MR 25
Ymchwiliad i recriwtio meddygol
Inquiry into medical recruitment
Ymateb gan: Coleg Brenhinol y Radiolegwyr
Response from: Royal College of Radiologists
Written Evidence to Medical Recruitment Inquiry – Clinical Oncology
Introduction
Clinical Oncologists (CO) treat cancer using the full range of non-surgical options: radiotherapy, and systemic anti-cancer therapies, SACT (chemotherapy, biological and immunological therapies, hormonal therapies.)
Cancer treatments have improved significantly since the millennium. The overall workload has increased, as has the complexity and the need for specialisation. Radiotherapy is used in 40% of curative cancer treatments, and is a fundamental part of palliative cancer treatments.
The number of incident cancer cases in Wales is consistently increasing by about 1.5% per year1. Conservative assumptions are that there will be a 4% annual growth in radiotherapy demand up to 2021, followed by a 2% annual growth up to 2031. There will be a concurrent annual increase in SACT demand of 5% up to 2021, followed by a 2% annual growth up to 20312.
SACT is also provided by Medical Oncologists, who are not trained to give radiotherapy. There is significant overlap in SACT provision between clinical oncology and medical oncology.
Radiotherapy in Wales is provided by 3 regional cancer centres: in Rhyl (North Wales Cancer Treatment Centre, NWCTC, Glan Clwyd Hospital), Swansea (South West Wales Cancer Centre, SWWCC, Singleton Hospital), and Cardiff (Velindre Cancer Centre, VCC). Whilst Clinical Oncologists do clinics in peripheral hospitals, they are ultimately based in one of the 3 centres because of the need to supervise radiotherapy treatments.
Specialist Registrar training is carried out in all 3 centres. In South Wales, trainees rotate between Swansea and Cardiff. North Wales trainees are linked to the Mersey Deanery. The Welsh training schemes are highly regarded and popular, and applications are oversubscribed. The training of a Specialist Registrar up to consultant level nominally takes 5 years, full time. In Wales the average duration of training is now more than 8 years because of maternity leave, less than full time working, postgraduate research degrees and clinical fellowships.
The 2015 RCR Clinical Oncology Census3
The average 2015 UK figure for WTE consultant Clinical Oncologists is 11.9 per million per radiotherapy centre. Wales as a whole is above average at 13.3 though there is significant regional variation. Velindre Cancer Centre is staffed above the UK average, but the two other smaller Welsh centres are below the national average.
WTE consultant Catchment WTE CO consultants
Clinical Oncologists population per million population
NWCTC 8.0 699,794 11.4
SWWCC 9.5 899,735 10.6
VCC 23.6 1,499,556 15.7
All Wales 13.3
UK 11.9
22% of CO consultants working in Wales are International Medical Graduates.
The UK average per centre for Clinical Oncologists plus Medical Oncologists pmp is 19. The Wales average is the same.
It should be noted that although the full amount of PAs contracted is recorded in the census, these figures for WTE are capped at 10 Programmed Activities (Pas, sessions.) Around the UK, 50% of consultants work 11PAs or more and these are therefore not reflected in this figure. It also excludes research and additional responsibility PAs.
Consultant numbers pmp is a useful basic comparator but it has clear limitations. Overall size of the department, and geographic considerations are also critical particularly for rural North and South West Wales.
Smaller departments lose out on efficiencies of scale. They have difficulties with specialisation, cross-cover, on-call rotas, non-clinical activities such as service development and research. The impact of staff leaving is proportionately greater: in September 2016 North Wales was down to 6 working CO consultants due to staff leaving.
The South West Wales and North Wales centres both service a geographically dispersed catchment. Clinics are provided at local District General Hospitals. Patient-centred treatment, provided close to home where possible, is a priority. 76% of Welsh CO consultants travel to more than one site on a daily basis (UK average 42%.) Travelling time to distant peripheral units is an issue when there is limited consultant resource, and a requirement to supervise radiotherapy at base.
Retirement
Percentage (and headcount) of the current consultant workforce expected to retire in the next
10 and 15 years
These figures do not reflect the fact that there are increasing numbers of post-retirement consultants still working (2/10 CO consultants at the SWWCC.) These consultants perform a vital service, but do not generally take part in the on-call rota, and can leave at short notice.
In addition, very senior consultants, often with general skills and expertise, are frequently impossible to replace like-with-like. The modern needs for specialisation mean that a replacement job plan may require 2 or more new posts.
Unfilled posts
The 2015 RCR census lists 21 consultant vacancies in the UK, including 3 in Wales. 9 of these vacancies had failed to appoint. This is likely to be an underestimate: chronically unfilled posts may not be re-advertised. Employment of post-retirement consultants allows for deferral of new posts.
The census also highlights the fact that this is a UK-wide issue, and that Wales has to compete nationally. In a seller’s market, where all UK regions and hospitals compete for the best appointments, less wealthy peripheral areas with hard-pressed units will always be at a disadvantage compared to large prestigious centres.
The issue is complicated by increased national scarcity in some of the less popular cancer specialties such as gynaecological brachytherapy.
As an example, in Autumn 2016 SWWCC advertised for 3 new CO consultants, and did not receive any shortlistable applications.
Conclusions
There is an imbalance in the Clinical Oncology consultant workforce across Wales. North Wales and South West Wales are understaffed both in absolute and relative terms, and this threatens the sustainability and development of first class cancer services to the Welsh population.
The consultant CO staffing pmp at VCC is a reasonable target for both North Wales and South West Wales and revenue should be provided to achieve and sustain this. This figure is above the UK average, but considering the extra demands of geography and the need to grow 2 small centres to sustainable size, this is justifiable.
Recruitment will be problematic for the foreseeable future. There is a national and international market for good candidates, and Wales has to compete: this is difficult especially outside the Southeast4. There will be a national shortage of newly qualified consultants in the face of increasing demands, and retirement of senior consultants. There is no quick solution to this: long term strategy and realism are needed.
· Welsh training numbers should increase: given current demand, Wales would be able to fill extra training posts. Wales trainees are more likely to stay in Wales long term, although this is never guaranteed. Flexibility to increase numbers is hampered by a perennial question of who in Wales should pay for extra trainees. A priority should be for Welsh Government and the Wales Deanery to sort this out.
· Wales has to promote itself as a place to practice first class medicine, and as a place to live.
· Recruitment has to look outside the UK.
· Although consultants are unavoidable, there is a significant opportunity to expand the skill-set and working practice of specialist nurses, therapists, treatment radiographers, and pharmacists to take on and develop some of the doctors’ traditional roles. There is also an incentive to use IT for remote working. To a significant extent Wales has already innovated in this respect out of necessity, for example with radiographer-led breast cancer radiotherapy planning; nurse-led Chemotherapy Day Units in peripheral District General Hospitals facilitated by networked electronic chemotherapy prescribing; videoclinics.
References
1. Welsh Cancer Intelligence and Surveillance Unit Official Statistics 2014 data 3 February 2016
http://www.wcisu.wales.nhs.uk/cancer-in-wales-1
2. Transforming cancer services in South East Wales programme business case
DRAFT Version 0.53 7 December 2016, Velindre NHS Trust.
3. Clinical Oncology UK workforce census 2015, the Royal College of Radiologists
https://www.rcr.ac.uk/clinical-oncology/service-delivery/rcr-workforce-census
4. Wales is not an Island, Academy of Medical Royal Colleges Wales
http://www.aomrc.org.uk/amrcw/professional-opinion/
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