An Update on UK Rheumatology Consultant Workforce Provision: the BSR/ARC Workforce Register 2005–07: Assessing the Impact of Recent Changes in NHS Provision M
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Rheumatology 2008;47:1065–1069 doi:10.1093/rheumatology/ken099 Advance Access publication 18 April 2008 An update on UK rheumatology consultant workforce provision: the BSR/ARC Workforce Register 2005–07: assessing the impact of recent changes in NHS provision M. J. Harrison1, C. Deighton2 and D. P. M. Symmons1 Objectives. To describe changes in the provision of rheumatology services, monitor the pattern of inequalities in UK rheumatology service provision since 2005, and to summarize the 3-yr impact of the new National Health Service (NHS) consultant contract and the Musculoskeletal Services Framework in England and Wales. Methods. Questionnaires about timetable and working conditions were sent to all consultants on the BSR/ARC UK Workforce Register in January 2007, along with the personal and job-related details currently held about them on the register to update. The questionnaire included a visual analogue scale asking ‘how concerned are you that your current post might be under threat’ ranging from 0 ‘Not at all’ to 100 ‘Extremely’. Results. The response rate of the 2005 and 2007 surveys were 89 and 87%, respectively. Levels of optimal provision now exceed 70% in England and Wales, and 50% in Scotland and Northern Ireland. Levels of provision remain substantially higher in London than anywhere else. The median level of perceived job threat in the UK was 31 (interquartile range 11–61). Consultants in areas where provision is highest and a higher proportion of services are run in conjunction with Clinical Assessment and Treatment (CAT) centres report higher perceived job threat. Conclusions. Provision of rheumatology services has continued to expand over the past decade; however, inequalities persist at national and sub-national level. There is evidence of improvement in regions with the lowest provision, but there are indications of increased perceived job threat in areas with traditionally higher provision and where CAT centres have been introduced. KEY WORDS: Rheumatology workforce, Healthcare delivery, Service provision. Background Musculoskeletal Services Framework (MSF) affecting England and Wales and published since the last workforce update [8]. At The United Kingdom Consultant Rheumatology Workforce the time of the last review the new consultant contract was in place Register was established in 1971 to record details of all National for most consultants and appeared to lead to a median increase Health Service (NHS) consultant rheumatologists. The register of 6 h/week that consultant rheumatologists worked [5]. It was has been held on behalf of the British Society for Rheumatology unclear whether this increase in reported hours worked reflected (BSR) and Arthritis Research Campaign (ARC) at the ARC a genuine increase or better recognition of existing working Epidemiology Unit since 1983. The register is updated biennially, patterns. The latest review provides a good opportunity to assess with the most recent review being completed in 2007. the impact of the new contract over an extended period. The objective of the register is to monitor and summarize The main emphasis of the MSF is to improve access to services changes in the provision of rheumatology services nationwide. by an actively managed patient pathway that includes moving A key area of continuing interest has been the inequality in services closer to the patients, and reducing the time from numbers of whole-time equivalent (WTE) consultant rheumatol- presentation to the general practitioner (GP) to receiving hospital ogists at both national and regional level. Provision is assessed treatment [8]. In some areas, Clinical Assessment and Treatment against benchmark levels of provision, most recently the BSR Services (CATS) have been established as a mechanism to ‘triage’ needs-based estimate of rheumatology healthcare requirements, patients at the interface between primary and secondary care. which recommended that optimal provision would be one WTE They aim to ensure more efficient patient pathways appropriate consultant rheumatologist per 90 000 population [1]. This figure for patient needs. CATS may be comprised of a variety of health assumes that rheumatologists provide a service for both inflam- professionals including consultants, GPs with special interests matory and non-inflammatory musculoskeletal conditions; and (GPwSI), clinical nurse specialists and a range of allied health that consultant rheumatologists have the support of specialist professionals. In theory, CATS should allow quicker assessment, rheumatology nurses. A series of publications [2–5] has sum- investigation and advice and onward referral where necessary [8]. marized changes using information from the BSR/ARC The call for services to be provided closer to the patient’s home Rheumatology Workforce Register, most recently based on the may lead to more rheumatology services being provided in 2005 update [5]. primary care possibly by GPwSIs or clinical nurse or physiother- Working practice in rheumatology is currently in a state of apy specialists [8]. transformation, having been affected by the new consultant Improvements in the care pathway are supported by the use of contract introduced in 2004 [6, 7] and, more recently, the Independent Sector Treatment Centres (ISTC) where gaps in provision, such as musculoskeletal procedures, are identified. 1ARC Epidemiology Unit, The University of Manchester, Manchester and 2Clinical ISTCs may provide up to 15% of surgical procedures and an Affairs Committee, The British Society for Rheumatology, London, UK. ‘increasing number’ of diagnostic procedures [9]. The MSF targets Submitted 14 January 2008; accepted 7 February 2008. an 18-week pathway between GP referral and hospital treatment Correspondence to: D. P. M. Symmons, ARC Epidemiology Unit, Stopford by December 2008 [8]. Reduction of waiting times may lead to Building, The University of Manchester, Oxford Road, Manchester M13 9PT, UK. a permanent increase in the use of ISTCs [9]. To be on target E-mail: [email protected] for the 18-week pathway, the waiting time for an outpatient 1065 ß 2008 The Author(s) This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1066 M. J. Harrison et al. appointment from GP referral would be 11 weeks at the time of TABLE 1. Response rates the 2007 update. The aim of this article is to describe changes in the provision of 1997 2001 2003 2005 2007 rheumatology services in response to the MSF in England and Number of consultants mailed 412 480 506 542 584 Wales and continue to monitor the pattern of inequalities in Males (%) 80 78 78 76 75 rheumatology service provision since 2005, and to summarize the Females (%) 20 22 22 24 25 Total response rate, n (%) 350 (85) 443 (92) 474 (94) 482 (89) 510 (87) 3-yr impact of the new NHS consultant contract. Number of questionnaires 297 (72) 407 (85) 437 (86) 463 (85) 437 (75) completed, n (%) Methods In January 2005 and 2007, each consultant on the BSR/ARC Rheumatology Workforce Register database was sent a copy of the personal and job-related details currently held about them on TABLE 2. Distribution of specialties for the UK and its constituent countries, n (%) the register to update, and a questionnaire asking about their timetable and working conditions. The data held include demo- Specialty graphic details, training and qualifications, type of contract, Rheumatology hospitals at which each consultant works and their colleagues Pure and acute Rheumatology at each hospital. The questionnaire sought further detail about rheumatology medicine and other working practices, conditions and responsibilities and service n (%) n (%) n (%) structure, and also asked for details of any new consultants UK 419 (77) 89 (17) 27 (5) appointed since the last survey. The 2007 questionnaire contained England 367 (80) 67 (15) 24 (5) Scotland 23 (58) 16 (40) 1 (3) a visual analogue scale asking ‘how concerned are you that your Wales 21 (91) 0 (0) 2 (9) current post might be under threat’ which ranged from 0 ‘Not Northern Ireland 8 (57) 6 (43) 0 (0) at all’ to 100 ‘Extremely’. A first reminder was sent to non- responding consultants after 6 weeks, followed by up to two subsequent reminders after 6 weeks of non-response thereafter. Finally, a personalized reminder letter was sent 6 months after (Table 2). Seventeen per cent of consultants now combine rheu- the initial mailing. matology with acute medicine, and 5% combine rheumatology As in the previous update, levels of provision at national and with another specialty. In Scotland and Northern Ireland, 40–43% regional levels were compared against the benchmark of one WTE of consultants also do acute medicine, whereas in England and rheumatologist per 90 000 population [10]. Each consultant con- Wales 80 and 91%, respectively do pure rheumatology. tracted for 10 programmed activities (PAs) or more in rheumatol- The numbers of consultants increased for all countries of the ogy was counted as one WTE. Those working fewer than 10 PAs, UK and all regions of England apart from the North West and had a WTE number calculated by dividing the number of South East (Table 3). Overall consultant numbers for the UK contracted PAs by 10. Consultants combining rheumatology increased by 6% between 2005 and 2007 and the number of WTE with another specialty only counted as contributing their pure consultants increased by 9%. This increased level of provision led rheumatology sessions. Where consultants did not indicate to a 5% increase in the percentage of optimal provision levels in their sub-specialty (e.g. pure rheumatology/combined with acute the UK. The greatest increase in WTE provision between 2005 medicine), they were allocated a sub-specialty commitment in and 2007 was seen in Northern Ireland. Levels of WTE optimal line with the underlying proportion for their country. Where provision now exceed 70% in England and Wales.