Written evidence submitted by Dr Polly Edmonds, Dr David Brooks, Dr Amy Proffitt and Dr Mike Jones (RTR0015)

Case for Palliative Medicine being designated a priority speciality for expansion in training numbers

Executive Summary

There is an urgent requirement to increase the number of palliative medicine trainees nationally, with Palliative Medicine designated a priority specialty for expansion.

Palliative Medicine improves patient survival, health-related quality of life and symptom burden; patient satisfaction with care; patient depression; improved chances of dying in preferred place of care.  Palliative Medicine consultations in hospital can also reduce cost per patient episode of the order of $3200.

The Covid-19 pandemic has highlighted the importance of palliative care as a front line service across the health system.  Alongside the demographic changes, with an ageing, multi-morbid, population, the need for palliative care is rapidly increasing.  The Covid-19 pandemic is likely to have ongoing consequences in relation to delayed diagnosis of significant illness, leading to increased morbidity and mortality.  This is likely to increase demand for palliative care further.

Consultants are essential components of specialist palliative care services, for clinical expertise, quality improvement, education, research, management and leadership, as outlined by the 2004 NICE Improving Outcomes Guidance ‘Improving supportive and palliative care for adults with cancer’ [CSG4][1].  Data from the annual RCP census and SAC workforce returns highlights that the UK is not training sufficient doctors to become consultants in Palliative Medicine to meet expected expansion, upcoming retirements and existing consultant vacancies; this gap between supply and demand is likely to be exacerbated by the Covid pandemic, the move to dual training and increasing LTFT working.

Proposal: Palliative Medicine is designated a priority specialty for an expansion of training numbers

The Case for Prioritisation

Demographic changes

Demand for palliative care is rising.  An increasing and ageing population is surviving longer with life-limiting conditions and multiple morbidities and current estimates suggest that approximately 75% of people approaching the end of life may benefit from palliative care[2]. These demographic changes have been exacerbated by the Covid-19 pandemic. In January 2021, Cicely Saunders International published an action plan for better palliative care[3]. In 2017, Etkind et al forecast that, due to changing population demographics and disease patterns, at least half a million people in England and Wales would need palliative or end of life care every year by 2040, with cancer and dementia the main drives of increased need.2 However, the updated modelling by Cicely Saunders International suggests we have already reached the level of demand projected for 2040 in 2020 due to the Covid-19 pandemic, whilst many people were not able to access the palliative care they needed[4]. In the coming years, there will sadly be an additional group of patients, both with cancer and non-cancer diagnoses, whose healthcare presentations were delayed due to the Covid pandemic and now have advanced disease requiring palliative care support. 

In a series of potential solutions, the Cicely Saunders International action plan highlights the importance of all services being staffed to provide excellent face-to-face palliative care seven days a week, with 24/7 advice and support. However, delivery of 24/7 palliative care in all settings is currently challenged, with gaps in provision of specialist palliative care out of hours. The 2019 National Audit of Care at the End of Life demonstrated that only 36% of 207 participating acute hospitals in England and Wales provided face to face specialist palliative care for a minimum of 8 hours a day, 7-days-a-week[5].

There is consistent and comprehensive evidence for better outcomes following palliative care[6], including: survival[7] [8], health-related quality of life and symptom burden; patient satisfaction with care; patient depression; improved chances of dying in preferred place of care. Specific evidence exists to support improved outcomes where palliative medical consultants undertake home visits[9].

Approximately 27% of NHS spend is in last year of life. Hospital costs are by far the largest cost elements of end of life care.[10] Recent comprehensive and systematic review shows that those receiving palliative care consistently cost less in terms of their overall healthcare.[11] Most of the potential cost savings relate to reduction in use of acute hospital-based healthcare. Specifically, those patients that had Specialist Palliative Care consultations within 3 days of admission saved $3200 (£2360) per patient episode on average[12].               

Workforce Challenges - CCT/consultant vacancies

There are several contributory factors indicating that we are not training sufficient workforce to meet increasing demand.

1. Rising consultant vacancies with no increase in trainees achieving CCT

SAC workforce data has consistently demonstrated a gap between the number of trainees completing training (average 37 per year, range 31-43) and the number of vacant consultant posts (Figure 1).

In 2021, 85% of doctors completing training had taken up substantive consultant posts.

2. Current consultant workforce: significant regional variation

The 2020 RCP census shows that the average population per full time equivalent (FTE) consultant full time equivalent (FTE) consultant is 84,977, with marked regional variation (from 46.474 population per FTE consultant in Kent, Surrey and Sussex to 287,000 population per FTE consultant in Scotland – North, Figure 2). The census demonstrates that consultants are most likely to be working in rural/hub town locations in East of England, Northern, Yorkshire & Humber, South West, Scotland – North and Wales – North.

Figure 2: Locations of consultant Palliative Medicine Physicians and full time equivalent vs. population by nation and region

3. Current consultant workforce: less than full time working

The latest RCP census demonstrates a 30% increase in the total number of consultants between 2014 and 2020 (Figure 3). In 2020, the RCP data showed 694 substantive consultants, 76% of whom are female and 57% working less than full time (LTFT).

Figure 3

The SAC workforce data from 2021 correlates with the RCP data, recording 669 substantive consultants working in the UK, with 206 (31%) working full time and 463 (69%) working LTFT (516 WTE). The slight discrepancy in numbers may be accounted for by missing data in the SAC workforce return from small non-training units.

The proportion of consultants working LTFT in Palliative Medicine is significantly higher than other medical specialties (the 2020 RCP census recorded an average of 24% of consultants in medical specialties working LTFT, compared to 69% of Palliative Medicine consultants.) The shift towards more substantive consultants working LTFT suggests that in Palliative Medicine, 1.5 doctors are required to fill each vacant consultant post.

In addition to the substantive posts, the 2021 SAC workforce survey identified an additional 43 locum consultant posts and 89 vacant consultant posts.

Based on historical expansion, the RCP expects there to be 847 substantive consultants nationally by 2024 (Figure 2).

4. Anticipated Retirement

The 2020 RCP census demonstrated that 18% of consultants are over 55 and may retire in the next 5 to 10 years (Figure 4). In the 2021 SAC workforce return, services anticipated 81 consultant retirements in the next five years.

Figure 4: Consultant workforce by Age

Therefore, with only an average of 37 trainees achieving CCT annually, existing vacant consultant posts, anticipated retirements and expansion, we are not training sufficient workforce to meet the expected increase in demand.

Workforce – Trainees

The SAC workforce returns demonstrate a reduction in the total number of UK Palliative Medicine trainees from 240 (202 WTE) in 2016 to 227 (154 WTE) in 2021. The proportion of trainees working less than full time (LTFT) has increased from 30% in 2016 to 45% in 2021. In addition, at least 20% of trainees are out of programme each year.

Table 1: Trainee Numbers 2016-2021

Like the consultant 2020 census data, where there is marked variation in population served per FTE consultant, there is variation in the distribution of training posts in the UK. As London and KSS operate as one training scheme, it is not possible to separate out the London and KSS data. The regions that are least well served for consultant in the UK (e.g. Thames Valley, Wessex, East Midlands, East of England, Yorkshire & Humber, Scotland, Wales - North and Northern Ireland) also tend to have fewer trainees for the population served.

Table 2: Distribution of Palliative Medicine trainees in UK, 2021

Impact of less than full time working

The specialty has a relatively high proportion of trainees working less than full time (45% in the 2021 census), meaning that on average it takes an additional year to complete training. The relatively high proportion of LTFT trainees is welcomed, but has unintended consequences, for example services’ ability to deliver 24/7 on call.

Implementation of new curriculum – dual training with Internal Medicine

The implementation of the new dual accreditation curriculum from August 2022 is likely to cause issues with staffing of palliative care services, particularly in hospices, where there is often only one trainee and a relatively small medical workforce. With the new curriculum, trainees will be required to complete 12 months of internal medicine as part of their 48-month specialty training programme, which represents a reduction of time in specialty. This is likely to cause issues with staffing the on call rotas required to delivery 24/7 and 7-day-a-week palliative care services across hospital, hospice and community settings.

Hospices are an integral part of health systems and over the last few years, most hospices have evolved to manage ever more complex, medically unstable patients, thereby relieving pressure on acute services. Prior to the pandemic, hospices were already struggling to deliver compliant first on call rotas (exacerbated by the implementation of the junior doctor’s contract) and with the move to dual accreditation in the new curriculum, some hospices are threatening to withdraw from specialty training. The significant reduction in charitable income to hospices during the Covid-19 pandemic has exacerbated concerns regarding the financial viability of some hospices and made them less willing to support specialty training. A reduction in training capacity in hospices would significantly impact on the ability to deliver specialty training in the UK, with future knock-on effects on the attractiveness of hospice consultant posts to trainees and the viability of consultant leadership in hospices.

The 2019 consultation for the new curriculum highlighted multiple concerns regarding the impact of dual training on service provision, including the sustainability of on call services. Significant work is underway to mitigate the impact on service, with a range of models proposed across Deaneries. Whilst many regions are making progress in exploring models of reciprocity with other medicine specialties, most regions have also recognised that an increase in training numbers will be required for successful implementation, without destabilising services.

Conclusion

The current and future workforce pressures outlined above highlight the urgent need for and expansion in training numbers for Palliative Medicine. We propose Palliative Medicine is designated a priority specialty for an expansion of training numbers.

January 2022