Does the NHS need more consultants?

Karen Bloor, University of York

Tuesday, 22 April 2008

The British Medical Association's recently published report “Enhancing Quality” launched a campaign “for an immediate, focussed and planned expansion of consultant numbers where the evidence and need is clearly indicated”.¹ In contrast, last year’s House of Commons Health Committee report on workforce planning commented on the lack of attention to improvements in productivity and on the short-sightedness of expanding the health care workforce without first ensuring that the existing workforce is working effectively.² So, does the NHS need more consultants, or could this be seen as, in the words of Professor Kevin Grumbach, “adding more sugar to your coffee before you’ve stirred what’s already there”?³

The BMA’s viewpoint is straightforward – consultants, they argue, have the highest level of training in the NHS, and deliver the highest quality care to patients. Recent financial pressures have created what they term an “artificial freeze on necessary consultant expansion” and this is “beginning to impede improvements in the quality of patient care”.¹ They support their arguments particularly with reports from the medical Royal Colleges, which again focus on quality of care.

There are a number of additional arguments that the BMA could have used. Implementation of the European Working Time Directive, along with doctors increasingly working part-time, and the apparent steady decline in productivity of hospital consultants (measured crudely by using patient episodes per consultant per month)⁴ could create a need for more consultants even for the NHS to stand still. This trend could be exacerbated by the increasing proportions of women in medicine, as they are more likely to work part-time and also may see fewer patients than men.⁵ Increasing concern about the “reverse foreign aid” that is created by migration of doctors from African and other developing countries to the UK may also require further domestic expansion in doctor numbers.

There are, however, counter-arguments to the BMA’s position. Firstly, it seems that they are arguing for a short-term or even immediate expansion in the consultant workforce, rather than the usual medical workforce planning tactics of increasing medical school intake and waiting for a decade or so. This requires either speedier promotion of existing doctors in training, or encouraging consultants from overseas. Neither of these options is free from problems.

The BMA makes no comment about the overall expenditure consequences of their proposed expansion, or the opportunity costs foregone. The substantial recent increase in salary costs of employing consultants creates considerable incentives for further exploration of a different skill mix in health care, and there is increasingly an evidence base for the potential of non-medics conducting routine endoscopies,⁶ radiography⁷ and other previously medical roles. Physician assistants are also increasingly in place in areas of medicine such as anaesthesia.⁸ 

Finally, it is impossible to comment on this area without raising the issue of the huge variations in medical practice that have been ignored for decades in the NHS and elsewhere,⁹ the substantial variations in activity rates of existing consultants¹⁰ and the lack of attention to productivity in the consultant contract.¹¹ The public accounts committee pointed out that following the new contract, consultants pay increased by around 27%, their working hours decreased and there was no measurable improvement in productivity.¹¹ The Department of Health continues to produce comparative data on consultants’ clinical activity in ten specialties, which illustrates the level of variations between individuals, with and without adjustment for casemix differences, and highlights hospitals’ own consultants within the national distribution.¹² This should be developed further and used to improve measurement and management of consultant activity and variations in care. This should inform gradual adjustment of the consultant workforce, rather than precipitate large-scale expansion. Let’s stir the coffee before we add more sugar, and then add just a little at a time.

References: