Royal College of OBSTETRICIANS and GYNAECOLOGISTS

TheThe FutureFuture WorkforceWorkforce inin ObstetricsObstetrics andand GynaecologyGynaecology

EnglandEngland andand WalesWales

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June 2009 Royal College of Obstetricians and Gynaecologists

The Future Workforce in Obstetrics and Gynaecology England and Wales

Full Report

June 2009 Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG www.rcog.org.uk

Registered charity no. 213280

First published 2009

© 2009 The Royal College of Obstetricians and Gynaecologists

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RCOG Press Editor: Jane Moody Design & typesetting: Karl Harrington (FiSH Books, London) Contents

Foreword v Preface vii Abbreviations viii The Working Party ix Recommendations xi

Part 1 Introduction, overview and summary Introduction 3 Current workforce 7 Obstetrics and gynaecology: the present service 12 Implications for the future 15 Key points 17

Part 2 The subspecialties in obstetrics and gynaecology 1. Gynaecological oncology 23 2. Reproductive medicine 28 3. Fetal and maternal medicine 33 4. Consultant delivery suite presence: modelling of numbers 44 5. Urogynaecology 49 6. Sexual and reproductive health 57 7. Minimal access surgery 60 8 Menstrual disorders 63 9. Early pregnancy units 65 10. Paediatric gynaecology 67 11. Academic obstetrics and gynaecology 68 12. National consultant numbers 69 References 76 iv Appendix 1: Questionnaire to quantify clinical services in obstetrics and gynaecology 78 Appendix 2: Population by strategic health authority and primary care trust 89 Appendix 3: NHS maternity statistics (England) 90 Appendix 4: Illustrative job descriptions for subspecialist and special interest posts 93 Appendix 5: Fetal and maternal medicine tables 96 Appendix 6: Delivery suite consultant presence calculation 101 Royal College of Obstetricians and Gynaecologists Foreword v

On behalf of the College, I thank Dr David Richmond and his team for their enormous contribution to produce this report. One of the most difficult tasks for any country , organisation or specialty is to project and calculate the workforce needed in the next few years, the next decade and beyond. Many factors influence the calculation. Increased numbers are needed to balance retirements, attrition due to trained graduates leaving abroad, non-participation as full time consultants, more numbers needed to provide better quality , safe services and to provide consultant delivered service to meet the demands of the Clinical Negligence Scheme for T rusts (CNST) and the European W orking T ime Directive. These pressures are greater in obstetrics and gynaecology compared with many other specialties. The reduction in major gynaecological surgical procedures (such as hysterectomy for benign disease) owing to the use of levonorgestrel-releasing intrauterine systems and endometrial ablation techniques for menorrhagia, embolisation of fibroids and tape procedures for urinary incontinence instead of colposuspension has resulted in the need for fewer consultants to perform major gynaecological surgery. This adds a new dimension as to how we should train our future workforce. Our specialty has been ahead in this game by producing the report, The Future Role of the Consultant, which helped us to construct the curriculum and syllabus for core and advanced training. The curriculum in subspecialty and academic training will help us to train doctors appropriately for our future needs. Advances in knowledge and in the diagnosis and management of obstetric and gynaecological conditions are likely to influence our practice, which will indirectly influence the numbers needed in our workforce and changes in the curriculum. The Future Workforce in Obstetrics and Gynaecology keeps pace with the above thoughts and spells out the numbers providing this service in our specialty as a whole, the workforce in different subspecialties and the numbers in special interest areas. The requirements to fulfil the CNST standards expressed as consultant presence in the labour ward based on our documents Safer Childbirth and Standards for Maternity Care have greatly influenced the expansion in our workforce. The workforce numbers needed are generalists; those with special interest and subspecialists need to be calculated. These calculations should not be set in stone and need to be revisited from time to time, as the numbers needed will vary based on the advances in science, the reconfiguration of services and the expectations of the population. Prenatal diagnosis by free DNA from maternal blood may alter our practice of early ultrasound scan for nuchal thickness and the introduction of the human papillomavirus vaccine may influence the demand for colposcopy in 10–20 years. Continuous vigilance is needed to prevent overproduction of CCT holders, leading to inadequate consultant opportunities, or underproduction of CCT holders, leading to substandard service delivery and training. In the years to come, we should build on this document by having an electronic database that will provide up-to-date statistics. We should identify the services available as well as those not available but needed in each trust. This will help us to identify the type of consultants we need and to train our workforce accordingly . This document has considered the population base in the different regions, the number of surgical procedures, the number of specialised procedures, the trainee numbers, the current workforce and the possible expansion of workforce. This extensive research has resulted in 14 recommendations. The recommendations recognise that the consultants trained in general vi obstetrics and gynaecology will be able to handle all obstetrics and gynaecological emergencies. The Future W orkforce in Obstetrics and Gynaecology should help our profession to continue planning the workforce numbers needed to provide the best care for women’s health. Professor Sabaratnam Arulkumaran FRCOG President Royal College of Obstetricians and Gynaecologists Preface vii

This has been a daunting and enormous task, partly owing to the many variables which must be included. The European W orking T ime Directive, the introduction of Modernising Medical Careers, the publication of the RCOG’ s Safer Childbirth , Future Role of the Consultant and Standards in Maternity Care and Standards in Gynaecology documents, as well as the constant requirement to minimise risk, have influenced the findings. Hospital medicine needs to focus on how the service of the future will differ from that of the present. It is already apparent that consultants will increasingly deliver much more of the service than in the past. The shape of the specialty (for example, the medical aspects of gynaecology and the perceived reduction in trainee experience) is undoubtedly going to affect what consultants of the future undertake within their job plans. It seems inevitable that, although the majority of consultants will have the generic skills required to manage the labour ward and to provide emergency gynaecology cover beyond that, they will be appointed to much more specific roles than in the past. It is imperative that the training in specialty training years 6–7 reflects what the service needs. This is particularly important around the Advanced Training Skills Modules syllabus and whether it delivers the consultant of the future. Although the RCOG census captures information about the workforce in obstetrics and gynaecology, there is a serious lack of robust, national data about the activity undertaken. Consequently, wherever possible, we have attempted to ascertain the disease burden in order to estimate the consultant workforce requirements. How individuals or trusts divide the workload will inevitably be a local solution, as happens at present, where consultants have a range of interests and skills. The workforce calculations predicated upon disease burden are purely a guide, which we hope will be helpful over time. The calculations may not be perfect but they are at least a start and a template for the future. W e accept that some elements are more robust and detailed than others and this simply reflects the available evidence in each specialty area. What has become apparent is that it will not be possible for each unit (or trust) to provide all the services in obstetrics and gynaecology . It is therefore imperative that reconfiguration occurs, with appropriate networking of services to optimise the care for women. This will inevitably lead to some larger units and equally to the rationalisation of services in others. The RCOG can advise but it will be up to trusts, primary care trusts and strategic health authorities to decide on the specialist services they wish to provide. Only by coordinating consultant appointments across networks will it be possible to ensure the appropriate provision of services. Finally, workforce planning is notoriously fraught with pitfalls but, in 2009, it is essential for the future of our specialty. The trainees appointed in 2007 as year 1 specialty trainees will be ready for consultant appointment in 2014 and beyond. W e need to get it right. While I have chaired this committee, I am particularly grateful to Professor Stephen Robson for his contribution. David Richmond Chair and RCOG Workforce Advisor viii Abbreviations

AAC advisory appointment committee ART assisted reproductive technologies ATSM Advanced Training Skills Module BMFMS British Maternal and Fetal Medicine Society BSGE British Society Gynaecological Endoscopy CCT Certificate of Completion of Training EEA European Economic Area EU European Union EWTD European Working Time Directive FCE finished consultant episodes FTSTA fixed-term specialty training appointment FTTA fixed-term training appointment FY foundation year GO gynaecological oncology HES Hospital Episode Statistics HFEA Human Fertilisation and Embryology Authority IVF in vitro fertilisation MFM maternal and fetal medicine MMC Modernising Medical Careers NHS National Health Service NHSLA NHS Litigation Authority NICE National Institute for Health and Clinical Excellence NTN National Training Number PA programmed activity RM reproductive medicine SHO senior house officer SPA supporting professional activity SpR specialist registrar SRH sexual and reproductive health ST specialty trainee UG urogynaecology VTN Visiting Training number WTE whole-time equivalent The Working Party ix

Remit In July 2006, Council of the RCOG agreed to establish a working party to address the future needs of our specialty in England and Wales. The Terms of reference were: to review the present workforce, including the Faculty of Sexual and Reproductive Health Care and the subspecialties to develop models of care in line with The Future Role of the Consultant report1 to anticipate future workforce requirements in line with the recommendations of The Future Role of the Consultant report1 to define appropriate parameters on which to base Advanced T raining Skills Modules and subspecialty workforce planning to review the requirements of advanced training and to map the future workforce accordingly.

Membership David Richmond FRCOG, Chair and RCOG Workforce Advisor Stephen Robson MRCOG, Chair, Subspecialty Committee (2004–08) and Chair, Academic Committee (2008–) Maggie Blott FRCOG, Vice President RCOG Tahir Mahmood FRCOG, Vice President RCOG Christine Robinson FRCOG, President, Faculty Sexual Reproductive Health Richard Warren FRCOG, Honorary Secretary RCOG Ashley Fraser, NHS Employers Tracey Johnston MRCOG Mark James MRCOG, Members’ Representative, RCOG Council Henry Kitchener FRCOG, Chair, Academic Committee (2006–2008) Michael Paterson FRCOG, Fellows’ Representative, RCOG Council Vicky Osgood FRCOG, Workforce Review Team Chris Roseblade FRCOG, Chair, Deanery College Advisors Melissa Whitten, MRCOG, Chair, Trainees Committee (2004–07) Caroline Allen, Secretary to Working Party Royal College of Obstetricians and Gynaecologists x Ali MohammedMasoudAfnanFRCOG Mark HamiltonFRCOG Neil McClureFRCOG British FertilitySociety Philip Toozs-Hobson FRCOG Ashwani KumarMongaMRCOG Robert FreemanFRCOG British SocietyofUrogynaecology Arjun RavindranJeyarajahFRCOG John PriceFRCOG Andrew NordinFRCOG Gynaecological oncology Peter CReidFRCOG Roy FarquharsonFRCOG Keith EdmondsFRCOG In additionbyinvitation: Sian EJonesFRCOG Minimal accesssurgery Hassan ShehataMRCOG Margaret MRamsayFRCOG Gerald MasonFRCOG Jason Waugh FRCOG Catherine Nelson-PiercyFRCOG Alec SMcEwanMRCOG Society British MaternalandFetalMedicine Recommendations xi

1. All hospitals will not and cannot provide the full gamut of obstetrics and gynaecology services and, consequently, networking of care will be of paramount importance. This may necessitate reconfiguration of services and possibly sites but also may require cross-site working practices to develop. Obstetrics and neonatal networks must be linked for optimum care. 2. Although much of this report focuses upon the recognised subspecialty components, the areas less well covered (Part 2, Sections 6–11) require further scrutiny for appropriate workforce planning. The workforce of the future will require much tighter control of subspecialty trainee numbers, as well as programmes, and also the number of trainees undertaking each Advanced Training Skills Module (ATSM). 3. Subspecialty programmes should be coordinated by the RCOG Subspecialty Committee, perhaps in conjunction with a representative from the relevant specialist society who has an educational remit. Some programmes may need to be re-evaluated and/or limits placed upon the training site numbers. The opportunity to switch on/off training units should be considered and flexibility to move between subspecialty and ATSM programmes be considered to reach an appropriate balance. Overseas recruitment may prove an attractive proposition for vacant programmes. 4. ATSM programmes should be coordinated between the RCOG A TSM Officer and deanery heads of schools who, in turn, should plan their local training. The RCOG should not be seen as being overly prescriptive but flexibility will remain the key to planning for the future with appropriate levels of competition and choice. 5. Training via the ATSM route must deliver the consultant the service demands and must fulfil the requirements to cover emergency gynaecology and delivery suite as a minimum. The ATSMs must also provide the range of experience necessary to function as a consultant with a relevant special interest .This could be achieved by regular (2- yearly) review of the relevant ATSM curriculum. In addition, the opportunity exists to increase the clinical training within certain A TSMs by redirecting clinical experience from some subspecialty programmes. 6. The annual output of A TSMs must be monitored. It is anticipated that trainees will undertake at least two ATSMs in specialty training years (ST) 6 and 7 but probably more. 7. The majority of consultants will be expected to contribute to delivery suite care and this must include subspecialists where relevant. However , it must be realised that to function in the capacity of a gynaecological subspecialist, with the restrictions of the European Working Time Directive (EWTD), delivery suite out-of-hours care will lead to such levels of compensatory rest that the primary clinical focus will be diminished considerably. 8. Medical staffing and clinical activity data need to be collected in tandem with the focus on the direct clinical care programmed activity requirements to deliver that activity . 9. Regional College Advisors/heads of schools/chairs of specialty training committees should coordinate the census returns submitted by College hospital tutors for each ‘region’ of responsibility. xii 10. Attaining a consultant ceiling of approximately 3000 will take until approximately 2016–20, depending upon the expansion rate. Thereafter , retirement will level out at approximately 100/year . Factoring in competition, less-than-full-time working, emigration or attrition, we propose that the specialty training entrance target should be 150–160. Trainees will need appropriate career guidance during Advanced T raining. 11. Based on our projections and the numbers of specialty trainees at present, we shall start overproducing Certificate of Completion of T raining (CCT) holders from approxi- mately 2013–14. However, this depends upon consultant expansion in line with RCOG and National Health Service Litigation Authority standards for consultant presence on delivery suite. Any divergence will compromise the consultant opportunities further and will lead to overproduction and disillusionment of the trainee workforce. 12. We suggest that consideration is given to reducing specialty training numbers as a matter of urgency. Expansion of this grade to facilitate EWTD compliance should be resisted and other models of care pursued. The rider to this recommendation will be associated with birth rate change and any additional consultants required to provide service if specialty training numbers are reduced. 13. A debate with specialties providing parallel or complementary services should be considered. 14. Attention must be focused upon the service contribution provided by non-career-grade doctors and increasingly by post-CCT trust appointments. Although experience will be gained in the short term, there is a risk of a lack of career progression and job satisfaction in the longer term. The future of these posts needs addressing. Royal College of Obstetricians and Gynaecologists Part 1 INTRODUCTION, OVERVIEW AND SUMMARY

Introduction 3

The National Health Service is changing, medical education and training are developing and the delivery of care and patients’ expectations are growing. The challenge to us is to provide a workforce for the present with a realistic assessment of our needs over the next 10 years and beyond. Throughout this document we have attempted to adhere to the underlying College principles of aspiring to develop standards and enhancing the quality of our services. Workforce planning is not a science and in health care is subject to numerous external factors. Fundamentally, we are dependent upon the supply of qualified doctors, in terms of headcount and increasingly in relation to the whole-time equivalent (WTE) picture. In addition, we need to factor in the demand; that is, the number of staff the NHS is prepared to employ and the need, which is the estimated requirement to meet a specific standard of service; that is, a consultant-delivered service. Finally, there comes a time to draw a ‘line in the sand’ about where we are, what we have in terms of obstetricians and gynaecologists, what we need over the next 10 years and ideally how we get to that position through planning and direction of the service.

RCOG and workforce planning The RCOG, through its recent publications of Safer Childbirth2 and The Future Role of the Consultant,1 continues to champion standards within our specialty , particularly around consultant numbers and the need for increasing consultant presence on the delivery suite for longer periods of the day . This has been hampered by trusts’ and hospitals’ reluctance to resource these proposals without appropriate funding through payment by results or central resource. Maternity Matters3 and Lord Darzi’s Our Health Our Care, Our Say4 may force the issue of recruitment of additional consultants. It is against all of these variables that we have developed a plan for the future workforce in obstetrics and gynaecology . The topic of workforce has occupied the time of many Council meetings and committee deliberations. It has also been brought into sharp focus recently with the implementation of Modernising Medical Careers (MMC). 5 The RCOG’ s working party report, Medical Workforce and Service Delivery: A Blueprint For The Future , published in December 2000, covered the state of medical staffing in obstetrics and gynaecology at a time of considerable discontent and reorganisation. 6 The debacle of the late 1990s and early 2000s when the number of specialist registrars in training (the National Training Numbers) were reduced on the advice of the Specialist W orkforce Advisory Group and implemented by postgraduate deans is not something we wish to repeat. It took nearly 5 years to recover and regain the numbers of registrar trainees we had in 1999. MMC has restructured the face of postgraduate training. Basic training of two foundation years continues into specialty training for 2 years (ST1–ST2). T raining continues through ST3–ST7 completing core training by ST5 and then either Advanced Training Skills Modules (ATSMs) or a subspecialty training programme is undertaken, which occupy the ST6–ST7 years prior to the award of a Certificate of Completion of T raining (CCT). The link between trainee numbers and consultant opportunity remains poor and will continue to be so unless the recommended consultant expansion occurs. The RCOG needs to 4 describe a career path with an ultimate achievable goal encompassing flexibility, professional development opportunities and a modern work–life balance, or it is likely that recruitment will suffer . The original proposal in The Future Role of the Consultant 1 suggested a consultant population of approximately 2500 but some account must be made for consultants wishing to work less than full time. Bearing this in mind, the RCOG needs to plan for this potential number and tailor the training number requirements accordingly .

Methodology A working party was established, which met on five occasions from September 2006. In addition to these meetings, external input was sought from representatives of each of the subspecialties on the Subspecialty T raining Committee, who worked in collaboration with their respective specialist societies. Although up-to-date information about workforce is reasonably accurate, the measure and data capture of workload on a national basis is extremely poor . In addition, knowledge of programmed activity (PAs) nationally by consultant is unknown. To address this shortfall, the working party developed a questionnaire to quantify the clinical service activity in obstetrics and gynaecology and the consultant input to service that activity. The latter was based upon consultant WTEs and their direct clinical care P A allocation to that particular service. The questionnaire was distributed to all clinical directors in England and W ales in January 2007 (Appendix 1), asking for activity detail, job plan programmed activity allocation to aspects of clinical and managerial care, as well as information about workforce numbers. Only 58 replies (32%) were returned, despite numerous reminders. In addition, the data were incomplete and often incorrect. A very basic summary is presented at the end of the questionnaire. Whether the questionnaire was too detailed, misunderstood or sought information which was too difficult to retrieve is uncertain and this is an area for future consideration if workload becomes a more integral part of the RCOG annual census. In addition, the RCOG 2008 census data were used for cross reference with the NHS Hospital Episode Statistics submitted by all trusts on a monthly return. Epidemiological estimates of disease burden were accessed by literature search and specialist society contribution. Substantive variations in data collection are described in the relevant sections. The structure of obstetrics and gynaecology with five recognised subspecialties directly influenced the scope of the work and the detail provided for analysis. Royal College of Obstetricians and Gynaecologists The report focuses on two main areas: 1. current workforce provision – via national survey, census data, focused deanery surveys, and so on 2. disease burden – based on prevalence, outpatient/inpatient management workload and consensus views on number of appointments, and so on. Cognisant of the increasing number of trust mergers and the desire to establish effective clinical networks within geographic regions, it was agreed to base workforce requirements on the number of subspecialist and special interest consultants required to deliver care to a defined total population of one million (for gynaecology) and 10 000 deliveries (for obstetrics). In so doing, it was hoped that this would facilitate deanery schools/specialist training committees to plan the number of training opportunities (via subspecialty and ATSM programmes) required. In addition, we agreed that the working year, as far as calculation was concerned, would be based upon 42 weeks and that the model contract would be limited to ten programmed activities. This would constitute one WTE consultant. Furthermore, in terms of service provision, it is the number of P As devoted to clinical care 5 that is important and not purely the number of consultant posts. This distinction may become less important in the future as there is more consistency in the number of direct clinical care

PAs incorporated into individual job plans. However , it is expected that there will remain The Future Workforce in Obstetrics and Gynaecology variations in the number of direct clinical care P As devoted to subspecialist/special interest care, not least between clinical academics appointed by higher education institutions (who are likely to make up an increasing proportion of subspecialists) and NHS trust consultants. Finally, it is recognised that the job plan of a consultant at appointment is likely to be very different from that prior to retirement. W e all have different priorities and skills which develop during a long career and consequently, the focus of PAs will often change.

Background issues

Demographics The population of England and W ales is 53.7 million and is rising at 0.5% per year (see Appendix 2 for population by strategic health authority and primary care trust). In medical schools, the gender balance is changing, with 60% of students now female. Less than full time training, flexible job plans, career breaks and attempts to improve the work–life balance have all led to more flexible work and retirement plans. The W orkforce Review Team estimates that WTEs will continue to reduce from 0.93 to 0.85–0.8 by 2020. By then, for every 100 consultants, this will equate to only 80–85 as regards service availability . The European Commission Directive on Mutual Recognition of Professional Qualifications was implemented in October 2007 and will undoubtedly increase medical mobility across member states. There are 12 000 doctors from the European Economic Area (EEA) registered with the General Medical Council. The immigration policy has yet to be clarified and obviously this may have a considerable impact upon the supply line.

National obstetrics and gynaecology activity data Increasing births and decreasing deaths, coupled with international migration, have contributed to a population growth since 2000. The total number of births in England and Wales has increased and now stands at 669 601 in 2006. In England, regional variation has occurred, with a 0.8% increase seen in the East Midlands, East and London, and a decline of 2% in the North and Yorkshire. In addition, although the overall population has risen by 8% in the last 30 years, the age profile has changed, in that the population over the age of 65 years has risen during this time by 31% (that is, from 7.4 million to 9.7 million) while the population under 16 years has fallen by 19% in the same time frame. Fertility rates for 2006 give an average number of 1.86 children/woman throughout her reproductive life (15–49 years) in England and Wales. This is an increase of nearly 4% since 2005 (1.79 children/woman) and is the fifth consecutive annual increase from a low point in 2001 when the total fertility rate was 1.63 children/woman. The last time the total fertility rate reached the 2006 rate was 26 years previously, in 1980.The general fertility rate for 2006 was 60.2 live births/1000 women aged 15–44 years, an increase on 2005 (58.3 live births/1000 women aged 15–44 years). The fertility rate for women aged 40 years and over continued to rise (11.4 live births/1000 women aged 40–44 years). This figure has more than doubled since 1986.There has been a continued rise in the proportion of births to mothers born outside the UK: 21.9% in 2006 compared with 20.8% in 2005 and only 12.8% in 1996. 6 Information on maternity activity , taken from the NHS Maternity Statistics (England) released in November 2007, relates to the most recent and comprehensive data set of births. In 2005–06, there were 609 300 deliveries in England, of which 97.4% took place in 175 hospitals (593 400) and 2.6% (15 900) at home. This is an increase of 1.6% and 0.3%, respectively, compared with 2004–05. It continues the annual rise seen each year since 2001–02, when there were 541 700 hospital births and is close to the birth levels seen in 1993. A selection of tables relating to the maternity outcome (England) is presented in Appendix 3.

Outpatient activity (gynaecology) There has been a year on year increase in new patient referrals (3% in 2004–05 and 9% in 2005–06) to a figure of 1 129 524 new patients and a further 1 715 187 follow-up patients. As a specialty, this would rank third behind trauma and orthopaedics and ophthalmology (Table 1.1).

Table 1.1. Total outpatient attendances, England and Wales, 2005/06 (new and follow-up patients)

Specialty New Follow-up Total (n) (%)

Totals 14 918 796 35 039 342 50 038 667 100 Trauma and orthopaedic 2 068 029 3 953 660 6 022 842 12.0364 Ophthalmology 1 375 152 3 741 930 5 120 671 10.2334 General surgery 1 428 537 2 184 631 3 613 366 7.2211 General medicine 927 223 2 511 410 3 440 608 6.8759

Gynaecology 1 129 524 1 715 187 2 845 031 5.6857 Ear, nose & throat 1 030 348 1 515 975 2 547 594 5.0913 Dermatology 788 799 1 609 289 2 400 051 4.764 Clinical haematology 141 751 1 802 462 1 944 298 3.8856

Obstetrics 566 679 1 205 029 1 771 812 3.5409 Urology 480 571 1 130 851 1 611 474 3.2205 Paediatrics 462 954 1 101 284 1 564 370 3.1263 Royal College of Obstetricians and Gynaecologists Midwife episode 100 316 144 715 245 456 0.4906

European Working Time Directive In 2009, under European law, the EWTD will change the working week from a maximum of 56 hours to 48 hours; a reduction of 14% in time available for service, learning, teaching and research. It is unlikely that there will be further hours reduction in the foreseeable future and, consequently, this should be a stable factor from 2009 onwards and therefore will not influence workforce calculations further. Current workforce 7

RCOG census comparative information, England and Wales, May 2007 The 18th RCOG annual workforce census is based upon the information returned to the College as of the 14 May 2007 and published in May 2008. 7

Consultants There are 1701 consultant posts, of which 72 appear to be vacant and, of those in post, 82 are locums. Consultant expansion has been 3.2% over the last 12 months. The retirement numbers appear to be static at around 30/year and the average age at retirement age is 61.5 years. The retirement number should begin to rise over the next 2–4 years to around 45/year. It remains to be seen, however, whether all of these posts will be filled and, if so, the nature of the replacement job plans. The calculations of workforce are based on a consultant working for 30 years. If this were to change (for example to a retirement age of 67 years) it would impact on total numbers needed. The gender breakdown (Table 1.2) of the workforce shows a continuing feminisation, such that, in 2009, 32% of all consultants are now female. The number of consultants working less than full time remains static at 5.6%.

Table 1.2. Gender of medical workforce in England and Wales (at 14 May 2007)

Male (n) Female

(n) (%)

Consultant 1114 515 32 Specialist registrar UK/EU, ST3–7 164 336 67 Specialist registrar visiting, ST3–7 225 357 61 Senior house officer UK/EU, FY/ST1–2 89 222 71 Senior house officer visiting, FY/ST1–2 142 328 78

8 3.6% 7 3.2% 6 5

(%) 4 3 2 1 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 1. Consultant expansion 1995–2007 8 Figures 1 and 2 show consultant expansion over the last 12 years and the number of advisory appointment committees (AACs) held on behalf of the RCOG (2004–2007). The total number of AACs held in 2004 was 132; in 2005, the figure was 121 and in 2006, 109. In the calendar year 2007, there were 111 consultant AACs held (some had more than one interview panel). At the time of writing (December 2008) there have been 108 advisory appointment committees against a background of 220 CCT awards. The breakdown by specialty of the 2007 appointments is as follows: fetal/maternal medicine (60) gynaecological oncology (18) reproductive medicine (7) urogynaecology (6) other (16): 5 minimal access surgery 6 early pregnancy assessment unit/emergency gynaecology 2 medical education 3 ‘non-specific’.

40

35

30

25

20

15

10

5

0 2005 2006 2007 2008 Royal College of Obstetricians and Gynaecologists

January–March July–September

April-June October–December

Figure 2. Consultant Appointments Committees 2005–2008

Subspecialty and special interests of consultants The breakdown of subspecialty and special interests by consultant is shown in T able 1.3. While these data are of some value in trying to identify the national service requirements, it is acknowledged that they do not capture all consultants practising in each of the recognised subspecialty disciplines. Finally, of the 1629 consultants in post, 78% practise both obstetrics and gynaecology, while only 8% undertake only obstetrics and 13% only gynaecology . Table 1.3. Consultants by subspecialty and special interests, England and Wales (at 14 May 2007) 9 Fetal Gynaecological Reproductive Urogynaecology medicine oncology medicine The Future Workforce in Obstetrics and Gynaecology Consultants practising 236 181 150 127 Subspecialty accredited 42 37 19 7 Subspecialty (not accredited) 15 40 24 16 Special interest 179 104 107 104 Total sessions 744 906 482 318

Specialist registrars and specialty trainees The specialist registrar position (specialty trainees from 2007) this year appears to have remained remarkably static, with a total number of registrars in post at 1082 (and 29 unfilled). Of the total in post, 500 are from the UK or the European Union and 582 are visiting trainees; 772 are described as type-1 trainees and 310 as type-2 trainees (fixed-term training appointments). At present, 67% of the UK/European Union registrar trainees are female and 61% of visiting trainees are female. The impact of MMC on the trainee workforce will not be evident until the 2008 census. The 2007 and 2008 intake of specialty trainees (England and W ales) is shown in Table 1.4. The total equates to approximately 200 trainees in each year of training in England. It is this figure that needs to be taken into account when planning the consultant workforce for the future.

Table 1.4. Specialist trainee numbers appointed by deanery, England and Wales, 2007 and 2008

Specialty trainee year

1 (2008) 1 (2007)

East of England 15 9 East Midlands 12 13 Kent, Surrey, Sussex a 16 London 67 50 Mersey 12 12 North West 20 20 Northern 12 14 Oxford 7 7 South West Peninsula 2 5 Severn 8 6 SYSH 8 8 Wessex 2 12 West Midlands 20 19 Yorkshire 14 14 Wales 3 9 Total 202 213 a KSS and London ST1 numbers combined in 2008 10 CCT awards The number of CCT awards per year appears to fluctuate considerably . There were 142 in 2007 and 220 in 2008 calendar year (average 150–170). The Workforce Review Team works on the premise that 80% of doctors with Visiting Training Numbers stay in the UK and that 2% of the total numbers of specialist registrars although ‘graduating’ with CCT do not progress to consultant appointment. These figures need urgent validation to complement the RCOG workforce planning in advance of the cohort of MMC specialty trainees gaining CCT from 2014 onwards.

Certificate of Eligibility for Specialist Registration In addition to CCT awards, a number of doctors qualify for specialist registration via Article 14 receive a Certificate of Eligibility for Specialist Registration. In 2007, 26 doctors qualified via this route and in 2008 the number was 29.

Senior house officers The total number of SHOs (these became FY2/ST1/ST2/fixed-term specialty training appoint- ment (FTSTA)1 and FTSTA2 in 2007) in post appears to have declined by 63 with 1416 in post; 781 of these wish a career in the specialty of obstetrics and gynaecology and 635 are registered for a career in general practice; 60% of the career SHOs (470) are visiting trainees, 50% of whom wish to take up a UK consultant post. This is a considerable reduction from the 2006 census. Seventy percent of all career SHOs are female. The breakdown is such that of the total only 56 (7.1%) are male UK trainees. The SHO grade ceased in 2007 with the implementation of the MMC grades and in future will be assimilated into either FY2 or ST1–2 grades). W e do not have any robust information of the number of FY2 posts at present.

Other staff The staff and associate specialist doctor (non-training grade doctors, previously non-career grades) numbers have risen by 79% from 243 to 431 (excluding locums and clinical assistants and hospital practitioners), while the consultant numbers have risen by 44% in 10 years. Adding in clinical assistants and hospital practitioners, the total figure stands at just

Royal College of Obstetricians and Gynaecologists over 600. Recently, there has also been the appointment of post-CCT doctors to short-term trust posts for 1–2 years to deal with service and the demands of EWTD compliance. At present, we do not know the numbers in this group. The contribution to the ‘work done’ and sessional commitment is considerable and is shown in the T ables 1.5 and 1.6.

Workforce trend analysis 1997–2007 SHO numbers have remained remarkably static between 1997 and 2007, at 1500. The ‘career’ denomination (that is, those not wishing to enter general practitioner training) has fluctuated considerably, from a high of 1015 in 1998 to 605 in 2002.The present number is 781. The total specialist registrar number has risen from 983 to 1056 (England), a rise of 7.4%. The breakdown of type, however, shows that the NTN group has fallen by 27% (667–484) while the VTN/FTT A group has risen by 73% (from 316 to 546). This differentiation disappeared with the introduction of MMC in August 2007 as all specialty trainees are eligible for CCT on completion of training (Table 1.7). 11 The Future Workforce in Obstetrics and Gynaecology ) n ) n 27 54 80 78 ( 113 554 Consultants a 242 1079 243 1054 )( SAS sessions n 13 61 26 39 127 Male Female b b 35 40 240 115 106 117 Total Visiting specialist registrars prior to NTN/VTN introduction; specialist registrars Visiting specialist b ) ( SAS doctors n 96 Consultants ( GP CAREER 598650650 959819 839681 641684 605 632661 642 562671 697 498 699 427 65 725 433 48 428 45 520 45 176 531 56 250 125 270 268 226 272 293 292 280 277 256 1091 405 253 1150 425 233 447 1229 519 1319 435 1374 1396 1467 1517 564 1015 681 272 531 974 667 316 594 781 484 258 288 431 1629 SHO SHO SpR NTNSpR VTNSpR/FTTANTNSpRSHO SHO SpR NCCG Workforce trend analysis by grade,Workforce England, 1997–2007 (at 14 May 2007) Non-consultant career grades: associate specialists, staff grades, trust doctors; 2000 2001 2002 2003 2004 2005 2006 1999 1998 1997 East AngliaMersey North Thames (E) North Thames (W)North WesternNorthernOxford South Thames (E) South Thames (W)South WesternTrent 80 105Wessex 174 MidlandsWest 80Yorkshire 129 124 102 93 19 35 68 23 89 24 47 153 149 42 21 89 212 376 38 232 92 34 301 26 485 44 449 21 251 22 295 400 31 298 537 237 261 354 2007 a Table 1.7. Table Wales Deanery Table 1.6.Table by deanery, Staff and associate specialist (SAS) sessions (at 14 May 2007) Wales and England Hospital practitioners Grade Table 1.5.Table numbers,associate specialist Staff and May 2007) (at 14 Wales and England Associate specialists/locum associate specialists associate Associate specialists/locum Staff grades/locum staff grades Staff grades/locum doctors/locum trust doctors Trust Clinical assistants registrar title obsolete from 2007,registrar grade merging into specialist trainee 12 Obstetrics and gynaecology: the present service

Background The Future Role of the Consultantrecognises a gradual change in the specialty such that there will be less surgical gynaecology with an expansion of medical and outpatient based treatments.1 Specialty trainees will be expected to train in core obstetrics and gynaecology to the end of ST5 and then continue core emergency skills up to the end of training, while gaining additional experience through either A TSMs or subspecialty training to equip them for future consultant posts. The majority of obstetrics and gynaecology is carried out by consultants practising both components of the specialty. In the most recent census, of the 1629 consultants in post, 1273 were practising both obstetrics and gynaecology, 139 were only practising obstetrics and 217 only practising gynaecology. To date, there are 314 accredited subspecialists, a minority of whom provide a combined service and at least a further 100 acting in a subspecialty capacity: the so called ‘grandfathers’. There are 1082 specialist registrars (specialty trainees) in post, of whom 100 are registered in subspecialty training, which equates to approximately 26% of years ST6–7.

Advanced training All trainees will undertake at least two of the 20 A TSMs during years ST6–7. The diversity of the modules (T able 1.8) is such that some will lend themselves more to the medical/ conservative end of the spectrum and others to surgical treatments. Each school of obstetrics and gynaecology or deanery are likely to provide the majority of the ATSMs, although some where the practice is limited may be confined to one or two national centres. Regulation of numbers of trainees undertaking each A TSM will be at the level of school or deanery , with overall coordination by the ATSM office at the RCOG. It is anticipated that consultants with ATSM training will provide a generalist service with a special interest component. This aspect of workforce planning will obviously require careful monitoring until the pattern of consultant expansion becomes clearer.

Subspecialties Royal College of Obstetricians and Gynaecologists Subspecialty training was introduced in 1984 following the Report of the RCOG W orking Party on Further Specialisation within Obstetrics and Gynaecology .8 There are five recognised subspecialties within obstetrics and gynaecology: gynaecological oncology (GO), maternal and fetal medicine (MFM), urogynaecology (UG), reproductive medicine (RM) and sexual and reproductive health (SRH). Each subspecialty has a separate curriculum and logbook, available on the RCOG website (www .rcog.org.uk/education-and-exams/ curriculum/sub-specialty) and training is overseen by the Subspecialty Committee of the RCOG and Faculty of Sexual and Reproductive Health Care in collaboration with local deanery specialty training committees or schools of obstetrics and gynaecology . A subspecialist is a consultant (a) who has successfully completed subspecialty training and has been awarded a CCT in the subspecialty and (b) who devotes at least 50%, and probably more, of their working time to the subspecialty . Consultants in sexual and reproductive health have always spent 100% of their time working in that field. Currently, approximately 10% of the consultant workforce are subspecialists. Table 1.8. Advanced Training Skills Modules statistics (at 29April 2008) 13 Module Registered trainees Completed trainees

Fetal Medicine 6 The Future Workforce in Obstetrics and Gynaecology Advanced Labour Ward Practice 93 3 Labour Ward Lead 23 2 Maternal Medicine 14 Advanced Antenatal Practice 6 Acute Gynaecology and Early Pregnancy 14 1 Gynaecological Oncology 9 2 Sub-Fertility and Reproductive Endocrinology 8 Urogynaecology 16 Benign Abdominal Surgery 12 Benign Vaginal Surgery 12 1 Benign gynaecological Surgery: Laparoscopy 11 Colposcopy 2 Vulval Disease 3 Abortion Care 2 Sexual Health Menopause 1 Paediatric and Adolescent Gynaecology 2 Medical Education 10

Total 255 7

Current training provision The number of accredited subspecialists and RCOG approved training programmes in the UK as of March 2008 is shown in T able 1.9. There has been a progressive increase in the number of subspecialty training programmes since 1984 and this has led to concerns that too many subspecialists may be being trained, with the result that newly accredited subspecialists may not attain a subspecialist consultant post. The types of consultant post attained by accredited subspecialists is shown in Table 1.10. The reasons for subspecialty accredited individuals not working as subspecialist consultants are not known. However, when attempting to determine the number of subspecialist consultants (and hence the number of subspecialty training programmes) required it is important to acknowledge that: (a) some accredited subspecialists will work in large secondary level units (often by choice) and (b) some non-subspecialty accredited consultants (that is, consultants

Table 1.9. Number of accredited subspecialists and approved subspecialty training programmes in the UK (data from RCOG Subspecialty Training Committee at 4 March 2008)

GO MFM UG RM SRH

Accredited subspecialists 97 114 24 77 20 Approved training centres 28 24 15 20 15 Approved programmes 42 36 17 28 23 14 Table 1.10. Type of consultant post attained by accredited subspecialists Subspecialty Pure Special General Overseas Unknown subspecialist interest or not yet appointed

Reproductive medicine 43 15 14 7 7 Maternal and fetal medicine a 62 30 1 6 15 Gynaecological oncologya 64 6 4 8 15 Urogynaecology 12 5525 Sexual and reproductive health a 180202

a A further 6 subspecialty trainees (two in maternal and fetal medicine, 3 in gynaecological oncology and 1 in sexual and reproductive health) did not achieve subspecialty accreditation

with a special interest) will work in tertiary units where, with post-CCT experience, they may acquire expertise in specific clinical areas that is at least equivalent to a subspecialist. Finally, Table 1.11 outlines the numbers of trainees by subspecialty and their projected year of completion of training.

Current service provision: clinical networks Following the publication of A Policy Framework for Commissioning Cancer Services ,9 regional networks in gynaecological oncology have been established, comprising cancer units and cancer centres. The majority of subspecialists work in cancer centres while cancer units are staffed predominantly by gynaecologists with a special interest in gynaecological oncology. Regional care networks are less well established in the other subspecialties. However , the potential to improve patient care by effective clinical networking is widely accepted. Optimal management of complex or rare problems is best provided by a team with appropriate clinical, management and research skills. These teams should be led by subspecialists and based in regional (tertiary) centres. The effectiveness of regional networks is dependent upon the establishment of guidelines for the assessment and/or management of cases in secondary Royal College of Obstetricians and Gynaecologists units and referral into the tertiary centre. In the future, appointees to special interest posts in secondary units will have completed the relevant ATSM(s) during their training.

Table 1.11. Currently registered subspecialty trainees and year of expected completion of training

Year of expected completion GO MFM UG RM SRH

Currently registered (n) 3226141612 2007 33112 2008 79466 2009 14 4553 2010 79211 2011 onwards 1 1230 Attempts to determine the number of consultants required to provide subspecialist services 15 across England and Wales are dependent on the distribution of workload between subspecialist and special interest consultants. This undoubtedly varies by subspecialty and by region. The Future Workforce in Obstetrics and Gynaecology Throughout the next sections we have assumed a 42-week working year and have focused upon direct clinical care P As for activity per million (total) population (for gynaecological services) or per 10 000 maternities (for obstetric services). Specimen job plans have been included for all the subspecialties in Appendix 4.

Implications for the future This working party has identified a number of issues which require further careful consideration: training consultant job plans responsibilities of the on-call consultant census workforce Advisory Committee.

Training

Length and structure of the specialty training programme The length and structure of our specialty training programme would benefit from review . The present minimum training time to CCT is 7 years. Progression occurs through the completion of appropriate competences. After 2 years of basic training and once appropriate competences are attained, a trainee moves on to the middle-tier rota for a further 3 years to complete core training. A minimum of 2 more years are then spent in advanced training including the appropriate ATSMs or subspecialty training prior to CCT. For a number of reasons, but in the main, because of reduced hours of work due to EWTD restrictions, there is accumulating evidence of an increasing number of trainees who, within 2 years, are failing to achieve the necessary competences to proceed to ST3. There is also evidence that trainees are finding it increasingly difficult to complete the minimum of two ATSMs and gain the necessary experience within the 2 years of advanced training to subsequently act independently as a consultant. Given that CCT should represent completion of training, it is difficult to support the trend towards post-CCT fellowships, which ostensibly have been advertised to enable doctors to gain additional experience in a trust prior to consultant appointment. Accordingly, the working party recommends that consideration is given to increasing basic training to 3 years, with a further 2 years to complete core training and 3 years in advanced training. This should ensure adequate opportunity to achieve the competences in basic training necessary to act on the middle-tier rota and then sufficient time to complete ATSMs, particularly in surgical craft areas of special interest, within advanced training. This significant change in the structure of specialty training requires careful consideration and the need for, and benefits of, lengthening the training programme by 1 year would have to be persuasive if it were to be acceptable to the Postgraduate Medical Education and Training Board. 16 Consultant competence It is essential that training to CCT , including the necessary A TSMs, equips the day-one consultant with all the competences and skills required for independent practice in the areas of service delivery required by the modern NHS. The development of the ATSMs has been as a continuation of the earlier Special Skills Modules. T o ensure that the new consultant workforce has the necessary expertise in the relevant areas of clinical need, the nature and curricula of ATSMs require continuing review and development.

Consultant job plans There is growing recognition that clinical care, both day and night, will become increasingly consultant based. Working within clinical teams will become ever more important to ensure safety and so that the full range of skills can be provided 24 hours a day , 7 days a week. As the number of consultants increases, there should be recognition that newly qualified consultants will contribute the major part of hands-on patient care. However , as the role, experience and interests of a consultant develop, so it is likely that their role in service delivery will change, as they further develop roles in clinical leadership, teaching and mentoring. There will also inevitably be increasing specialisation and extension of their senior role into other areas of the wider NHS, including management and contributions to external bodies (such as the Department of Health and Royal Colleges). During the course of a consultant’ s career, the evolution and changes in an individual’ s job plan are likely to reflect on their input into acute service delivery . The impact of ‘seniority’ must be a consideration in workforce planning and the organisation of local working patterns. The working party recommends that further work is undertaken into the factors that influence the evolution of a consultant’s role and the enhancement of career development that recognises and facilitates job plan changes so as to use this experience to the benefit of clinical services and professional teams. The College must be seen to promote consultant career progression and development underpinned by continuing professional development and revalidation.

Responsibilities of the on-call consultant Royal College of Obstetricians and Gynaecologists The RCOG is committed to a consultant-delivered service. While permanent solutions are being sought and implemented, the RCOG has, for the interim period, made recommend- ations to ensure that patients receive high-quality , safe care and to provide appropriate support for trainees. The RCOG recommends that the on-call consultant should attend in person, whatever the level of the trainee, in a number of high-risk situations including, for instance, eclampsia, maternal collapse, caesarean section for major placenta praevia, major postpartum haemorrhage and return to theatre for laparotomy . It is recognised that implementation of these recommendations is likely to result in more night work for the consultant on call. Where necessary, depending on the intensity of their workload it is therefore recommended that consultants should rearrange their clinical duties so that they have no fixed clinical activities the following morning or day.10 Census 17 The capture of meaningful data to inform the working party with regard to clinical activity and the workforce in obstetrics and gynaecology has been difficult. The RCOG annual census The Future Workforce in Obstetrics and Gynaecology is, by its mechanism of data collection, at least 12 months out of date at publication. Through the development of information technology and better linkage with trusts and College tutors, up-to-date or ‘live’ data should be obtainable. In addition, information will be gained about the PA contribution of each consultant and, therefore, their contribution to service delivery . The measurement of clinical activity relies on central information such as via Hospital Episode Statistics. The College does not wish to duplicate data capture but does require this clinical information for an understanding of workload and working patterns. Analysis of activity can then be made with national, strategic health authority, trust or individual comparisons. The continuing collection (census) of accurate data on both workforce and activity is essential if there is to be the best possible guidance for future workforce planning.

Workforce Advisory Committee The working party recommends that the RCOG W orkforce Advisory Committee should be reinstated and should include among its membership the Workforce Advisor (chair), the chair of the Specialty Education Advisory Committee, the chair of the Subspecialty Committee, the ATSM Officer, the V ice President (Education) the chair of the T rainees’ Committee (or representative), Head of Postgraduate T raining and representatives from the Department of Health.

Key points

Assumptions Workforce calculations are based on the number of subspecialist and special interest consult- ants required to deliver care to a defined total population of one million (for gynaecology) and 10 000 deliveries (for obstetrics). The working year, as far as calculation is concerned, is based upon 42 weeks and the model contract is limited to ten PAs. This constitutes one WTE consultant. The population of England and Wales is 53.7 million (2006).

1 Gynaecological oncology We propose that there should be three subspecialists/million population and five special interest consultants/million over the next 5 years. We propose there should be seven subspecialty trainees/year and 11 trainees with a special interest/year. We estimate that the service should aim for 160 subspecialists and 265 consultants with a special interest/year. See Part 2 Section 1 for details. 18 2 Reproductive medicine We propose there should be 2.5–3.0 subspecialists/million population and approximately four consultants with a special interest. We propose there should be six subspecialty trainees/year and approximately 8–10 trainees with a special interest/year. We estimate the service should aim for 140–150 subspecialists and approximately 200 consultants with a special interest. See Part 2 Section 2 for details.

3 Fetal and maternal medicine We propose there should be 8.7 direct clinical care subspecialty P As/10 000 maternities (that is, two to three WTE) and 21.7 direct clinical care P As/10 000 maternities provided by consultants with a special interest (that is, 7–10 WTE). We propose there should be six subspecialty trainees/year and approximately 24 trainees undertaking a special interest ATSMs across the different elements/year (that is, four fetal, ten maternal medicine and ten advanced antenatal practice). We estimate the service should aim for 150 subspecialists and between 480–725 consultants with a special interest (this depends upon either three or two direct clinical care PAs/special interest consultant). To provide optimal patient care with the best use of trained consultant manpower , high- risk obstetric services may be best delivered on a network basis whereby individual units or trusts provide some specialist services and refer to adjacent units or trusts for others (or when local specialist consultants are unavailable). There is an urgent need to increase the number of trainees undertaking A TSMs in obstetrics. See Part 2 Section 3 for details.

4 Delivery suite

Royal College of Obstetricians and Gynaecologists The majority of consultants will be expected to undertake some obstetric duties for the foreseeable future, with the exception of the majority of the gynaecological subspecialists. The number of trainees undertaking an ATSM specific to delivery suite activity requires further assessment. We propose that there should be 10–15 trainees completing the labour ward lead ATSM/year. As the majority of consultants of the future are likely to have a role on the delivery suite, it is recommended that all trainees, with the exception of those undertaking gynaecological subspecialties, would be expected to take the Advanced Labour Ward Practice ATSM at some stage in years ST6–7. The number of WTE consultants for the delivery suite alone equates to nine for 168 hours, five for 98 hours and three for 60 hours. Any other direct clinical care activity for obstetrics and/or gynaecology needs to be added. See Part 2 Section 4 for details. 5 Urogynaecology 19 We propose there should be one subspecialist/million population and approximately six to seven consultants with a special interest/million population. The Future Workforce in Obstetrics and Gynaecology We propose there should be three subspecialty trainees/year and approximately 12 trainees/year with a special interest undertaking appropriate ATSMs. However, until the curriculum of this module and the experience it provides has been assessed, any restriction of subspecialty training opportunities should be exercised with caution. We estimate the service should aim for 50–55 subspecialists and approximately 350 consultants with a special interest. See Part 2 Section 5 for details.

6 Sexual and reproductive health We propose that there should be 200 specialty trained consultants to act as service leads in primary care trusts. We estimate 225–250 additional consultants with a contribution to service. See Part 2 Section 6 for details.

7 Minimal access surgery We propose that there should be 20–25 trainees/year undertaking appropriate A TSMs, with two to three developing advanced laparoscopic skills/year. This element of service requires more detailed information and workforce planning. See Part 2 Section 7 for details.

8 Menstrual disorders This element of service requires more detailed information and workforce planning and has significant implications for the number of trainees undertaking benign gynaecological surgery in addition to those undertaking urogynaecology as an A TSM. The very approximate estimation is for ten trainees/year undertaking benign gynaecological surgery ATSMs. See Part 2 Section 8 for details.

9 Early pregnancy assessment units We suggest that early pregnancy assessment unit and emergency gynaecology care undertake an urgent review of service to map the future requirements and that, for the present, 15–20 trainees undertake an appropriate ATSM each year. See Part 2 Section 9 for details.

10 Academic obstetrics and gynaecology We propose that three to four trainees undertake the appropriate academic training pathway each year. 20 We suggest that there needs to be greater emphasis and investment in clinical academic training posts.

General We have calculated the contribution which subspecialty and special interest obstetricians could make to the total delivery suite cover requirements and we have provided an estimate of the shortfall of delivery suite P As that would need to be provided by special interest gynaecologists. The calculations for each of the subspecialties are robust. The calculations for benign gynaecological surgery (including paediatric gynaecology) are a reasonable guess. The calculations for the remainder (medical gynaecology, early pregnancy assessment units and emergency gynaecology) are a best estimate. Based on current trainee recruitment, retirements and loss of CCT holders, we have estimated the impact on total consultant posts through to 2020.The consultant requirement is approximately 2850 at a contract of ten P As or 3000–3100 as equivalence of full-time working becomes more clear.

Synopsis The provision of safe, high-quality care requires an appropriately sized, skilled, competent and well-trained workforce. These workforce figures and calculations represent the best estimates possible and must now guide us towards planning the necessary workforce that has the skills and expertise, in the appropriate areas, to deliver quality care, which will be increasingly consultant delivered. While acknowledging the complexities of workforce planning and the continuing rapid evolution of service delivery, there is a clear need for consultant expansion from the present 1800 consultants to approximately 3000. Training numbers and programmes must reflect the future needs for service delivery. Training numbers should approximately reflect projected consultant opportunities; annual recruitment into specialty training should reduce to approximately 150–160 trainees/year. In view of the impact of the EWTD, urgent consideration should now be given to lengthening Royal College of Obstetricians and Gynaecologists the duration of the training programme. Workforce planning, mediated through deaneries and postgraduate schools, should now move to encompass planning the number of trainees entering into subspecialty training and into the various ATSMs. There is still much to achieve but the recommendations of this working party, fully considered by the RCOG Council, should now be adopted. Implementation of the recommendations will go a long way to shaping the high-quality service to which we all aspire. Part 2 THE SUBSPECIALTIES IN OBSTETRICS AND GYNAECOLOGY

1 Gynaecological oncology 23

Key points We propose that there should be three subspecialists/million population and five special interest consultants/million over the next 5 years. We propose there should be seven subspecialty trainees/year and 11 trainees with a special interest/year. We estimate that the service should aim for 160 subspecialists and 265 consultants with a special interest/year.

Current service provision Gynaecological oncology services throughout the UK are delivered by managed networks and there are strong established links between the cancer centre and units. There are currently 42 cancer centres in the UK, each of which serves an average population of 1.6 million. 11 The multidisciplinary teams based in the cancer centres are led by subspecialist gynaecological oncologists. Currently, there are 80 subspecialist gynaecological oncologists working in England and Wales (Subspecialty Training Committee, 2008). In addition, it is estimated that there are 60–70 consultants whose working practice is equivalent to an accredited subspecialist but who were trained before the introduction of subspecialty training (so-called ‘grandfathers’) (M Paterson, personal communication). Data from the last RCOG Medical Workforce report, published in 2008 (but referring to the workforce census of 2007), reported the number of ‘accredited’ and ‘not accredited’ subspecialists in gynaecological oncology as 37 and 40, respectively, inferring significant consultant expansion and/or substantial under-reporting in the census.6 The same report indicated there were 104 consultants with a special interest in gynaecological oncology in England and W ales. The total number of programmed activities (P As) provided by all consultants practising gynaecological oncology (that is, subspecialist and special interest) was reported to be 906/week (or around 17/million population).6 A more detailed analysis of consultant gynaecological oncology subspecialist provision in four cancer networks in the UK is shown in T able 2.1. On average, there were 2.4 sub- specialist consultants/million population providing an average of 15.7 (range 11.0–19.4) PAs of clinical care/week/million population (with each consultant providing an average of 6.8 PAs of direct clinical care).

Gynaecological oncology workload and predicted changes in incidence of gynaecological cancers The number of gynaecological cancers diagnosed in England and W ales in 2004 is shown in Table 2.2.12 Overall, there were nearly 15 000 cancers diagnosed (or 283/million population). Cancer is diagnosed in less than 10% of women with suspicious symptoms, such as post- menopausal bleeding, and, hence, it is estimated that around 200 000 women/year will require screening to diagnose all gynaecological cancers. Table 2.1. Current gynaecological oncology subspecialist provision within four cancer networks within the 24 UK (source: A Jeyarajah, personal communication) Network Population Accredited Grandfathers* Consultants/ Total direct Direct (million) subspecialists million clinical care clinical care population PAs/week PAs/million population NE London 1.6 3 2 3.1 29.0 18.1 Yorkshire 2.7 6 0 2.2 52.5 19.4 Kent & Medway 1.59 1 1 1.3 17.5 11.0 Northern Ireland 1.7 3 2 2.8 24.0 14.1 Average 1.9 – – 2.4 – 15.7 * Consultants whose working practice is equivalent to an accredited subspecialist but who were trained prior to the introduction of subspecialty training.

The population in England and W ales is rising steadily and people are living longer . This trend is likely to continue, as is the increasing immigrant population from the European Union.13 Currently, cancers of the ovary, uterus and cervix are the fourth, fifth and ninth most common cancers in females in the UK. The number of new cases of gynaecological cancer is expected to rise to 18 000 by 2020 (T able 2.3). Specifically , the considerable rise in the incidence of cancer of the endometrium, due to both increased obesity and other significant comorbidities in the population and also to the fact that fewer hysterectomies are being performed for benign reasons, is expected to continue. The likelihood is that the referral of such patients to cancer centres is only likely to increase in the present climate, particularly as the older consultants with a broad range of surgical experience are replaced. Although not as dramatic, the incidence of ovarian cancer is also expected to rise (25%), owing to an aging population.14 In addition, there are a number of clinical trials looking at primary surgery/interval debulking. Thus, in the future, more aggressive surgery may be advocated in this group, as seems to be the case in Europe and the USA. In contrast, the incidence of cervical cancer has fallen by 25% in the past 10 years. There is, however , recent evidence of reduced uptake in cervical screening in young women. 15 Furthermore, with increased immigration from areas of the world where screening is not available, this perceived reduction in disease may not be as dramatic as hoped. In areas of the UK where screening uptake is low (such as Northern Ireland), the incidence of cervical cancer has not fallen. It is therefore predicted that there will only be a further small fall in the incidence of cervical

Royal College of Obstetricians and Gynaecologists cancer in the next 10years, which is likely to be nearer 12%. Although it is predicted that vaccination against high risk human papillomavirus will significantly reduce the incidence of invasive disease for cervix and vulva, it is unlikely to have much effect before 2020. Finally , subspecialists also undertake a significant amount of complex benign surgery . W ith the overall reduction in gynaecological surgical experience within the specialty , it is likely that this workload will increase.

Table 2.2. Gynaecological cancers in England and Wales, 2004 (source: Cancer Research UK)11 Cancer Cases (n) Rate/million female population Cervix 2377 89 Endometrium 5708 200 Ovary 5778 217 Vulva 907 33 Vulva 213 8 Total 14983 547 Table 2.3. Numbers of gynaecological cancers in England; recorded versus predicted incidence7 25 Cancer 2001 2020 Percentage change Cervix 2420 2123 –12 The Future Workforce in Obstetrics and Gynaecology Endometrium 4684 7149 +53 Ovary 5612 6933 +24 Total 12716 16205 +27

Workforce needs in gynaecological oncology Two approaches were taken to address manpower needs in gynaecological oncology . Firstly, the opinion of professional groups was sought regarding the number of consultant subspecialist posts. Secondly, using assumptions on average caseload, the number of P As to deliver care to women with gynaecological cancers in England and W ales was estimated.

Professional opinion

Network site-specific group leads survey To inform the prediction of manpower needs over the next 10–15 years, the network leads in gynaecological oncology surveyed their members to profile the projected retirements and local appointments. They also enquired about the number of subspecialists that gynaecological oncology leads considered would be required to staff their cancer centres. Replies were forthcoming from 50% of leads and the perceived average need was 3.5 gynaecological oncologists. Assuming an average consultant works seven direct clinical care PAs, this equates to 24.5 P As/centre (or, assuming an average of 1.6 million population/ centre, around 15 PAs/million population).

Workforce planning in Scotland The RCOG carried out an assessment of the medical work force planning in Scotland in 2005.16 Based on the then current practice of special interest practitioners in cancer units carrying out a considerable amount of subspecialist work (especially surgery on ovarian cancer) with less centralisation of care in cancer centres, the W orkforce Committee recommended 16 subspecialists (in three centres) for a population of 5.1 million (that is, 3.1 subspecialists/million population). Assuming that a consultant works an average of seven direct clinical care PAs, this equates to 21.7 PAs/million population.

Cancer reform strategy In 2007, the British Gynaecological Cancer Society and Network Site Specific Group leads submitted a joint paper to inform the NHS Cancer Reform Strategy Development Group of future developments in gynaecological cancer .17 The document acknowledged the likely increase in gynaecological cancer over the next 5 years and that patients would be on average older and would have more comorbidities and that treatments would become more complex. The document also acknowledged an increased use of laparoscopic surgery and a greater tendency for surgeons to work in closer teams with two consultants at times operating together. Other additional demands identified were extended multidisciplinary team working, reduction in support from middle grades (European W orking Time Directive), cancer access 26 targets, peer review and extra administrative duties. The document recommended that 3.5 subspecialists/million population were required to provide care within cancer centres. Again assuming a consultant works an average of 7 direct clinical care P As, this equates to 24.5 PAs/million population.

Number of cancers treated Based on the assumption that each gynaecological oncology subspecialist treats approxi- mately 100 new gynaecological cancers/year , the impact of different levels of subspecialist gynaecological oncology consultant provision for England and W ales is shown in Table 2.4. A manpower target of three subspecialist consultants/million population equates to a total of 159 consultants and 1113 P As of subspecialist care. This would provide care for around 16 000 women with gynaecological cancer. This is in line with the number of cases predicted to occur by 2020.

Gynaecologists with a special interest in gynaecological oncology There are around 200 cancer units in England and Wales (M Paterson, personal communication). Each recognised cancer unit should have a gynaecologist with a special interest in gynaecological oncology leading a local multidisciplinary team and performing a certain amount of surgery. The provision of care in cancer units is changing, owing to a continuing trend towards centralisation of oncology treatment and the retirement of gynaecologists with the skills necessary to perform oncological surgery. This is reflected in the RCOG gynaecological oncology ATSM, which does not include complex surgery . As more and more new consultants holding this A TSM are appointed as lead clinicians of cancer units, it is anticipated that the amount of cancer surgery performed outside cancer centres will reduce further. With greater emphasis being placed on meeting cancer access standards, it is likely that all but the smallest hospitals will require a gynaecologist with a special interest in gynaecological oncology who will organise services locally and work closely with the cancer centre team. In the future, this would be a consultant who has completed the A TSM in gynaecological oncology with or without additional ATSMs (such as in colposcopy or advanced abdominal surgery). It is envisaged that such posts will include three to four direct clinical care PAs (not including colposcopy). In larger hospitals, consultants with a special interest in gynaecological oncology may also need a deputy with one to two P As dedicated to the service. Other

Royal College of Obstetricians and Gynaecologists consultants or health professionals may also contribute to the colposcopy service.

Table 2.4. Total number of consultant posts (and programmed activities) and new cancers treated with different levels of subspecialist provision/million population Subspecialist Total consultant Total subspecialist Total subspecialist New cancers consultants subspecialistsa clinical care PAs/ clinical care PAs/ seen (n)c million weekb week/million population populationa 2.5 132.5 928 17.5 13 250 3.0 159.0 1113 21.0 15 900 3.5 185.5 1299 24.5 18 550 4.0 212.0 1484 28.0 21 200 a Assumes population of England and Wales is 53 million7 b Assumes each consultant provides 7 PAs of direct clinical care c Assumes each consultant sees an average of 100 new gynaecological cancers/year Recommendations 27 The number of subspecialist gynaecological oncologists should be increased to a maximum of three/million population over the next 5 years (providing a total of around 1100 P As of The Future Workforce in Obstetrics and Gynaecology clinical care/week or 21 PAs/week/million population). With this manpower provision, each cancer centre would have an average of four subspecialist gynaecological oncologists. Thereafter, there may be a need to increase subspecialist provision further , depending on updated information on the incidence of gynaecological cancers. The number of gynaecologists with a special interest in gynaecological oncology should be increased to a maximum of five/million population over the next 5 years (providing a total of around 1000 P As of clinical care/week or 19 P As/week/million population). W ith this manpower provision, each cancer unit would have 1.0–1.5 gynaecologists with a special interest in gynaecological oncology . If it assumed that around 200 000 women/year require screening to diagnose all gynaecological cancers (see above), this would mean that each gynaecologist with an interest in gynaecological oncology would screen approximately 750 women/year. As with subspecialist numbers, there may be a need to increase special interest consultant numbers thereafter , depending on updated information on the incidence of gynaecological cancers.

Conclusions Data on the incidence of gynaecological cancers and established clinical care networks in gynaecological oncology suggest that the recommended manpower numbers are reasonably robust. Thus, in a deanery with a population of 3.5 million and two cancer centres, a gynaecological oncology network would require 10.5 subspecialist and 17.5 special interest gynaecological oncologists. Translating these numbers into the required number of subspecialty and A TSM training programmes is dependent upon a number of assumptions, particularly the average number of years a consultant works (Table 2.5). If this is assumed to be 30 years then the aim should be to appoint 5.6 subspecialists and 8.8 consultants with a special interest in gynaecological oncology/year. To allow for some ‘wastage’ within the training system and also to retain some degree of competitiveness for consultant posts, it would seem reasonable to recruit no more than seven gynaecological oncology subspecialty trainees and 11 special interest trainees in England and Wales/year.

Table 2.5. Number of subspecialists and consultants with a special interest in gynaecological oncology required/year in England and Wales, assuming a manpower target of 3/million and 5/million population, respectively Average working life of Subspecialist consultants Consultants with a special interest a consultant (years) needed/year (n) in gynaecological oncology needed/year (n) 25 6.4 10.6 30 5.6 8.8 35 4.5 7.6 28 2. Reproductive medicine

Key points We propose there should be 2.5–3.0 subspecialists/million population and approximately four consultants with a special interest. We propose there should be six subspecialty trainees/year and approximately 8–10 trainees with a special interest/year. We estimate the service should aim for 140–150 subspecialists and approximately 200 consultants with a special interest.

Current service provision The core clinical service provided by reproductive medicine consultants is the assessment and management of couples with subfertility, particularly in vitro fertilisation (IVF) and assisted conception. Other areas of clinical expertise may include complex gynaecological endo- crinology and andrology , endometriosis, paediatric gynaecology , recurrent miscarriage, menopause, termination of pregnancy and contraception, chronic pelvic pain and premenstrual syndrome and psychosexual counselling. Subspecialist consultants in reproductive medicine develop specialist services in some of these clinical areas (such as endometriosis and reproductive endocrinology), often supported in larger units by consultant gynaecologists with a special interest in the clinical area. In many units the reproductive medicine consultants undertake the surgical management of the complex endometriosis cases. For other areas of reproductive medicine practice within a unit, services may be provided entirely by gynaecologists with a special interest in this subspecialty. Most subspecialists also contribute to emergency and elective gynaecological care and some may even contribute to emergency obstetric care. Currently, there are 77 Members and Fellows of the RCOG accredited as reproductive medicine subspecialists; 43 are known to work as subspecialists in reproductive medicine and a further 15 as gynaecologists with a special interest in reproductive medicine (Part 1, T able 1.9). Data from the last RCOG Medical Workforce Report, published in 2008 (but referring to the Workforce Census of 2007), 6 reported the number of ‘accredited’ and ‘not accredited’ subspecialists in reproductive medicine in England and W ales was 19 and 24, respectively , with a further 107 consultants having a special interest in reproductive medicine. However there are concerns about underreporting of consultant numbers in the census, as mentioned earlier. According to the W orkforce Report, the total number of P As provided by all consultants practicing reproductive medicine (that is, subspecialist and special interest) was 482 (around 3.2 PAs of clinical care per consultant/week).6 The nature of these sessions is unspecified and could include outpatient clinics (fertility , hormone replacement therapy and so on), oocyte retrieval, embryo transfer, theatre sessions and administration. Reproductive medicine workload 29 Reliable national data exist for the number of IVF cycles from the Human Fertilisation and Embryology Authority (HFEA). 18 There are 70 HFEA licensed clinics in England and W ales The Future Workforce in Obstetrics and Gynaecology providing 44 275 cycles of IVF/year in 2006, (an average of approximately 630 cycles/centre). The demand for IVF and other assisted reproductive technologies (AR T) is constantly growing and it is not envisaged that the NHS provision of AR T will meet the National Institute for Health and Clinical Excellence recommendations, at least for the foreseeable future. Thus, a substantial proportion of AR T in England and W ales will continue to be delivered in the private sector, frequently by consultants with concurrent NHS subspecialist appointments. In an attempt to ascertain other consultant-based clinical activity related to reproductive medicine the Hospital Episode Statistics (HES) for England in 2005/06 were searched under diagnoses relevant to reproductive medicine (female subfertility , ovarian dysfunction, recurrent miscarriage, endometriosis, menopause and perimenopausal disorders, male infertility and testicular dysfunction). 19 HES data provide information on the care provided by NHS hospitals and for NHS patients treated elsewhere. While outpatient data would have been the most useful, it was clear that referral data relating to reproductive medicine in general and fertility-related problems in particular were grossly inaccurate. Statistics on inpatient data appeared more robust and a detailed breakdown for reproductive medicine related diagnoses is provided in T able 2.6 and a summary of finished consultant episodes (FCE) for relevant diagnoses is shown in Table 2.7. However, HES data give no indication of the level of complexity of the cases and, hence, it is not possible to make inferences about what proportion of cases in each diagnostic group are managed by general gynaecologists, gynaecologists with a special interest in reproductive medicine and subspecialists. Furthermore, it is unclear what proportion of the FCEs ascribed to endometriosis was directly related to subfertility . If it is assumed that 20% of the total FCEs are managed by subspecialists and that there are only 43 practicing subspecialists in England and Wales (Part 1, Table 1.9) then each subspecialist would only contribute 255 FCEs related to reproductive medicine/year. This suggests that the reproductive medicine workload is underestimated in the HES data.

Workforce needs in reproductive medicine Owing to the lack of accurate data on reproductive medicine workload and the uncertainties regarding subspecialist and special interest workload, it proved impossible to derive robust estimates of manpower needs in reproductive medicine. In an attempt to provide some guidance on subspecialist consultant numbers, two approaches were taken. Firstly , based on current subspecialist provision and, secondly, based on infertility workload.

Current subspecialist consultant numbers According to the last RCOG manpower report there are 150 consultants with a subspecialist or special interest in reproductive medicine.6 If it is assumed that approximately 50% of these posts will ultimately be staffed by subspecialist consultants then approximately 75 subspecialists (1.4/million population) would be required delivering 525 P As of clinical care per week (or 9.9 P As/week/million population). This equates to approximately one subspecialist/HFEA licensed centre in England and Wales. Royal College of Obstetricians and Gynaecologists 30 –410 0–14 575 10 All ages 558 7 60–74 15–59 24315 0–14 13536 b) Male 3142 24468 All ages 7748 75+ 13578 60–74 15–59 0–14 52 16458 134 75+ 16754 60–74 15–59 0–14 169 All Ages 169 7 60–74 15–59 0–14 1678 13 All ages 7 14 1647 60–74 15–59 0–14 All 75+ 66 1240205 60–74 252 15–59 ages 2 01 – 0–14 69930281442071 2405 1021370114195 9800 9789 (years) ( 10056 16287 2 10 a) Female Table 2.6. l gs953 FCEs =Finishedconsultant episodes 245 All ages 661 7 60–74 15–59 g ru FE Amsin Eegny atn Dycss Beddays Daycases Waiting Emergency Admissions FCEs Age group l gs19816783 16948 All ages ENDOMETRIOSIS RECURRENT MISCARRIAGE OVARIAN DYSFUNCTION FEMALE INFERTILITY TESTICULAR DYSFUNCTION MALE INFERTILITY MENOPAUSE AND PERIMENOPAUSAL DISORDERS 5 5 5 5 +660641 +–––––– +441331 +3 optleioe eae orpoutv eiie England2005/06 Hospital episodesrelatedtoreproductivemedicine, n –––––– –––––– –––––– 11011– 873438 73 ) ( 7702 1604 3044 1664 951 245 661 600 556 132 170 169 101791 10 51 130899 145689 n 21 5 ) ( 4814578 1458 3829511414140 17134 20925 1348 4614877 1476 5 10 10826 11804 360 457 417 531 424 n 9 7 5 0 6 1 5 7 6 5 ) list ( 6745 1076 2343 1121 423 555 121 109 292 514 124 120 10 39 n 53 ) ( 17 9428083 6984 5116 1165 1928954 7109 882 445 140 854 231 611 409 139 896 10 18 27 n 12 ) ( 3949 4832 1381 5352 1421 140 165 135 584 61 21 39 21 n – 3 0 1 ) Table 2.7. Summary of finished consultant episodes related to reproductive medicine (source: Hospital 31 Episode Statistics for England 2005/06)17 CATEGORY FCEs The Future Workforce in Obstetrics and Gynaecology Female infertility 10056 Ovarian dysfunction 1675 Recurrent miscarriage 169 Endometriosis 16950 Menopause 24470 Male infertility 576 Testicular dysfunction 953 Total 54852

FCEs = finished consultant episodes

Infertility workload While the distribution of ART workload between NHS and the private sector may change in the future, this does not impact on manpower planning, as all consultants providing these services need to be appropriately trained. It is reasonable to suggest that in the future all ART workload should be supervised by a reproductive medicine subspecialist (even though they themselves may not carry out all the practical procedures). In terms of AR T cycles, professional opinion amongst reproductive medicine subspecialists indicates that approximately 300 AR T cycles/subspecialist/year is a reasonable workload (N McClure, personal communication). Based on this figure, there would be a requirement for 147 subspecialists (2.77/million population) to manage the around 44 275 ART cycles currently performed in England and W ales. This equates to around two subspecialists/HFEA licensed centre in England and Wales. It has been estimated that there are approximately 1000 referrals for subfertility/year/million population (that is, 53 000/year in England and W ales.16,20 While many of these will be managed by gynaecologists with a special interest in reproductive medicine, probably around 50% will be seen by a reproductive medicine subspecialist either as a ‘tertiary’ referral or as a secondary referral from their local population. The number of subspecialists required to manage these referrals depends on the number of new referrals seen in each outpatient clinic and the average number of P As subspecialists dedicate to seeing subfertility patients/week (Table 2.8). A survey of reproductive medicine subspecialists indicated that a reproductive medicine subspecialist has on average 1.0–1.5 P As/week dedicated to subfertility outpatient work and during each clinic (PA) they see an average of five new referrals for subfertility (N McClure, personal communication). Thus, manpower estimates using subfertility referral data are broadly consistent with those derived from AR T workload and suggest a requirement for around 105–110 subspecialist reproductive medicine consultants.

Recommendations The number of reproductive medicine subspecialists should be increased to a maximum of 2.5–3.0/million population over the next 5 years (providing a total of around 750 P As of clinical care/week or 19 PAs/week/million population). With this manpower provision, each HFEA licensed centre in England and Wales would have around two subspecialists. Table 2.8. Number of subspecialist consultants in reproductive medicine required to manage the infertility 32 referrals in England and Wales depending on variations in consultant working practice New referrals/clinic (n) PAs dedicated to subfertility outpatient work/weeka (n) 1 1.5 3 210 140 5 126 84 7 90 120 a Assumes there are 53 000 infertility referrals in England and Wales/year, of which 50% are seen by reproductive medicine subspecialists (either as secondary or tertiary referrals) and each subspecialist works an average 42 weeks/year

Owing to the lack of robust data on reproductive medicine workload, other than subfertility, and the diversity of special interests provided by reproductive medicine consultants, it is not possible to make any robust estimates of manpower needs for gynaecologists with a special interest in reproductive medicine. It is anticipated that the provision of reproductive medicine services to a defined population will be dependent on the local expertise available. This expertise is unlikely to be available in every NHS trust, requiring the development of clinical networks. While many reproductive medicine services will be provided by consultants with relevant ATSMs (such as those covering subfertility and reproductive endocrinology , benign gynaecological surgery: laparoscopy , menopause, paediatric and adolescent gynaecology), with referral of complex cases to subspecialists, other services are more likely to be provided by gynaecologists working in partnership with sexual and reproductive health subspecialists (for example, abortion care, sexual health, menopause).

Conclusions The absence of accurate data on the incidence and referral patterns of most aspects of reproductive medicine practice means that subspecialist manpower recommendations can only be made on the basis of subfertility and AR T workload. This has obvious limitations. However, based on the data available, a deanery with a population of 3.5 million would require nine subspecialists in reproductive medicine to oversee subfertility services. No recommendations can be made about manpower needs for consultants with an interest in reproductive medicine. Royal College of Obstetricians and Gynaecologists The number of reproductive medicine subspecialists required/year depends upon the average number of years a consultant works. If this is assumed to be 30 years then the aim should be to appoint five subspecialists in reproductive medicine/year . To allow for some ‘wastage’ within the subspecialty training system and also to retain some degree of competitiveness for consultant subspecialty posts, it would seem reasonable to recruit no more than six reproductive medicine subspecialty trainees in England and Wales/year. 3. Fetal and maternal medicine 33

Key points We propose there should be 8.7 direct clinical care subspecialty P As/10 000 maternities (that is, two to three WTE) and 21.7 direct clinical care P As/10 000 maternities provided by consultants with a special interest (that is, 7–10 WTE). We propose there should be six subspecialty trainees/year and approximately 24 trainees undertaking a special interest ATSMs across the different elements/year (that is, four fetal, ten maternal medicine and ten advanced antenatal practice). We estimate the service should aim for 150 subspecialists and between 480–725 consultants with a special interest (this depends upon either three or two direct clinical care PAs/special interest consultant). To provide optimal patient care with the best use of trained consultant manpower , high- risk obstetric services may be best delivered on a network basis whereby individual units or trusts provide some specialist services and refer to adjacent units or trusts for others (or when local specialist consultants are unavailable). There is an urgent need to increase the number of trainees undertaking A TSMs in obstetrics.

Introduction Although subspecialty training includes both fetal and maternal medicine, there is an increasing trend for distinct fetal medicine and maternal medicine clinical networks. While subspecialist consultants may contribute to both services in tertiary centres, consultants in secondary units tend to have a special interest in one area. W orkforce needs were therefore estimated for fetal medicine and maternal medicine separately. Further, with the introduction of the advanced antenatal practice A TSM, there was also a need to consider the possible impact of consultants with this special interest on maternal medicine and fetal medicine workload.

Current service provision in fetal medicine

Deanery survey To accurately determine current consultant care provision for fetal medicine, a survey was conducted, via subspecialty leads in five regional centres. Data were collected on current consultant P As dedicated to fetal medicine in all units within the respective deaneries (Northern, Y orkshire, SW Thames, W essex and W est Midlands) (T able 2.9). Data were supplemented, where necessary, by direct telephone contact. Complete data were available from three deaneries, while limited data were available for W essex and W est Midlands. Consultant PA commitment to fetal medicine ranged from 6.68–9.09/10000 maternities in the three deaneries with complete data, of which 2.68–3.23 P As/10000 maternities were provided by subspecialists. Table 2.9. Consultant programmed activities (PAs) for fetal medicine in five deaneries 34 Deanery Deliveries (n) Units (n) PAs/week (n) PAs/week/10 000 maternities (n)c Special Subspecialist Special Subspecialist interest interest Northern 33019 14 20.0 10 6.06 3.03 Yorkshire 41157 13 16.5 11 4.00 2.68 SW Thames 34051 8 17.0 11 4.99 3.23 Wessex 28279 10a 12.0 10 6.45 3.54 W Midlands 59418 17b 17.5 17 7.41 2.86

a Data available for 6 secondary units; b data available from 7 secondary units; c PA calculations/10 000 deliveries based on total secondary care deliveries from units returning data

National manpower survey Forty-seven of the 61 units (including 164 199 deliveries) which returned the questionnaire provided data on fetal medicine clinics. These included tertiary referral units (with subspecialist and special interest consultants) and secondary units (with special interest consultants). Assuming that one fetal medicine clinic equates to one P A of consultant time, the number of PAs/week/10 000 deliveries averaged 7.95. This figure for total fetal medicine sessional support is consistent with that obtained from the limited but complete deanery survey described above.

Fetal medicine manpower requirements based on disease burden To better inform consultant manpower needs in fetal medicine, A McEwan, in collaboration with the Education and T raining Group of the British Maternal and Fetal Medicine Society (BMFMS), undertook a detailed analysis of ‘theoretical’ fetal medicine workload based on the number of outpatient visits (appointments) required for fetal medicine cases/10 000 maternities. This was based on the reported prevalence of fetal anomalies and the clinical

Royal College of Obstetricians and Gynaecologists experience of the group. The list of conditions was taken directly from the fetal medicine section of the subspecialty curriculum.

Antenatal fetal medicine outpatient workload The estimated number of outpatient visits to special interest and subspecialist consultants, according to the main diagnostic groups within fetal medicine, are shown in Table 2.10. Some of the assumptions underpinning these calculations are detailed in Appendix 5. The proportion of secondary care cases referred to subspecialist consultants was determined by consensus; for example, for some anomalies (such as anencephaly) the majority would be managed entirely by consultants with a special interest in fetal medicine, for others (such as cardiac outflow tract anomalies) all cases will be referred to a subspecialist for diagnosis and management. The number of outpatient visits for each anomaly or diagnosis was also determined by consensus; for example, for continuing cardiac outflow tract anomaly diagnosed outside a tertiary unit, a total of four outpatient appointments was assumed (one initial appointment with a local special interest consultant and three appointments with a subspecialist consultant). The incidence of specific fetal anomalies was obtained from the UK 35 Congenital Anomalies Registers and EUROCA T (European Surveillance of Congenital Anomalies). The proportion of cases detected before birth was calculated from East Midlands

& South Yorkshire Congenital Anomalies Register data. The Future Workforce in Obstetrics and Gynaecology Other assumptions made were: 80% of maternities are booked in secondary care units. An average fetal medicine visit (appointment) is 30 minutes but allowance was made for the increased time required for new referrals (assumed to be 60 minutes: equivalent to two review visits). Some isolated soft markers (such as increased nuchal fold, pyelectasis) would have a repeat scan by a consultant with a special interest in fetal medicine. Many cases of nuchal thickening will be picked up in the future as part of first-trimester screening. These cases are not double counted but it is recognised that continuing pregnancies will warrant further appointments. Table 2.10 indicates that the total number of outpatient visits required to provide fetal medicine services to a population of 10 000 maternities/year is 1884, of which 825 are provided by subspecialist consultants. In an attempt to confirm these calculations, the fetal medicine consultant outpatient workloads from two secondary level units (Fife, kindly provided G T ydeman, and Epsom and St. Helier , kindly provided by H Shehata) and one tertiary level unit (Royal V ictoria Infirmary, Newcastle (kindly provided by P Moran) were reviewed (T able 2.11). On initial inspection, it appears that the calculated workload significantly underestimated the actual consultant fetal medicine workload in these units, particularly within secondary care. However , the data provided are total consultant ultrasound appointments and include scans for several indications not included in the detailed analysis undertaken by the BMFMS group, such as nuchal translucency screening and monitoring of small-for-gestational-age fetuses.

Table 2.10. Summary of special interest and subspecialist workload by number of visits in fetal medicine Anomalies Special interest Subspecialist visits/10 000 visits/10 000 maternities maternities Fetal anomaliesa 394 399 Down syndrome screening and diagnosisb 164 168 Red cell alloimmunisationc 107 78 Monogenic disordersd 24 30 Fetal growth restrictione 48 12 Multiple pregnanciesf 294 125 Maternal infectionsg 28 13 Total 1059 825 a For detailed analysis see Appendix 7.1; b For detailed analysis see Appendix 7.2; c For detailed analysis see Appendix 7.3; d Based on data from Yorkshire region where chorionic villus sampling rate for monogenic disorders = 11/10 000 (G Mason, personal communication): assumes all cases already counselled by a clinical geneticist; e Majority of these cases will be managed by consultants with a special interest in advanced antenatal practice. However, assume severe preterm fetal growth restriction (incidence 10/10 000 maternities) managed locally by special interest and/or subspecialist consultants (average 6 visits); f For detailed analysis see Appendix 7.4; g For detailed analysis see Appendix 7.5 Table 2.11. Number of outpatient consultant fetal medicine appointments or scans in 2006 in three units 36 with an established fetal medicine service Type of unit Deliveries/unit Fetal medicine Structural Visits/10 000 (region) (n) visits or anomalies maternities (n) appointments (n) (n) Fifea Secondary 3453 646b 92 1870 Epsom & St Heliera Secondary 4965 1637a 69 3297 Newcastleb Tertiary 5699 (29340) 3947 N/A 1347 a Includes all consultant scans; b Includes all fetal medicine appointments

Postnatal and preconception fetal medicine outpatient workload Consultants with expertise in fetal medicine will see women (with or without their families) for post-termination counselling and for preconception counselling (usually one visit each). The group was unable to find any published data on the workload involved. At the Royal Victoria Infirmary, Newcastle (a tertiary fetal medicine unit covering nearly 32 000 births), an average of six visits (3 hours)/week are devoted to postnatal and preconception counselling (S Robson, personal communication). This equates to approximately 1.88 visits/week/10 000 maternities This workload is expected to be less for consultants with a special interest in fetal medicine (assumed to be one visit/week/10 000 maternities).

Inpatient fetal medicine workload Determination of inpatient workload for fetal medicine disorders is extremely difficult to estimate but is likely to be very low (estimated at 1 hour/week/10 000 maternities for a subspecialist consultant and 0.5 hours/week/10 000 maternities for a special interest consultant).

Summary The total consultant-based fetal medicine workload is shown in T able 2.12. Assuming eight visits/PA and a working year of 42 weeks, this equates to 3.06 subspecialist P As and 3.46

Royal College of Obstetricians and Gynaecologists special interest PAs/week/10000 maternities. The subspecialty PA figure is very similar to that determined in the deanery survey. The special interest PAs are slightly lower but this does not take account of areas of practice currently undertaken by consultants with a special interest in fetal medicine that, in the future, will fall within the remit of consultants with a special interest in advanced antenatal practice, such as monitoring small fetuses.

Current service provision in maternal medicine

Deanery survey Information on consultant maternal medicine provision was also collected from the detailed survey of the five deaneries reported above. Complete data were provided from three deaneries (Table 2.13); the information from Wessex and West Midlands was so limited as to be of no value. Consultant P A commitment to maternal medicine ranged from 3.81–6.35/10 000 maternities, of which 0.88–1.70 PAs/10 000 maternities were provided by subspecialists. Table 2.12. Calculated consultant PA workload/week required to deliver fetal medicine services for 10 000 37 maternities Special interest Subspecialist Total The Future Workforce in Obstetrics and Gynaecology Antenatal outpatient visits/year (n) 1059 825 1884 Postnatal/preconception outpatient visits/year (n) 52 98 150 Inpatient ‘visits’/year (n) 52 104 156 Total visits/year (n) 1163 1027 2190 Total PAs/yeara (n) 145.4 128.4 273.7 Total PAs/weekb (n) 3.46 3.06 6.52 a Assumes each visit or appointment is 30 minutes and each PA is 4 hours; b Assumes each consultant works 42 weeks/year

National manpower survey Fifty two of the 61 units who returned the questionnaire provided data on maternal medicine clinics. These included tertiary referral units (with subspecialist and special interest consultants) and secondary units (with special interest consultants). Assuming one maternal medicine clinic equates to one P A of consultant time, the number of P As/week/10 000 deliveries averaged 3.39. This figure for total maternal medicine sessional support is somewhat less than is suggested in the detailed deanery survey .

Maternal medicine manpower requirements based on disease burden To better inform consultant manpower needs in maternal medicine, J Waugh, in collaboration with the Education and T raining Group of the BMFMS, undertook a detailed analysis of ‘theoretical’ maternal medicine workload based on the number of outpatient visits (appointments) required for maternal medicine cases per 10 000 maternities. This was based on the reported prevalence of diseases and the clinical experience of the group. The list of conditions was taken directly from the maternal medicine section of the subspecialty curriculum.

Table 2.13. Consultant programmed activities (PAs) for maternal medicine in three deaneries with complete data Deanery Deliveries (n) Units (n) PAs/week (n) PAs/week/10 000 maternities (n)c Special Subspecialist Special Subspecialist interest interest Northern 33019 14 16.0 5 4.84 1.51 Yorkshire 41157 13 14.5 7 3.52 1.70 SW Thames 34051 8 10.0 3 2.93 0.88 a PA calculations/10 000 deliveries based on total secondary care deliveries from units returning data 38 Antenatal maternal medicine outpatient workload The estimated number of outpatient visits to special interest and subspecialist consultants, according to the main diagnostic groups within maternal medicine, is shown in T able 2.14 (for comprehensive data see Appendix A5.6). The number of outpatient visits for each diagnosis and the proportion of secondary care cases referred to subspecialist consultants were determined by consensus. The prevalence of specific maternal diseases was obtained from the medical literature. In performing these calculations, it was accepted that disease severity varies substantially and this should be reflected in the expertise of the consultant providing care; for example, the majority of women with asthma can be managed by any competent obstetrician but 10% would benefit from the expertise of a consultant with additional expertise in maternal medicine. For significant cardiac, renal and connective tissue diseases, the group followed recommendations that all women should be managed in a specialist clinic that includes a consultant with subspecialty expertise, such as an obstetric cardiac clinic. 21–23 In larger centres, other specialist clinics may already exist or may be developed in the future; for instance, obstetric haematology , obstetric neurology . It is anticipated that special interest consultants would benefit from referring some complex cases to these clinics. The proportion of cases that would benefit from involvement of a subspecialist consultant is difficult to estimate and will vary with disease but is likely to be 10–20% (consensus opinion). Women with certain disorders were excluded from these calculations: cases generated by risk-factor screening who are at increased risk of medical disorders (such as women who are obese): it was acknowledged that, in the future, these cases may contribute to the workload of consultants with expertise in maternal medicine women with physical signs and symptoms that rarely reflect medical diseases, such as heart murmurs women with certain chronic infections (such as HIV) and psychiatric diseases, as it was considered that, in the future, such cases may be more appropriately managed by consultants with expertise in advanced antenatal practice. Table 2.14 indicates that the total number of outpatient visits required to provide maternal medicine services to a population of 10 000 maternities per annum is 9871.5, of which 2246.5 are provided by subspecialist consultants. In an attempt to confirm these calculations, the maternal medicine consultant outpatient workloads (in terms of the outpatient caseload) Royal College of Obstetricians and Gynaecologists

Table 2.14. Calculated consultant PA workload/week required to deliver maternal medicine services for 10 000 maternities Special interest Subspecialist Total Antenatal outpatient visits/year (n) 6279 1715.5 7994.5 Postnatal outpatient visits/year (n) 686 171 857 Preconception outpatient visits/year (n) 400 100 500 Inpatient ‘visits’/year (n) 260 260 520 Total visits/year (n) 7625 2246.5 9871.5 Total PAs/yeara (n) 476.6 140.4 617 Total PAs/weekb (n) 11.35 3.34 14.69 a Assumes each visit or appointment is 30 minutes and each PA is 4 hours; b Assumes each consultant works 42 weeks/year from one secondary level unit (West Middlesex, kindly provided by J Girling) and one tertiary 39 unit (Queen Charlotte’ s Hospital, London, kindly provided by C Nelson-Piercy) were reviewed (Table 2.15). For most disease categories, the predicted caseload approximated that actually seen in the two units, with the exception of hypertension and endocrine disorders The Future Workforce in Obstetrics and Gynaecology (notably gestational diabetes mellitus), presumably reflecting fewer referrals for these conditions than predicted. W ith recent evidence that treatment of gestational diabetes improves outcome, 24 it is anticipated that more women will be referred to consultants with maternal medicine expertise.

Postnatal and preconception maternal medicine outpatient workload Consultants with expertise in maternal medicine will see many women with medical disorders for postnatal assessment and a minority for preconception counselling (usually one visit each). The impact on outpatient workload is shown in Appendix A5.6. It was assumed 50% of women with significant medical diseases return for postnatal review (approximately 1285 cases/10 000 maternities) and 20% will be provided by consultants with subspecialist expertise in maternal medicine. Preconception care is recommended for women with renal disease, cardiac disease, epilepsy, types 1 and 2 diabetes and those with previous severe pre- eclampsia. Best practice suggests that women with connective tissue disease should also be seen for preconception advice. The equates to around 500 visits/10000 maternities, of which it was assumed that 20% will be with subspecialist consultants.

Inpatient maternal medicine workload Inpatient workload for maternal disorders is extremely difficult to estimate. Review of admissions to the antenatal ward at the Royal V ictoria Infirmary, Newcastle (a tertiary regional unit with around 6000 maternities) indicated that, at any one time, there were, on average, two women with medical disorders on the ward. The most common diagnoses were

Table 2.15. Maternal medicine outpatient antenatal caseload from two UK units, 2006: West Middlesex University Hospital, a secondary unit with around 3800 maternities/year, and Queen Charlotte’s Hospital, London, a tertiary unit with around 5000 maternities/year Disease West Middlesex Queen Charlotte’s Predicted University Hospital Hospital, London cases/10 000 maternities Cases Cases/10 000 Cases Cases/10 000 (n) (n) maternities (n) (n) maternities (n) Hypertension 41 108 100 200 310 Renal 11 39 48 96 47 Cardiac 31 8273 146 22 Liver and gastrointestinal 51 134 89 178 173 Respiratory 17 45 46 92 103 Endocrine 220 579 145 290 675 Neurology 38 100 55 110 134 Connective tissue disease 20 52 44 88 40 Haematology/thromboembolic 52 137 84 168 150 Dermatology and other (including infections) 33 86 5 10 60 Total 514 1352 689 1378 1714 40 hypertension (20%), thromboembolic disease (13%), acute infection (13%), severe hyperemesis (11%), diabetes (9%), cardiac disease (8%) and neurological disease (4%) (J Waugh, personal communication). Assuming that such cases are reviewed every weekday by a maternal medicine consultant, this equates to 2 x 0.167 x 5 = 1.67 hours/week or 0.42 P A of inpatient work for 6000 maternities and 0.7 P A/10 000 maternities.

Summary The total consultant-based maternal medicine workload is shown in T able 2.14. Assuming 16 visits/PA and a working year of 42 weeks, this equates to 3.34 subspecialist PAs and 11.35 special interest P As/week/10 000 maternities. Unlike the calculations performed for fetal medicine, no allowance has been made in these figures for subspecialist consultants also looking after special interest workload in their own units. Assuming that 20% of bookings occur in tertiary units then more appropriate figures are 5.61 subspecialist P As and 9.08 special interest PAs/week/10 000 maternities. These figures are significantly greater than the current service provision identified in the deanery survey . It is assumed that this reflects the widely accepted under -provision of maternal medicine services (especially within secondary units) and the changes in clinical care, especially for women with gestational diabetes. 24

Advanced antenatal practice Antenatal care has traditionally been an integral part of the work of all consultant obstetricians. As such, consultants have been expected to manage a wide range of antenatal problems, with the typical exceptions of pregnancies complicated by specific fetal abnormalities and significant maternal medical disorders. This model of antenatal care is becoming less attractive, at least in larger units, where a degree of consultant specialisation is now the norm and certain conditions and disorders (such as substance abuse, twins) are managed by a specialist team, often incorporating allied professionals and specialist midwives. While few studies have addressed the clinical and cost effectiveness of such specialist antenatal clinics, it is counterintuitive that women will not derive tangible benefits from being cared for by a team with specialist expertise. Indeed, this was the rationale for the development the A TSM in advanced antenatal practice. However , manpower planning for this aspect of obstetric care is extremely difficult for the following reasons: Royal College of Obstetricians and Gynaecologists few, if any, of the current consultant obstetric workforce were trained in ‘advanced’ antenatal practice future job descriptions for consultants with a special interest in advanced antenatal practice are likely to vary significantly, depending upon the specific training (and expertise) of the individual, current consultant provision within the unit and the booking and delivery workload. Thus, depending on the local consultant expertise and interest, some clinical problems could be managed by consultants with different ATSMs (such as multiple pregnancies, pregnancies complicated by obstetric cholestasis, small-for -gestational-age fetuses and red cell alloimmunisation). Advanced antenatal practice manpower requirements 41 based on disease burden To better inform consultant manpower needs, M Ramsay , in collaboration with the The Future Workforce in Obstetrics and Gynaecology Education and Training Group of the BMFMS, undertook an analysis of potential workload, based on a detailed review of relevant clinical workload seen at the Nottingham University Hospitals Trust (which covers approximately 10 000 maternities across two sites). The list of diseases was taken directly from the advanced antenatal practice A TSM curriculum. The total consultant-based advanced antenatal practice is shown in Table 2.16. Assuming 16 visits/PA and a working year of 42 weeks, this equates to 9.14 special interest P As/week/ 10 000 maternities.

Recommendations The number of subspecialist PAs required to deliver maternal and fetal medicine services for 10 000 maternities is 8.7. There are currently approximately 670 000 deliveries in England and Wales25 and, assuming that each subspecialist contributes an average of 4 P As/week to maternal and fetal medicine services, this equates to approximately 150 maternal and fetal medicine subspecialists. The number of consultant P As required to deliver special interest (non-acute) services in obstetrics for 10 000 maternities is 21.7. Calculations based principally on outpatient workload suggest that the relative P A contributions of consultants with a special interest in fetal medicine, maternal medicine and advanced antenatal practice are 3.5, 9.1 and 9.1, respectively. Services can be provided in a variety of ways, with clear overlaps between patient groups that can be managed by consultants with different special interests. However, there is a need to increase the number of training opportunities in maternal medicine and advanced antenatal practice.

Table 2.16. Calculated consultant PA workload/week required to deliver advanced antenatal care for 10 000 maternities Situation, condition Prevalence/10 000 Cases requiring Visits/ Visits/10 000 or disease maternities special interest pregnancy maternities (n) care (n) (n) (special interest) (n) Perinatal psychiatry 350 350 3 1050 Teenage pregnancy 560 560 2 1120 Older women (> 40 years) 320 320 2 640 Drug misuse 133 133 3 399 Multiple pregnancies 172 146 7 1022 Previous stillbirth 94 94 6 564 Social disadvantage/ethnic minority 500 500 2 1000 Infection (including HIV) 50 50 7 350 Total visits/year 6145 Total PAs/yeara 384.1 Total PAs/weekb 9.14 a Assumes each visit or appointment is 30 minutes and each PA is 4 hours; b Assumes each consultant works 42 weeks/year 42 Conclusions There is an urgent need to increase the number of trainees undertaking ATSMs in obstetrics. While the driver for this is to provide prospective obstetrician presence on the delivery suite,2 careful planning is required to ensure obstetricians are appropriately trained for non-acute obstetric work and that job descriptions reflect service needs. W ith the increasing centralisation of high-risk obstetric care and the development of obstetric networks, trusts need to consider what obstetric services they can and should provide and what skills, other than acute obstetrics, are required from their consultant obstetric workforce to deliver optimum care. Strategic health authorities should be involved in this process. A model obstetric network for a region with 30 000 maternities is shown in Figure 2.1. The regional centre provides invasive fetal therapy , neonatal surgery and highly specialised maternal medicine services (such as obstetric cardiac or renal clinic). However , unless the network covers a small geographical area (for example, in a major conurbation), there is likely to be a need for a second tertiary centre to provide subspecialist fetal medicine (notably chorion villus sampling), maternal medicine and level-three neonatal intensive care facilities.

Unit A (3100) Unit F (2500) MLU (400) Unit G (2150) 1 Special interest FM 1 Special interest FM 1 Special interest FM 2 Specal interest MM 1 Specal interest MM 1 Specal interest MM 2 Special interest AAP 1 Special interest AAP 1 Special interest AAP

Unit B (1350) Unit H (1550) 1 Special interest MM 1 Special interest MM 1 Special interest AAP 1 Special interest AAP Centre A (6050) 5M FM subspecialist Unit C (1700) 1 Specal interest MM 1 Special interest MM 1 Special interest AAP Unit I (1250) 1 Special interest AAP 1 Special interest MM 1 Special interest AAP

Unit D (1550) Royal College of Obstetricians and Gynaecologists 1 Special interest MM Unit J (1700) 1 Special interest AAP 1 Special interest MM

Centre B (3500) Unit E (1700) 2M FM subspecialist Unit K (1200) 2 Specal interest MM 1 Special interest AAP 1 Special interest FM 1 Special interest AAP 1 Specal interest MM 1 Special interest AAP

MLU (400)

Figure 2.1. Model obstetric network for 30 000 maternities with two tertiary maternal and fetal medicine (MFM) centres, both with level 3 neonatal intensive care units but only offering one invasive fetal therapy unit (Centre A) and 11 secondary care units (two with a linked midwifery-led unit (MLU) managed by ten trusts (indicated by colour); AAP = advanced antenatal practice, FM = fetal medicine, MM = maternal medicine Translating these numbers into the required number of subspecialty and A TSM training 43 programmes is dependent upon a number of assumptions: particularly the average number of years a consultant works. If this is assumed to be 30 years and the average consultant contributes 4 PAs of subspecialist maternal and fetal medicine work then the aim should be The Future Workforce in Obstetrics and Gynaecology to appoint five maternal and fetal medicine subspecialists/year (8.7 x 67/4 x 30). To allow for some ‘wastage’ within the subspecialty training system and also to retain some degree of competitiveness for consultant subspecialty posts, it would seem reasonable to recruit no more than six maternal and fetal medicine subspecialty trainees/year in England and W ales. If it is assumed that consultants with a special interest contribute 2 PAs of care related to their special interest then the aim should be to appoint four consultants with a special interest in fetal medicine/year, ten consultants with a special interest in maternal medicine/year and ten consultants with a special interest in advanced antenatal practice/year in England and Wales. 44 4. Consultant delivery suite presence: modelling of numbers

The majority of consultants will be expected to undertake some obstetric duties for the foreseeable future, with the exception of the majority of the gynaecological subspecialists. The number of trainees undertaking an ATSM specific to delivery suite activity requires further assessment. We propose that there should be 10–15 trainees completing the labour ward lead ATSM/year. As the majority of consultants of the future are likely to have a role on the delivery suite, it is recommended that all trainees, with the exception of those undertaking gynaecological subspecialties, would be expected to take the Advanced Labour Ward Practice ATSM at some stage in years ST6–7. The number of WTE consultants for the delivery suite alone equates to nine for 168 hours, five for 98 hours and three for 60 hours. Any other direct clinical care activity for obstetrics and/or gynaecology needs to be added.

Principles The purpose of this section is to model the number of consultantAs P needed to cover a delivery suite. Currently, the standards required are based on the number of deliveries in a unit. Thus, it is necessary to model the workforce requirement for 60, 98 and 168 hours of presence/week.

Modelling assumptions It is possible to make a variety of assumptions; however , the approach taken is to look at a maximum productivity model. In this, consultants work 7.5 direct clinical care sessions in a ten-PA contract. All the direct clinical care P As are for delivery suite. Each P A is calculated as 4 hours from 08.00 hours to 20.00 hours. This is slightly at variance with the current consultant contract but avoids the need to develop a very early start shift pattern commencing at 07.00. Outside these hours, each P A consists of 3 hours. It is assumed that consultants work 42 weeks of the year and that they would work an EWTD-compliant shift pattern, which minimises the need for breaks yet allows healthy working. This would suggest a 3- and 4-day split of the week for night duty. As far as daytime duty is concerned, it is possible that the shifts might be split in the same way or as a 5- and 2-day split. On this basis, consultants would not need immediate time off after the day shift but would need to have blank days in a rolling rota to compensate for the extra hours worked in the labour ward weeks. This can be minimised by optimum positioning of the changeover day. The 60- and 98-hour models will require substantial compensatory rest some of which may be derogated to additional leave over a 3–6 month period. This may equate to 10–15 days/year and needs factored into any equations. Consequently , the working week may actually reduce to nearer 40 weeks in some instances(that is, 52 minus 7 weeks’ annual leave, 2 weeks’ study and potentially 1 week of professional leave. The compensatory element may 45 reduce this to 40 weeks). Trust solutions to working more than 60 hours will vary, depending upon circumstances and acceptance by the consultant body altering their terms and conditions of contract. Arithmetically, it will not alter the consultant numbers excessively. A The Future Workforce in Obstetrics and Gynaecology worked example is shown in Box 2.1 for 60 hours’ presence. The calculations for 98- and 168-hour presence are presented in Appendix 6. The calculation for 98 and 168 hours is shown in Table 2.17 but based on the same principles. It is only theoretical but provides an idea of numbers involved as a minimum.

Box 2.1. A worked example of consultant WTE requirement for 60 hours’ presence 60 hours can be provided over 7 days, as shown here, or over 5 days with 12 hour shifts; the consultant WTE requirement is similar 60 hours consultant presence = 8.6 hours/day with 4 hours of covered break times This is 40 hours at normal time = 09.00–17.00 (4 hours/P A) + 20 hours at premium rates of 3 hours/PA = 16.6PAs/week The break cover contribution is 30 minutes every 4 hours, which, in normal time = 2.5 hours and for premium time to 1 hour = 0.9 P A/week Each consultant works 42 weeks x 7.5 P As = 315 PAs/year The delivery suite requires 52 weeks x 17.5 P As = 910 PAs This equates to approximately 3 consultants

It is expected that, during the consultant’ s session on the delivery suite they would have no other clinical commitments. Consultants will also need time within their rota to fit the 10 hours/week of supporting professional activity (SPA). The modelling is based on 12.5-hour shifts, which include 30 minutes hand over . Any increase in this time results in a problem with the obligatory 11-hour rest period in 24 hours under the EWTD and may lead to three shift days, which tends to increase the disruption to working patterns as the delivery suite cover becomes more frequent. The modelling should also include break periods. It is a matter of discussion as to whether this requires direct cover by another consultant or whether, given the episodic nature of delivery suite work and close cooperation between staff, this could not be covered internally . Modelling suggests that a considerable increase in staffing is required if rest cover is factored in and, given the nature of practice, it may be difficult for other colleagues to provide this cover . However, the arithmetic is based on 42 weeks. If 40 or 41 weeks becomes the denominator , the true WTE requirement will probably lie between the two figures.

Table 2.17. Minimum staff levels (WTEs) required for prospective delivery suite presence Weekly hours of cover Break times Covered Not covered 60 3 – 98 6 5 168 12 9 46 Pragmatic view of additional direct clinical PA availability for clinical provision (obstetrics and or gynaecology) The aforementioned calculations deal only with delivery suite cover . Most units will employ consultants with a combined obstetrics and gynaecology interest. Some of the larger units may have already split the provision of care into pure obstetrics and pure gynaecology and, further, some may have a mixture of the two. However, the majority of consultants in the UK practice with combined job plans (approximately 78%). In this section we have provided a table of consultant requirements to cover a range of 30–80 direct clinical care PAs in addition to those covering the delivery suite (that is, for maternal and fetal medicine, antenatal clinic, gynaecology theatre or outpatient clinics) irrespective of the hospital configuration (Table 2.18). It is based on the assumption that all contracts will be ten PAs and each consultant will have 7.5 direct clinical P As and 2.5 SPAs. Each hospital or trust will have to identify its own requirements. Any additional P As may be for direct clinical care or for management purposes and would simply affect the local situation. Additional considerations include: all SPA activity would have to take place during a normal working day (that is, Monday–Friday, 07.00–19.00 or local arrangement, such as 08.00–20.00) each hospital would have to agree on the ‘working year’ each hospital would have to decide what proportion of the non-delivery-suite direct clinical care PAs described in Table 2.18 would need prospective cover. This would range from 0–100% and would affect the consultant requirements as shown.

Summary To provide consultant cover on labour ward for 168 hours, 52 weeks of the year , without prospective rest break cover and 70 P As additional direct clinical care activity for 42 weeks (without covering this aspect prospectively) would require 18 consultants (that is, 9 + 9). If this activity was all covered prospectively, the number required would rise to 21 consultants (that is, 9 + 12). Each consultant has a ten-P A contract with a 7.5 direct clinical care PA/2.5

Royal College of Obstetricians and Gynaecologists SPA split. There will undoubtedly prove to be many and varied solutions to this issue. In some situations, the answer will prove to be financial and in others, staffing variations. Colleagues are encouraged to share their hospitals’ solutions with the Workforce Advisor at the RCOG.

Table 2.18. Direct clinical care PAs in addition to those required for delivery suite for hospitals needing 30–80 direct clinical care PAs Direct clinical care extra activity WTE requirements 52 weeks 42 weeks (no prospective cover) 30 5 4 40 7 5 50 8 7 60 10 8 70 12 9 80 13 11 Obstetric staffing by unit size 47 The NHS Litigation Authority (NHSLA) has published guidelines for accreditation of 26 delivery suite units (June 2008 – Chapter 11). The proposals, based upon unit size and The Future Workforce in Obstetrics and Gynaecology consultant presence on the delivery suite mirror the recommendations in Safer Childbirth 2 and are to be piloted for 12 months but at present they are not mandatory . The RCOG Hospital Recognition Committee information, albeit relating to 2005, demonstrated that only 50% of obstetric units in the UK had fulfilled the standard of 40-hour labour ward cover in response to the recommendation of Towards Safer Childbirth in 1999.27 The recommended standards of consultant presence are shown in T able 2.19. In a study prepared for Safer Childbirth, it was suggested that only 30% of units purporting to have 40- hour cover actually achieved this. Some had consultants available but undertaking other duties and others had not managed to deal with the prospective cover element. Units delivering 2500–4000 births/year should have a 60-hour presence, those delivering 4000–5000 births/year a 98-hour presence; those delivering over 5000 births/year should achieve a 168-hour presence at varying times. Those units delivering less than 2500 births would need to reach a local decision based on availability , financial resource and other clinical demands. At present, there are 62 of these units. The consultant number estimation based on this proposal is shown in Table 2.20. From the most recent RCOG census, 26 units would need to provide 168-hour presence at a minimum of nine WTE obstetricians for each unit. 6 This will require a significant expansion of consultants: theoretically , before the first output of specialty trainees in 2014. The standards as shown are not achievable in the time frame suggested by the RCOG and at present adopted by the NHSLA. If money is to be made available, a phased approach to these standards would seem advisable to coincide with the apparent rise in doctors awarded CCT or Certificate of Eligibility for Specialist Registration. The whole process is scheduled for completion by 2010–2011. The table of unit size and consultant requirements shown in Table 2.20 equates to approximately 800 obstetricians to prospectively cover the delivery suite. It must be recognised, however , that the smaller the unit the greater the difficulty in estimating numbers of consultants. Additional hospital clinical duties would need to be provided in addition to the above. Using the information in Table 2.18 allows hospitals to determine their additional service workload and whether that component needs prospective cover . The smaller the unit, however , the less likely the compliance. The larger the unit, the greater the difficulty in achieving the recommendations purely on financial terms.

Table 2.19. Proposed standards of delivery suite consultant presence and timescale for implementation Categorya Units Consultant presence (year of implementation) (n) Deliveries (n) 60 hours 98 hours 168 hours A 62 < 2500Local – – B 86 2500–40002009 – – C1 26 4000–50002008 2009 – C2 18 5000–6000 2008 2008 2010 C3 8 > 6000 2008 2008 2008 a hospital/unit categories defined in Safer Childbirth2 Table 2.20. Suggested total number of consultants required for delivery suite cover on prospective basis, 48 England and Wales, based upon calculations from Table 2.19 Categorya Units Consultant presence (n) WTE (n) Deliveries (n) 60 hours 98 hours 168 hours A 62 ~ 3 < 2500 Local – – B 86 ~ 3 2500–4000 258 – – C1 26 ~ 5 4000–5000 – 130 – C2 18 ~ 9 5000–6000 – 90 162 C3 8 ~ 9 > 6000 – 40 72 a hospital/unit categories defined in Safer Childbirth2

Reconfiguration of units will impact upon the total requirements purely on economy of scale. The obvious conclusion is that all consultants, probably with the exception of the majority of gynaecological subspecialists, will be expected to provide some element of obstetrics service and probably delivery suite presence. Royal College of Obstetricians and Gynaecologists 5. Urogynaecology 49

Key points We propose there should be one subspecialist/million population and approximately six to seven consultants with a special interest/million population. We propose there should be three subspecialty trainees/year and approximately 12 trainees/year with a special interest undertaking appropriate ATSMs. However, until the curriculum of this module and the experience it provides has been assessed, any restriction of subspecialty training opportunities should be exercised with caution. We estimate the service should aim for 50–55 subspecialists and approximately 350 consultants with a special interest.

Introduction Urogynaecology is the specialty dealing with pelvic floor dysfunction in the female. Pelvic floor dysfunction may result in urinary incontinence, pelvic organ prolapse and lower urinary tract symptoms, such as overactive bladder, painful bladder syndrome, and also lower bowel dysfunction such as faecal incontinence in the postnatal period. It has been estimated that approximately three million people are regularly incontinent of urine in the UK 28 and an average primary care trust with a population of 150 000–200 000 could have 6000–8000 adults who are incontinent, with the cost to the NHS estimated to be in excess of £400 million/year . In addition, the ageing population could have a significant impact on the disease burden in this area. The recent NICE guidelines on urinary incontinence state, ‘there should be a nominated clinical lead in each unit working within the context of an integrated continence service’. 28 These individuals should be special skills or ATSM trained. The Department of Health’s 18- week pathways for urinary incontinence and prolapse also underpin urogynaecological care. A urogynaecology subspecialist would be expected to coordinate the service within a region or strategic health authority and to provide a resource for advice and tertiary referrals. In addition, they will need to collaborate with urologists, colorectal surgeons, specialist nurses and physiotherapists, and to work as part of a multidisciplinary team. They are likely to be involved with or manage conditions requiring more complex or revisionary surgery , such as fistula, conduit formation, clam cystoplasty , botulinum toxin injection and sacral neuromodulation. In addition, they are increasingly involved in intrapartum and postnatal care but they will also be advocates for the promotion of a reduction in pelvic floor dysfunction through all phases of pregnancy care. NICE recommends that surgery should be undertaken only by individuals who have had appropriate training and who will carry out a sufficient caseload to maintain their skills. An annual workload of at least 20 cases/primary procedure for stress urinary incontinence is recommended. This is also recommended for combined incontinence and prolapse surgery . 50 Current service position

Outpatients There are no data available to describe reliably the referral volume and pattern of women with urinary incontinence and/or prolapse, nor do we have information on the ‘conversion rate’ (the number of patients added to a surgical waiting list divided by new patients seen). Anecdotally, this varies from 12–40%.

Inpatients A breakdown by category and year, for England, is presented in T able 2.21 and this gives a flavour of surgical activity . Further analysis by looking at hospitals where subspecialty training in urogynaecology exists suggests that approximately 12% of all urogynaecological surgery is carried out in such centres, with the remainder in other NHS units. If one refines

Table 2.21. Hospital Episode Statistics for benign gynaecological surgery including Urogynaecology, 2001/02–2005/06, England Procedure Procedure 2001/02 2002/03 2003/04 2004/05 2005/06 code M521 Sling 224 175 266 193 237 M522/523 Colposuspension 2637 1940 1379 785 553 M538 Transvaginal tape 4047 5292 6637 7290 7853 M563/568 Injectable 1121 1172 831 746 1146 P18 Colpocleisis 60 68 52 69 81 P22 Manchester repair 445 383 290 264 327 P231 Anterior and posterior repair 4780 5221 5644 5654 6138 P232 Anterior repair 7575 7864 8320 8560 9492 P233 Posterior repair 4191 4891 5233 5406 5718 P238/239 Other repair process 77 275 256 263 260 P234 Enterocele 213 418 382 363 339 Royal College of Obstetricians and Gynaecologists P242/243 Sacrocolpopexy 884 925 987 949 998 P244/248/249 Vaginal vault ?Sacrospinous fixation 250 291 293 255 299 P251 Vesicovaginal fistula 86 78 88 91 115 P252 Urethrovaginal fistula 13 7 5 13 15 P253 Rectovaginal fistula 99 125 123 142 145 P254 Ureterovaginal fistula 3 4 3 2 4 Q071/72/73 Transabdominal hysterectomy and colpectomy 576 529 442 437 250 Q074 Transabdominal hysterectomy 32702 31503 29264 27938 28510 Q075 Subtotal transabdominal hysterectomy 3274 3076 2911 2683 2764 Q081/82/83 Vaginal hysterectomy and colpectomy 212 186 216 157 174 Q088/89 Vaginal hysterectomy 7248 6856 6933 6345 6479 Totals 70717 71279 70555 68605 71897 the search, tertiary centres account for 34% of sling operations, 23% of vesicovaginal 51 fistulas, 16% of vaginal hysterectomies and 11% suburethral slings (transvaginal tapes) as examples. The volume of surgery of a urogynaecological nature has remained remarkably constant over the last 5 years. The case mix, however , has changed. The total number of The Future Workforce in Obstetrics and Gynaecology hysterectomies has fallen by 13%, while the numbers of continence procedures have risen by 25% and those of prolapse operations have increased by 28%. The RCOG census, which describes gynaecological surgery in broad terms, describes 55 000 operations of a urogynaecological nature (excluding all abdominal and laparoscopic hysterectomies).6 The majority of urogynaecology surgery is carried out in hospitals by consultants with a special interest. Any workforce proposal must fill the gap as such ‘grandfathers’ retire. This clinical work will need to be undertaken by trainees who have completed subspecialty training or the appropriate ATSM. What is still uncertain is whether the proposed ATSM training in years ST6–7 will be adequate for the needs of the specialty .

The Current workforce in urogynaecology

Subspecialists Currently there are 24 accredited subspecialists in urogynaecology (Part 1, T able 1.7) who have trained in 15 approved centres in the UK. Of these, 12 are in subspecialist consultant posts (many still involve obstetric cover), five in ‘special interest’ posts, two are overseas and the remainder are either accredited or have yet to be appointed consultants. There are 14 trainees currently registered for training. Unfortunately, there have been few posts created in urogynaecology recently; in 2006, only 5% of the consultant appointments were in the subspecialty. Two were for subspecialists and the other three for special interest. In 2007, there were a further six posts (approximately 6% of the total) in urogynaecology (one subspecialist and five special interest). Interestingly , at the time of writing, there appears to have been a sudden increase of urogynaecology posts throughout 2008.

Special interest consultants Special interest consultants are less well defined. In the most recent RCOG census, 126 consultants in total registered that they were practising urogynaecology but it is likely that there are considerably more actually undertaking any aspect of urogynaecological surgery .6 In practice, they will need to function as the lead consultant for the service and provide the majority of the primary surgery for incontinence and prolapse. They will usually link with either a subspecialist urogynaecologist or surgeon in another discipline, such as urology or colorectal surgery. The majority of their gynaecological workload will be in the specialty and they will provide an urodynamic investigation service. However, in addition, they will usually have a job plan with sessions including obstetrics and often other ‘general’ gynaecology outpatients and surgery. It is this area where there is a broad range of experience, with some consultants performing a small number of vaginal repairs to others performing total pelvic floor mesh insertion. If ATSM training does not provide the consultant the service needs, this will increase the referrals to tertiary units and affect the calculations we have proposed.

Training The new A TSM in urogynaecology will allow a trainee to perform mostly office urogynaecology (that is, urodynamics and other investigations such as cystoscopy, ultrasound and conservative therapies). As part of general training, such individuals should be able to 52 select appropriate treatments for patients. The dilemma, however, appears to be the interface between the trainee undertaking an A TSM and the subspecialty trainee who, by and large, will have a wealth of theoretical and practical skills, together with a surgical repertoire to deal with the majority of clinical presentations. At present, the majority of urogynaecological surgery is performed by consultants with a special interest in the subject. A TSM trained consultants of the future will be expected to perform primary surgery such as vaginal hysterectomy, repairs and midurethral tapes. Any increase in complexity will require a review of the surgical training in benign gynaecology to satisfy the need for greater experience within the ATSM or we will need to recalculate the subspecialty numbers to accommodate the shortfall. An example of this is vault prolapse surgery . Activity data would suggest about 1300 procedures/year. This surgery is not covered by the ATSMs in urogynaecology or benign gynaecology and yet it would prove a significant workload for 24–50 subspecialists where it is included within the syllabus. However, it is recognised that there is the possibility of post- CCT surgical training in specific operations if a ‘network’ is deficient in surgical provision for a particular condition. In addition, at the subspecialist end, a small number of regional centres will be required to manage problems such as fistulae or diversionary surgery . These super-specialist or national resources are likely to evolve in subspecialty centres where an individual(s) possess or have acquired a specific interest and appropriate surgical skills. At present, far too many units are performing less than five such procedures/year and this should cease. Finally, it is recognised that urogynaecology subspecialty trainees may undertake obstetric duties in light of consultant opportunities and coordinate the management of patients suffering urogynaecological symptoms from obstetric trauma

Predicted numbers of urogynaecologists in England and Wales Over the next 10 years there will be no retirements of existing subspecialists in urogynaecology. However, there will be ten subspecialty trainee programme directors (‘grandfathers’) who are anticipated to retire in that time. Their replacements will need to be subspecialists. The calculations below for a urogynaecology workforce are based on the following criteria: prevalence of urinary incontinence and pelvic organ prolapse burden of disease based upon surgical activity (RCOG census and HES data) 6,20

Royal College of Obstetricians and Gynaecologists a number of assumptions have had to be made which include: the ‘working year’, the number of PAs of surgery/consultant/week and also the number of major procedures per PA purely for the sake of calculating numbers, it has been assumed that the subspecialist carries out the secondary or tertiary surgery and that the consultant with special interest training undertakes the primary procedures; it is recognised that there will be considerable crossover.

Prevalence of urinary incontinence and pelvic organ prolapse

Urinary incontinence The reported prevalence of urinary incontinence ranges from 12% to 40% in various epidemiological studies with approximately 10% having bothersome urinary leakage. 29–36 Within the ten regions of England comprising 152 primary care trusts and Wales, the female 53 population between the ages of 20–85+ years is 20 997 280. The overall prevalence of severe urinary incontinence would be approximately 10% and severe stress urinary incontinence would be 40% of this figure. It is likely that 70% of these patients will require surgery . A The Future Workforce in Obstetrics and Gynaecology lifetime risk (over approximately 60 years) will result in 9799 operations for stress urinary incontinence/year. With a 15% failure rate, this would result in 1470 additional cases/year requiring repeat surgery in subspecialty centres (Table 2.22).

Prolapse The prevalence of prolapse is approximately 30% in women aged 20–59 years, with an estimated 11% lifetime risk of undergoing surgery for prolapse by the age of 80 years. 35 The prevalence of faecal incontinence is approximately 5–10% but most of these patients will be seen either in joint clinics or by colorectal surgeons. This equates to approximately 38 500 prolapse procedures. With a recurrence rate of 20–40%, this results in an additional 11 549 secondary procedures/year. The total breakdown by disease burden for both incontinence and pelvic organ prolapse in England and Wales is shown in T able 2.23.The analysis is also broken down into strategic health authorities to give reasonable population numbers from which to base the consultant requirements and direct clinical care PAs.

Workforce calculations based on surgical activity The true urogynaecology surgical activity for England and W ales is estimated at 50 000 procedures/year. Accurate data are almost impossible to identify. This figure is an average of the HES calculation (minus the abdominal hysterectomy numbers), the RCOG census returns and the prevalence calculations for England and Wales. In essence, 80% of the surgical load will be primary procedures (40 000 operations) and 20% of the total will be of a secondary or tertiary nature (10 000).

Table 2.22. National prevalence tables for urogynaecology based on lifetime risk of 60 years and expected failures of surgery by strategic health authority, England and Wales, 2006

FEMALES Strategic Health PERSONS Incontinence SUI Surgery 60 years Failures Prolapse 60 years Failures Authoritya All ages (n) All ages 20–85+ 10% 40% 70% lifetime 15%b 11% lifetime 30%b risk risk

North East 2555708 1308305 1001702 101170 40468 28328 472 71 111287 1855 556 North West 6853154 3498701 2670528 267053 106821 74775 1246 187 293758 4896 1569 Yorkshire/Humber 5142394 2615153 1997711 199771 79908 55936 932 140 219748 3662 1099 East Midlands 4364214 2206865 1695314 169531 67813 47469 791 119 186485 3108 932 West Midlands 5366694 2727196 2068523 206852 82741 57919 965 145 227538 3792 1138 East Of England 5606570 2853823 2190404 219040 87616 61331 1022 153 240944 4016 1205 London 7512372 3798270 2918271 291827 116731 81712 1362 204 321010 5350 1605 South East Coast 4248280 2190050 1690808 169081 67632 47343 789 118 185989 3100 930 South Central 3989475 2019671 1544397 154440 61776 43243 721 108 169884 2831 849 South West 5124084 2618529 2040087 204009 81603 57122 952 143 224410 3740 1122 Wales 2965885 1521111 1169535 116954 46781 32747 546 82 128649 2144 643 Total 53728830 27357674 20997280 2099728 839891 587924 9799 1470 2309701 38495 11549

England and Wales 53728830 27357674 20997280 England 50762945 25836563 19827745 Wales 2965885 1521111 1169535 a Boundaries as of July 2006; b Number of women whose operations can be expected to fail Table 2.23. National prevalence data for urogynaecology based on lifetime risk of 60 years and expected 54 failures of surgery by strategic health authority in women aged 20–85+ years, England and Wales, 2006 Strategic Health Age 20–85+ Incontinence Prolapse Procedures/ Authoritya years 60 years Failures 60 years Failures year (n) lifetime risk (0.15)b lifetime risk (0.3)b North East 1 011 702 472 71 1855 556 2954 North West 2670528 1246 187 4896 1469 7798 Yorkshire and Humber 1997711 932 140 3662 1099 5833 East Midlands 1695314 791 119 3108 932 4950 West Midlands 2068523 965 145 3792 1138 6040 East Of England 2190404 1022 153 4016 1205 6396 London 2918271 1362 204 5350 1605 8521 South East Coast 1690808 789 118 3100 930 4937 South Central 1544397 721 108 2831 849 4510 South West 2040087 952 143 3740 1122 5957 Wales 1169535 546 82 2144 643 3415 Total 20997 280 9799 1470 38495 11549 61312

England & Wales 20997280 England 19827745 Wales 1169535 a Boundaries as of July 2006; b Number of women whose operations can be expected to fail

National estimates (England and Wales)

Subspecialists Using the surgical activity estimate (50000 procedures annually) 50–55 subspecialists will be required. They will be expected to perform 4–6 major procedures/week (T able 2.24). Training programmes should be coordinated to supply the demand and be tailored to realistic expectations. Consequently, with a consultant working for 30 years, we should be training two subspecialists/year once the steady state has been reached. However , the effects of the Royal College of Obstetricians and Gynaecologists EWTD, emigration, less than full time working and national consultant contracts might suggest that this figure should be increased in the short term. Furthermore, we need to assume that there will be no retirement of present subspecialists within the next 10 years but that approximately one ‘grandfather’ will retire each year from 2012 onwards. As all subspecialty training programme directors are expected to be subspecialty trained, three trainees should be trained/year for the next 10 years to achieve the requisite number of subspecialists by 2017. Other ‘spare’ programmes might be available for training international doctors or potentially extending the surgical repertoire of ATSM trainees. If, however, over the next 3–5 years the proposed model, does not provide CCT holders with appropriate experience, particularly within the special interest grade, subspecialty numbers may need to increase to accommodate the shortfall.

Special interest consultants The calculation of special interest consultant numbers is probably too vague and should be left to smaller denominators, such as the local population and geography of a strategic health Table 2.24. Subspecialist and special interest consultant requirements in urogynaecology, England and Wales 55 Consultant type Majors/week 2 3 4 5 6 The Future Workforce in Obstetrics and Gynaecology Subspecialist – – 60 48 40 Special interest consultant 476 317 238 – –

authority or primary care trust. An estimate is provided in T able 2.24, again based upon a major surgical throughput of 2–4 major procedures/week. Relevant populations for each authority and trust have been provided. An approximate distribution based purely upon population by strategic health authority is provided in T able 2.25. This will guide the potential number of ATSM opportunities that might need to be provided. Each deanery will need to map its own consultant numbers, consultant age profile and special interests to determine the number training via the ATSM route at any one time. It is assumed a surgeon performs between two and six urogynaecological major procedures/ week and has a 42-week working year. Table 2.24 shows the number of consultants required. It is also assumed that they will have sufficient outpatient activity and direct clinical care PAs to service the surgical workload.

National urogynaecology workforce and capitation Based on a population of 53 million, the consultant requirements for England and Wales are approximately 50–55 subspecialists and approximately 350 consultants with a special interest, which equates to 1/million and 6–7/million, respectively. An approximate calculation of consultant requirements is shown in Table 2.24.

Table 2.25. Urogynaecology subspecialist and special interest consultant numbers by strategic health authority Strategic Health Authoritya Persons Females Consultants (n) (n)(n) Subspecialty Special interest North East 2 555 708 1 011 702 2–3 17 North West 6 853 154 2 670 528 7 45 Yorkshire and Humber 5 142 394 1 997 711 5 33 East Midlands 4 364 214 1 695 314 4 29 West Midlands 5 366 694 2 068 523 5 35 East Of England 5 606 570 2 190 404 6 36 London 7 512 372 2 918 271 7–8 49 South East Coast 4 248 280 1 690 808 4 27 South Central 3 989 475 1 544 397 4 26 South West 5 124 084 2 040 087 5 33 Wales 2 965 885 1 169 535 3 20 Total 53 728 830 20 997 280 54 350

England & Wales 53 728 830 20 997 280 England 50 762 945 19 827 745 Wales 2 965 885 1 169 535 a Boundaries as of July 2006 56 Conclusions The recommendations are to aim for at least a core of 50–55 subspecialists and an output of three subspecialty trainees/year. The number of special interest consultants depends upon a host of factors, some of which may impact on the subspecialty recommendations but ultimately will depend upon the surgical expertise of the A TSM trainee of the future. At present, we recommend 350 consultants with a designated special interest in urogynaecology and, consequently, approximately 12 trainees/year. The burden of disease may increase with the ageing population and these figures may need reconsidered in the longer term. Royal College of Obstetricians and Gynaecologists 6. Sexual and reproductive 57 health

Key points We propose that there should be 200 specialty trained consultants to lead the service in each primary care trust. We estimate 225–250 additional consultants with a contribution to service.

Introduction Sexual and reproductive health is an emerging specialty, with its roots in the family planning services, that now offers an enhanced and expanding clinical service. The aims of the National Strategy for Sexual Health and HIV 37 are increasingly enabling sexual and reproductive health, genitourinary medicine and gynaecology services to work together to provide holistic clinical care with developing liaison with education and social services. Sexual and reproductive health services have a pivotal role in tackling the high unintended pregnancy rate, particularly in the 13–19 year age range 38 and rising incidence of sexually transmitted infections, 39 together with other areas of reproductive health. A new CCT has been agreed by the Postgraduate Medical Education and T raining Board (2008) and the curriculum will be developed during 2008–09. The old subspecialty must be decommissioned and, when this process is agreed and completed, the new training programme will commence. It is hoped that additional funded training posts will be made available rather than destabilising the obstetrics and gynaecology specialty training numbers.

Present workforce Sexual and reproductive health services operate within different models of healthcare provision but, despite this, services are almost completely based in primary care trusts. At present, there are 96 consultants in England and W ales. In addition, there are 46 lead associate specialists and 17 lead senior clinical medical officers. As the non-consultant post- holders retire, it is expected that they will be replaced by consultants. The associate specialist grade is due to close and the senior clinical medical officer grade has already done so. The consultant workload can be summarised as follows: service leadership (often single handed): health service strategic planning and management clinical governance for levels 1–3 of the National Strategy for Sexual Health and HIV, England public health activities: heath needs assessment health promotion informing commissioning multi-agency and multi-organisational network foundation 58 clinical activities: Each service has a different provision profile. Working in partnership, the following components maybe included: contraception sexual health promotion and screening sexually transmitted infection management to level 2 termination of pregnancy services psychosexual counselling menopause services ultrasound colposcopy elements of medical gynaecology training Eighty percent of all training in sexual and reproductive health takes place in the community services. The Faculty of Sexual and Reproductive Healthcare is responsible for the Membership (previously MFFP) and Diploma (formerly DFFP), as well as letters of competence in education, intrauterine techniques and subdermal implant insertion and removal. Additionally, there is training for special skills in menopause, vasectomy , ultrasound, abortion and foundation sexual problems. support for primary care.

Workforce requirements The workload and scale of the issues that need to be tackled mean that the current number of leadership posts is insufficient. The Health Protection Agency40 and Independent Advisory Group on Sexual Health and HIV41 recommend one WTE consultant/125 000 population (or 0.8/100 000), which the Faculty fully endorses. The calculation has also been accepted by the RCOG Scottish Committee Workforce report.16 In effect, this would suggest 425 individuals. A staged approach is required and the initial target is to ensure each primary care trust or health region has one specialty trained consultant leading the service. It is envisaged that the additional necessary posts for service delivery would be filled by a mixture of obstetrics and gynaecology trainees who demonstrate a special interest in sexual and reproductive health by undertaking ATSMs and trainees from the proposed sexual and reproductive health training

Royal College of Obstetricians and Gynaecologists programme. A pragmatic approach needs to be developed that provides the highest quality of service provision and training capability . In this context, it would be appropriate to propose that each primary care trust (approximately 160) should have service leads who are specialty trained. If this equates to subspecialty training as now or specialty training within the new curriculum then provision of the numbers required, programmes for training and resource at present remain questionable. As some trusts are very large and complex, with indicators resulting in high levels of sexual ill health, two will be needed. Thus, 200 specialty trained consultants are required with the remaining workforce (approximately 225–250) coming from a variety of backgrounds such as those in obstetrics and gynaecology with a special interest in sexual and reproductive health, genitourinary medicine or public health. Further attention may be required to describe the relevant training paths and programmes in each of the disciplines. This will, however, bring together specialists from hospitals, community and primary care services, with predicted benefits in service quality and governance. However , it is likely that the majority will come through the obstetrics and gynaecology route, working in the local acute trust but with sessions delivering sexual and reproductive health care, mainly in the community. This approach must be debated fully but it may provide a potential solution with advantages 59 to trainees, the RCOG and the Faculty , particularly if the present level of specialty trainee recruitment continues. The Future Workforce in Obstetrics and Gynaecology

Subspecialty training At present, there are 11 trainees undertaking subspecialty training and 15 centres accredited to provide 24 posts. Assuming a 3-year training programme, there appears to be a massive shortfall in the workforce or the proposed model will require a long-term solution, particularly if the primary stem of training is to be from obstetrics and gynaecology . A potential solution may lie in the advanced training opportunity from an ATSM in sexual and reproductive health or related interests, such as colposcopy or abortion care. Currently , no trainees are undertaking the sexual health A TSM and only two are taking the abortion care module. This needs urgent attention. Policy decisions to move aspects of gynaecological care into the community will result in increasing numbers of consultant gynaecologists working in the community. It is anticipated that these consultant gynaecologists would work with the consultants in sexual and repro- ductive health, further enhancing the community-based service accessible to the population that they serve. 60 7. Minimal access surgery

Key points We propose that there should be 20–25 trainees/year undertaking appropriate A TSMs, with two to three developing advanced laparoscopic skills/year. This element of service requires more detailed information and workforce planning.

Introduction Information about the numbers of consultants performing hysteroscopy and laparoscopy and their level of competence is lacking. Further , while there is information on the number of trainees who have completed the old Special Skills Module and more recent A TSM, there is no reliable information on disease burden. The broad principles of manpower planning for minimal access surgery have been developed in collaboration with the British Society Gynaecological Endoscopy (BSGE).

Advanced hysteroscopic surgery and ATSM All units in England and W ales should be able to offer outpatient hysteroscopy , ideally to include both diagnosis and therapy. The BSGE understands that there are 120 units offering outpatient hysteroscopy but very few offer therapy (we estimate 10–15 units).The A TSM addresses this deficiency by including operative outpatient hysteroscopy in the new logbook. All units should have at least one individual with advanced hysteroscopic skills who can offer resection of polyps, fibroids, septa, adhesions and especially first-generation resection and ablation. Most trainees will learn a second-generation technique but certain women require a first-generation technique. These more difficult cases may end up being referred to tertiary centres if the numbers of appropriately trained individuals remains low . There are 71 trainees who have completed the SSM/A TSM (plus eight non-trainees) and 49 trainees currently registered on the SSM/A TSM (plus eight non-trainees). W ithin the next 12–18 months, there will be 120 trained potential consultants with these skills.

Laparoscopy All units should be able to offer women the advantages of intermediate laparoscopic surgery or, at the very least, be able to manage 90% of ectopic pregnancies laparoscopically and treat mild to moderate endometriosis and ovarian cysts. This would require at least one WTE in each unit and two individuals in the larger units who have these skills; that is, approximately 250 gynaecologists. At present, there are 76 trainees (plus five non-trainees) who have completed the relevant SSM/ATSM) but we do not know how many appropriately trained individuals there were before the SSM became available in March 2005. Advanced laparoscopic surgery and ATSM 61 The BSGE calculates that there are 10–12 gynaecologists performing advanced laparoscopic

surgery for severe endometriosis at present. The calculation given below is only an estimate The Future Workforce in Obstetrics and Gynaecology within this specialist area. T aking the UK population base from 2005–06, the female population of England aged 15–45 years equates to 10.5 million women as a potential group. Literature suggests a prevalence of endometriosis between 3% and 10%. 42–47 The disease burden within this group ranges from 0.3 to 1 million. The prevalence of severe disease in those with endometriosis ranges from 5% to 30%. Hence, the number of women affected is 15 000–300 000 and, within the 30-year cohort, this amounts to 500–10000 new cases/year. A reasonable conservative estimate is thus 5000 women with severe disease in England requiring treatment/year. The calculation of trained laparoscopic consultants (T able 2.26) is based upon the disease burden of severe endometriosis and a surgical year of 42 weeks. Each centre has at least two laparoscopists and each has two sessions of surgery/week. However, much of the calculation is based upon an estimate of the disease burden within a broad confidence limit. The working week, other commitments, prospective cover and less than full time working are just a few considerations which will impact upon the calculation. Furthermore, it is unlikely that A TSM training will provide the necessary volume of experience for a specialty trainee with CCT to replace a consultant retiring with 20–30 years of laparoscopic experience. T o this end, and mindful of the above the number of specialist minimal access centres, should probably equate to nearer 20 with at least two but potentially three consultants/centre.

Conclusion There are approximately 200 units in England and Wales and appropriate networking will be required to match the training opportunities with consultant retirements for hysteroscopy and laparoscopy. Heads of obstetrics and gynaecology schools will need to match the training opportunities with likely service need but be mindful of the requirement to develop a number of trainees with appropriate aptitude and skills to achieve advanced laparoscopic skills for the future.

Table 2.26. Estimation of number of laparoscopic centres required in England for treatment of severe endometriosis based upon disease burden of 5000 cases/year Cases/year/surgeon Cases/centre Centres required Laparoscopists 84 168 30 60 126 252 20 40 168 336 15 30 252 504 10 20 336 672 7 14 420 840 6 12 504 1008 5 10 62 Using a similar template to that of the subspecialties, albeit with very limited available evidence of the disease burden and recognising that the majority of this surgery is likely to be performed in patients within the reproductive age range (15–44 years) numbers can be approximated: one to two consultants performing hysteroscopy for every unit in the country requires 250 consultants. There is a similar number for laparoscopy and this equates to approximately 75/million women in this age category and 6/million for the advanced laparoscopic group. Assuming a 30-year life of a consultant means training 20–25 trainees with hysteroscopic/laparoscopic skills/year and two to three advanced laparoscopic trainees. Royal College of Obstetricians and Gynaecologists 8. Menstrual Disorders 63

Key points This element of service requires more detailed information and workforce planning and has significant implications for the number of trainees undertaking benign gynaecological surgery in addition to those undertaking urogynaecology as an A TSM. The very approximate estimation is for ten trainees/year undertaking benign gynaecological surgery ATSMs.

Introduction Activity analysis is difficult particularly as the diagnosis codes and procedure codes are poorly recorded. Analysis of International Classification of Disease codes from the ninth and tenth iterations, coupled with operation codes for hysterectomy and endometrial ablation, have shown marked changes over the last 16 years (Figure 2.1). Between 1989 and 1995, the number of hysterectomies performed for menorrhagia was approximately 23000. Since then, there has been a gradual but sustained decline in surgical management of this condition. In 2005, there were 7370 hysterectomies for menorrhagia and 11 018 endometrial ablations. This equates to a 67% reduction in hysterectomy and a 20–25% reduction in the surgical management compared with 1989–90. The reduction in hysterectomy is likely to be related to more conservative management in primary care and the introduction of the medicated intrauterine coil in 1995. Although the initial license was for contraception, the awareness of its efficacy in menstrual control rapidly grew such that approximately 110 000 such devices are used each year for all indications. In 1989, there were 828 consultants and 717 registrars (155 specialist registrars and 562 registrars), with approximately 25 staff and associate specialists. This should be compared with 1630 consultants, 1030 specialist registrars and 400 staff and associate specialists in 2007. This equates very roughly to a trainee performing/observing 32 hysterectomies for menorrhagia in 1989 with one performing seven in 2007. The non-training staff (consultants and staff and associate specialist doctors) numbers/hysterectomy have also fallen from 27:1 to 3:1 during the same time frame. The impact of this decline on the availability of training opportunities for benign major abdominal surgery has yet to be measured. Furthermore, of the hysterectomies for menorrhagia that are performed, it is likely that only 25–30% will be construed as the ‘easy’ procedures available for the trainee to gain experience. This, coupled with the reduced hours for elective surgical exposure, will substantially reduce the training opportunities in this area of the specialty. The number of hysterectomies for fibroids in 2005/06 was 10 222 and obviously some of these will have been at the easier end of the spectrum. Finally , there were 52 hysterectomies performed as a caesarean hysterectomy or for intractable postpartum haemorrhage in the same time frame. This has ramifications for consultant experience, especially in those units which have split, with consultants practising obstetrics in isolation. 64 Assuming 30 000 ablations and hysterectomies/year (excluding gynaecological oncology and urogynaecological procedures) equates to 600 procedures/week. ATSM numbers would then depend upon the numbers of procedures/consultant: 300 consultants nationally equates to ten trainees/year. There are approximately 11 000 endometrial ablations/year, which equals 210/week. If this number is added to the hysteroscopy group, it would suggest a need for approximately 30 ATSM trainees/year. Benign hysterectomy procedures total 39 000 (transabdominal and vaginal hysterectomy), some of which will be urogynaecological (therefore, assume approximately 30 000 abdominal procedures or 575 procedures/week). A proportion of these procedures will be performed laparoscopically by oncologists or those with specific minimal access skills. The average consultant will perform two procedures/week in a 42-week year , which equals 84 procedures/year. This in turn suggests nine or ten trainees should be taking the benign surgery ATSM each year. This is only approximate and probably would need expanded by 75–100% in view of aptitude, less than full time working considerations and other considerations. Royal College of Obstetricians and Gynaecologists 9. Early pregnancy units 65

Key point We suggest that early pregnancy unit and emergency gynaecology care undertake an urgent review of service to map the future requirements and that, for the present, 15–20 trainees undertake an appropriate ATSM each year.

Background The denominators for early pregnancy care are 669 601 births plus 200 000 termination of pregnancies plus approximately 150 000 miscarriages as potential sources for access to early pregnancy unit care across the UK every year . The capture of miscarriage data (from the Office for National Statistics and HES) is poor and only an estimate.

Capacity required Feedback from colleagues with expertise in this area was sought from all UK regions. All colleagues are supported in a multidisciplinary team environment with advanced nurse practitioners and ultrasonographers dedicated to early pregnancy sessions in a clinical area exclusively for early pregnancy care. The consensus suggests that early pregnancy units partnered to maternity units delivering 5000 births or more would require two direct clinical care sessions for early pregnancy care/week. Such colleagues provide continuous support for the early pregnancy unit throughout the working week in dealing with complex cases and unforeseen emergencies. A further session should address this ad hoc requirement. Overall, therefore, a minimum of three direct clinical care sessions/week is regarded as a core standard requirement to provide elective early pregnancy care. In units with between 2500 and 5000 births/year the P A allocation would be two to three and for the smaller units up to 2500 births one or two P As might be appropriate. Estimation of capacity could be planned locally on number of births in that unit. Alternatively, a regional approach can be taken for the total quantum of sessions required. The demographic spread of female numbers across the UK by region is known, so that a ‘division’ of demand can be apportioned according to number of women in that region aged 15–44 years. The Association of Early Pregnancy Units survey has accurate reports from 61 of 131 units contacted.48 Further data collection and analysis continues. From initial returns, 61 units have verifiable numbers and accurate data collection systems. From these, extrapolation to a national figure can be made. For example, 186 850 women were seen in the 61 units during 2007 (mean of 3117 women seen/unit). Given 131 units nationally , 408 000 attenders/year are seen in the UK. Regional variations in reporting are large and, consequently, there are limitations with these data at present. Suffice to say that calculating WTE requirements on the above data is impossible. However, the service will require a lead for service in each of the 200 units 66 nationally. Additional personnel to deal with the disease burden will also be required, as well as a consultant contribution to emergency gynaecology care. It is possible to envisage that we need to train approximately 30–40 ATSMs/year. Royal College of Obstetricians and Gynaecologists 10. Paediatric gynaecology 67

It is very difficult to make an assessment in paediatric gynaecology , as there are no activity statistics, partly because patients are seen in a variety of clinical settings. Most straightforward clinical work is handled very well by general gynaecologists. Specialist services should be only available in tertiary centres but this only need be in limited areas. The clinical activity, particularly surgery, can be very occasional and if there are too many centres attempting to care for these cases, experience will be diluted. Congenital problems fall into two distinct groups: neonatal and early childhood and adolescent.

Neonatal and early childhood All neonatal and early childhood cases are now dealt with by paediatric urologists with minimal advice from gynaecologists and this does not need addressing from an RCOG manpower perspective.

Adolescent The incidence of adolescent anomalies is between 1/5000 and 1/30 000. There are two units in London providing services to most of the south of England and this is based on approx two PAs/week in one centre and two PAs/month at the other. There is also a centre in Leeds. There is probably a need for a further one or two centres (possibly in the Midlands and North West or Wales). In addition, there needs to be a gynaecologist with a special interest in each strategic health authority to deal with the local non-surgical problems and the facility to refer centrally if appropriate. It is difficult to define this activity in P A terms because the number of cases is low. Interaction with paediatricians, particularly around puberty , is also limited, as this aspect tends to be managed within paediatric endocrinology . However, it would be useful to have a dialogue with the Royal College of Paediatrics and Child Health to improve networking and to allow patients a better holistic experience. 68 11. Academic obstetrics and gynaecology

We propose that three to four trainees undertake the appropriate academic training pathway each year. We suggest that there needs to be greater emphasis and investment in clinical academic training posts.

Background Clinical academics have always made a substantial contribution to obstetrics and gynaecology, not only in terms of research endeavour but also in terms of providing a service which has often been highly specialised. There is broad acceptance that academic training is threatened by poor recruitment and retention. It is, therefore, paramount that we ensure that there is a healthy future for academic obstetrics and gynaecology to underpin the research led advances in clinical care. A failure in this regard will risk obstetrics and gynaecology becoming a service-led and not a research-led specialty . In 2000, academic consultants in obstetrics and gynaecology accounted for 10.5% of the total consultant numbers in the UK and, by 2004, this had fallen to 7.1%. 49 The number of clinical academics, overall, during that time had fallen by 15% but there had been a fall of 24% in clinical lecturer posts. One reason for this fall has been the trend within universities to invest in non-clinical lectureships as opposed to clinical academic training posts to optimise output for the Research Assessment Exercise. The realisation that the threat to academic medicine was very real and threatened to devalue not only research but also teaching and clinical care, led to the establishment of a new academic training track. This consists broadly of an academic clinical fellowship for 3 years following entry into specialty training. This is then be followed by an externally funded research fellowship for up to 3 years and then by a lectureship for up to 4 years, if subspecialty training is being undertaken. In total, this could involve 12 years following the foundation programme. These new academic training arrangements provide an unparalleled opportunity to develop a new cadre of highly talented clinician academics, who will provide the next generation of senior academic appointments. Planning an academic workforce in the future is fraught with difficulty because the number of individuals who will be employed in this capacity is not mandated by service needs but by the quality of their research and teaching within medical schools. Existing posts risk being vacated in the absence of suitable appointees but the availability of talented individuals will also persuade medical schools not only to reappoint but to create new posts. It is therefore, essential that as many high-quality training opportunities as possible are identified and talented individuals found to take up these training opportunities. Over the next 5 years, more than 20 academic clinical fellows should have been appointed in obstetrics and gynaecology in England, together with a similar number of so-called ‘Walport’ lectureships, with additional lectureships in various medical schools around the country . Current position 69 Data were obtained from ten medical schools: Liverpool, Cardiff, Leicester , Bristol,

Nottingham, Cambridge, Derby , Newcastle, Manchester and University College London, The Future Workforce in Obstetrics and Gynaecology regarding academic staffing levels. There were 42 academic consultants or four to five for each medical school, of whom 17 are Higher Education Funding Council for England (HEFCE) funded, 16 NHS funded and the rest part NHS and part HEFCE funded. There were 32 academic trainees, varying between one and 4.5 WTEs/centre. W ith respect to the number of direct clinical care PAs, there is a mean of 4–4.5 PAs/consultant. Information was sought on the number of academic consultants who are subspecialists. Of the 42 academic consultants, 29 were described as academic subspecialist consultants. T en of these were in fetal and maternal medicine, nine in reproductive medicine and eight in gynaecological oncology, with a couple of others in urogynaecology and sexual and reproductive health. Information was sought about retirements; nine retirements were expected in the next 5 years and 13 in the next 10 years. Not all of these retirements will be at professorial level. The need to replace vacated posts is critical from the academic point of view, as outlined above. If these posts are not replaced, there would be a service gap and, in some cases, this could be quite significant, requiring an additional NHS consultant to provide the service. Across the country, there could be at least 100 consultant equivalents in academic posts, which, in terms of direct clinical care P As, is probably the equivalent of around 70 full-time consultants. Using similar assumptions to other sections this would equate to three to four trainees/year undertaking appropriate academic training. The need for a vibrant academic sector in obstetrics and gynaecology will not be predicated on service needs but on the necessity to have a prominent place in academic medicine to translate new insights into improved clinical care. 70 12. National consultant numbers

The stark message from the exercise we have conducted is the overwhelming need to increase the consultant staffing of delivery suite. At the same time, however , the strength of our specialty lies in its diversity and the opportunity for most consultants to provide a combined obstetrics and gynaecological service. The expansion of consultant numbers seems inevitable and the key will be to maintain that diversity in future job planning and consultant appointments. For these proposals to succeed, it is essential that the majority of consultants, with the exception of subspecialists in gynaecological oncology and reproductive medicine, contribute direct clinical care P As to covering some of the obstetric service and inevitably therefore the delivery suite. Trying to plan for a consultant ceiling is difficult; the delivery suite component is the easiest equation, followed by those of the subspecialties. In these areas, the calculations are robust. The difficulty surrounds the estimation of consultant numbers required in the other areas (abnormal menstruation, pain and endometriosis, early pregnancy complications and emergency gynaecology, as examples).This also includes sexual and reproductive health and, although much work has already been carried out between the RCOG, the Faculty and the Department of Health, it remains unclear where the funding or postgraduate stream is coming from. Their calculations have therefore been left out of this section; however , a proposal is described in the recommendations. There are a number of assumptions which have been made in attempting to derive the consultant numbers for the future: all job plans are 10 PAs each consultant has 2.5 SPAs in addition, each consultant has a contribution of (ward round, management, on-call, administration, education and training) equivalent to 1.0–2.5 P As each consultant provides a minimum of 5.0–6.5 direct clinical care P As in a 10-PA contract for 42 weeks/year; any addition to 10 P As is likely to be service in the majority of cases the number of delivery suite units and their size is taken from the RCOG census 6 the PA requirement for the delivery suite is based on 40-, 60-, 98- and 168-hour presence for 52 weeks, depending upon size, but conforms to the RCOG and NHSLA recommendations the gynaecological calculations are per million population the obstetric calculations are per 10 000 maternities subspecialists in obstetrics provide 4 non-acute direct clinical care P As/week (that is, not delivery suite) special interest consultants provide 2–3 direct clinical care P As/week related to their special interest area subspecialists in gynaecology provide 5.0–6.5 direct clinical care P As in their specialty. Table 2.27. Estimated numbers of consultants/million population by subspecialty 71 Subspecialist Special interest Total/million Total England Total/million Total England population (n) & Wales (n) population (n) & Wales (n) The Future Workforce in Obstetrics and Gynaecology Gynaecological oncology 3 160 5 270 Reproductive medicine 2 105 4 ~ 200 Urogynaecology 1 50 6–7 350

Gynaecology The estimated numbers of consultants/million population by subspecialty are shown in Table 2.27.

Obstetrics a) The estimated numbers of consultants/10 000 maternities for all non-delivery suite activities in maternal and fetal medicine to manage 670 000 births in England and Wales is 150 subspecialists (assuming that each undertakes four direct clinical care PAs) and 480 consultants with a special interest (assuming that each undertakes four direct clinical care PAs). If they cover only two direct clinical care P As, the WTE consultant number rises to 725. b) There are approximately 200 delivery suite units in England and Wales (Table 2.19). c) The RCOG /NHSLA recommendations are shown in Table 2.28. It must be recognised that these are the minimum PA requirements for each group. Issues such as breaks and formal handover may need additional resource: d) If all of the units shown in Table 2.28 achieved the optimum staffing levels, this equates to a service requirement of 3964 P As/week. If, however, only 50% of units achieved the optimum and the other 50% achieve the next level down with the smaller units with less than 2500 deliveries achieving 20- or 40-hour presence, the requirement is 2847 PAs/week. e) Taking the maternal and fetal medicine (non-acute) PA estimation of 8.7 subspecialty PAs and 21.7 PAs as special interest/10 000 maternities (see Fetal and maternal medicine recommendations, page 33), this equates to 583 P As/week and 1454 PAs/week, respectively, for England and Wales (total births = 670 000). f) The national PA obstetric requirement (d + e) therefore equates to approximately 4884–6001 PAs/week.

Table 2.28. RCOG/NHS Litigation Authority recommendations for delivery suite cover Unit size (n deliveries/ Units (n) Consultant presence PAs/year year) aimed for (hours) < 2500 62 40 520 2500–4000 86 60 780 4000–5000 26 98 1456 5000–6000 18 168 2652 > 6000 8 168 2652 Table 2.29. Numbers of consultants required to deliver obstetrics 72 Direct clinical care PAs 4884 PAs 6001 PAs 5.0 977 1200 5.5 888 1091 6.0 814 1000 6.5 751 923

g) The number of consultants required to deliver obstetrics is as shown and depends upon the compliance with the recommendations for delivery suite consultant presence and the weekly contribution of direct clinical care availability at 5.0–6.5 direct clinical care PAs (Table 2.29). h) However, as by far the majority of consultants in England and W ales provide both obstetrics and gynaecology, a pragmatic solution is needed. Assuming that maternal and fetal medicine subspecialists (150) contribute two delivery suite P As/week and special interest consultants (450–725) contribute three delivery suite P As/week, then the estimated number of delivery suite PAs/week provided by obstetricians would range from 1650 PAs (that is, 150 subspecialists x 2 = 300 + 450 special interest consultants x 3 = 1350 = 1650 P As) to 2475 PAs (150 subspecialists x 2 = 300 + 725 special interest consultants x 3 = 2175 = 2475 P As). The average is 2050 PAs. Therefore, the shortfall of delivery suite cover required by the gynaecology interest consultants will range from 797 PAs to 1914 PAs, depending upon the compliance with RCOG/NHSLA guidance (that is, 2847 PAs to 3964 PAs – 2050 PAs; see d above). In effect, this means that, if each gynaecologist provided two sessions/week in obstetrics (either delivery suite or clinics) for 42 weeks of the year , this equates to approximately 680 consultants. Obviously, at the special interest end of the spectrum, there would undoubtedly be crossover of service between the obstetricians and the gynaecologists.

Total consultant base Accurate totals are of little value, owing to the large number of assumptions but it would seem reasonable to consider approximately 2850 as a total, taking into account the data in Table 2.30 and then factoring in the aspects of gynaecology for which the data remain poor . Royal College of Obstetricians and Gynaecologists After the gynaecological subspecialties, minimal access surgery , menstrual dysfunction and paediatric surgery are then more closely defined but it is as yet difficult to determine a finite consultant number. The final group, which includes emergency gynaecology, early pregnancy issues and the contribution of obstetrics and gynaecology to sexual and reproductive health, is the least well defined of all.

Table 2.30. Subspecialty and special interest consultant numbers Subspecialists/million Total England Special interest Total England population (n) & Wales consultants/million & Wales population (n) Gynaecological oncology 3 160 5 270 Reproductive medicine 2.5–3.0 140–150 4 ~ 200 Urogynaecology 1 50–55 6–7 350 Matenal and fetal medicine 150 480–725 Delivery suite 680 Total ~ 500 1980 ~ 2225 73 The Future Workforce in Obstetrics and Gynaecology c 2587 2240 2311 2370 2423 2486 2546 supply ) Total posts Total n f b 110 110 110 110 110 110 110 New posts equivalence a and increase to 2587 ( and increase e 1631 1669 1661 1649 1643 1653 1650 abroad 15% go 93% Over/under Consultants required to keep current state current to keep required Consultants ) d n ) n 69 31 39 51 57 47 50 ( ) retirement ( ) retirement n ) 2% wastage ) 2% n consultants ( Year CCTs ( CCTs Year Year Current WRT projected Retirement projected Current Year WRT 200720082009 17002010 17002011 17002012 17002013 1700 40 1700 40 1700 41 42 45 1660 47 1660 54 1659 1658 110 1655 110 1653 110 1646 110 1770 110 1840 110 1909 110 1977 2042 2105 2161 2007 142 2008 220 2009 150 3 2010 160 4 2011 160 3 21 2012 170 3 33 2013 180 110 3 23 2014 200 170 3 0 24 2015 200 116 4 60 24 2016 200 124 4 6 26 2017 200 124 4 14 27 131 4 14 30 139 4 21 30 154 29 30 154 44 30 154 44 154 44 44 2018 200 2019 200 2020 200 4 4 4 30 30 154 30 154 44 154 44 44 2020 1700 2014 1700 201520162017 1700 2018 1700 2019 1700 1700 1700 3.0–3.5% expansion number of 110 consultant posts Effect of Workforce Review Team (WRT) projected retirements on the current total of 1700 consultants projected retirements on the current (WRT) Team Review Workforce Effect of Number projected to practise outside the UK Number projected to practise WRT estimate WRT Total consultant number to 2020 Total Effect of less than full time working f d e b) Trainees c a b a) Consultants Table 2.31. by 2020 Wales Table in England and consultants/year reach and stay at 2500 example to Worked Table 2.32. Alterations to ‘wastage, emigration and equivalence’ 74 a) Consultants Year Current Retirements Effecta New postsb Total postsc consultants (n) (n) 2007 1700 40 1660 110 1770 2008 1700 40 1660 130 1840 2009 1700 41 1659 160 1979 2010 1700 42 1658 180 2117 2011 1700 45 1655 160 2232 2012 1700 47 1653 140 2325 2013 1700 54 1646 120 2391 2014 1700 31 1669 120 2480 2015 1700 39 1661 120 2561 2016 1700 51 1649 120 2630 2017 1700 57 1643 120 2693 2018 1700 47 1653 120 2766 2019 1700 50 1650 120 2836 2020 1700 69 1631 120 2887 a Effect of Workforce Review Team (WRT) projected retirements on the current total of 1700 consultants b 3.0–3.5% expansion number of 110 consultant posts c Total consultant number to 2020

b) Trainees Year CCTs (n) 2% wastaged 5% go 88% Over/under (n) abroade equivalencef supply/year 2007 142 3 7 116 6 2008 220 4 11 180 50 2009 150 3 8 123 –37 2010 160 3 8 131 –49 2011 160 3 8 131 –29 2012 170 3 9 139 –1 2013 180 4 9 147 27

Royal College of Obstetricians and Gynaecologists 2014 200 4 10 164 44 2015 200 4 10 164 44 2016 200 4 10 164 44 2017 200 4 10 164 44 2018 200 4 10 164 44 2019 200 4 10 164 44 2020 200 4 10 164 44 d WRT estimate e Number projected to practise outside the UK f Effect of less than full time working

In addition, we know that, for every 100 consultants, this equates to the equivalent of only 90, owing to less than full time working and the academic influence upon service provision, for example. This is likely to fall further over the next 10 years to nearer 85%. Consequently, a base of nearer 3000–3100 consultants seems realistic. Workforce model for CCT holders 2008–2020 75 In the worked examples (Table 2.31 and 2.32), two scenarios are presented. The first relates to the current state of 1700 consultants and the expected retirements/year . The consultant expan- The Future Workforce in Obstetrics and Gynaecology sion is then included to reach a total of 2587, with a steady state expansion of 3.5% a year . MMC will impact around 2014–2015 but may take a further 2–3 years to realise the true figure of 200 awards/year . There is then natural wastage or drift and less than full time working, which results in the oversupply seen in the final column of T able 2.31. In the second worked example (T able 2.32), the impact of the NHSLA/RCOG recommend- ations for delivery suite cover are shown. The consultant expansion varies, in particular over the next 5 years, to accommodate the predicted delivery suite requirements with a reduction thereafter. This will, however, generate a supply of 2887 consultants. As MMC is thought to have attracted more UK and European Union trainees, the ‘drift’ will fall but it is also thought that the equivalence effect of less than full time working will fall from its present 93–88%. The over/undersupply is seen in the final column of T able 2.32. The implications are such that, in the short term, demand may outstrip the supply of CCT graduates. However, by 2014 and beyond, the CCT numbers are likely to be far in excess of what is then required, which will be retirements only unless there is a major shift in NHS care or hours of work. The obvious conclusion is either to slow down the delivery suite staffing proposals or quickly redesign the specialty training programme and numbers that are being recruited annually . Any reduction in specialty trainees would affect service provision and on-call rotas. This needs further debate urgently.

Estimated training opportunities/year (SST and ATSMs) The minimum training requirements/year (subspecialty numbers and A TSM opportunities) are summarised in Table 2.33.

Table 2.33. Estimated training opportunities/year (subspecialty training and ATSMs) Clinical area SST/ATSM trainees (n) Maternal and fetal medicine subspecialty 6 Fetal medicine special interest 4 Maternal medicine special interest 10 Advanced antenatal practice special interest 10 Delivery suite lead 10–15 Gynaecological oncology subspecialty 7 Gynaecological oncology special interest 11 Urogynaecology subspecialist 3 Urogynaecology special interest 12 Reproductive medicine subspecialty 5 Reproductive medicine special interest 8 Advanced minimal access surgery 3 Surgical gynaecology (minimal access) 30 Academic O&G 3–4 Paediatric gynaecology ~ 1 Sexual and reproductive health subspecialty 4 + Sexual and reproductive health special interest potential 10 + Early pregnancy/emergency gynaecology 15–20 + 76 References

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Questionnaire to quantify clinical services in obstetrics and gynaecology

National questionnaire analysis The 50 returned questionnaires represent 191 474 deliveries (32%), 275 000 new gynaecol- ogical referrals (25%), 83 370 inpatient procedures and 73 097 daycase operations.

Obstetrics The deliveries can be broken down to a spontaneous vaginal delivery rate of 63.5%, an instrumental delivery rate of 11.8% and a caesarean section rate of 24.4% (emergency 14.94% and elective 9.43%). The preterm delivery rate was 1.54% and babies less than 1.5 kg 0.26% (n = 500). The induction rate was 17.8% and multiple pregnancy rate was 2.1%. Of the questions asked: 100% of the maternity units were part of a regional transfer network 26% had a policy to transfer preterm births at less than 30 weeks to a regional centre 6% had a policy to transfer between 31 and 34 weeks to a pegional centre 90% of units accepted perinatal transfers from other units 70% had separate caesarean section theatre staff, of which 50% were for all caesarean section operations 46% had a separate caesarean section theatre for elective cases 76% had a separate back-up theatre for emergencies 95% had access to at least high-dependence facilities with 38% having a separate obstetric high-dependency unit. Other obstetrics elements included: 44% units had a dedicated labour ward consultant without any other clinical commitments for 40 hours on a prospective basis.

Gynaecology Although activity data were requested, much of the information on direct clinical care P As related to a particular activity or subspecialty was not recorded. Finally, the PA provision for managerial activity was incomplete. The gynaecological activity is as follows: 275 140 new referrals 350 638 follow-up patients 79 83 370 Inpatients

73 097 day cases The Future Workforce in Obstetrics and Gynaecology 77 687 emergencies seen. Surgical activity: 7039 abdominal hysterectomies (excluding for cancer) 3170 vaginal hysterectomies not for prolapse 6852 prolapse operations 3294 incontinence operations 7502 endometrial ablations 14 307 outpatient hysteroscopies 62 612 colposcopies 500 ectopic pregnancies (medical management) 1154 ectopic pregnancies (laproscopy) 511 ectopic pregnancies (laparotomy) The following pages show the questionnaire that was issued. 80 ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS

DEANERY: NHS TRUST NAME: PERSON COMPLETING: Contact telephone: Email:

1. NATIONAL OBSTETRIC DATABASE (12 month data 2005 or 2005/06) Does your trust have a: Consultant-led labour ward YES/NO Co-located midwife-led birth centre YES/NO Stand-alone midwife-led birth centre YES/NO

Number Percentage Total number of deliveries Deliveries under consultant care Deliveries under midwife-led care Deliveries under GP care Home births

Birth centres

Number of Number of Co-located Transfer Distance Average travel centres deliveries rate from main time from main unit unit 1 Royal College of Obstetricians and Gynaecologists 2 3

Which CNST Level has your trust achieved? Level 0 Level 1 Level 2 Level 3 Which BAPM level is your neonatal unit? Level I Level II Level III Consultant-led units: 81 Is your unit part of a regional neonatal transfer network? YES/NO

Do you transfer preterm < 30 weeks to a regional centre? YES/NO The Future Workforce in Obstetrics and Gynaecology Do you transfer preterm 31–34 weeks to a regional centre? YES/NO Does your unit accept perinatal transfers from other consultant units? YES/NO Is your unit part of a regional perinatal (mat) network? YES/NO Is there separate theatre staff for caesarean sections (CS)? YES/NO If yes: Elective only? YES/NO All CS? YES/NO Is there a separate elective CS theatre? YES/NO Is there a second back-up theatre? YES/NO Is there an obstetric HDU? YES/NO If yes: How many beds Is there an adult ICU on-site? YES/NO Is there an adult HDU on-site? YES/NO Does your trust provide private obstetric facilities? YES/NO If yes, how many deliveries If yes, how many CS

2. OBSTETRIC STATISTICS

Number % or rate Total no. of deliveries SVD Forceps Ventouse Vaginal breech delivery Emergency CS Elective CS Induction rate Multiple pregnancy Preterm delivery (< 37 >32 weeks) Preterm delivery < 32 wks Obstetric hysterectomy Maternal death Perinatal mortality rate = (SB = NND = ) 82 2.1. How many hours/PAs of dedicated consultant cover with no other clinical commitment does your unit achieve/week? 10 PAs (40 hours) 15 PAs (60 hours) 20 PAs (80 hours) 42 PAs (168 hours) Other:

2.2. How many hours/PAs of consultant cover with other clinical commitment does your unit achieve/week? 10 PAs (40 hours) 15 PAs (60 hours) 20 PAs (80 hours) 42 PAs (168 hours) Other:

3. OBSTETRIC SERVICES PROVIDED 3.1 Outpatient clinics

Number Number of per week attendances per year Community-based midwife ANC Hospital-based midwife ANC Community-based doctor ANC Hospital-based doctor ANC (excluding specialist clinics) Specialist ANC

Does your unit have: a dedicated ECV clinic YES/NO a prepregnancy counselling service YES/NO

Royal College of Obstetricians and Gynaecologists a drug dependence antenatal support service YES/NO a daycare pregnancy assessment unit YES/NO Number of pregnancy assessment unit PAs by consultants: Number of pregnancy assessment unit sessions by junior doctors:

3.2. Obstetric ultrasound Are all women offered: a dating scan YES/NO a nuchal translucency scan YES/NO a mid-trimester anomaly (level 2) scan YES/NO Does your unit provide: Amniocentesis YES/NO CVS YES/NO 83 tertiary fetal medicine YES/NO

tertiary maternal medicine YES/NO The Future Workforce in Obstetrics and Gynaecology How many PAs per week are provided by obstetricians for: Specialist scanning/invasive procedures Maternal medicine

4. OBSTETRIC STAFFING

Total number WTE obstetricians WTE subspecialist obstetricians PAs for dedicated daytime labour ward cover PAs for elective caesarean section lists PAs for antenatal clinics PAs for obstetric ward rounds PAs for obstetric scanning PAs for predictable on-call by consultants PAs for unpredictable on-call by consultants 84 5. NATIONAL GYNAECOLOGY DATABASE (12 month data 2005 or 2005/06) Total number of new gynae referrals Total number of new colposcopy referrals

Total number Gynae. beds Gynae. inpatients major cases minor cases Operating lists Daycase lists (if separate) Day cases Gynae. emergencies seen Gynae. emergencies admitted Abdominal hysterectomies (not cancer related) Vaginal hysterectomies – not for prolapse Operations for prolapse Operations for urinary incontinence Operations (ablative procedures) for menstrual problems Outpatient hysteroscopies Colposcopies Royal College of Obstetricians and Gynaecologists 6. GYNAECOLOGICAL SERVICES PROVIDED 85

YES/NO Number of PAs

per week The Future Workforce in Obstetrics and Gynaecology Is there a dedicated infertility clinic (level I) Is there a dedicated infertility clinic (level II) Is there a dedicated infertility clinic (level III) Is there an IVF unit in your hospital Is it Private/NHS/university funded Is there a dedicated recurrent miscarriage clinic Is there a dedicated reproductive endocrine clinic Is there a dedicated PMS clinic Is there a dedicated menopause clinic Is there a dedicated chronic pelvic pain clinic Is there a dedicated urodynamic assessment clinic Is there a combined advanced gynae-urology clinic Is there a rapid access clinic (? cancer)

7. GYNAECOLOGY AUDITABLE STANDARDS OF CARE 7.1. Early pregnancy loss Total number of ectopic pregnancies: Does your unit offer option of management of ectopic pregnancy by: Medical methods YES/NO If yes, number Laparoscopic surgery YES/NO If yes, number Is there an early pregnancy assessment unit (EP AU) YES/NO 7.2. Gynaecological cancer services Are you a cancer unit? YES/NO Are you a cancer centre? YES/NO Is there a dedicated rapid access clinic for suspect gynae malignancies? YES/NO Is there an MDT/gynaecological oncology clinic? YES/NO Number of new cancers/year Number of RCOG subspecialist consultant PAs for gynae cancer Number ‘Grandfather’ subspecialist PA sessions for gynae cancer 86 7.3. Reproductive medicine Is there an NHS IVF unit? YES/NO If yes, number of cycles per year Is there a private IVF unit YES/NO If yes, number of cycles per year Number of consultant PAs in reproductive medicine YES/NO If yes, number of cycles per year

8. UROGYNAECOLOGY Number of urodynamic sessions/week Number patients per year for assessment Number of consultant PAs in urogynaecology Royal College of Obstetricians and Gynaecologists 9. TRAINING OPPORTUNITIES FOR SPECIALIST TRAINING 87

Do you have adequate workload and YES/NO How How many The Future Workforce in Obstetrics and Gynaecology supervisors to offer training in the following? many in completed training? training over the past one year? Subspecialty training Labour ward management leadership Basic obstetric ultrasound scanning Advanced obstetric ultrasound training RCOG/RCP obstetric U/S diploma Maternal medicine Fetal medicine U/S imaging in the mx of gynaecological conditions Management of an infertile couple Assisted reproduction BSCCP/RCOG certification in colposcopy Basic urodynamics Advanced urogynaecology Medical management Medical education Paediatric and adolescent gynaecology Special interest in gynaecological oncology MAS level II-III Pelvic floor surgery 88 10. WORKFORCE ISSUES: Total WTE Number of consultants Number of consultants – obstetrics only Number of consultants – gynaecology only Total number of PAs – obstetrics Number of PAs for ‘on call’ Intensity = Total number of PAs – gynaecology Number of PAs ‘on call’ (if different from above) Intensity = Total number of ‘fixed clinical’ sessions: obstetrics Total number of ‘fixed clinical’ sessions: gynaecology Number of SHOs Number of FY2s Number of SpRs 1–3 Number of SpRs 4–5 Number of SAS sessions

Number of PA’s over and above 2.5 SPAs for:

Number Clinical Director Clinical Lead Deanery College Advisor Programme Director Royal College of Obstetricians and Gynaecologists College Tutor Postgrad Tutor (Deanery) Guidelines Lead Governance Lead Other

11. CHANGES IN SERVICE Are there any proposed closures/mergers/reconfiguration of service that will affect your unit? YES/NO If Yes, please briefly outline what these are: Appendix 2 89

Population by strategic health authority and primary care trust

Strategic Health PERSONS FEMALES Authority All ages (n) All ages 20–85+ 20–24 25–29 30–34 35–39 40–44 North East 2555708 1308305 432172 88677 73910 76729 92881 99975 North West 6853154 3498701 1170304 232337 201427 215054 256186 265300 Yorkshire/Humber 5142394 2615153 887528 184272 155568 162042 191413 194233 East Midlands 4364214 2206865 740295 143119 124159 137489 166740 168788 West Midlands 5366694 2727196 904298 173788 160181 167868 200280 202181 East Of England 5606570 2853823 943649 160035 165997 184458 213971 219188 London 7512372 3798270 1623707 275180 373699 355348 322330 297150 South East Coast 4248280 2190050 701038 115267 118951 133917 162484 170419 South Central 3989475 2019671 705217 129277 125407 136644 155265 158624 South West 5124084 2618529 813761 146976 135278 151362 185292 194853 WALES 2965885 1521111 1169535 96844 81237 86612 105344 110710 Total 53728830 27357674 10091504 1745772 1715814 1807523 2052186 2081421

England and Wales 53728830 27357674 9402716 1745772 1715814 1807523 2052186 2081421 England 50762945 25836563 8921969 1648928 1634577 1720911 1946842 1970711 Wales 2965885 1521111 1169535 96844 81237 86612 105344 110710

Strategic health authority FEMALES 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+ North East SHA 93247 83044 87136 69894 64068 57903 50794 39190 34254 North West SHA 238179 212352 227803 187754 164459 145575 128038 100536 95528 Yorkshire/Humber SHA 176041 155902 168995 138133 120059 107994 94736 75436 72887 East Midlands SHA 150279 135274 148004 125546 101530 89673 80015 63926 60772 West Midlands SHA 179356 163757 173715 151844 127519 112832 99981 79480 75741 East Of England SHA 191685 174403 192660 161455 131510 118638 106090 85646 84668 London SHA 244596 201709 193350 151104 128421 113458 100770 81700 79456 South East Coast SHA 148595 133685 148131 125025 103007 95044 86850 72305 77128 South Central SHA 140410 122956 129324 106427 84730 75774 67472 55318 56769 South West SHA 176343 163876 183045 159428 130452 117787 108986 92416 93993 Wales 101456 94617 105236 89838 75657 66905 58885 49591 46603 Total 1840187 1641575 1757399 1466448 1231412 1101583 982617 795544 777799

England and Wales 1840187 1641575 1757399 1466448 1231412 1101583 982617 795544 777799 England 1738731 1546958 1652163 1376610 1155755 1034678 923732 745953 731196 Wales 101456 94617 105236 89838 75657 66905 58885 49591 46603 90 Appendix 3

NHS Maternity Statistics (England)

Labour and delivery The majority of women start labour spontaneously (68.7%); 11% have a planned (elective) caesarean section and 20.2% are induced. Interestingly , the onset of labour and mode of delivery differs by UK government office region (T able A3.2). The spontaneous onset of labour is lowest in the North West at 65.3% compared with 71.2% in London and the North East. The elective caesarean section rate has risen every year since 1980 when the figure was 4% (Table A3.3). The overall caesarean section rate is 23.5%, with a regional variation of 21.2% in the North East to 26.1% in London, with the major determinant being the emergency caesarean section contribution of 14.1%, compared with 5% in 1980 (T able A3.4). There has been a fairly constant instrumental delivery rate at 10–11%, with a reversal of the forceps to ventouse ratio such that, now , 68% of the instrumental deliveries are by ventouse extraction.

Gestation In 2005–06, about 89% of deliveries occurred between 37 and 41 weeks of gestation, 4% were considered post-term and the remaining 7% preterm (before 37 weeks of gestation); 6% occur between 32 and 36 weeks and 0.9% between 28–31 weeks. There were 3150 deliveries between 20 and 28 weeks of gestation (0.4%) (Table A3.5). The pattern has been similar for the past 10 years. The relationship between onset of labour and mode of delivery is shown in T able A3.6. Overall, 52% of mothers had a spontaneous onset of labour and spontaneous delivery; 36% of all hospital deliveries included some form of anaesthesia (T able A3.7). When labour was spontaneous, 14.3% occurred each day of the week, while 7% of elective caesarean sections occurred at the weekend (Table A3.8). A further interesting factor relates to numbers of women changing their delivery location from intended to actual but this focuses upon the home/hospital site rather than midwife–led unit to hospital (Table A3.9).

Other pregnancy related issues In each of the years between 1990 and 2005–06, there have been approximately 45 000 miscarriages and 9000 ectopic pregnancies. Detail is included in the following tables. Table A3.1. NHS hospital deliveries: method of onset of labour, England, 1980 to 2005–06 91 Year Total (n) Spontaneous Caesarean Induction Surgical Oxytocic Surgical (%) section (%) induction drugs and drugs

(%) (%) (%) (%) The Future Workforce in Obstetrics and Gynaecology 1980 601 500 75.4 4.0 20.6 – – – 1985 605 100 77.6 4.9 17.5 – – – 1989–90 633 500 76.7 5.0 18.3 4.3 8.1 5.9 1990–91 652 100 76.9 5.3 17.7 3.6 8.4 5.7 1991–92 643 800 76.7 5.6 17.6 3.0 9.7 5.0 1992–93 624 600 77.5 5.7 16.8 2.9 9.4 4.4 1993–94 620 200 76.0 6.2 17.7 2.8 10.3 4.7 1994–95 604 300 73.7 6.8 19.5 2.9 11.7 4.9 1995–96 592 600 72.6 7.2 20.2 3.1 12.3 4.8 1996–97 594 500 71.6 7.7 20.7 3.2 12.5 5.0 1997–98 585 000 70.3 8.4 21.3 3.3 12.9 5.1 1998–99 577 500 69.4 8.9 21.7 3.3 13.0 5.4 1999–00 565 300 68.5 9.6 21.8 3.5 12.6 5.7 2000–01 549 600 68.7 9.8 21.5 3.6 12.2 5.8 2001–02 541 700 68.1 10.4 21.5 3.1 12.0 6.4 2002–03 548 000 69.0 10.5 20.5 3.6 11.5 5.4 2003–04 575 900 69.2 10.6 20.2 3.6 10.8 5.8 2004–05 584 100 69.7 10.7 19.6 4.1 9.9 5.5 2005–06 593 400 68.7 11.0 20.2 4.6 10.1 5.6 Reproduced with the permission of the Department of Health

Table A3.2. NHS hospital deliveries: method of onset of labour by region, 2005–06 Region Total Spontaneous Caesarean Induction Surgical Oxytocic Surgical (%) (%) section (%) induction drugs and drugs (%) (%) (%) (%) England 100 68.7 11.0 20.2 4.6 10.1 5.6 North East 100 71.2 8.3 20.4 4.4 9.0 7.1 North West 100 65.3 12.3 22.3 4.3 9.5 8.6 Yorkshire & Humber 100 71.1 8.6 20.3 7.3 8.6 4.4 East Midlands 100 68.5 9.4 22.2 3.0 10.6 8.6 West Midlands 100 66.8 10.6 22.6 5.1 11.1 6.4 East 100 69.7 11.3 19.0 5.7 8.6 4.7 London 100 71.2 11.6 17.2 3.1 10.5 3.5 South East 100 68.6 11.9 19.4 4.7 10.1 4.9 South West 100 65.9 12.6 21.5 3.9 13.8 3.8 Reproduced with the permission of the Department of Health Royal College of Obstetricians and Gynaecologists 92 040 8 0 5008181772030.1 0.1 0.3 0.1 0.3 0.1 7.2 0.3 0.1 7.0 0.3 0.1 1.7 7.1 0.5 0.1 1.6 7.2 0.4 0.1 1.8 1.5 7.2 0.5 1.7 1.5 7.4 0.5 0.8 1.9 1.7 7.1 1.0 2.0 1.8 6.5 65.0 1.0 2.1 1.7 65.5 100 0.9 584 2.0 1.7 65.9 900 2004–05 1.5 575 2.0 65.6 000 2003–04 1.1 548 2.2 65.1 700 2002–03 1.2 541 66.3 600 2001–02 1.0 549 67.7 300 2000–01 1.12.42.15.90.70.1 565 69.2 500 1999–00 577 70.6 000 1998–99 585 70.8 500 1.5 2.8 2.3 5.40.70.2 1997–98 594 71.5 600 1.3 3.3 2.5 4.80.70.2 1996–97 592 72.5 300 1.3 3.5 3.0 3.70.70.2 1995–96 604 74.4 200 1.1 3.6 3.0 3.10.70.2 1994–95 620 75.1 600 1.2 3.9 3.0 2.70.80.2 1993–94 624 75.6 800 1.1 4.0 3.5 2.10.80.3 1992–93 643 76.7 75.4 100 1.4 3.9 3.9 1.60.80.3 1991–92 2.5 5.33.80.70.9 652 75.8 500 1990–91 100 2.0 5.54.20.60.9 633 605 75.3 1989–90 100 2.1 5.64.20.60.91.0 586 75.8 1985 400 1.1 5.74.60.61.0 578 75.5 1984 600 1.0 6.25.10.71.21.3 574 1983 500 601 1982 1980 050 9 0 4207201972030.1 0.3 7.2 1.9 2.0 0.7 64.2 Reproduced withthepermissionofDepartmentHealth 400 593 2005–06 Year Total Spontaneous Table A3.3. H optldlvre:mto fdlvr,Egad 1980to2005–06 England, methodofdelivery, NHS hospitaldeliveries: etxOhr ocp Ventouse Forceps Vertex Other o Other Low ntuetlBec reh asra Other Caesarean Breech Breech Instrumental extraction oa lcieEmergency Total Elective 22.9 22.7 22.0 22.0 21.5 20.6 19.1 18.2 17.0 16.3 15.5 15.0 13.8 12.9 12.4 11.3 10.4 10.1 10.1 10.1 23.5 9.0 4.0 5.00.1 . 360.2 0.2 13.6 0.2 13.1 0.3 9.4 12.7 0.4 9.6 12.7 0.4 9.3 12.7 0.6 9.3 12.0 0.5 8.8 11.1 8.6 10.4 8.0 7.9 7.3 9.70.3 6.9 9.50.1 6.5 9.00.2 6.1 8.90.2 5.6 8.10.2 5.5 7.40.2 5.3 7.10.1 4.9 6.30.2 4.9 5.50.1 4.6 5.50.1 4.6 5.50.1 4.6 5.50.0 . 410.2 14.1 9.3 Appendix 4 93

Illustrative job descriptions for subspecialist and special interest posts

A. Subspecialist gynaecological oncologist Activity PA Multidisciplinary team meeting 1 Joint oncology clinic 1 Operating theatre 2 Specialist clinics (e.g. genetic, rapid access, colposcopy) 2 Ward round(s), counselling patients and families 1 Administration 0.5 Total 7.5

B. Special interest in gynaecological oncology Activity PA Multidisciplinary team meeting 0.5 Operating theatre (including day cases) 1 Specialist clinics (e.g. rapid access, follow-up gynaecological oncology/joint clinics) 2 Ward round(s), counselling patients and families 0.5 Total 4

Mandatory ATSM: Gynaecological Oncology Optional ATSMs: Colposcopy, Benign Abdominal Surgery

C. Subspecialist in reproductive medicine Activity PA Subfertility clinic 1.5 Specialist clinic (e.g. endocrinology and andrology, endometriosis, recurrent miscarriage, menopause, paediatric gynaecology) 1 Operating theatre 1 Assisted reproduction techniques 3 Ward round, counselling subfertile couples, HFEA administration 0.5 Administration 0.5 Total 7.5 94 D. Special interest in reproductive medicine Activity PA Subfertility clinic 1 Specialist clinic (e.g. endometriosis, recurrent miscarriage, menopause, paediatric gynaecology, sexual health and abortion care 1 Assisted reproduction techniques 1 Operating theatre 1 Total 4

Mandatory ATSM: Subfertility and Reproductive Endocrinology (only mandatory for consultants providing subfertility services) Optional ATSMs: Benign Gynaecological Surgery: Laparoscopy, Menopause, Paediatric and Adolescent Gynaecology, Abortion Care

E. Subspecialist in maternal and fetal medicine Activity PA Fetal medicine, ultrasound list 2–3 Maternal medicine, specialist antenatal clinic (e.g. twins) 2–3 Delivery suite 2 Administration 0.5 Total 7.5

F. Special interest in fetal medicine Activity PA Fetal medicine/ultrasound list 1–2 Specialist antenatal clinic (e.g. maternal medicine, twins) 1–2 Delivery suite 3 Other (e.g. ward round, maternity assessment unit) 1 Administration 0.5 Total 7.5

Royal College of Obstetricians and Gynaecologists G. Special interest in maternal medicine Activity PA Maternal medicine clinic(s) 1–2 Specialist antenatal clinic (e.g. substance misuse) 1–2 Delivery suite 3 Other (e.g. ward round, maternity assessment unit) 1 Administration 0.5 Total 7.5 H. Special interest in advanced antenatal practice 95 Activity PA

Ultrasound list 1 The Future Workforce in Obstetrics and Gynaecology Specialist antenatal clinics (e.g. twins, perinatal psychiatry) 2 Delivery suite 3 Other (e.g. ward round, maternity assessment unit) 1 Administration 0.5 Total 7.5

I. Subspecialist in urogynaecology Activity PA Theatre 2–3 Urogynaecology clinics (urodynamics, perineal, joint) 2–3 Other (ward round, multidisciplinary team meeting, administration, gynaecology outpatient clinics) 2.5 Total 7.5

J. Special interest in urogynaecology Activity PA Theatre 1–2 Urodynamic clinic 1 Other clinics (gynaecology and antenatal outpatient clinics) 2–3 Other (ward round, administration, delivery suite) 2.5 Total 7.5 96 Appendix 5

Fetal and maternal medicine tables

Table A5.1. Number of outpatient special interest and subspecialist visits (appointments) for each structural fetal anomaly

Anomaly Antenatal Antenatal TOP Cases Visits (special Visits/10 000 detection cases/10 000 (%) referred interest/sub maternities rate (%) maternities to subspec. specialist)a Special Subspec. (n) (%) (n) interest (n) (n) Central nervous system Anencephaly 97 5.5 95 20 2.3/0.8 13 4 Encephalocele 89 1.3 90 100 1.7/2.4 2 3 Spina bifida 89 5.6 80 100 1.8/2.6 10 15 Ventriculomegaly 83 4.6 40 30 2.4/1.4 11 7 Microcephaly 20 0.9 40 80 2.1/3.3 2 3 Holoprosencephaly 85 1.2 90 100 1.7/2.4 2 3 Dandy Walker 83 1.4 80 100 1.8/1.8 2 3 Cardiopulmonary cyst 100 100.0 0 0 0.8/0.2 80 20 Cardiac Outflow tract anomaly 49 4.3 30 100 0.8/3.6 3 16 Hypolastic/univentricular heart 92 4.0 60 100 0.8/3.5 3 14 atrioventricular canal defect 92 1.0 60 100 0.8/3.5 1 4 Ventricular septal defect 10 10.0 50 100 0.8/3.6 8 36 Valve problems 40 6.0 40 100 0.8/3.7 5 22 Coarctation 29 1.2 40 100 0.8/3.7 1 5 Arrhythmias 100 10.0 0 100 0.8/1.7 8 17 Other 55 6.0 40 100 0.8/3.7 5 22 Genitourinary Renal agenesis 75 3.3 40 20 2.7/0.8 9 3 Renal pelvic dilatation 100 73.0 0 0 0.24/0.06 18 4 Hydronephrosis 80 9.3 10 30 3.4/1.4 31 13 Cystic kidney disease 78 5.4 30 50 2.56/1.6 14 8 Megacystis/LUTO 90 0.4 50 100 1.2/4.1 0.5 2 Bladder exstrophy 50 0.3 50 100 1.2/3.7 0.4 1 Genital 12 1.5 10 100 1.6/3.1 2 5 Other 57 6.0 10 90 1.8/2.9 11 17 Pulmonary Cystic adenomatoid malformation 60 1.0 10 100 3.0/2.5 3 3 Diaphragmatic hernia 80 3.0 30 100 2.2/3.5 7 11 Pleural effusion 100 1.0 10 100 2.3/3.2 2 3 Abdominal wall/gastrointestinal Gastroschisis 96 5.4 5 100 3.9/3.5 21 19 Exomphalos 86 3.7 70 100 2.1/2.3 8 8 Duodenal atresia 26 0.5 50 100 2.8/2.1 1 1 Oesophageal atresia 26 0.7 60 100 2.6/2.0 2 1 Echogenic bowel 100 7.1 10 20 3.1/0.9 22 7 Ascites 100 1.6 40 100 2.1/2.9 3 5 Other 10 0.6 50 100 2.0/2.8 1 2 Neck and face Facial cleft 43 7.5 25 100 2.2/1.6 17 12 Cystic hygroma 95 5.9 80 40 2.3/1.1 14 6 Nuchal translucency > 3.5 mm 100 10.0 50 100 0.8/1.2 8 12 Skeletal Osteochondrodysplasias 73 1.0 60 100 0.8/3.9 1 4 Talipes 60 4.2 0 0 1.6/0.4 7 2 Musculoskeletal (excluding talipes) 30 3.9 50 100 1.2/2.8 5 11 Abnormal digits 7 1.6 50 100 1.2/2.7 2 4 Limb reduction defects 47 3.8 50 80 1.9/2.0 7 8 Other limb anomalies 30 0.8 30 50 2.6/1.4 2 1 Other Hydrops (non-immune) 100 10.0 70 100 1.6/2.8 16 28 Amnion rupture sequence 80 0.3 90 70 1.9/1.3 0.6 0.4 All other 35 1.3 50 100 2.0/2.8 3 4 TOTAL 394 399

a See table A5.2; LUTO = lower urinary tract obstruction, Subspec. = subspecialist, TOP = termination of pregnancy Table A5.2. Number of special interest and subspecialist visits (calculated using anencephaly as an 97 example); assumptions: 80% of women book at secondary care units; 20% of cases with anencephaly referred to a subspecialist

Proportion Termination Proportion Special Total Subspecialist Total The Future Workforce in Obstetrics and Gynaecology of cases of of cases interest special visits/case subspecialist booked pregnancy referred visits/case interest visits outside rate to visits tertiary unit subspecialist Secondary booked case: Termination 0.8 0.95 0.8 3 1.82a 0 0 Continuing 0.8 0.05 0.8 5 0.16 0 0 Secondary booked case referred: Termination 0.8 0.95 0.2 2 0.3 1 0.152 Continuing 0.8 0.05 0.2 5 0.04 2 0.016 Tertiary booked case: Termination 0.2 0.95 1.0 0 0 3 0.57 Continuing 0.2 0.05 1.0 0 0 6 0.06 Total 15 2.32 12 0.8 a 3 x 0.8 x 0.95 x 0.8 = 1.82

Table A5.3. Number of outpatient special interest and subspecialist visits (appointments) generated by Down syndrome screening/10 000 maternities Secondary unitb Tertiary unit Total (n) Total accepting Down syndrome screeninga 6000 1500 7500 Total first-trimester screeningc 4800 1200 6000 Total second-trimester screeningd 1200 300 1500 First-trimester high risk 144 36 180 Second-trimester high risk 60 15 75 Counselling visits (following high-risk result)e 122 31 153 CVS tests (all by subspecialists)f 101 25 126 Amniocentesis tests 42 11 53

Subspecialist visits 31 + 101 + 25 + 11 168 Special interest visits 122 + 42 164 Assumptions:a 75% eligible population accept screening; b 80% of bookings in secondary care units; c 80% of women have first-trimester screening (with 3% false-positive rate); d 20% women book too late for first-trimester screening and have triple test (with 5% false-positive rate); e 40% of counselling in high-risk cases undertaken by specialist midwives; f 6 70% of women with a high-risk result opt for an invasive test; CVS = chorionic villus sampling, TOP = termination of pregnancy Table A5.4. Number of outpatient special interest and subspecialist visits (appointments) generated by red 98 cell antibodies/10 000 maternities Incidence/10 000 Visits/case Secondary Tertiary maternities unit unit Anti-D cases: Not requiring transfusiona 8 8 0.8 x 8 x 8 = 51.2 0.2 x 8 x 8 = 12.8 Requiring transfusionb 5 14 Secondary booked case 0.8 x 4 x 5 = 16 0.8 x 10 x 5 = 40 Tertiary booked case 0.2 x 14 x 5 = 14 Other antibodies: 6 Not requiring transfusiona 8.0 8 0.8 x 6 x 8 = 38 0.2 x 6 x 8 = 9.6 Requiring transfusionb 0.4 Secondary booked case 0.8 x 4 x 0.4 = 1.3 0.8 x 4 x 0.4 = 1.3 Tertiary booked case 0.2 x 8 x 0.4 = 0.64 Subspecialist visits 78 Special interest visits 107 Assumptions: a All surveillance using middle cerebral artery Doppler in secondary level units undertaken by special interest consultants; b Fetal transfusions require equivalent of two visits (1 hour)

Table A5.5. Number of outpatient special interest and subspecialist visits (appointments) generated by multiple pregnancies/10 000 maternities Incidence/1000 Visits Visits maternities (special interest) (subspecialist) Monochorionic twin surveillance:a 30 Secondary booked cases (no TTTS) 20 20 x 11 = 220 Secondary booked cases (TTTS) 4 4 x 7 = 28 4 x 8 = 32 Tertiary booked cases (no TTTS) 5 5 x 11 = 55 Tertiary booked cases (TTTS) 1 1 x 13 = 13 TRAP 0.3 0.3 x 8 = 2.4 Conjoined 0.2 0.2 x 4 = 0.8 Dichorionic twin with growth discordanceb 6 4 x 6 = 24 2 x 8 = 16

Royal College of Obstetricians and Gynaecologists Higher-order multiples:c 2.3 Secondary booked cases (not referred) 0.8 x 2.3 x 8 = 14.7 Secondary booked cases (referred) 0.8 x 2.3 x 4 = 7.4 0.2 x 2.3 x 4 = 1.8 Tertiary booked cases 0.2 x 2.3 x 8 = 3.7 Total 294 125 Assumptions: a of 150 twin pairs, 30 monochorionic, of which, 24 book in secondary unit; b Only cases with severe preterm growth discordance managed by fetal medicine; c 50% referred to subspecialist Table A5.6. Numbers of outpatient special interest and subspecialist visits (appointments) generated by 99 maternal infections/10 000 maternities Incidence/10 000 Visits (special Visits maternities (n) interest) (n) (subspecialist) (n) The Future Workforce in Obstetrics and Gynaecology Chickenpoxa 5 15.8 4.6 Cytomegalovirusb 2 6.32 1.84 Parvovirus:c Affected (transfusion) 1 1.6 5.2 Screening 1 4.48 1.6 Total 28.2 13.2 Assumptions; a Most cases managed by special interest consultant (4 visits) with 5% cases referred to subspecialist;b Although 1% of women seroconvert during pregnancy, usually only detected after diagnosis of fetal anomaly (included in structural anomalies): incidence of other cases estimated at 2/10 000; c estimate incidence of affected cases needing fetal transfusion 1/10 000 and cases with proven seroconversion (after contact) 1/10 000, of which 10% require transfusion

Table A5.6. The estimated number of outpatient visits to special interest and subspecialist consultants according to diagnostic groups within maternal medicine Disease Prevalence/ Cases Cases Visits/ Visits/ Visits/ 10 000 requiring requiring pregnancy 10 000 10 000 maternities special subspecialist (n) maternities maternities interest care (special (subspecialist) care interest)

Hypertension Essential (on treatment) 300 120 30 3 360 90 ? Chronic/white coat 300 60 0 3 180 0 Previous pre-eclampsia 100 70 30 3 210 90 Renal Reflux nephropathy 10 0 10 10 0 100 Glomerulonephritis 5 0 5 10 0 50 Polycystic 1 0 1 10 0 10 Calculi 5 0 5 10 0 50 Other (e.g. transplant) 1 0 1 10 0 10 Recurrent urinary tract infection 200 20 0 2 40 0 Other low grade renal 50 5 0 3 15 0 Cardiac Congenital 20 0 20 10 0 200 Acquired Dysrrhthmia Cardiomyopathy 2 0 2 10 0 20 Liver & gastrointestinal Chronic liver disease 1 0 1 5 5 0 Obstetric cholestasis/ gallbladder disease 100 90 10 3 270 30 Acute fatty liver 1 0 1 5 0 5 PKU 101505 Hepatitis (A, B, C) 10 9 1 5 45 5 Inflammatory bowel disease/ coeliac disease 10 9 1 5 45 5 Irritable bowel disease 20 9 1 5 45 5 Severe hyperemesis 30 25 5 5 125 25 Reflux 20 9 1 5 45 5 100 Table A5.6. The estimated number of outpatient visits to special interest and subspecialist consultants according to diagnostic groups within maternal medicine (continued). Disease Prevalence/ Cases Cases Visits/ Visits/ Visits/ 10 000 requiring requiring pregnancy 10 000 10 000 maternities special subspecialist (n) maternities maternities interest care (special (subspecialist) care interest)

Respiratory Sarcoid 10 9 1 10 90 10 Asthma 500 40 10 5 200 50 Cystic fibrosis 2 1 1 10 10 10 Infection/acute 40 36 4 5 180 20 Tuberculosis 1 1 0 10 10 0 Endocrine Insulin-dependent diabetes mellitus 40 38 2 13 494 26 Type 2 diabetes mellitus 10 9 1 13 117 13 Gestational diabetes (treatment) 300 285 15 5 1425 75 Gestational diabetes (diet) 300 300 0 2 600 0 Hypothyroid 50 8 2 3 24 6 Hyperthyroid 10 9 1 7 56 7 Other (Addison’s, phaeo’s, prolactinomas, diabetes insipidus) 5 0 5 13 0 65 Neurology Epilepsy 67 60 7 7 420 49 Myasthenia gravis 0.5 0 0.5 7 0 3.5 Migraine 50 45 5 5 225 25 Multiple sclerosis 10 9 1 7 56 7 Cerebral vein thrombosis 4 0 4 7 0 28 Cerebral haemorrhage 2 0 2 7 0 14 Other (tumours, Guillan Barre) 1 0 1 7 0 7 Connective tissue disease Systemic lupus erythematosus 5 0 5 13 0 65 Rheumatoid arthritis 5 0 5 7 0 35 Antiphospholipid syndrome 20 0 20 13 0 260 Mobility issues 10 10 0 4 40 0 Haematology and thromboembolism

Royal College of Obstetricians and Gynaecologists Severe anaemia 20 18 2 7 126 14 Thalassemia 10 8 2 7 56 14 Sickle cell disease 10 8 2 7 56 14 Thromboctyopenia 300 5 5 7 35 35 Coagulation disorders 10 5 5 13 65 65 Jehovah witnesses 10 10 0 2 20 0 Deep vein thrombosis 10 9 1 7 63 7 Pulmonary embolism 20 18 2 7 126 14 Thrombophilia/previous venous thromboembolism 50 40 10 7 280 70 Dermatology Eczema 400 5 0 2 10 0 Psoriasis 200 5 0 2 10 0 Pruritic urticarial papules and plaques of pregnancy 50 50 0 2 100 0 Pemphigoid gestationis 0.2 0 0.2 10 0 2 Total 6279 1715.5 Appendix 6 101

Delivery suite consultant presence calculation

60-hour consultant presence 8 hours/day plus 4 hours/week for covered break times 15.9 PAs/week = 40.0 hours @ normal PA = 10.0 PAs = 16.0 hours @ OOH PA = 5.3 PAs ?-hour breaks/week = 2.5 = 0.3 PAs 1.0 0.3 PAs One consultant works: 42 x 7.5 PAs/year = 315.0 PAs (10-PA contract) Needed to cover: 52 x 15.9 PAs/year = 830.7 PAs/year So consultants needed/year: 2.64 consultants = WTE = 3 consultants

98-hour consultant presence 14 hours/day No covered break times or handover 28.08 PAs/week

One consultant works: 42 x 7.5 PAs/year = 315.0 PAs (10-PA contract) Needed to cover: 52 x 28.1 PAs/year = 1460.2 PAs/year So consultants needed/year: 4.6 consultants = WTE = 5 consultants

98-hour consultant presence 14 hours/day Covering 30 minutes/3 hours for breaks:

Breaks = 0.5 hours every 4 hours = 4/14 hours ?-hour break normal hours = 0.1 PA + 3 0.4 PA/day = 31.86 ?-hour break OOH = 0.2 PA + 1 0.2 PA/day Needed to cover: 52 x 31.9 = 1656.7 P As/year So consultants needed/year: 5.3 consultants = WTE = 6 consultants 102 168-hour consultant presence (option 1) 12.5-hour shifts, built-in handover 30 minutes each shift change No covered break times 53.4 PAs/week One consultant works: 42 x 7.5 PAs/year = 315.0 PAs (10-PA contract) Needed to cover: 52 x 53.1 PAs/year = 2763.3 PAs/year So consultants needed/year: 8.8 consultants = WTE = 9 consultants

168-hour consultant presence (option 1) 12.5-hour shifts, built-in handover 30 minutes each shift change Covering break times: In 1 week: Normal hours = 60 = 15 PAs 36% of weekly time Out of hours = 108 = 36 PAs 64% of weekly time Breaks = 0.5 hours every 4 hours = 3 hours/24 hours 21 hours/week (168 hours) So add on: Normal hours = 7.5 PAs 22.5 Out of hours = 13.5 PAs 13.5 = 72 PAs/week One consultant works:42 x 7.5 PAs/year = 315.0 PAs (10-PA contract) Needed to cover:52 x 72 PAs/year = 3744 PAs/year

So consultants needed/year: 11.9 consultants = WTE = 12 consultants

Delivery suite calculations of PAs/unit size 1. Ideal: 62 units < 2500 need 40-hour presence (62 x 520 PAs = 32 240 PAs/year) Royal College of Obstetricians and Gynaecologists 86 units 2500–4000 need 98-hour presence (86 x 1456 PAs = 125 216 PAs/year) 26 units 4000–5000 (26 x 1456 PAs = 37 856 PAs/year) 18 units 5000-6000 (18 x 1456 PAs = 26 208 PAs/year) 8 units > 6000 need 168 hour cover ( 8 x 2652 PAs = 21 216 PAs/year) Total 242 736 PAs/52 = 4668 PAs/week 2. Midway solution: 62 units, 50% at 40 hours and 50% at around 20 hours = 24 120 PAs 86 units, 50% at 40 hours, 40% at 60 hours and 10% at 98 hours = 61 984 PAs 26 units, 50% at 60 hours, 50% at 98 hours = 25 688 PAs 18 units, 50% at 60 hours and 50% at 98 hours = 20 124 PAs 8 units, 50% at 98 hours and 50% at 168 hours = 16 432 PAs Total 148 348 PAs/52 = 2853 PAs/week 3. Subspecialty consultants – 8.7 PAs/10 000 maternities = 583 PAs/week 4. Special interest consultants – 21.7 PAs/10 000 maternities = 1454 PAs/week