RCoA representation to Spending Review 2021

This representation sets out what the RCoA believes is needed to put the anaesthetic workforce on a more sustainable footing to enable it to meet the increasing demand for hospital services in the aftermath of the COVID-19 pandemic.

About the Royal College of Anaesthetists

With a combined membership of 24,000 fellows and members, representing the three specialties of anaesthesia, intensive care and pain medicine, the Royal College of Anaesthetists (RCoA) is the third largest medical royal college by UK membership.

Executive Summary

The RCoA would like the Treasury to consider an increase in the number of higher anaesthetic training places, specifically an additional 100 higher anaesthetic training places (ST4) each year for four years starting with the recruitment round in August 2022. This would:

• Offer much needed additional capacity as senior trainees can quickly contribute to the elective recovery backlog, while at the same time provide cover for COVID-19 wards and ICUs in case of future surges.
• Through additional capacity, help to safeguard the physical and mental wellbeing of an anaesthetic workforce which is exhausted and not fully recovered from bearing the brunt of the pandemic on the front line.
• Offer considerable cost savings at a time when Trusts are increasingly relying on agency locums, bank staff and overtime to cover the additional lists required to bring down waiting lists (see cost benefit analysis and case studies below).
• Help plug the current consultant gap in anaesthesia, enabling the ambition for a consultant led service, the expansion of the Anaesthesia Associates workforce and the expansion of perioperative care pathways, leading to more efficient surgical services and better patient outcomes.

The vital role of anaesthesia in the NHS, during COVID-19 and the recovery from the pandemic

Anaesthesia is the single largest hospital specialty in the UK, and anaesthetists play a critical role in the care of two-thirds of all hospital patients.

Anaesthesia plays a critical role in the delivery of secondary healthcare. Many areas of the NHS could simply not function without anaesthetic services, not just surgery, but also maternity, emergency, and trauma and pain services, to name just a few.

The specialty of anaesthesia has been at the heart of managing the sickest COVID-19 patients in high-risk environments and is front and centre in the efforts to restore surgical services following the peak of the pandemic while still managing COVID patients[1]. Their unique skillset and training allow anaesthetists to be quickly cross-skilled and redeployed to support Intensive Care, making them an essential component of the NHS services and the ‘reserve’ workforce which will be needed to manage future COVID-19 surges and pandemics.

Current workforce trends for the specialty of anaesthesia

Data collected through the latest RCoA Medical Workforce Census 2020[2] paints a worrying downward trend for the UK anaesthetic workforce:

• More than 9 out of 10 hospitals in the UK have at least one unfilled consultant post.
• There were 680 funded but unfilled consultant posts, and 374 unfilled and not funded (aspirational*) consultant posts at the time of completing the latest census.
• There were 243 funded but unfilled SAS posts, and 113 unfilled and not funded (aspirational) SAS posts at the time of completing the latest census.
• The funded workforce gap in consultant anaesthetists has been steadily increasing across the UK from 4.4% in 2015 to 8% in 2020. In addition, there is an aspirational gap is currently at 4%, so the total consultant workforce gap is 12%.
• The anaesthetic workforce is ageing. 39% of the workforce is 50 years of age or older, meaning that this group will be expected to retire in the next 5-10 years.
• In summary 1,410 additional anaesthetists (1054 Consultants and 356 SAS anaesthetists) are required to fill current workforce gaps at a time when the NHS is struggling to recover from the backlog and waiting lists. The average anaesthetist across all grades treats 750 patients per year, therefore the current shortfall in anaesthetic cover could result in over 1 million procedures being delayed a year, compounding further the current waiting lists and patient experience.

*the number of unfunded anaesthetists required to deliver the service sustainably

Morale and wellbeing of the anaesthetic workforce

Anaesthesia is a specialty at high risk of burnout under normal circumstances. The COVID-19 pandemic has had a detrimental impact on the physical and mental wellbeing of anaesthetists. Our members have suffered[3] 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.

A recent survey on factors affecting retention in anaesthesia and career intentions[4] revealed that:

• 1 in 4 (25%) Consultants and 1 in 5 (20%) SAS Anaesthetists plan on leaving the NHS within 5 years
• 1 in 10 SAS Anaesthetists and Consultant Anaesthetists were currently working less than full time and at least 2 in 10 were considering working less than full time within the next 5 years.

This could mean that around one third of the anaesthetic workforce may be working less than full time within 5 years.

The COVID-19 pandemic has exacerbated the issue of chronic excessive workload for NHS staff, identified by the Health and Social Care Committee’s report on workforce burnout and resilience in the NHS and social care as the ‘no. 1 key predictor of staff stress and staff intention to quit’.[5]

Short- to medium-term solution for expanding anaesthetic workforce capacity to support the elective recovery

The RCoA would like HM Treasury and the Department of Health and Social Care to consider an increase of 100 higher anaesthetic training places (ST4) each year for four years starting with the recruitment round in August 2022.

This small increase would offer much needed additional capacity, offer support to anaesthetic staff who are too tired to cover additional lists and support the reduction in waiting lists, as this cohort of senior anaesthetic trainees would be able to take ever more complex procedures as they progress through the training programme. This cohort could also support COVID wards in case of pandemic surges. Critically anaesthesia schools would be able to accommodate such an increase.

In the long-term, this investment would help enable the development of a consultant led service which would train and supervise the expanding Anaesthesia Associates workforce, the growth of perioperative care pathways and support emergency departments, which are also struggling to meet demand.

Cost/benefit analysis: The following calculations make some basic assumptions that anaesthetic departments are trying to fill the current gap of 1400 anaesthetists performing 6 lists per week, which equates to 369,600 lists over a 44 weeks period.

Cost of additional lists provided in house: If department can provide in house for these additional lists by paying staff overtime or employing contract locums, additional payments for these sessions range from £260-600, therefore the cost per annum is around £96m-222m.

Cost of additional lists provided by agency locums: If departments are not able to staff additional lists in house and they have to use agency locums at a cost of £1760 per day, they could be spending £459,096 a year on just the salary for one agency locum anaesthetist. If only a quarter of the additional 436,800 lists were filled by agency locums, then this would cost £192m per year.

Cost of additional lists provided by higher anaesthetic trainees: the salary of a senior trainee (ST4-ST8) is on average £51,547, therefore an increase in higher anaesthetic trainees of 100 every year for four years would be in the region of £82.5m.

Cast studies of anaesthetic departments’ expenditure on paying for agency locums, bank staff and overtime.

We have surveyed our network of Clinical Directors to understand the cost of employing agency locums and bank staff to cover additional lists. The use of agency locums and bank staff is variable in Trusts, however when it is not possible to find cover internally, this comes at a considerable cost.

The quotes below provide an idea of the costs incurred by Trusts trying to meet the demand for additional lists during and in the aftermath of COVID-19.

• “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 fill most of our gaps “in house” by working extra bank shifts, pleas see breakdown of costs below:
  Consultants - £550/half day = £1100/day (the majority)
  Specialty Doctors - £61/h = £640/day
  SpR – £58/h = £609/day
  The rates for on call gaps are higher (due to antisocial hours and longer shifts):
  Specialty Doctor £825 /night shift
  SpR £800/night shift”
   
• “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).”
   
• “We have had various agency locums in place over the last 12 months, shown in the table below. We have also used “bank” staff - these are mostly “retire & return” ex-colleagues. “Extra contractual” is our own workforce working on their non-clinical days. “Trainee bank” is our trainees volunteering to cover extra work for “bank” payments. All of this is to cover in-hours, Mon-Fri elective demand.

  The figures shown are “sessions” and the total is 1756. If you want the data as “days” you need to divide all the numbers by 2. Total days is 878, which equates to almost 7 wte Consultants that we are short.”

 

 

• “We have used Agency locums to cover 96 sessions of work over the last 2 months (approx 48 days). We expect this number to grow as we enter recovery post-covid. We have an additional Agency Locum starting in 2 weeks for a minimum of 3 months. Over the past 12 months we have covered 425 (approx 212 days) sessions via internal paid locums.”
   
• “We have approx 8 additional sessions per week, the rate varying but approx £5000 per week for our hospital. (Small hospital, 10 theatres)”
   
• “40% of junior doctor service in our department is provided by locally employed doctors. Some gaps on junior doctor rota are covered by agency doctors. We are struggling to fill consultant posts.”
   
• “We have not been using agency locums but have been crucified by high levels of acting down payments and needing to offer enhanced locum rates to our own staff to get them to pick up extra shifts.

  We need WLI payments to cover routine elective work because our consultants are having their PAs soaked up by propping up an understaffed resident rota.

  Acting down payments for consultants are approx £140 per hour. Enhanced rates for registrar locums - £75p/h for day shifts, £100 for nights. WLI payments for additional elective work - £550 for weekdays, £700 at weekends. This is per session ie half a day.

  Sounds a lot, and it is, but this is the level of incentive required to get people to work beyond their contract. Very, very expensive.”
   

• “We have not used any agency locums luckily enough, however we are asking the department to service 6-5 extra lists each weekend, which costs £1000 per list every week.  This is in order to try to recover the waiting list position.  We are therefore spending about £5000 per week, and as a fairly good approximation we represent 0.2% of hospital spend in the UK. Increasing staffing is the only way to save the NHS, money alone won’t fix it.”
   
• “Over the past year, we have had 53 shifts covered by agency anaesthetists.  If you included in house extras (similarly expensively covered), the total would be hundreds and hundreds…”

For any enquiries about this representation please contact Elena Fabbrani, Policy and Patient Information Manager, efabbrani@rcoa.ac.uk.
 

[1] The anaesthetist during COVID-19. RCoA 2021

[2] RCoA Medical Workforce Census. 2020

[3] Findings from COVID-19 Winter Snap Poll. RCoA, 2021.

[4] Respected, valued, retained – working together to improve retention in anaesthesia. RCoA 2021

[5] Workforce burnout and resilience in the NHS and social care – Committees. UK Parliament, 2021.