LTW0008
Written evidence submitted by The British Society for Rheumatology (BSR)
British Society for Rheumatology is the UK’s leading specialist medical society for rheumatology and musculoskeletal professionals. We support our members to help deliver the best care for their patients, in order to improve the lives of children, young people and adults with rheumatic and musculoskeletal disease.
Our members represent the entire profession - from those at the beginning of their career to the most senior consultants, researchers, academics, nurses and health professionals from across the multi-disciplinary team. Together, they form a powerful voice for paediatric, adolescent and adult rheumatology in the UK.
As the voice of rheumatology health professionals in the UK, we are, naturally, concerned with the impact the Long-Term Workforce Plan (LTWP) will have on the rheumatology workforce and are pleased to take this opportunity to comment on the modelling for the plan.
Our response is broken down according to the broad themes identified in the call for evidence. We would be happy to provide further information or to act as a witness in the inquiry, should the committee find it helpful.
In reading the National Audit Office’s (NAO) report on NHS England’s modelling for the Long Term Workforce Plan, we found its assessment of the design of the modelling very convincing. The model takes a reasonable technical approach to health workforce modelling; however, it has significant weaknesses and relies upon optimistic modelling assumptions, especially in terms of workforce productivity. Our comments on modelling are limited as we can only assess it based on the information in the Long-Term Workforce Plan (LTWP) and the NAO report, as we do not have access to the model itself.
Modelling needs to make specialty specific projections
The workforce modelling has one obvious flaw not acknowledged in the NAO report – it is not broken down by medical specialties. The LTWP makes only a cursory acknowledgement of medical specialty training, saying: “We will need to ensure adequate growth in foundation year placements and expansion of specialty training in future years, commensurate with the growth in undergraduate medical training.” Without any dedicated specialty workforce planning, it is unclear how this “commensurate” foundation and training places will be implemented or funded. It is a missed opportunity to not include projections for foundation and specialty training, which would enable NHSE to make evidence-led specialty workforce planning decisions.
It’s unclear whether the overall training figures will be fit for purpose for individual medical specialties. Each medical specialty will have different projected future service demands and scope to adopt innovations to achieve the LTWP’s ambitious productivity targets. Key specialty-specific professional membership organisations, alongside the BMA and RCP, will need to be consulted to ensure these overall figures are appropriate. Future iterations of the modelling must account for the expansion of foundation and specialist training places, as well as for the distribution of newly trained nurses, AHPs, pharmacists, etc. in specialist services.
The LTWP is predicated on achieving an ambitious productivity increase of 1.5-2%, which is well above the long-term average. Comparably, Office for National Statistics (ONS) data shows that UK healthcare productivity grew by 0.9% on average per year between 1997-2019. The LTWP modelling assumes the NHS workforce will become more productive each year, and therefore in its modelling adjusts downward the total number of workers it will need in the future. This growth relies on major investments in technology, innovation and capital, and it optimistically assumes recruitment and retention targets are achieved.
Productivity reforms may not be relevant to all specialties
While the areas highlighted in the LTWP present opportunities, it also risks significantly underestimating the workforce shortfall. We urge caution particularly when applying these predicted productivity increases to specialty-level projections, as some of these innovations and reforms may be inappropriate or otherwise already in practice. If the data is not sufficiently granular to make specialty level recommendations as NHSE has argued, it brings into question whether sufficient analysis of the feasibility of these productivity innovations and reforms has been done for various specialties.
Productivity targets must factor in capacity needed to deliver training
It is also not clear from the LTWP whether the modelling accounts for possible temporary decreases in productivity due to senior clinical staff needing to supervise and provide appropriate training for qualifying and newly qualifying clinical staff. In particular, the growth of apprenticeship routes to education will put some strain on existing senior clinical staff to deliver. This is not an insignificant task and will result in temporary reductions in capacity for senior clinical staff in supervisory and training roles.
Current NHS clinical staff are already very time poor, and struggle to make time for their own professional development and often have limited clinical supervision within their job plans. We surveyed 145 rheumatology specialist nurses about their job plans and career development, and we found 86.8% did not have time allocated for clinical supervision, and 58.9% did not have time allocated for external study days and/or training. Given the training and education needs of many existing staff are not being met, it is difficult to imagine how new training will be facilitated without hits to productivity in other areas.
Availability of specialty-level data to inform training projections
NHSE has argued that the data in the model is not sufficiently granular to enable national decisions on specialist workforce planning. However, several of the input models, such as the Elective activity projections and Waiting list interventions tool mode, should be able to be disaggregated by medical specialty to show demand for specialist services and inform the development of specialty specific workforce projections. NHSE also collects extensive publicly available data related to service demands that is disaggregated by specialty and care setting. If further data is needed to improve upon the model, it is vital NHSE identify the data needed and develop a plan to collect it to inform future iterations of the LTWP modelling.
Many of the specialty membership bodies may be in possession of some of this data through quality improvement audits and other data collection exercises. The National Early Inflammatory Arthritis Audit (NEIAA), commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme, collects service-level data across England and Wales. Service data is benchmarked to regional and national comparators against NICE Quality Standard 33 and other key metrics. It assesses waiting times, time to treatment, clinical response to treatment and patient reported outcomes. All of which could be used to assess demand levels on parts of rheumatology services.
Growing the specialty workforce can save money and improve health outcomes
In not including specialties, we believe NHSE has missed an opportunity within their modelling to show the true impact of increasing the NHS workforce. Our own modelling shows growing the UK rheumatology workforce is a cost-effective intervention in the treatment of adults with newly diagnosed rheumatoid arthritis (RA) and can save the NHS money.
We commissioned Costello Medical to model the cost-effectiveness of growing the rheumatology workforce to better understand the economic and health benefits. Our research shows growing the rheumatology workforce is a cost-effective treatment for newly diagnosed (or as it is known incident) rheumatoid arthritis (RA), delivering the kinds of health improvements we would expect from a treatment approved by NICE. It has an incremental cost-effectiveness ratio (ICER) of £5,821 (cost/QALY)[i] far below the typical threshold of £20,000–30,000 ICER accepted by NICE. That means it improves patient health measured in quality-of-life adjusted years (QALY) for a quarter of the incremental cost of the typical treatment considered.
Our research shows that more patients will achieve remission in the first year of treatment and that fewer complications will arise leading to surgery due to our workforce recommendations. Patients will use fewer other health resources, including A&E, improving overall service capacity and realising gains in productivity. In the first year, the reduction in other healthcare costs due to better patient outcomes would entirely offset the salaries of hundreds more rheumatology specialists. That means the NHS would effectively save money in the first year of treatment, amounting to about £100 per incident RA patient.[ii]
This modelling only looks at the impact of the workforce on adults with incident RA, meaning it vastly underestimates the impact of our recommendations as it does not capture the positive impacts it would have on the care of the over 200 other rheumatic conditions throughout patients’ lifetimes. We believe similar positive impacts should be expected in the treatment of these conditions, and that the paediatric workforce could expect similar positive improvements in health outcomes of children and young people.
This example illustrates the benefits of growing the specialist workforce and the importance of ensuring that we do not leave out medical specialties in our workforce planning. You can visit our webpage (https://www.rheumatology.org.uk/improving-care/policy/workforce) to read more about our recommended rheumatology workforce numbers and our cost-effectiveness modelling.
We cannot comment on the cost of the entire LTWP training place expansion. However, as stated in the previous section, we question whether the £2.4 billion funding includes the costs of increasing foundation and specialty training places to meet the demand as we double medical undergraduate places by 2031/32. Medical undergraduate studies are only the first step in the pipeline for medical training with consultants expected to undertake 2 years of foundation training followed by 5-8 years of specialty training. We need to ensure that this “commensurate” expansion of foundation and specialty training is appropriately costed and funded.
Foundation and specialty training is costly. For rheumatology, our research shows an additional 159 FTE adult rheumatology consultants and 12 paediatric rheumatology consultants are needed with the cost of their training being 120.5 million and 9.2 million respectively.[iii] This figure accounts for medical undergraduate training and is based on achieving this growth in the specialty by 2030, accounting for less than full time (LTFT) working trends. We are just one of the 65 medical specialties, many of which are not included in the LTWP modelling projections, which will require additional funding for specialty training places. This represents a significant gap in funding, unless NHSE can assure the committee the £2.4 billion includes the “commensurate” expansion of foundation and specialty training.
May 2024
[i] Cost-effectiveness modelling of growing the rheumatology workforce (2023) BSR.
[ii] Cost-effectiveness modelling of growing the rheumatology workforce (2023) BSR.
[iii] The people we need (2023) BSR.