Report prepared by Harriet Gordon, Chris Romaya

Consultant gastroenterologists

There are currently (at 30.9.09) 1041 UK gastroenterology consultants, an increase of 5.2% from last year. Of these consultants 889 are male (86%), 144 female. Across all medical specialties 27% consultants are female.

Numbers of consultants in different parts of the UK by year

Annual expansion (%) of consultants in different parts of the UK by year

Fig.1 Consultant numbers by age

Retirements expected

The current average retirement age is 62.2 (range 55-66), unchanged from previous years. 

Of the consultants currently working an average of 20 state that they intend to retire each year over the next 8 years, or around 165 retirements.  Due to alterations in the pension plans there may be an increase prior to 2012. 

It is estimated that we need approximately 6 WTE gastroenterology consultants per 250,000 populations or around a total of 1900 consultants across the UK. Therefore we need approximately 850 more new consultants over and above retirement replacements. This would be achievable over the next 9 years if expansion is maintained at 7%. There are already approximately 800 SpRs in training, and if the average training time continues at 7 years, then there are sufficient trainees already in place to meet this target.

However expansion, which was running at 6-7% until 2005, dropped to 2-3 % for 2 years. It has increased to just over 5% in the last 2 years, possibly attributable to political requirements from targets e.g. the '18 week pathway'. This may drop off in the next few years as NHS resources have been reduced

Number of Consultant Gastroenterologists reaching retirement age in the next 10 years

Part-time and academic appointments

There are currently 62 declared part-timers (7%). However there are also 27 acute physicians working in acute medicine/gastroenterology.

Currently there are 102 academics, 10% increase from last year, and they receive an average of 6 Pas for the gastroenterology component of their contract.

Contracts

• 46 work >12 pas, with 0-8 (median 4) in GIM
• 259 work 12 Pas, with 0-9 (median 3) in GIM
• 241 work 11 Pas, with 0-8.5 (median 3) in GIM
• 122 work 10 Pas (16% women), 0-8 (median 2) in GIM
• 85 work <10 (% women), 0-5 (median 2) in GIM

Of those working 12 or more Pas they report in reality working 2 Pas in excess of their contract, and this excess is usually clinical gastroenterology as opposed to GIM or SPA.  Of those working 10 Pas or less, they report working approximately to contract. 

Within the medical specialties the average number of Pas is 11.6, with an average of 2.8 hours worked above this. 

Distribution of gastroenterologists nationally

Table 4: Distribution of gastroenterology consultants by SHA/health board

The population statistics for England came from the Department of Health, from GP registrations in 2008, and therefore may under-represent, missing those not registered. The Wales, Scotland and Northern Ireland statistics come from their 2008 national census.

The average gastroenterologist in the UK serves a population of 58,523. In England the average is 61,067, varying from around 40,000 in London and the NE to double this, around 80,000 on the South Coast/South central.

In Wales the average is 61,090, in Northern Ireland 59,197. In Scotland the average is 53,284, varying from 42,075 in the Borders and Lothian to 61,173 in Northern Scotland.

Thus there continues to be significant variation across the UK, with the areas surrounding London having among the highest populations per gastroenterologist, and London the lowest.

Single handed gastroenterologists
There are currently 6 single handed gastroenterologists remaining within the UK, 4 in England, 1 in Scotland and 1 in Northern Ireland.

Non-consultant career grades
There are 354 in total:

• 87 associate specialists (increased from 69 last year)
• 64 staff grades
• 57 clinical assistants
• 28 consultants from other specialties (care of the elderly, radiology) contributing to gastroenterology
• 20 trust doctors
• 98 hospital practitioners/GPs, majority working one session per week

Other than the increase in associate specialists, the numbers have remained stable. 

Of these 4 have registered with PMETB for entry onto the specialist register via article 14.  Of these 3 have been approved and are likely to seek to become consultants.  

Nurses in gastroenterology
There are currently 723 nurses working in clinical gastroenterology within the UK, an increase of 105 (17%) over the last 12 months. 

• 363 Nurse endoscopists/nurses performing > 1 session endoscopy/week
• 208 Clinical nurse specialists (including IBD, hepatitis, nutrition, alcohol liaison)
• 183 Nurse practitioners
• 13 Nurse consultants

The 363 performing regular endoscopy (1-10 sessions, median 2 per week), an increase from 339 last year. 

Surgeons in gastroenterology
473 perform 0.5-3 sessions (median 1) per week of OGD, and 648 perform 0.5-2 (median 1) sessions per week of lower GI endoscopy

Trainees in Gastroenterology in the UK

There are 795 gastroenterology trainees in the UK, or an increase of 33 (4%) from last year, despite a freeze on posts.  Within the trainee population there are:

• 471 trainees in hospital posts (increased by 9 or 2% from last year)
• 142 trainees taking time out for a period of formal research or OOPE, a stable number
• 53 VTNs (the same as previous year)
• 64 LATs, an increase of 7 (12%) on the previous year
• 33 acting as locum consultants, the same as last year
• 22 academic registrars/lecturers, an increase of 7 (47%), with 23 ACFs
• 41 less than full time trainees, 38 in hospital posts, 3 in research

The mean training time is 7.2 years.

There are currently 11 in specialised hepatology posts, although there are 16 posts available nationally.  Trainees have been reluctant to move out of region for a 12 month post, and also do not want to designate themselves 'hepatologists' and potentially reduce their job opportunities in the future, despite a drive to increase the number of hepatologists nationally. 

Table 5: Distribution of grade of those in Registrar posts (30/09/09)

In Scotland there has been a reduction in 1 clinical NTN post, against a 20% reduction of most medical specialties within Scotland, which has previously been a net exporter of trainees to become consultants. 

Gender
33% of the trainees are now female, compared to 30% last year.  Within the Royal College of Physicians the average for all medical specialties is 47%.

There are 41 less than full time trainees (5% of all trainees), of which 40 are female (15% of female trainees), against a national average of 25% of female trainees, 1% of male trainees, for all medical specialties. 

Career aims of trainees
Of those who expressed a preference:

• 159 (36%) teaching hospital
• 129 (34%) hepatology post
• 65 (8%) academic post (gastroenterology or hepatology)
• 55 (7%) work less than full time
• 7 (0.01%) solely accrediting in gastroenterology
• 98% VTNs would opt to remain in the UK

Distribution of trainees across UK
Almost all regions (other than Oxford) have a significant proportion of LAT/LAS posts, and all regions have trainees out of programme undertaking research/other activities, varying from over half in the Eastern Deanery to 1 in Northern Ireland. 

fig 2 Distribution of trainees across UK

The distribution of trainees to population shows that London continues to have twice the national average of hospital registrars for population at one hospital registrar per 63,000 population rather than the average of one for 129,000. 

fig 3 Relationship of hospital trainees to population

fig 4: Relationship of trainees to consultants

Trainee expansion
There has been an increase of 33 trainees (4%) over the last 12 months, in the context of a national freeze on numbers. 

Since 2003 there has been an increase from 430 trainees to 795, or an 85% increase.   This has been driven initially by the EWTD and then by a desire to replace posts vacated for OOPE by NTNs rather than LATs. 

Table 6: Number of trainees in different parts of the UK by year

Outcome of trainees >6 months post CCT
49 trainees are more than 6 months post CCT and unappointed to a consultant post.  Of these:

• 33 in locum consultant posts,
• 11 research experience
• 5 are working within the NHS in clinical other posts

Predicted CCT dates

fig 5: Graph of predicted CCT dates

There are a stable number of retirements expected over the next 5 years of around 15-20 per year.  These leaves around 100 predicted CCT holders in excess of retirements, per year.   7% expansion would require 73 new consultant posts next year.

fig 6: Graph of projected retirements and predicted CCT dates

Expansion
The Royal College of Physicians 'Working for Patients' estimates that a population of around 250,00 requires 65-75 gastroenterology Pas per week, or 6 WTEs working 10-12 Pas.  On this basis we need 859 more gastroenterologists, or 1900 in total. 

With consultant expansion at 7% this would take 9 years to achieve.  There are predicted to be around 100 CCT holders with a CCT in excess of retirements over the next few years, so a rate of at least 7% expansion has the required CCT holders available, and the NTNs are already enrolled for the next 7 years.  This assumes a retirement rate of around 20 per year.  However if expansion is less than this there are likely to be CCT holders without consultant posts.

Fig 7: Graph of expansion at 3%, 5% and 7%

Increased need for gastroenterologists:

• National screening programmes.  Bowel cancer needs have been included in these figures
• Increased hepatology requirements from a change in population behaviour, i.e. increase in obesity, alcohol misuse
• Increasing requirement for 7 day, 24 hour working week
• Drive for political targets e.g. '18 week pathway'
• Increase in the number of consultants working less than full time. 

Reduced need for gastroenterologists:

• If gastroenterologists withdraw from GIM rotas
• If others take on traditional gastroenterology roles, e.g. radiology replaces endoscopy

There has been a predicted excess of CCT holders over consultant jobs recently.  CCT holders have taken jobs in acute medicine/gastroenterology (27 appointed in the last 5 years).  However there are now acute medicine trainees gaining specialist CCTs and it is likely that they will access these jobs in the future. 

Surrogate markers for pressure on jobs:

• There are 9 posts unfilled nationally, similar to last year. 
• The average number of jobs that a CCT holder apples for is 4
• The average success rate per job application is 18%, one of the lowest rates for all medical specialties

Conclusions
As with all the large medical specialties gastroenterology is predicted to train an excess of CCT holders over jobs available in the next few years, around 100 per year over predicted retirements. 

7% consultant expansion over the next 9 years would achieve the 1900 gastroenterologists it is estimated that the UK requires, however expansion has fallen to 5% and below in recent years.  Even at 7% expansion there would be a predicted 15 CCT holders without a consultant job. 

It would seem appropriate to freeze the total number of trainee posts now, and consider a post reduction in the future.