Written evidence submitted by the Royal College of Ophthalmologists (RTR0013)
1.1 The Royal College of Ophthalmologists provides training, professional development and guidance for our 4,000 members who include ophthalmologists in training, consultants, SAS doctors and other eye care professionals such as optometrists. We ensure high standards of patient care in the prevention and treatment of eye diseases and other eye conditions.
1.2 Ophthalmology is the largest outpatient specialty in the NHS, with 8 million appointments in England in 2020. It is vital that we have the workforce in place to meet the huge and growing level of patient need.
1.3 Our response highlights the need to:
Expanding medical school and specialty training places
2.1 In the long term, it is clear that we need to start training up more doctors now if we are to meet future demand. The UK has an ageing population with an increased prevalence of multiple health conditions, requiring ongoing treatment for many years. The starting point needs to be a substantial expansion in the number of medical school places, as outlined by the Academy of Medical Royal Colleges and Medical Schools Council.
2.2 Increasing the number of medical school places will not however be effective on its own if we want to increase the medical workforce. A corresponding increase in the number of Foundation Programme and specialty training places will be needed too.
2.3 In ophthalmology, over the last five years we have seen just a 2.3% increase in those training in the ophthalmology workforce, according to NHS Digital statistics. That is despite a huge increase in demand on the specialty, with outpatient attendances in ophthalmology up by 12% in the five years to 2019/20, and a third (33%) over the last ten years. As of November 2021, there are also now almost 600,000 patients on the waiting list for an ophthalmology procedure – 10% of the entire NHS waiting list.
2.4 Already the largest single outpatient specialty by volume with 8 million attendances each year, we know demand is set to rise significantly in the coming years. This is primarily due to ophthalmology services being particularly concentrated on people aged over 75. NHS Digital data from 2019/20 shows that those aged 75 and over made up 19.6% of all outpatient attendances, but that figure for ophthalmology was almost double at 36.4%. As the UK population ages, the number of people living with sight loss is expected to increase by over a third in the next decade, reaching 2.8 million by 2030.
2.5 An exacerbating factor on ophthalmology workforce demand is the fact that innovative new treatments have emerged in recent years. For example, later stage “wet” age-related macular degeneration (AMD) can now be successfully managed with intravitreal injections of drugs such as ranibizumab, aflibercept and bevacizumab. This typically means that patients will need eight injections a year for the rest of their life.
2.6 In their 2021 Atlas report, Public Health England pointed to the ‘shortage of consultant and specialty training posts required to meet the increasing demand for specialist ophthalmic care’. They highlighted that England had 2.5 consultant ophthalmologists per 100,000 population, well below the recommended 3-3.5 level. Our 2018 census found that over three quarters (77%) of NHS units in the UK had unfilled consultant posts – equating to 14% of all consultant posts. Two thirds (67%) of units were relying on locums, a huge cost to the NHS and taxpayer.
Expanding the multidisciplinary team to deliver more capacity in the short-medium term
2.7 Like many other specialties, in ophthalmology there are opportunities to further develop and enable the multi-disciplinary team (MDT) to perform roles. This will provide more capacity in the system, enabling doctors to spend more time diagnosing and treating patients. In ophthalmology this is already happening to a significant extent, with all eye care units relying on clinicians such as nurses, optometrists and orthoptists to provide services traditionally delivered by medical staff.
2.8 Recognising the role that the wider MDT plays in delivering care, we help to provide Ophthalmic Practitioner Training (OPT). This is a training programme for hospital-based ophthalmic nurses, optometrists and orthoptists who wish to develop their skills further to deliver patient care. With the support of NHS provider organisations, NHS England and Health Education England, the OPT programme could be expanded to help increase capacity.
2.9 Non-graduate roles such as technicians and image graders can also be quickly trained, which can increase the capacity to deliver eye care services. This is particularly relevant in the context of the rollout of community diagnostic centres, where large volumes of diagnostic data will need to be collected and analysed quickly to help clear the backlogs. We are already working with NHS England to collate information for trusts on how to train technicians, but investment in these roles by trusts and NHS England could provide a quick boost to capacity.
2.10 The RCOphth’s Cataract Services and Workforce Calculator Tool provides an example of how to plan the delivery of services across a MDT. It enables accurate MDT workforce planning, using a workforce calculator to plan the staff needed to deliver cataract services using community or hospital-based pathways.
Training the medical workforce
Flexibility and length of Curriculum
3.1 RCOphth supports approaches to training doctors based on outcomes rather than time, which has the potential to bring doctors through more quickly into the system. We are introducing changes to Ophthalmic Specialist Training (OST) from 2024, which will mean some ophthalmologists in training might be able to complete training more quickly, with a minimum time of five and a half years. It currently typically takes seven years to complete OST.
3.2 The inclusion of special interest training within the training envelope will also shorten the time to starting consultant posts as it will greatly reduce the need to undertake post-Certificate of Completion of Training (CCT) fellowships. The proposed new OST Curriculum is awaiting regulatory approval. It will be important that HEE local offices and Deaneries, through Heads of School and Training Programme Directors, support and educate trainers locally to implement the new training model.
3.3 Like other specialties, the OST Curriculum has been redeveloped to support a flexible training programme which develops a workforce that is adaptable in response to changing service need. Ophthalmologists in training will continue to develop skills to manage acute out-of-hours eye care and general skills to deliver holistic care necessary for patients presenting multiple ophthalmic morbidities. In addition, they will develop specialist skills by the end of their training in at least two special interest areas to ensure consultant teams can deliver the highest quality specialist surgery and clinics.
Enabling SAS doctors to progress via CESR
3.4 Training opportunities for SAS (Staff grade, Associate Specialist, and Specialty) doctors are also an important part of expanding the medical workforce. We believe that there should be more opportunities for SAS doctors to train and work towards CESR (certificate of eligibility for specialist registration) so that they can join the consultant workforce.
3.5 Despite an over-subscription to current ophthalmology training posts and an ability to provide more training, Health Education England is unable to support more training places due to a lack of funding and is supportive of new routes to supply the workforce with consultants.
3.6 RCOphth delivers the Ophthalmic Local Training (OLT) programme, which is the same as that used by trainee ophthalmologists. This programme, with the support of NHS England, HEE and trusts, could be expanded to bring much-needed consultant ophthalmologists through more quickly.
3.7 Expanding the OLT programme, which enables more SAS doctors to progress to consultant level, would also help recruitment and retention locally and internationally. On this latter point, as the GMC stated in its 2020 State of Medical Education and Practice report, ‘International Medical Graduate (IMG) doctors tend to work as SAS or LE doctors initially’. In 2021, 41% of all doctors in the UK received their primary medical qualification outside the UK, but for SAS doctors this was 70%.
Better system planning at the national level
3.8 What we ultimately need to ensure we make the right long term decisions on who and how we train across the health and care workforce is more transparency. Along with many other organisations in the health and care sector, RCOphth believes that Clause 34 in the Health and Care Bill should be amended to do that.
3.9 At present, Clause 34 of the Bill only requires the Secretary of State to ‘publish a report describing the system in place for assessing and meeting workforce needs’. This would not tell us whether we are training enough people now to deliver health and care services in future. We believe that the legislation should require the Secretary of State to also publish independent assessments of current and future workforce numbers every two years consistent with Office for Budget Responsibility (OBR) projections.
3.10 This would increase transparency and accountability for workforce planning, and provide strong foundations to take strategic long-term decisions about funding, workforce planning, regional shortages and the skill mix required to help the system keep up with rising patient need, based on evolving changes in patient demand and in working patterns among staff.
3.11 This same point about the need for clear data being in the public domain is also relevant when considering the role that integrated care systems (ICSs) will play, as they move onto a statutory footing in 2022. ICSs will be able to make local assessments of workforce need and invest in new roles, but this needs to be underpinned by long term projections at a national level.
4.1 Bringing more people into the workforce and upskilling those already there is just one half of the workforce equation. Greater focus needs to be paid to retaining the existing workforce, which would have a significant boost for capacity at little financial cost. Our 2018 census found that 27% of ophthalmology consultants were aged 55 and over and thus approaching retirement. This cohort will have significant experience and knowledge that they want to use to continue to help patients and the next generation of doctors. More flexible job plans, including less than full time (LTFT), that allow for increased involvement in education and training, would be a significant boost in enabling this.
Supporting a better training experience
4.2 It is vital to develop and help retain the existing trainee workforce. We were therefore worried by the results of the 2021 GMC Training survey, which showed that trainees in ophthalmology experienced the biggest increase in burnout of any specialty.
4.3 COVID-19 has significantly hampered training opportunities. Over half (53%) of ophthalmology trainees reported they had not been given additional opportunities to undertake the required number of practical procedures, notably higher than the 43.5% across all trainees. Similarly, when reflecting broadly on their experience of the pandemic, ophthalmology trainees were significantly less likely to say they developed clinical skills they would not otherwise have gained, and significantly more likely to say they worked in a service provision role that had no benefit at all for their training.
4.4 This balance between service provision and training opportunities is however a challenge that predates COVID-19. In the RCOphth 2019 National Trainee Survey, when asked about their most negative training experiences, respondents cited the impact of increasing service provision on training opportunities. Other common negative experiences included poor surgical exposure in special interest rotations and difficulty in obtaining adequate cataract surgery numbers.
4.5 Given almost half of NHS cataract procedures in England are being carried out in the independent sector, one area where HEE, NHS England and other stakeholders need to work together is to increase the training opportunities available in the independent sector. This will help to ensure a better training experience for ophthalmologists in training, increasing the likelihood they can progress through training and reach consultant level.