moved abroad, 1 has taken up a full time management role, 1 has died. Of the 8 retirements, the mean retirement age has fallen from 63 years in 2012 to 61 years in 2013 (range years). This may have been because of the reduction in the pension lifetime allowance to 1.5 million in There are 14 substantive consultants (all male) who have taken their pension but continue to work as consultants ranging in age from 56 to 67 years (mean 64 years). Information on PAs worked was available for 13; 7 (54%) work less than 10 PAs and 6 (46%) work 10 or more PAs. Table 3: Number of consultant reaching retirement age in the next 10 years Numbers at 30/09/13 England Wales Scotland N Ireland Totals >60 years at Reaching 60 or more in the next 10 years There are currently 99 consultants in the UK aged 60 years or more. In addition there are 345 consultants reaching the age of 60 over the next 10 years or a total of 444 consultants.

7 This is an average of 44 retirements per year if the average age of retirement reduces to 60 (which it might as the pension life time allowance reduces again to 1.25 million in April 2014). There are 536 consultants in the years age group, therefore in 10 years the average number of retirements per year may increase to 54.

8 Fig 4: Age/gender distribution of substantive consultants: numbers lt ants su n 80 c o f o r e 60 b m u N 40 Female Male Age (years) n w o k n n U

9 Acute medicine/gastroenterology: 14 consultants are working within acute medicine and gastroenterology, a 56% increase on On call for endoscopy: 1173 (81%) of those who answered this question have some sort of endoscopy on call rota, ranging from 1:1 to 1:52 on call frequency. 20 (1.4%) have an ad hoc/goodwill rota. 6% of consultants giving information no longer take part in a GIM on call but this question was only answered by 169 consultants (13%) so may not be accurate. From RCP data 64% of hepatologists are not committed to GIM. Academics Of the 918 consultants who answered the question, 112 (12%) described themselves as academics and 17 (15%) of these academics were female. 34 were professors, 4 associate professors 39 senior lecturers, 5 lecturers and 5 readers. The majority (71, 63%) were specialising in gastroenterology with GIM, 8 (7%) were just doing pure gastroenterology, 29 (26%) had a hepatology interest (19 hepatology, 6 hepatology & gastroenterology, 4 hepatology, gastroenterology & GIM); there were 2 gastro epidemiologists & 2 neurogastroenterologists. In addition there were 10 consultants who did not describe themselves as academic who were professors, senior lecturers, readers or clinical teachers. PAs Gastroenterology consultants are contracted for an average of 10.8 PAs, median 11 PAs, mode 12 PAS. Fig 5: Distribution of PAs paid Distribution of gastroenterologists nationally

10 Less than whole time (LTWT) appointments Details of total contracted PAs were available for 847 of the 1255 consultants (67%). 90 are contracted for <10 PAs in total (11% of respondents for this question). The LTWTE work 6.6 PAs on average (median 7 PAs, range 0 9 PAs). Of the LTWTEs, 47 (52%) are female. There has been a significant increase in male LTWTEs, many of whom are recently retired and returning to work part time, or those taking an increasing role in management. This has been seen in other medical specialties. Regional variations Table 4: Distribution of substantive gastroenterology consultants by SHA SHA Pop (1,000s) for 2011 No. cons 30/9/12 No. cons 30/9/13 % change Population served by 1 consultant North East ,625 London ,298 Scotland ,403 North West ,636 South West ,429 West Midlands ,016 Northern Ireland ,739 East of England ,139 Yorkshire & the , Humber Wales ,699 East Midlands ,873 South East Coast/South Central ,078 UK ,344 Population statistics 2011: Office for national statistics population census census/population and household estimatesfor the united kingdom/stb 2011 census population estimates for the unitedkingdom.html (accessed Mar 2014).

11 The RCP document Consultant physicians working for patients in 2011 predicted that we need 69 PAs per week or 6 whole time equivalent (WTE) consultants in Gastroenterology (with GIM) all working 11.5 PAs per week per 250,000 population. For the current UK population of 63,181,775 this is a total of 1516 WTE. Therefore ideally 1 WTE consultant should serve a population of 41,677. The average gastroenterologist in the UK currently serves a population of 50,344. In England the average is 50,296, in Wales there is one consultant per 55,699 population, in Northern Ireland one per 51,739 population and in Scotland one per 47,403. There continues to be significant variation across England; South Coast/South Central having among the highest populations per gastroenterologist (69,078) and the North East the lowest (34,625). Only the North East & London meet the RCP recommendation of number of gastroenterologists for the population served. Single handed gastroenterologists There are 16 consultants working alone, 15 of whom have nearby hospitals, 1 is working on an island. Non consultant career grades (NCCGs), GPs & other consultants There are 333 in total, of which there are 219 medical NCCGs, 52 GPs, 31 other consultants, 30 surgical NCCGS, & 1 scientist: 74 associate specialists 61 staff grades 52 GPs working 45 of whom provide 0.5 to 3 endoscopy sessions per week (median 1 session). 32 hospital practitioners 30 consultants from other specialties (e.g. care of the elderly, radiology) contributing to gastroenterology 28 clinical assistants 25 trust doctors 1 honorary consultant 1 clinical scientist The above work 0 7 endoscopy sessions per week, median 1 session Compared to last year, there has been a reduction in the number of associate

12 specialists & an increase in the number of trust doctors. Nurses in gastroenterology There are currently 891 specialist nurses working in clinical gastroenterology within the UK, an increase of 23 (2.6%) compared to last year. This does not include specialist screening practitioners (SSPs) or stoma nurses where accurate numbers are not known from this survey. There are: 316 nurse endoscopists/nurses performing > 1 session endoscopy / week, a 9.3% increase compared to IBD nurses 134 hepatology nurses 69 cancer nurses 50 nutrition nurses 20 alcohol nurses 7 PEG nurses 7 physiology nurses 3 IBS nurses 3 dyspepsia nurses 2 IDA nurses 1 pre assessment nurse 78 nurses whose role was not specified 23 nurses with more than 1 role (not included in the above) 16 research nurses Within these groups there are: 329 Nurse practitioners 16 Nurse consultants Surgeons in gastroenterology There are 1287 GI surgeons in the UK contributing to service provision. 485 perform sessions (median 1) per week of OGD, 740 perform (median 1) sessions per week of lower GI endoscopy and 73 perform sessions (median 1) per week of ERCP.

13 Trainees in gastroenterology On there were 784 gastroenterology trainees in the UK, a reduction of 22 (2.7%) on 2012: 387 NTNs in hospital posts 171 trainees out of programme (127 OOPR (5 LTWT), 17 OOPC (4 LTWT), 16 OOPE (1 LTWT), 8 OOPT (3 acting up, 1 ATP), 3 OOP). 58 LATs 44 trainees holding academic training numbers (23 clinical fellows (1 LTWT), 6 lecturers, 14 in research, 1 CT2,, 1 in advanced training programme (ATP)) 29 clinical fellows (12 without an NTN) 25 LTWT trainees in clinical posts (1 VTN) 24 locum consultants (4 LTWT, 1 VTN) 10 VTNs (3 post CCT, 4 OOPR) 9 lecturers without an academic NTN 6 CESRs 7 ATPs (an underestimate) 7 post CCT fellows 2 locum appointment for service (LAS) (no NTN) 2 CMTs (no NTN) 2 time expired SpRs (1 abroad) 1 industry post 674 are in the UK training scheme and 58 are LATs and may choose to count their LAT time to wards training (732 in total). 36 are post CCT, the training of 16 will not count towards CCT. Over the last 4 years there has been a reduction of 1 gastroenterology training post in the UK.

14 Table 5: Distribution of UK trainees (30/09/13) England Wales Scotland N Ireland UK Specialist Registrar/Lecturer (Clinical) Out of programme Visiting Registrar LAT Locum Consultant Academic NTN Post CCT fellow Less than whole time trainees Some trainees may be counted in more than one category if for example they have an academic NTN and also work LTWT. There would appear to be an increase in the number of trainees out of programme, working as locum consultants and working LTWT. There has been a significant reduction in the number of WTE NTN holders in clinical posts compared to 2012 (34 in England, 2 in Wales, 3 in Scotland and 4 in Northern Ireland). There has also been a reduction in the number of LATs (from 65 to 58) due to difficulties in recruitment. There has been an increase in the number of post CCT fellows (from 2 to 5) and visiting registrars (from 7 to 10). In addition there are CMTs, clinical fellows and LASs in clinical posts, but numbers are insufficient to cover, leaving gaps in the service (on the 2 nd Sept 2013 there were 28 unfilled posts in the UK (TPD census 2013)).

15 Table 6: Number of trainees in training or within 6 months of CCT date in different parts of the UK by year England Wales Scotland Northern Ireland Total % change The 9.6% reduction in trainees in 2012 reflects a change in the definition of trainees to those training or within 6 months of CCT date. This was the first year that this definition was applied. If the total trainee population is used, as in 2011 and before, then the total number of trainees is 784, 11 below the peak number in Gender Gender is known for 775 trainees. 270 (35%) are female. This is higher than 2012 (33%) but still significantly lower than the average percentage female for all medical specialties within the Royal College of Physicians: 48% (JRCPTB database Aug 2012). There are 39 LTWT trainees (24 in clinical posts, 5 OOPR, 4 on parental leave, 1 OOPE, 1 VTN, 4 locum consultants), representing 5% of the total trainees. 100% of these are female, or 14% of the female trainees. 25% of female trainees are LTWT trainees in all medical specialties. National Advanced Training Programme Posts (ATPs) Hepatology 16 hepatology ATPs were offered in the UK in 2013/14 and all of them were filled. 13 out of the 14 (93%) posts in England have been filled with trainees who will not have gained their CCT or will be in their 6 months post CCT grace period at the end of the post (1 ST5, 6 ST6, 6 ST7), 1/14 (7%) has been filled with a post CCT trainee. The Scottish Hepatology ATP post has been filled with a Scottish pre CCT trainee.

16 In 2014/15 there will be 15 English & 1 Scottish posts (16 in total). The 15 English posts have recruited nationally for the first time in 2014 and all were filled. At least 9 posts have been filled with pre CCT trainees. Scotland will join the national recruitment process for 2015/16 posts. Nutrition Three nutrition ATP posts were offered in 2013/14 (St Mark s/addenbrookes, John Radcliffe and Hope Hospitals). 1 post was filled with a pre CCT trainee, 1 post was unfilled and 1 post was filled with a post CCT trainee so these two posts were removed from the training programme for posts have been offered for 2014/15 (2 St Mark s/addenbrookes, John Radcliffe Hospital, Hope Hospital). All posts have been filled, 3 with pre CCT trainees and one who will be >6 months CCT at the end of the year, extending training time. Relationship of trainees to population There is a variation across the UK for the number of trainees per population (figure 6). As with consultants there is a higher density of trainees to population in London (1: 38,000), however this has reduced from 1:34,000 last year. The devolved nations and the South West have the lowest density: Scotland 1:108,000, the South West 115,000, Wales 1:118,000 and Northern Ireland 1:129,000. Fig 6: Population served by 1 trainee e in tra r e p n tio la u p o. p o N SHA

17 Fig 7: Trainees in each LETB s e in 50 tra f o40 r e b m30 u N London NET London NWT London South Peninsula Severn Wessex KSS Oxford East of England LETB East Midlands West Midlands Mersey Yorkshire North & Humber Western Northern Scotland Wales Northern Ireland Total No. trainees Numbered clinical posts Trainees in clinical training posts Academic NTNs LATs LTWT OOP Trust posts Locum consultants Unknown In this figure trainees are linked to LETB according to NTN and may be working in a different LETB e.g. if on an OOPT. Clinical training posts include: StRs, LATs, LTWT, academic, lecturers, ATPs, training fellow posts. Trust posts include: CMTs, LASs, trust fellows Some trainees are counted in more than one category e.g. an academic LTWT trainee who is on maternity leave would be counted in academic, LTWT & OOP.

18 Fig 8: Total number of consultants and trainees in each LETB Consultant:trainee ratio according to LETB CCTs awarded Table 7: No CCTs awarded by year No. CCTs CCTs were awarded from 1 st Oct 2012 to the 30 th Sept In this cohort the mean UK training time from appointment to grade to CCT was 6.35 years (range 3.00 to years). Of these 108 CCT holders, 56 are still working in training posts (13 are more than 6 months post CCT), 1 has left Gastroenterology & 3 have moved abroad (3.7% loss). 38 (35%) have been appointed to substantive consultant posts, 3 to locum consultant posts, 2 are in post CCT fellowships and 5 have left their LETB

19 and their current status is unknown. Of the 41 CCT holders appointed to a consultant post, 24 (59%) took up posts in the region in which they trained and 17 (41%) moved regions for the consultant post. Predicted CCT dates Fig 9: Graph of predicted number of CCTs per year T s C. 100 o N d 80 te ic d 60 re P UK England N Ireland Scotland Wales Year Figure 9 shows the predicted number of CCTs each year in the UK. This takes no account of CCT drift trainees delaying their CCT by a few months or years by taking time out of program, going LTWT, having training time extended at ARCP or choosing not to count LATs. The number of predicted retirements (consultants reaching 60 years of age) is 16 per year for the next 3 years, increasing to 38 in 2017 then falling to 22 (average 22 per year over the next 5 years) (figure 10). This leaves around 100 predicted CCT holders in excess of retirements, per year. 4 of these will probably leave the UK workforce leaving 96 who will require a job. 5% expansion would result in 63 new consultant posts next year. 100 new consultant posts require an 8% expansion of consultants.

20 Fig 10: Planned retirements and CCT dates r 100 e b m 80 u N Predicted No. CCTs No. cons reaching 60 yrs of age Year Outcome of trainees >6 months post CCT Table 8 & figure 11: Number of trainees >6 months post CCT without a substantive consultant post No. >6/12 post CCT s 70 e in 60 tra f 50 o r e40 b m u 30 N Y 78 trainees are more than 6 months post CCT and unappointed to a substantive consultant post, a 6% reduction on last year.

21 Of these: 21 are in locum consultant posts (2 are VTNs) 15 are in specialist registrar posts (2 are VTNs) 13 are in research (1 is a VTN) 7 are in post CCT fellowships (3 are VTNs) 4 are working abroad 3 are on maternity leave 1 has taken a career break 10 are unknown (2 VTNs) Outcome of LATs in Gastroenterology There have been 168 Gastroenterology LAT posts in the three years 30 th Sept (2011: 45, 2012: 65, 2013: 58) filled by 122 individuals (some trainees have had more than one LAT post). Of these 122 trainees, 32 are existing LATs leaving 90 individuals. 47 of these 90 trainees (52%) have obtained an NTN in Gastroenterology, 2 (2%) have obtained an NTN in another specialty (acute internal medicine & geriatrics), 1 (1%) has obtained a research post and in 40 (44%) the current employment status is unknown. Career aims of trainees 165 of 784 trainees answered questions regarding career aims. 51 (31%) want to be a consultant in a district general hospital (DGH), 49 (30%) want to be a consultant in a teaching hospital (TH), 26 (16%) would work in either a DGH or TH and 2 (1%) did not know. 49 (30%) want to be a general gastroenterologist and 27 (16%) want to be a hepatologist. The following want to be a general gastroenterologist with a subspecialty interest in: IBD 47 (28%), endoscopy 42 (25%), bowel cancer screening 41 (25%), hepatology 41 (25%), ERCP 32 (19%) and nutrition 27 (16%). 20 (12%) are planning to obtain a consultant post abroad (and another 3 are considering working abroad), 2 others (1%) plan to work in the UK but outside the NHS.

22 Consultant job advertisements & appointments Table 9: Number of substantive gastroenterology consultant advertisements by SHA SHA No. posts New / Replacement Appointed Not No Withdrawn advertised / Unknown N (%) filled applicants Scotland 11 7/1/3 5 (45%) Northern Ireland 5 1/0/4 2 (40%) Wales 3 2/0/1 2 (67%) North West 20 12/1/7 11 (55%) North East 15 7/3/5 5 (33%) Yorkshire & the 20 14/3/3 14 (70%) Humber West Midlands 7 3/1/3 5 (71%) East Midlands 4 1/2/1 4 (100%) East of England 11 5/4/2 7 (64%) London 9 6/3/0 7 (78%) South West 12 4/5/3 11 (92%) South East Coast / South Central 13 5/4/4 10 (77%) Total /27/36 83 (64%) 31 (24%) 15 (12%) 1 (1%) There were 130 substantive consultant jobs advertised between 1 st Oct 2012 & 30 th Sept 2013 (111 in England, 11 in Scotland, 5 in Northern Ireland and 3 in Wales). 67

23 (71%) were new posts and 27 (29%) replacement posts. Only 83 (64%) of these posts were filled. There were no applicants for 15 posts (12%). The largest numbers of unfilled posts are in the North of the UK. This suggests trainees are prepared to wait for the right job for them (be it specialty or location) rather than move for any job. 67 substantive consultants started their posts between 1 st Oct 2012 & 30 th Sept 2013 (58 in England, 4 in Scotland, 2 in Northern Ireland and 3 in Wales). 23 (34%) were locum consultants prior to appointment to the substantive post (11 of the these (48%) were appointed to the same Trust in which they were locum consultant). 44 were trainees prior to appointment to the substantive post (32 specialist registrars, 3 acting up as consultants, 3 research registrars, 3 visiting registrars, 2 post CCT fellows and 1 out of programme). Table 10: Distribution of substantive consultant job seekers (according to current post rather than original LETB) in next year by SHA SHA Locum consultants Post-CCT trainees Trainees obtaining CCT in next year Total Scotland Northern Ireland Wales North West North East Yorkshire & the Humber West Midlands East Midlands East of England London South West South East Coast / South Central Total Table 11: Distribution of substantive consultant jobs & potential retirees by SHA SHA Locum consultants Unfilled posts 60 years years Scotland Northern Ireland Wales Total

24 North West North East Yorkshire & the Humber West Midlands East Midlands East of England London South West South East Coast / South Central Total Tables 10 & 11 show the distribution of substantive consultant gastroenterology job seekers according to SHA as well as the posts available & the number of consultants who are 55 or more years of age and who might retire. The only area where the number of trainees significantly outweighs the number of jobs is London which will therefore be a net exporter of trainees. Future changes in consultant numbers Increased need for gastroenterologists: National screening programmes. Current bowel cancer screening programmes needs have been included in the RCP figures. From March sites started to pilot the national flexible sigmoidoscopy screening programme for the population between years of age Bowel Scope. The plan is to roll it out nationally from 2014 to 2016 with 60 million pounds investment from the Department of Health. The BSG has estimated that the extra work for FSig will require 93 WTE individuals, not necessarily doctors, divided across the 59 screening centres. This requirement has not been included in the RCP workforce estimates. Recent BSG Barrett s oesophagus guidelines (Oct 2013) have recommended considering endoscopic screening in patients with chronic GORD symptoms and multiple risk factors (at least three of age 50 years or older, white race, male sex, obesity), with a lower threshold in the presence of family history. Hepatology. Increased hepatology requirements from a change in population behaviour, i.e. increase in obesity, diabetes and alcohol misuse. The National Liver Plan asks for a trained Hepatologist in every trust.

25 The future hospital commission proposals (March 2012): continuous 7 day care, holistic inpatient care by a single team with specialist input, specialist medical care in the community Management of UGI bleeding. NICE (June 2012) recommends that unstable patients should have an OGD immediately after resuscitation and everyone else within 24 hours. Units seeing more than 330 cases per year should offer daily endoscopy lists. 7 day consultant present care (Dec 2012). Increasing requirement for 7 day consultant present care, necessitating increased consultant gastroenterologist time at weekends in most acute settings. Estimating that weekend working comprises a ward round and an endoscopy list on each weekend day/ bank holiday, then in 52 weeks there will need to be 104 weekend days work, plus 8 bank holidays, making 112 days per year. These could be days in lieu, often targeting Mondays/Tuesdays after a weekend, or taken as annual leave (Wirral model currently used successfully). If taken as annual leave then 112 days equates to 22 weeks leave, or almost 0.5 WTE. With approximately 220 Trusts across the UK, this would need about 110 new consultants. Other services may choose to take Gastroenterologists off GIM on call to compensate for specialty work at the weekend and increase the number of acute physicians and geriatricians instead to cope with the larger number of acute medical admissions over the age of 65 years. Increase in the number of consultants working LTWT due to larger number of female gastroenterologists and retirements brought forward by the reduction in the pension lifetime allowance (LTA). Changes to the NHS pension. The pension LTA fell from 1.8 million to 1.5 million on This resulted in some consultants retiring sooner than predicted, taking their pensions, and coming back to work on a LTWT contract. This does increase new appointments but at a lower rate than predicted. The LTA will reduce further to 1.25 million on Anyone retiring at age 60 with 37 years service & a level 6 clinical excellence award (CEA) or a level 3 CEA award with full added years on the 1995 contract would exceed the pension LTA (LTA = annual pension x20 + lump sum; annual pension = 1/80 pensionable pay x No. years membership; lump sum = 3 x

26 annual pension). An ageing population who are high users of Gastroenterology services. The current consultant workforce is paid a median of 11.5 PAs, most working more than this. There would appear to be saturation of available resources to enact the increased demands, necessitating an increase in gastroenterologists to meet needs. Reduced need for gastroenterologists: If gastroenterologists withdraw from GIM rotas (although not if this is to compensate for 7 day gastroenterology services). If others take on traditional gastroenterology roles, e.g. radiology replaces endoscopy. If curative treatments are found, e.g. new treatments for hepatitis C. Changes to commissioning to a 1 year of care model rather than payment by results. This would drive secondary care to be more efficient to preserve profit, for example by screening out unnecessary referrals. Changes to the NHS pension. Changes to the NHS pension scheme in 2015 may link usual retirement age (currently 60 for most) to State Pension age (increasing to 66 in ). If this occurs there might be a 6 year retirement vacuum leading to an excess of CCT holders over jobs in 13 years when protection arrangements cease. Future changes in trainee numbers Removal of LAT posts. Health Education England supported by COPMeD proposes to remove LAT posts by Aug 2015 in all specialties as they are felt to be wasteful use of the training budget as most do not go on to get an NTN. This will mean that LETBs & TPDS are less likely to release trainees to go OOP unless an extra NTN can be weaved into the training programme (which may be difficult in small LETBs). This would shorten average training time although probably the number of trainees seeking post CCT experience would increase. Shape of training review (Oct 2013). This places more emphasis on trainees getting broad based specialty training (e.g. medicine or general practice) in 4

27 6 years after Foundation programme. A small proportion would go on to credential in sub specialty areas such as gastroenterology driven by workforce & patient needs. The implications of this for our specialty are still under discussion. Surrogate markers for pressure on jobs: The number of trainees >6 months post CCT without a substantive consultant appointment has fallen slightly to 78, but remains twice that in % of advertised substantive gastroenterology consultant posts were not filled and 12% had no applicants. Conclusions As with all the large medical specialties gastroenterology is predicted to train an excess of CCT holders over jobs available in the next few years, around 100 per year over predicted retirements. 5% consultant expansion over the next 4 5 years would achieve the 1584 gastroenterologists it is estimated that the UK requires. Expansion is lower than it should be as a significant number of consultant posts cannot be filled, especially in the north of the UK. The number of CCT holders >6 months post CCT without a substantive consultant posts has plateaued. The majority of CCT holders without a substantive post remain working in gastroenterology. It is likely that the need for gastroenterologists will increase in coming years due to expansion of screening programmes, population demographic changes and the requirement for the service to cover evenings, weekends & bank holidays. Thus there is increasing need for gastroenterology services that should provide more employment for CCT holders as increased income from tariffs (not applicable everywhere) should fund the posts.