Rheumatology Advance Access originally published online on April 18, 2006
Rheumatology 2006 45(11):1416-1421; doi:10.1093/rheumatology/kel129
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Developments in rheumatology consultant manpower provision: the BSR/arc Workforce Register 2003–05
arc Epidemiology Unit, The University of Manchester 1Clinical Affairs Committee, The British Society for Rheumatology, UK.
Correspondence to: Deborah P. M. Symmons, Professor of Rheumatology and Musculoskeletal Epidemiology, arc Epidemiology Unit, Stopford Building, The University of Manchester, Oxford Road, Manchester M13 9PT, UK. E-mail: Deborah.Symmons{at}manchester.ac.uk
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Abstract |
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Objectives. To summarize the changes and continuing inequalities in rheumatology service provision in the UK between 2001 and 2005.
Methods. Questionnaires about demographics and workload were sent to all consultants on the BSR/arc Workforce Register in January 2003 and 2005.
Results. A total of 94% of 506 consultants responded in 2003 and 89% of 542 in 2005. About 19% of the consultants practice rheumatology with acute medicine. Levels of optimal provision exceed 60% in England and Wales, but are below 50% in Scotland and Northern Ireland. The levels of provision in London are substantially higher than anywhere else. The median number of hours worked per week has increased from 35.2 in 2003 to 41 in 2005.
Conclusions. Rheumatology continues to expand. There is inequality with better provision in England (especially London) and Wales than Scotland and Northern Ireland. Patterns of nurse and Senior House Officer (SHO) provision correlate with consultant numbers. Thus, the catalyst for improved service is consultant expansion.
KEY WORDS: Rheumatology workforce, Healthcare delivery, Service provision
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Introduction |
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The United Kingdom Rheumatology Workforce Register was established in 1971 to record the details of all NHS consultant rheumatologists. The register has been held on behalf of the British Society for Rheumatology (BSR) and Arthritis Research Campaign (arc) at the arc Epidemiology Unit since 1983. The register is updated biennially, with the most recent review being completed in 2005.
The objective of the register is to monitor and summarize changes in the provision of rheumatology services. A key area of interest has been inequality in the number of consultant rheumatologists in the UK, at both national and regional level. Provision is assessed against benchmark levels of provision. Most recently, the BSR needs-based estimate of rheumatology healthcare requirements, recommended that optimal provision would be one whole time equivalent (WTE) consultant rheumatologist per 90 000 population [1]. This figure assumes that rheumatologists provide a service for both inflammatory and non-inflammatory musculoskeletal conditions; and that consultant rheumatologists have the support of specialist rheumatology nurses.
A series of publications [2–4] has summarized changes using information from the BSR/arc Rheumatology Workforce Register, most recently in 2002 [4]. Frequent changes in administrative boundaries and reorganization of the NHS have hindered consistent analysis of trends at the regional level. This 2005 review is no different; the eight NHS Executive Regions used in the review of 1997–2001 were phased out and replaced with four English Directorates of Health and Social Care (London, Midlands & Eastern, North and South) with Wales, Scotland and Northern Ireland reporting to their National Executives [5]. The latest available population statistics for the NHS Executive Regions were estimates for mid-2000 calculated in April 1999 [6].
Additionally, a significant change in working practice occurred between the 2003 and 2005 Workforce Register updates with the introduction of the new consultant contract in 2004. The consultant timetable is now in the form of programmed activities (PAs). Each PA is of 4 h duration and may be allocated to direct clinical care (DCC) or supporting professional activities (SPA) (e.g. education, audit) [7, 8]. The standard full-time contract is 10 PAs usually in the ratio of 3 DCC:1 SPA. For part-time consultants, the proportion of SPA will be higher because the requirement for continuing professional development (CPD) is constant. Rheumatologists in the UK either practise in pure rheumatology or rheumatology plus another specialty (usually acute medicine).
This article summarizes the changes and continuing inequalities in rheumatology service provision since 2001.
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Methods |
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In January 2003 and 2005 each consultant on the BSR/arc Rheumatology Workforce Register database was sent a copy of the personal and job-related information held about them, and an accompanying questionnaire about their timetable and work conditions.
The consultants were asked to check the details held on the register for accuracy and correct any mistakes. The data held include details about their demographics, contract, hospitals at which they work, colleagues at each hospital and previous training.
The questionnaire asked in more detail about working practice and responsibilities. After approximately six weeks, a first reminder was sent to non-responding consultants, followed by a further reminder 
4 weeks later. In the 2005 survey, a personalized third reminder letter was sent.
To compare the levels of provision at national and subnational levels against the benchmark of one per 90 000 population [1], WTE were calculated. In 2003, a WTE was regarded as 10 rheumatology sessions per week (one session = 3.5 h). Anyone working nine or more rheumatology sessions was regarded as a WTE. Those working less were regarded as a proportion of WTE by dividing the number of sessions by 10. In 2005, anyone contracted for 10 PAs or more was regarded as one WTE. For those working fewer than 10 PAs, their WTE was calculated by dividing the number of contracted PAs by 10. Where information on the attribution of sessions or PAs was missing, we assumed that consultants combining rheumatology with another specialty performed five rheumatology PAs per week (with the remainder spent in the other specialty). Consultants not indicating their subspecialty were allocated a subspecialty (i.e. pure rheumatology or combined with acute medicine), in line with the underlying proportion for their country.
The population estimates for the UK and its constituent countries were based on the Office for National Statistics population estimates based on the 2001 census [9] for the 2003 survey and the projected population figures for 2006 for the 2005 survey.
The provision per population for NHS Executive Regions within England was calculated using denominator populations taken from the Department of Health web site [6].
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Results |
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The response rate of the biennial surveys was maintained at excellent levels achieved between 1997 and 2001 (Table 1), although more reminders were sent in 2005 to achieve this. The majority of responders returned both the personal details form and the questionnaire. By the 2005 review, 90% of the respondents had accepted the new consultant contract. The percentage of female consultants has gradually risen, from 20% in 1997 to 24% in 2005. Similarly, there is a growing trend for part-time work, with the percentage (excluding maximum part-time work) increasing from 16% in 2003 to 21% in 2005. The proportion of consultants contracted for pure rheumatology has continued to rise to almost three quarters of all rheumatologists (Table 2). The number of consultants who combine rheumatology with rehabilitation (6%) or some other specialty (1%) continues to decline. The proportion combining rheumatology with acute general medicine remained constant at
20% of all rheumatologists. The proportion of consultants doing pure rheumatology varies between countries. In Scotland and Northern Ireland half of the consultants practise pure rheumatology, whereas in England and Wales 75 and 95%, respectively, practise pure rheumatology, in 2005. The number of consultants with academic commitments rose by 8% between 2003 and 2005, although the percentage is stable at 25%.
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The number of consultants increased for all regions and countries except Scotland (which remained constant). The overall increase in consultant numbers for the UK between 2003 and 2005 was 8% (Table 3). There was an 8% increase in WTE consultants and a 5% increase in the percentage of optimal provision levels in the UK. Levels of WTE optimal provision exceed 60% in England and Wales, but are below 50% in Scotland and Northern Ireland. This pattern was the same at both time periods, although provision improvements in England and Northern Ireland exceeded those in Wales and Scotland. The same pattern was also evident in the absolute number of consultants and the size of population per consultant.
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At the regional level there were no clear trends. The levels of provision in London continue to exceed the levels of provision throughout the remainder of the UK. The greatest increase in provision was seen in the North West region, with 11 extra WTE consultants resulting in a 15% increase in level of optimal provision.
The dichotomy evident in rheumatology provision described above is not evident in a range of other specialties (Table 4). In all other specialties listed, Scotland has the highest level of provision per 100 000 population of the UK. However the Royal College of Physicians (RCP) does not present results in WTE or look at the provision of rheumatology as separate from acute medicine.
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The change in consultant contract between the register updates was reflected by noticeable differences in reported working hours per week. The average full time consultant in 2003 reported a median of 35.2 h per week (IQR 31.5–38.8) compared with 41 (IQR 36–46) in 2005. Comparing the breakdown of commitments between 2003 and 2005 is complicated by the new terminology. As an approximation, the clinics, ward rounds and associated administration and paperwork reported in 2003 and 2005 were regarded as DCCs, whilst the remaining administration and paperwork and CPD were considered SPAs. The commitments reported in Table 5 suggest that an excess of DCCs drives the higher working hours in 2005. The number of hours per week spent in outpatient clinics was comparable in 2003 and 2005 (Table 5). In 2005, the median number of ward rounds reported per week was two for full-time consultants; this is probably equivalent to the median time of 3.5 h reported in 2003.
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Most full-time consultants are working more than 10 PAs [median 11 (IQR 10–11.5), Fig. 1]. The overall ratio of DCC to SPA was 3.1:1. There was no difference in the distribution and number of PAs between consultants in pure rheumatology and those in rheumatology plus acute medicine.
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The median number of new referrals per consultant for the UK has remained constant at 15 (IQR 10–20) per week during the period 2003–05 (Table 5). The number of referrals per consultant is highest in Northern Ireland (median 19.5, IQR 15–20) and lowest in Scotland (median 12, IQR 10–20) despite approximately equivalent levels of provision in these two countries. The increase in consultant numbers in Wales corresponds with a large increase in new referrals despite the modest increase in actual WTE provision. The median number in England was 15 and in Wales 16.
The majority of consultants in the UK now have a rheumatology clinical nurse specialist (92%) and/or a rheumatology Senior House Officer (SHO) (73%) in their department (Fig. 2). The percentage of consultants reporting to have a rheumatology clinical nurse specialist in 2003 showed a similar picture of inequality as the WTE rheumatologist provision, with the higher levels of provision in England and Wales. A similar trend was apparent for rheumatology SHOs in 2005. The pattern of unequal distributions of clinical nurse specialists appeared to diminish between 2003 and 2005 as the percentage reporting these specialists approached 100%. There were no apparent differences in the number of nurses or SHOs per consultant.
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Approximately 20% of the consultants in the UK perform at least one paediatric session per month.
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Discussion |
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The gradual improvements seen in the 1997–2001 report [4] continued through 2003–2005. The number of consultants for the UK increased by
30 extra per year, in line with previous years. The large increases have reduced the population served per WTE from 149 258 in 2003 to 138 507 in 2005. This is a continuation of the decrease from 191 913 in 1997 to 164 165 in 2001. The RCP [1] percentages of optimal WTE provision for this review are calculated on the basis of one WTE consultant per 90 000 population. In previous reviews, recommended provision was calculated on the basis of one WTE consultant per 85 000 population [10]. Consequently, 6% of the levels of optimum WTE provision described in this review can be attributed to this change in definition. The change is due to the increase in rheumatology nurse provision taking over some of the follow-up role. In spite of the improvements in the levels of provision for the UK as a whole, an inequality in WTE provision has emerged with the levels of provision in England and Wales being 20% closer to the optimal levels of provision than those in Scotland and Northern Ireland. During the study period, the level of provision improved for each country of the UK, apart from Scotland where it deteriorated. London continues to have by far the highest level of provision in the UK. This is consistent with the pattern of provision within England seen both in individual medical specialties (Fig. 3) and for all hospital, public health medicine and community health service medical and dental staff [11]. London has the highest ranked level of provision for six out of seven of the major medical specialties and is ranked in the top three for all seven. However, trauma and orthopaedic consultant provision still follows a different distribution from that of other medical specialties, as described in the review of 1997–2001 [4]. London is ranked fifth in the levels of consultant trauma and orthopaedic surgeon provision and levels are lowest in the regions surrounding London (South East and East of England). The pattern of SHO provision in 2005 and clinical nurse provision in 2003 mirrored the pattern of consultant provision as one might expect. Essentially there is a need for a certain level of consultant provision before the junior and supporting staff can be appointed. The catalyst for improved services has to be consultant expansion.
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The number of consultants combining rheumatology with rehabilitation continues to decline and no new appointments have been made in this specialty. Thus, the proportion of consultants doing pure rheumatology has increased. Despite predictions that the combination of rheumatology with acute medicine would either increase or decrease dramatically, it has remained constant at 20%. Since, on average, consultants combining rheumatology and acute medicine only spend half their time doing rheumatology (and so are regarded as a 0.5 WTE for rheumatology), the proportion of consultants combining rheumatology and general medicine tends to vary inversely by region and country with the level of provision.
The number of rheumatology professors and senior lecturers (i.e. academic appointments) has increased substantially (from 137 to 147). Much of this is due to internal promotions. There has been difficulty in recruiting clinically qualified academics to vacant chairs in rheumatology—perhaps because of the perceived difficulty in achieving simultaneously in the delivery of high quality and volume research, education and clinical activity. Thus, non-clinical scientists have filled several recent vacancies.
The introduction of the new consultant contract has resulted in an apparent increase in the number of hours worked per week by whole time (and maximum part-time) consultants from 35 to 41. This probably represents better recognition of the hours worked by consultants rather than an actual increase in working time. For this reason we have, for consistency with previous results, calculated the number of WTE and population per consultant on the assumption of a maximum workload of 10 PAs per consultant. If we had, for example, regarded someone contracted to work 12 PAs as 1.2 WTE then the number of WTE rheumatologists in the UK would rise to 450 and the population per WTE consultant would fall to 132 967. Given that the European Working Time Directive requires all consultants to be contracted for no more than 10 PAs over the next few years, this means there will be a need for considerable consultant expansion in order to maintain the current level of service.
Another reason for not basing too much emphasis on PAs over 10 is the inconsistency between Trusts with regards to the recognition of working hours in the new contract. Many Trusts have adopted ‘blanket’ policies rather than reviewing individual timetables. Many universities have awarded their entire consultant workforce with 10 PAs regardless of their clinical commitments.
The full impact of changes in consultant contracts may not yet be clear. This change in organization of consultant working time occurred during the period of this review, and was not completed for all consultants by the start of 2005. The conclusions drawn from this review about workload are also based on consultants’ perception of their workload and these perceptions have not been validated. The next BSR/arc biennial review is due in January 2007, by when a new consultant contract should be fully implemented and any consequences evident.
In conclusion, the level of provision in the UK has continued to improve since 2001. However, the level of improvement has differed between regions and has altered the pattern of inequality in provision in the UK. The introduction of the new consultant contract appears to have altered the way in which consultants report their working pattern. Future reviews may be able to detect the impact of the revised working conditions on the consultants’ work and provision of rheumatology services in the UK.
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The arc/BSR Rheumatology Workforce Register is supported by a 5-year programme grant from the Arthritis Research Campaign and a special purpose grant from the British Society for Rheumatology. We are grateful to the rheumatology consultants in the UK who have completed the biennial questionnaires mailed to them by the Workforce Register staff.
The authors have declared no conflicts of interest.
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References |
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