We don't need more doctors...

July 3, 1998

Alan Maynard (below) and Michael Rees (right) suggest cures for two ills of the NHS on its 50th birthday

Forecasting the National Health Service workforce is rather like peering into an opaque crystal ball. The medical workforce is usually defined as doctors, with the rest of the employees - nurses, pharmacists, occupational therapists and other, usually largely female groups, being ignored. This "traditional" NHS approach has to be altered in the 21st century if scarce resources are to be used more efficiently.

Forecasters in Whitehall Village have not performed very well up to now. In 1944 the Goodenough committee concluded that there was a shortage of doctors and recommended an expansion of the medical schools. In 1957 the Willink committee concluded there was a surplus of doctors just as emigration, which they charted badly, was increasing. By 1968 the Todd committee concluded that there was a shortage of doctors and proposed a modest increase in medical school intake. In more recent years the fear of a renewed shortage has led to greater investment in doctor training.

This trend culminated in the 1997 Campbell committee report which concluded that there was a large shortage that required a 20 per cent increase in medical school input (1,000 new places). The government is considering the health care and financial implications of this proposed expensive investment.

Meanwhile, a nice crisis is emerging in the market for nurses. Training places are not being filled, the fall-out rate from nursing schools is high (some Scottish data indicate that the drop-out rate may be 25 per cent), students qualifying are not going into a nursing career and experienced nurses are leaving the profession.

One explanation of these trends is pay. Some qualified nurses seem more willing to work in Marks and Spencer than the NHS because pay is better and hours are regular. The Department of Health forecasts nurse numbers but provides only a "final balance sheet", keeping the modelling assumptions secret.

Another significant NHS labour market in disarray is that for pharmacists. Universities are producing people with considerable expertise in pharmacology. Yet the bulk of the profession gets locked up in the back of shops, not even allowed to count pills in these days of pre-packed medicines. This is a gross waste of expertise: pharmacists are generally more expert than doctors about the effects of pharmaceuticals and will increasingly practise their skills by containing GP extravagance.

To forecast and manage these inter-related labour markets in isolation may be politically opportune - it is a strategy that may keep all the professions isolated and quiet - but it is economic nonsense. For instance it appears that 30 to 70 per cent of the tasks done by doctors in primary care could be done by appropriately trained nurses. To varying and poorly measured extents, nurses diagnose, prescribe and even refer patients to hospitals in practices across the country, freeing doctors to do other tasks.

If nurses can be substituted for doctors in this way, could the existing GP:population list size be increased from, for instance, 1:1,800 to 1:3,000? If it could, this would increase the demand for nurses, who would have to be recruited back into the profession by better pay packages. Furthermore it would also undermine the Campbell committee's conclusion that there is a significant shortage of doctors.

Campbell's conclusions could be further eroded by doctor-nurse substitution in hospitals. The Audit Commission in December 1997 argued that nurse anaesthetists could replace medically qualified "gasfolk". Non-medically qualified radiotherapists can do some radiology as well as doctors. Nurses can do endoscopy with results similar to doctors if appropriately trained. If nurses take these and other tasks, surely the doctor shortage may be less acute?

Any changes in skill mix need to be based on evidence and facilitated by better management of forecasting and payment systems. At present the medical schools, and those wanting to be involved in this industry (eg Sussex, Plymouth, Durham, Keele and Hull universities), are bidding for parts of Campbell's recommended expansion of medical school places by 1,000.

The Whitehall machine will make significant and costly decisions before the summer recess. One consequence of such precipitate and isolated decision-making will be that skill mix opportunities may be ignored, the doctor stock increased inappropriately and other labour skills left under-utilised.

The extent to which substitution is efficient will depend also on the relative pay of professions. While nurses are cheap, their working week is shorter than that of doctors. If nurses' pay rises rapidly as their tasks become more complex, they may not be the competitive option for service delivery.

Hospital doctor remuneration is based on a salary together with a form of performance-related pay (distinction awards) and private practice income. This system is not efficient. The distinction award system is operated largely in secret by a cabal of doctors and the awards are graduated and generous (the A-plus award doubles the salary of a recipient). Not all hospital doctors have private practice but those that do can do well; many orthopaedic surgeons generate six-figure sums in addition to their NHS pay.

The government must become more objective and efficient in policy-making in the workforce area. Rather than adopt the Campbell committee proposals fully, it should move cautiously with regard to the doctor workforce, and vigorously pursue skill mix opportunities and the more efficient use of nurses and pharmacists in particular. Dealing with the professions in isolation is inappropriate when most health care is delivered by teams of which doctors are one part who, like the rest, need good management.

The NHS costs Pounds 44 billion annually and 70 per cent of its expenditure goes towards keeping the labour force, many of whose members are badly paid, in the style to which it is are accustomed. For 50 years the management of this vast army of people has been carried out with too much regard to doctor numbers and in isolation from the other professions. As Voltaire remarked "the role of the doctor is to amuse the patient whilst nature takes its course". In the future perhaps doctors can concentrate on this while government and management eradicates the deficiencies in the use of a costly, skilled and often demeaned NHS workforce.

Alan Maynard is professor of health economics at the University of York.

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