Written evidence submitted by the British Thoracic Society (RTR0042)
1.1 The British Thoracic Society (BTS) is the largest, most authoritative and inclusive respiratory membership body in the UK, and a registered charity. We have over 4,000 members from all areas of the respiratory workforce including doctors, nurses, pharmacists, allied health professionals, lung physiologists and healthcare scientists and other professionals with a respiratory interest. We represent the professional voice of respiratory medicine in the UK.
1.2 Thanks to its long-standing experience and expertise, and its direct connection to respiratory clinicians working at all levels within the NHS, BTS is in an ideal position to offer the Committee an insight into what is needed to future-proof the NHS respiratory workforce.
1.3 The NHS respiratory workforce has been under resourced and understaffed for many years [1 - 6] before the emergence of COVID-19 made these gaps stand out in an even starker way [7]. The term “winter pressures” that many on the committee will be familiar with, was coined to describe the increase in acute hospital admissions in the winter months which regularly stretch the healthcare system to its very limits.
The vast majority of the increase in admissions is due to respiratory conditions and imposes additional pressure on the respiratory workforce [8, 9]. Furthermore, throughout the coronavirus pandemic, the majority of patients ill with COVID-19 were in the care of respiratory professionals. Only around 10% of COVID-19 patients at the peak of COVID-19 hospitalisation was admitted to Intensive Care [10], leaving tens of thousands more in Respiratory Support Units and Respiratory Wards.
This imbalance continues today, but with the additional demands of maintaining regular respiratory services and recovering the backlog of care.
2.1 The British Thoracic Society view is that a comprehensive workforce plan is needed to ensure that appropriate numbers of staff are in place across the full multi-professional team. As highlighted by GIRFT [9, 11], the respiratory workforce requires an increase in consultants but also specialist nursing and at other professionals, such as physiologists and other allied health professions. This is particularly true for respiratory medicine, which is increasingly delivering integrated services by multidisciplinary teams, which operate across traditional NHS boundaries. This highly skilled, sustainable respiratory workforce is what is needed to deliver the holistic multi-professional care that matches the growing demands of the patient population.
2.2 Increases in numbers of respiratory professionals will involve attracting staff into the specialty while also retaining existing staff by ensuring they feel supported and valued in their roles. It is vital that we build sustainability and resilience into the workforce.
This can be done by optimising the available roles and career pathways available to specialist nurses, physiotherapists, physiologists, advanced clinical practitioners and physician associates, within primary, secondary and integrated care to ensure all roles are utilised appropriately and teams function across traditional healthcare boundaries.
2.3 We support the view that retention of staff is as important as recruitment to new posts. Working across healthcare needs to offer a long term, sustainable career choice and we need to ensure experienced staff across all disciplines are retained to foster training and education for junior staff members. Improving working conditions, for example through better job planning, getter allocation of time and a more flexible approach to the workforce and their needs.
2.4 The NHS people plan [12] emphasises flexible working and there has been a rise in less than full time working. The current narrow outlook of workforce planning must now adapt. A BTS survey of respiratory trainees showed 85% of respondents were at least considering working flexibly or LTFT in the future [13]. Data from the Royal College of Physicians shows that 24% of consultants are already working less than full time.
The benefits of flexible working to work-life balance, reducing burnout and building sustainable careers are well-documented. Options for portfolio careers, flexible training and working need to increase. This approach allows staff to pursue interests in education, research, leadership, management and postgraduate study – all of which benefit the NHS and patients in the long term.
2.5 Commissioning needs to recognise the benefits of integrated care systems as this approach will ensure care is optimised to patients at the point of need, and is delivered by the appropriate specialists. It is vital that people plan or workforce specifications are included in all commissioning documents or service specifications.
3.1 Winter is always a demanding period for the health system, and in particular for the respiratory workforce. Even before the pandemic, the NHS routinely experienced an increase in acute hospital admissions in the winter months (ref) due to a near doubling of acute admissions for respiratory illness. NHS Getting It Right First Time (GIRFT) [9] reported that during Winter Pressures, trusts allocate an increased number of patients to respiratory teams but without any corresponding increase in staff or resources.
Given the chronic shortages across the respiratory workforce [1-6] it is common for many respiratory patients to be managed on “outlying wards” managed by non-specialist, non-Respiratory teams. The practice of “outlying” is associated with poorer outcomes in those patients who are managed in this way [9] also leads to increased length of hospital stays which compounds pressure on hospital beds. A respiratory specialist, familiar with lung illness, will safely discharge a patient earlier than a non-respiratory specialist.
3.2 It is also the case that since March 2020 and for the foreseeable future, respiratory teams in both acute and primary care settings, will continue to deal with new cohorts of patients with COVID-19 in addition to those patients with other respiratory conditions: acute COVID (in hospital, on respiratory wards and respiratory support units), those discharged from hospital (follow-up care and clinics), community cases, and Long COVID.
3.3 Any recruitment and retention plan must focus on ensuring that the NHS has a level of staff and resources that allows it to accommodate and adapt to surges in demand without impacting day to day services. This must focus on utilising skills across teams and professional collaboration, in order to design and deliver targeted services, so patients receive appropriate care, at the appropriate time, from the appropriately skilled professional. Preparedness should be a priority.
3.4 BTS has called for an increase of at least 200 higher specialist training posts, in addition, we need to attract, train and retain members of the multi-professional respiratory team, including respiratory nurses, respiratory physiotherapists, speech and language therapists, and lung physiologists. Additionally, every respiratory workforce expansion must be accompanied by an adequate increase in the resourcing of the services essential for it to operate, for example physiology and radiology among several others, or risk creating bottlenecks that invalidate the gains made. This is the single most effective solution to most surges in the demand for respiratory care.
4.1 We support the recommendations made by the Health and Social Care Committee in the 8 June 2021 report on workforce burnout and resilience in the NHS and social care (8), which suggests the government should implement regular reviews of the workforce that the NHS really needs.
5.1 In 2021 BTS found that 82% of hospitals reported vacant respiratory consultant posts. This has been increasing over the years, from 40% of hospitals in 2016 and is reflected across the UK [6].
5.2 Currently respiratory staff are being asked to cover gaps within and across specialties, working beyond their hours, their job description, often with little support or recognition. This contributes significantly to burnout and further workforce shortages. It is also vital to plan for the increased numbers of staff planning to retire in the coming years.
5.3 On top of a regularly planned, long term training and recruitment drive across the respiratory workforce, the following changes should be considered as they can have an impact on individual workload and morale, and contribute to the perception that a career in respiratory medicine is worth pursuing:
6.1 BTS supports the view that a shift in focus from admission avoidance to admission prevention is needed. Integrated care systems will play a crucial role in this, by delivering:
6.2 In order for them to function effectively, integrated care systems must be commissioned with a workforce that includes the whole respiratory multi-professional team, a “whole service” approach to recruitment is needed. Showing an understanding of the importance of multi-professional working and a commitment to support it, will help attract healthcare professionals with an interest in integrated care as well as have a positive impact on those already working to deliver these services.
7.1 We are pleased to have this opportunity to highlight how the long standing shortages in the respiratory workforce can be addressed, to ensure best care is delivered to patients, to preserve the mental and physical wellbeing of the workforce, and to support the retention of current staff and avoid a drop in the recruitment of people into the specialty.
We would also be delighted to provide further written and spoken evidence in addition to this submission.
January 2022