Written evidence submitted by the Royal College of Anaesthetists (RTR0024)
- The Royal College of Anaesthetists is the professional body responsible for the specialty throughout the UK. We are the third largest medical royal college in the UK by membership. With a combined membership of more than 24,000 Fellows and Members, we ensure the quality of patient care by safeguarding standards in the three specialties of anaesthesia, intensive care and pain medicine.
- Anaesthetists play a critical role across many healthcare settings and have and continue to be leading from the frontline in the fight against the pandemic and the elective recovery. Simply put no additional surgical lists can take place without increasing anaesthetic workforce capacity.
- In October 2021 we published the report Respected, valued, retained - working together to improve retention in anaesthesia, investigating the factors affecting retention in anaesthesia and possible solutions to improve retention at individual, employers and systems level.
- The report also found that:
- 1 in 4 consultants and 1 in 5 SAS anaesthetists planned to leave the NHS within five years
- Around 1/3 of the anaesthetic workforce may be working less than full-time within five years
- Around 1/3 of respondents said that COVID-19 made them less inclined to stay working in the NHS.
- Anaesthesia is facing a perfect storm of workforce shortages, low morale and an ageing workforce. Our latest Census 2020 reveals a gap of 1400 anaesthetists currently. The 50 years + age group is now 39% of the workforce meaning that this group will be expected to retire in the next 5-10 years.
- Our members have suffered and continue to suffer high levels of fatigue and burn-out as a result of the pressures of managing COVID-19 patients while still maintaining emergency services and supporting the elective backlog recovery.
- The new variant Omicron is very likely to add even more pressure to a system creaking at the seams and the time is now for Government and healthcare leaders to do everything they can to support NHS staff to stay in work and to put in place sustainable short and long term plans, supported by supply and demand projections, for training and recruitment of the health and social care workforce.
- The evidence submitted in this document is based on the findings from and evidence gathered for the report and we hope it will be useful to the inquiry, as many of the factors affecting retention and possible solutions are applicable to other specialties and healthcare professions.
Anaesthetic workforce gaps, workforce trends and the need for long-term workforce planning
- When COVID-19 hit in 2020, the healthcare service in the UK was already lagging behind other European countries in terms of doctors per capita (2.8 doctors per 1000 people in the UK compared with 3.6 per 1000 people in other comparable countries), leaving it without the capacity to do its normal day to day work and deal with a new public health crisis. A recent report by the BMA calculates that since 2010, the number of doctors in secondary care in England alone has only risen by an average of 2.34% despite the fact that activity in NHS hospitals and community services has increased by over 25%.
- Looking to the future, the landscape is going to be challenging. The pandemic has had a devastating effect on the morale and wellbeing of the workforce. Anaesthetists, who have led on the frontline response to COVID-19, have suffered and continue to suffer poor mental health and high levels of burn-out. Difficulties in retaining staff risks delaying the elective backlog recovery even further.
- Increasingly, anaesthetic departments are having to spend considerable amounts of precious budget on expensive agency locums and bank staff or overtime to cover operations that otherwise could not take place. Below are some case studies from our network of Clinical Directors (anaesthesia)
“We have had one agency locum working 4 days per week for about a year. Assuming he took some annual leave, he has probably worked about 180 days over the last 12 months, costing £316,800.”
“We used locum consultant anaesthetists for 321 days from April 2020 until April 2021 and 96 days from April 2021 until August 2021 - estimated cost £733,920.”
- While expected to continue to support the recovery from the pandemic for several more years, the specialty will struggle to meet the increasing health demands of an ageing population without a long term and sustainable investment in its workforce.
- The number of anaesthetists (consultants and SAS) has grown slightly from 9,486 in 2015 to 10,057 in 2020 – but this is nowhere near enough to meet current demand, let alone meet the long-term needs of an ageing population with complex health needs. Equally worrying is that the number of SAS and Trust anaesthetists has remained largely unchanged since 2015, rising from 2,033 to 2,098 in 2020. SAS play a significant role in the delivery of elective and emergency services and are vital to ensure 24-hour anaesthetic cover.
- The census also tells us that the anaesthetic workforce has grown too slowly to meet demand for anaesthetic services. Based on data held by the GMC the number of anaesthetists in training has decreased by 12% since 2012.
- We have been lobbying Government for an increase of 100 additional higher anaesthetic training places every year for the next four years to provide an immediate boost to the anaesthetic workforce and reduce reliance on agency locums.
- In addition the 50 years + age group is now 39% of the workforce meaning that this group will be expected to retire in the next 5-10 years. However, with the right adjustments and flexibilities, we believe that many senior anaesthetists could stay in work and continue to make a contribution at a challenging time.
- Our report and latest census point to an increase in less than full time working and less than full time training. Around 1 in 10 SAS anaesthetists and consultant anaesthetists are currently working less than full-time and at least 2 in 10 are considering working less than full-time within the next five years. If this was extrapolated more widely, it could mean that around one third of the workforce may wish to work less than full-time within five years. A similar trend can also be seen in the next generation of anaesthetists, with 30% of anaesthetists in training considering working on a less than full-time basis after they complete their training.
- As more anaesthetists choose to work and train less than full time, the need to provide job plans that allow anaesthetists of all gender, ages and grades to stay in work will have an impact on workforce planning and will put additional pressure on the workforce because of the predicted decrease in participation rate.
- These are worrying trends warning that anaesthetic services will struggle to meet the increase in service demand both in the short and long term. Our own anaesthetic workforce projections show that the specialty will be short of 11,000 FTEs by the year 2040 if action is not taken, driven by factors such as population growth and ageing, increasing numbers of surgical interventions on offer, and the expansion of the anaesthetist role across the surgical pathway.
- However, so far, the Government is only publicly committed to training 4,000 more GPs and 50,000 more nurses. While there is a clear need for addressing shortages in these areas, there is currently no consistent workforce planning across all healthcare professions and there is a real risk that shortages in other less high-profile specialties will be overlooked, until such shortages reach critical levels. The specialty of anaesthesia is an example of this.
Pension taxation rules and impact on doctors approaching retirement
- One factor that is pushing anaesthetists either to retire early, or reduce their hours, is pension taxation – or, more specifically, the combination of pension taxation rules and the NHS pension scheme.
- As experienced anaesthetists are often high earners, they will often pay the highest rates of contributions into the scheme, be hit by a tax bill if the annual allowance is exceeded, and if they have been working for many years, they may also hit the lifetime allowance. In order to avoid these bills, many anaesthetists reduce their hours – or sometimes retire completely. Opting out of the scheme is also an option, but that represents a de facto pay-cut for doing the same work. Some NHS trusts have offered additional pay to (partly) compensate for the loss, but this is not universal.
- In our 2020 census, 1,133 consultants (14.4%) reduced their working hours as a result of the pension tax changes, and of the 333 consultants and 45 SAS doctors who retired in the year preceding the census, 82 had chosen to retire because of the pension tax rules.
- While we agree that those who earn the mostshould pay the most tax –we believe reform is needed to reform pension scheme rules/and or taxation rules, so anaesthetists are not pushed into reducing their hours or retiring early. At this time, the NHS needs all the staff it can get, so the case for reform is compelling and urgent.
Factors driving staff to leave the health and social care sectors
- To inform our report on retention we commissioned a rapid evidence review which compiled themes from 188 studies about retaining anaesthetists, surgeons and other NHS professionals. The published literature helped us identify the levels across which the key factors affecting retention in anaesthesia can be mapped against:
- individual-level factors such as mental wellbeing and burnout; physical issues associated with ageing; the extent to which professionals felt valued and satisfied with their work; and family commitments and other priorities
- role-related factors such as workload and working requirements, including working on-call; plus perceived autonomy in the role
- organisational/team-related factors such as organisational climate; leadership; communication; team morale; and supportive relationships
- system-level factors such as perceived bureaucracy; issues related to income and pensions; and concerns about litigation or risks.
- We also surveyed our members to better understand what encourages anaesthetists to leave and below is a summary of the key factors which were most mentioned:
- not feeling valued or well supported, including relationships with colleagues and managers
- wanting to pursue leisure interests and spend time with family
- concerns about taxes or pensions
- bureaucracy and leadership issues
- wanting to improve mental wellbeing, reducing stress or burnout
- could not sustain workload or being on-call
- lack of flexibility, reduced hours, breaks or leave
- lack of autonomy and respect.
- The report identifies work-life balance and the need for flexibility (or lack of) as two key factors affecting career decisions in anaesthesia and yet our members have also told us that flexible working and job plans are not consistently available to them. This leads many to leave or retire early out of frustration with rigid policies, unfavourable terms and conditions for those choosing to retire and return, and a reluctance to provide the adjustments they need to continue to contribute to the work of their departments. Key to addressing these issues are regular conversations between staff, managers and the wider teams to find solutions that work for everyone.
Recommendations to improve retention
- Our report makes 18 recommendations at individual, departmental and system level:
- What individuals can do to stay in work longer:
- Individuals should make use of available resources and take annual leave and time they need to look after themselves and recuperate.
- Individuals requesting flexible working and adjustments should be mindful of the impact of these requests on other team members and should be open to discussing options and solutions with managers and colleagues which work for the whole team.
- Individuals should recognise and be honest about physiological changes that might affect their ability to sustain current job plans and should seek help early.
- SAS and Trust Grade Anaesthetists should proactively use appraisals and yearly reviews of job plans to discuss career progression and agree Personal Development Plans with their appraisers and employers.
- Retired anaesthetists wishing to return should show flexibility and negotiate job plans that work for them, but also benefit the department and colleagues.
30. What managers and teams can do to improve retention
- Managers at all levels, including senior, should show compassionate leadership and foster a culture where staff are enabled and encouraged to seek help and the time off they require to improve their wellbeing.
- Managers should consider and support requests for flexible working and LTFT working to improve the work-life balance of staff and have clear policies about flexibilities and retirement options available to staff.
- Anaesthetic departments should actively support the professional development of SAS and Trust Grade Anaesthetists, using appraisals and yearly reviews of job plans to discuss opportunities for career progression available to them, for example the new specialist grade contracts or the Certificate of Eligibility for Specialist Registration.
- Policies for dropping on-call should be equitable for all non-training grade doctors, with due consideration of the intensity of resident on-call requirements.
- Employers should offer regular and tailored conversations about retirement and career plans as part of yearly reviews of job plans, including training for managers to have these conversations.
- Employers should allow changes to working environments and job plans to support employees’ changing physical needs, with support from occupational health services if required.
- Clinical Directors and Managers should regularly and proactively look at the age profile of their anaesthetic workforce to quantify and identify staff approaching retirement and initiate early conversations about retirement plans with these individuals.
- Managers and employers should foster a culture of respect towards senior anaesthetists and encourage a collaborative and team-based approach to flexible working.
31. What Government and healthcare leaders can do to improve retention:
- Government and NHS Leaders should safeguard the mental and physical wellbeing of NHS staff by setting realistic targets for reducing the waiting lists which allow burnt out staff to recuperate from the effects of the pandemic and enable them to access the resources and time off they need.
- Government should urgently invest in the expansion of the anaesthetic workforce and support an amendment to the Health and Care Bill from MPs which places a stronger duty on the Secretary of State for Health and Social Care to commission regular workforce projections and to act on them.
- NHS Leaders should standardise retention policies across providers, and these should be aimed at encouraging staff to stay in work as long and as healthily as possible and at making all NHS employers equally competitive and attractive places to work.
- Government and NHS Leaders should review how legislation to prevent discrimination on the grounds of age (The Equality Act 2010) applies to NHS employers, so that managers can have conversations around retirement and coming off on-call/overnight rotas without fear of employees raising formal grievances and to facilitate succession planning and retention strategies in departments.
- NHS employers and regulators should strive to remove barriers to retire and return, simplifying the administrative burden and issuing guidance at national level to support the safe return of retired doctors to practice.
- NHS leaders and government should strive to remove perverse pension taxation incentives which essentially encourage doctors to retire, rather than continue to work.
32. This is an important and welcome inquiry. The RCoA is keen to support the Committee with any additional information or through oral evidence. The RCoA is also one of 70 organisations campaigning for the amendment on workforce planning in the Health and Care Bill supported by the Chair of the Committee.
 RCoA. Medical Workforce Census Report. November 2020.
 Joint report by The Health Foundation, King’s Fund, Nuffield Trust. The healthcare workforce in England – make or break. November 2018
 British Medical Association. Medical staffing in England: a defining moment for doctors and patients. July 2021
 Royal College of Anaesthetists. Winter Snap Poll. February 2021
 The General Medical Council (GMC) List of Registered Medical Practitioners (LRMP) and national training survey (NTS) census records. (available on request)
 York Health Economics Consortium. Demand and Capacity Analysis for the UK Anaesthetic Workforce 2020-2040. August 2021
 RCoA/The Evidence Centre. What influences whether anaesthetists stay in the NHS? April 2021