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PLASTIC SURGERY

This document sets out factors that will be considered when assessing the supply and requirement of the future medical workforce. The first section of the fact sheet focuses on the future requirement of the specialty; the second section focuses on the current supply. This information will form part of the body of evidence used to advise recommendations of future medical training numbers. At this stage it does not present conclusions or recommendations. This is a live document that represents work in progress; it will be updated on an ongoing basis as information is located and made available to the CfWI. The CfWI will welcome relevant contributions to the content or interpretation of information within the medical specialty workforce fact sheets.

As a guide, the document is set out in the following divisions. Some of the themes that have been identified may overlap several divisions. Considerations for future requirements

Current Status of Specialty’s Requirement Demographics

Health and Lifestyle

Prevalence and estimated future incidence of factors that affect requirement Changes in practice which may affect level of service

Finished Consultant Episodes (FCEs) and Outpatient Attendances Weighted Capitation

Historical and forecast supply Existing Workforce Consultant projections Geographic distribution

Recruitment to further medical training Related healthcare workforce

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CONSIDERATIONS FOR FUTURE REQUIREMENTS

Current Status of Specialty’s Requirement

Developing a Modern Surgical Workforce, the report from the Royal College of Surgeons of England (RCSeng, 2005) recommends a ratio of one full time equivalent (FTE) consultant per 100,000 population. Based on subnational population projections by the Office of National Statistics (ONS) for 2010, this gives an estimated requirement of 522 FTE trained specialists for England. The Information Centre (IC) Census reports that there are 308 (291 FTE) Plastic Surgery consultants employed in England as of September 2009.

Vacancies and Locum Staff

The most recent data available (extracted via iView from ESR, March 2010) records that 1.5% of the practising consultant workforce are locums (5 locums out of a total of 320 consultants).

The IC vacancy survey (2008) records a 3-month vacancy rate of 2.2% for Plastic Surgery consultants in England. This is highest in London SHA at 11.5%. The remaining SHAs have vacancies rates of 0%.

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Demographics

Figure 1: 2031 population estimate and indication of age and gender of the population which relies most heavily on Plastic Surgery

Figure 1 represents the population of England as of 2010 and highlights the age and proportion of males and females that typically present for care in Plastic Surgery. The areas highlighted in blue and pink show the ages that require the most significant portion of Plastic Surgery services for males and females respectively. A grey area illustrates the population distribution where neither males nor females in the age range are typically treated or have interventions delivered by this speciality. The bold lines show the level of the population in 2031 by age band as predicted by the Office of National Statistics (ONS).

It indicates that the population aged between 0-54 is most reliant on Plastic Surgery and will drive the requirement for those services.

Figure 2 displays the relative population percentage growth per year broken down by age groups highlighting the variable rates over time and age.

Figure 2: Demographic Summary

In Plastic Surgery the age group which accounts for the most significant proportion of care required is generally the young and adult groups. The majority of the population served by Plastic Surgery is expected to grow at an average rate of approximately 0.5% per year up to 2031.

5% 4% 3% 2% 1% 0% 1% 2% 3% 4% 5% 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ A g e G ro u p 2010 Females most heavily reliant

2010 Females less heavily reliant 2010 Males most heavily reliant 2010 Males less heavily reliant Black outline -2031 population estimate 0-19 20-39 40-59 60+ all ages 2.03% 0.74% 0.53% 0.79% -0.01% 0.43% 0.01% 0.5% 2010 2017 2019 2025 2031 Time/years

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Health and Lifestyle Lifestyle Influences

The information presented here is meant to aid in identifying possible influences to future requirements of consultants in Plastic Surgery. These indicators have not been quantified but rather present intelligence from which future trends on the impact of requirements to the specialty may be ascertained. The information presented here does not constitute a complete list.

Common procedures and interventions performed by Plastic Surgeons are reconstruction as a result of trauma to the upper and lower limbs, or cancers of the head and neck, and breast.

Traumas

Typical behaviours and lifestyle choices that can lead to trauma incidents that require intervention by a plastic surgeon are:

• Violence

• Taking risks when driving, leading to road traffic accidents • Participation in sport –leading to injuries

• General risk taking attitudes that lead to accidents such as burns

The incidence of road traffic accident may change as a result of the withdrawal of speed cameras in parts of England. Cancers

The National Cancer Intelligence Network report, Cancer Incidence by Deprivation, England, 1995-2004, states that head and neck cancer

incidence has particularly strong associations with social deprivation. In the most deprived quintile of the population head and neck cancers had a ratio of 2.1 to 1 comparing the incidence rates in the most deprived with the most affluent (males and females combined). Therefore a swing in social deprivation levels could lead to a change in requirement for plastic surgeons.

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Prevalence and estimated future incidence of factors that affect requirement

The Oxford Cancer Intelligence Unit report, Profile of Head and Neck Cancers in England: Incidence, Mortality and Survival, summarises the incidence of head and neck cancers as follows:

‘The incidence of several Head and Neck cancers has risen between 1990 and 2006:

• Oral cavity cancer incidence has risen by more than 30%; immigration from the Indian subcontinent may have contributed to this trend,

since chewing of betel quid is an important risk factor. This finding supports the further development of oral cancer risk awareness programmes.

• Salivary gland cancer incidence has increased by around 37%, though the numbers remain small. The reasons for this rise are unclear, but

analysis of trends in different pathological subtypes might be informative.

• Oropharyngeal cancer incidence has more than doubled – the biggest rise in any head and neck cancer. Recent research suggests a

change in patterns of causation, with human papilloma virus (rather than smoking and alcohol) being the primary risk factor in a younger subpopulation.

• The incidence of palate cancer has increased by 66%. The reasons for this are unclear; further work is needed to establish whether the rise

is primarily in soft palate cancer (matching the rise in oropharyngeal cancer) or hard palate cancer.

• The incidence of thyroid cancer has doubled. This may be due in part to increased detection of small papillary carcinomas through the

imaging of goitres.

Laryngeal cancer has declined in incidence by 20% since 1990, but incidence has levelled off in the last five years. Laryngeal cancer is strongly associated with smoking and its falling incidence may reflect a reduction in smoking rates.

The incidence of nasopharyngeal and hypopharyngeal cancers has not changed significantly during the study period.

Incidence rates for all types of cancer (averaged over the last four years of the study period) vary significantly between the Strategic Health

Authorities and Cancer Networks with the lowest and highest incidence, but the geographical pattern of distribution varies from cancer to cancer. This may reflect the distribution of different risk factors, including those that predominantly affect certain ethnic groups. A general pattern of higher incidence in the north and west of the country is common but not universal; London often has high rates too, and the highest rates of oral

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cancer, nasopharyngeal cancer and palate cancer are found in parts of London.

The average national incidence rates vary from 0.39 per 100,000 population for nasopharyngeal cancer (an average of 208 cases per year across England) to 3.01 for laryngeal cancer and 3.02 for oral cancer (an average of 1729 and 1767 cases per year respectively).’

Changes in practice which may affect level of service

Procedures in Plastic Surgery are becoming more complex and therefore more labour intensive. This may increase the level of service required in the future.

The Royal College of Surgeons of England (2007) made the following statement in the Future of the Medical Workforce: College Response: ‘Historically the basis for calculating the requirement for surgical consultants was the ability to sustain an emergency and elective service in a system comprising teaching and district general hospitals. That mould has now been broken and going forward, workforce planning will need to take into account recent policy developments including the introduction of a range of different providers to the health system, making further economies in the use of specialist surgeons more likely. The workforce required to deliver a safe and efficient service will need to be planned against the locations in which that service will be delivered. For example, there is evidence to suggest that 96% of elective care by volume requires a critical care stay in fewer than 4% of cases. This gives some indication of the volume of work that could be safely undertaken in a separate

environment regardless of proximity to critical care and will be important in discussions relating to workforce planning and the reconfiguration of services.’

Cancer

The coalition government has asked Prof. Sir Michael Richards to review the Cancer Reform Strategy (CRS) of 2007. The consultation ends in September 2010, the outcome from this may have an effect on the requirement of Plastic Surgeons if there are changes in practice for cancer treatment as a result of the review.

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Skin cancer

The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) has made the following statement in 2010:

‘A high proportion of UK plastic surgeons' non-emergency work-load is spent treating and reconstructing patients with skin cancer. BAPRAS is concerned that young people in particular don't fully understand the dangers and long term health risks associated with skin cancer and feel that restricting use of sun beds will help prevent a further increase in levels of skin cancer in the UK.

Research from BAPRAS in 2009 showed that 28% of 18-24 year olds say the risk of skin cancer won't make them spend less time sunbathing. Of these, 43% said this was because the threat of skin cancer didn't occur to them, while 19% didn't realise they were at risk of developing it. In addition, 16% of 18-24 saying they would be too busy to get a mole checked and one in ten saying getting it looked at wouldn't even occur to them.’

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Finished Consultant Episodes (FCEs) and Outpatient Attendances Figure 3: FCE per year for Plastic Surgery

It is assumed that the recording and definition of FCEs in this speciality has not changed significantly over this time period, and therefore the rise in FCEs from 2005 onwards indicates an increase in activity in the speciality. Figure 4 shows the trend in outpatient FCEs from 2003-2008; it indicates a similar trend of an increase in activity.

Source: The NHS Information Centre, Hospital Episode Statistics for England. Inpatient statistics, 1998-2008.

0 50000 100000 150000 200000 250000 300000 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Fi n is h e d C o n su lt an t E p is o d e s (F C E s) Year starting

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Figure 4: All outpatient attendances per year for Plastic Surgery

Figure 4 shows outpatient data for Plastic Surgery. Note: The main specialty reflects the specialty under which the consultant with prime responsibility for the patient is registered. This is in contrast to

treatment outpatient attendances data which is also available, and is described as: ‘Treatment specialty reflects the specialty under which the consultant with prime responsibility for the patient is working’. Advice for interpretation of outpatient data is given as follows: ‘The outpatients’ dataset contains individual records for all outpatient appointments occurring in England, such as the type of attendance, ie whether it was a first or follow-up attendance, or the main specialty, ie the specialty under which the consultant with prime responsibility for

Source: The NHS Information Centre Hospital Episode Statistics, Main specialty Outpatient attendances for England, 2003 – 2008

the patient is registered. The latest HES data is available from the freely available data section of the HESonline website

[http://www.hesonline.nhs.uk]. For data breakdowns beyond the scope of the tables available, such as a count of appointments split by source of referral (ie whether or not the outpatient appointment was initiated by the consultant responsible for the outpatient attendance or not), please see the Request a tailor made report section of the HESonline website. Great care must be exercised when comparing HES figures for different years. Fluctuations in the data can occur for a number of reasons, eg organisational changes, reviews of best practice within the medical community, the adoption of new coding schemes and data quality problems that are often year specific. These variations can lead to false assumptions about trends. We advise users of time series data to carefully explore the relevant issues before drawing any conclusions about the reasons for year-on-year changes.’ 0 100000 200000 300000 400000 500000 600000 700000 800000 900000 1000000 2003 2004 2005 2006 2007 2008 A ll o u tp at ie n t a tt e n d an ce s (M ai n S p e ci al ty ) Year starting

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Weighted Capitation

Table 1: Table of six scenarios for each SHA based on weighted capitation for the possible requirements of junior doctors – Plastic Surgery

Strategic Health Authority

Ratio of Actual: Weighted capitation

Move all to average value

Move all to median value Move all to min Move all to 2nd min Move all to 2nd Max Move all to Max 0.99 1.04 0.01 0.51 1.40 1.63

North East 1.63 max max max max max max

North West 0.99 0 2 -39 -19 16 25

Yorkshire & The Humber 1.10 -3 -2 -31 -17 8 15

East Midlands 0.45 min min min min min min

West Midlands 0.83 5 6 -24 -9 17 23

East of England 1.40 -11 -9 -37 -24 0 6

London 1.23 -9 -7 -45 -26 6 15

South East Coast 0.51 10 11 -10 0 18 22

South Central 1.13 -2 -1 -19 -11 5 9

South West 0.76 6 7 -19 -7 16 22

Total -4 7 -223 -112 86 137

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Column 2 is the ratio of the actual capitation to the calculated theoretical capitation. Columns 3-8 are the scenarios where all except the most under capitated and the most over-capitated are moved to the mean, median, least, 2nd least, 2nd most and most capitated levels respectively. The values in the 2nd row are the mean, median, least capitated, 2nd least capitated, the 2nd most and most capitated respectively.

This analysis reveals that change in requirements range from an increase of 27% (2nd most capitated) to a decrease of 35.2% (2nd least capitated) on average when only WCAP is considered for Plastic Surgery junior doctors.

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HISTORICAL AND FORECAST SUPPLY

The supply of Plastic Surgeons is shown in Figures 5a-b. The figures are based upon the latest data available (SAS data only dates back to 2005).

Figures 5a-b: (a) Workforce supply (FTE) and, (b) Workforce supply (HC) – Plastic Surgery

The charts above show that the consultant workforce expanded by 5.0% during the past five years based upon the Information Centre (IC) census. The trend is reflected by middle grade medical staff together with trainees. The supply of plastic surgery staff over the next ten years is forecast to increase to 464FTE in 2018 (546 headcount), an average increase of 6% annually, based on the following assumptions:

0 100 200 300 400 500 600 700 800 900 1000 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 2 0 2 0 2 0 2 1 2 0 2 2 2 0 2 3 2 0 2 4 2 0 2 5 2 0 2 6 FT E Year

Cumulative historical workforce supply (FTE) and future consultant projections - Plastic Surgery

SAS All Trainees Consultants FTE (historic) Consultants FTE (forecast) 0 100 200 300 400 500 600 700 800 900 1000 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 2 0 2 0 2 0 2 1 2 0 2 2 2 0 2 3 2 0 2 4 2 0 2 5 2 0 2 6 H C Year

Cumulative historical workforce supply (HC) and future consultant projections - Plastic Surgery

SAS All Trainees Consultants HC (historic) Consultants HC (forecast)

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• retirement occurs at 60 years of age

• 5% of current trainees are delayed in completing their training by one year, 5% are delayed by two years, 5% by three years and 5% by four

years

• (there are nine international recruits per annum, however no young leavers (non-retirements) or returners per annum, • there is no conversion from staff grade or associate specialist posts to consultant posts

• there is a wastage rate amongst registrars of 1%.

In the past, the accuracy of WRT’s projections in this specialty have been true to within 1.12%, based upon records published by the IC from 2005 to 2008.

Existing Workforce

Supply

According to the 2009 IC census there are 291 FTE (308 headcount) consultants, while ESR records from September 2009 record 295 FTE (305 headcount). This is a difference of 1% in comparison to census records. The latest available data records 305 FTE consultants (320 headcount) (extracted via iView from Electronic Staff Records, March 2010).

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Figures 6a-b: (a) age profile (FTE) and, (b) age profile (Headcount) – Plastic Surgery

The chart shows a plentiful supply of younger staff and that a number of staff are working beyond typical retirement age - suggesting a possible impending retirement spike.

The IC three-month vacancy rate for all surgical consultants is 0.7% as of March 2008 (the latest available data); the three-month vacancy rate for Plastic Surgery consultants is marginally higher at 0.9%.

Geographic Distribution

Figures 2a and 2b below show the geographic distribution of doctors and trainees in absolute values and in relation to the weighted capitation of each Strategic Health Authority (SHA) (a definition of weighted capitation is given below*).

0 20 40 60 80 100 120 140 160 U n d e r 3 0 3 0 -3 4 3 5 -3 9 4 0 -4 4 4 5 -4 9 5 0 -5 4 5 5 -5 9 6 0 -6 4 6 5 -6 9 7 0 a n d o ve r FT E

Age bracket (years)

Consultant age profile (FTE) - Plastic Surgery

0 20 40 60 80 100 120 140 160 U n d e r 3 0 3 0 -3 4 3 5 -3 9 4 0 -4 4 4 5 -4 9 5 0 -5 4 5 5 -5 9 6 0 -6 4 6 5 -6 9 7 0 a n d o ve r H e ad co u n t

Age bracket (years)

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Tables 2a-b: (a) Number of Plastic Surgeons minus the weighted capitation value for each area, and (b) Actual number of medics in each area, across ten SHAs for Plastic Surgery

Number of doctors minus the weighted capitation, shown for Plastic Surgery by SHA - Based on latest data available as at

April 2010

Actual number of doctors by grade and SHA, shown for Plastic Surgery - Based on latest data available as at April

2010

Table (a) Table (b)

SHA Weighted Capitation Junior Doctors Staff Grade Specialty Doctor Associate Specialist Consultant Junior Doctors Staff Grade Specialty Doctor Associate Specialist Consultant North East 5.9% 10 -1 1 1 2 25 0 2 3 19 North West 15.2% 0 -1 1 0 -10 39 1 2 4 35 Yorkshire & The Humber 10.8% 3 0 -1 -2 -1 31 1 0 1 31 East Midlands 8.6% -12 -1 -1 1 -10 10 0 0 3 15 West Midlands 11.2% -5 2 -1 4 2 24 3 0 7 34 East of England 10.2% 11 1 -1 -3 8 37 2 0 0 38

London 14.1% 8 -1 1 -2 16 45 1 2 2 57

South East Coast 7.6% -10 0 -1 0 -5 10 1 0 2 17 South Central 6.6% 2 0 1 -1 -4 20 1 2 1 15

South West 9.8% -6 0 0 2 3 20 1 1 5 32

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The tables suggest that London, East of England and the North East SHAs have a higher proportion of both consultants and junior doctors than if provision were to follow weighted capitation. East Midlands SHA has a lower proportion of both consultants and junior doctors than if provision were to follow weighted capitation.

*The Department of Health uses a weighted capitation formula (WCAP) to distribute resources to primary care trusts (PCTS) based on the relative health needs of each PCT’s catchment area. If qualified doctors and trainees were equitably distributed according to the formula, all other columns in Table 8a would be zero. Values greater than zero indicate that the SHA has more doctors and trainees than would be included by WCAP; values less than zero indicate evidenced room for growth of the workforce.

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Recruitment 2009

The level of recruitment to further medical training is shown in table 3. The table illustrates the entry point situation for 2009. The data correspond to posts openly advertised but not those training posts secured by ‘run-through’ trainees:

Table 3: 2009 specialty recruitment for Plastic Surgery at ST3

Deanery Available Posts Accepted Posts Fill Rate

East Midlands 0 0 -

East of England 0 0 - Kent, Surrey and Sussex 0 0 -

London 23 10 43% Mersey 0 0 - North West 3 4 133% Northern 0 0 - Oxford 0 0 - Peninsular 0 0 - Severn 0 0 - West Midlands 0 0 - Wessex 0 0 -

Yorkshire and the Humber 0 0 -

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The table shows that there is an uneven distribution geographically, with the North West exhibiting a fill rate of 133% while London has a fill rate of 43%. In CfWI’s view, the degree to which the current numbers of available posts are filled together with the geographic distribution are essential factors in evaluating the requirement for additional posts.

Related Healthcare Workforce

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REFERENCES

• British Association of Plastic Reconstructive and Aesthetic Surgeons, 2010. Plastic surgeons welcome support to stop under 18s accessing

sunbeds. Available at http://www.bapras.org.uk/news.asp?id=580

• Cancer Incidence by Deprivation, England, 1995-2004. National Cancer Intelligence Network. Available at

http://library.ncin.org.uk/docs/081202-NCIN-Incidence_by_Deprivation_95_04.pdf

• Oxford Cancer Intelligence Unit, Profile of head and neck cancers in England: Incidence, mortality and survival. Available at

http://www.ociu.nhs.uk/sph-ociu/sph-documents/Final_Head_-_Neck_Profiles_04May2010.pdf

• Royal College of Surgeons, 2005. Developing a modern workforce. Available at

http://www.rcseng.ac.uk/publications/docs/modern_surgical_workforce.html

• Royal College of Surgeons, 2007. Future of the medical workforce: College response. Available at

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