Future Medical Workforce Project: phase 1 report

How will the role of a doctor need to evolve?

We asked doctors working in Scotland, how will the role of the doctor need to evolve to meet population needs in 15 years’ time?

Participants attending the focus groups and responding to the national survey, provided a variety of views on the current direction of NHS reform, the opportunities and challenges facing the future workforce. Their views are summarised below beneath themed headings.

"[It’s hard] trying to define what the future doctor will look like, because we don’t know exactly where we’re going to fit into that messy future picture." - Consultant, focus group attendee

NHS service reform

There was a split of views on whether regional services should be adopted, with concern over the attractiveness of roles outwith centralised areas. Those in remote and rural NHS boards were accepting that some regionalisation is needed and referenced existing successful hub and spoke models.

Doctors voiced scepticism over whether the shift to community care will happen given previous attempts and a poor track record on delivering on stated intentions. Some held the view that hospitals will still be required to deliver specialist care, particularly for the growing complexity of the population’s health. GPs typically interpreted greater care delivered in the community to mean more primary care and more GPs required. Consultants typically spoke about more innovations like hospital at home, greater diagnostics in the community or outpatient clinics taking place within community settings. It was also felt that greater generalist capabilities could help support greater community delivered care.

The potential of interface models^[16] was discussed, particularly in relation to the issue of risk and where it is held. The drivers of changing risk appetite were identified as having a more litigious society, more risk adverse society in relation to minor ailments or vaccines and a lack of time and continuity of care impacting how GPs can manage risk and practice realistic medicine.

Secondary care doctors voiced a desire to have more shared decision making and risk assessment with primary care – perhaps inviting GPs to take part in their MDT meetings. Some barriers to this were identified including issues such as siloed funding, IT systems and fraught relationships due to service pressures.

Population changes

When considering the future population health demands, participants spoke of the need for more generalism within the medical profession. Most doctors support a shift towards more generalism though this means different things to different people and previous attempts to support greater generalism were noted to have stalled.

Most agree that the principles of their broad-based training provide them a good basis by which to practice holistic care. To further encourage holistic care it was thought modular approaches to training earlier in careers should be adopted, similar to the current broad-based training programme, but Royal College curricular compatibility would need to be considered. It was felt that this was particularly relevant for those in remote and rural areas. Some doctors suggested that perhaps this was less about generalism and instead spoke of a need to emphasise certain skills – such as care of the elderly, frailty and palliative care within all specialties. There was discussion about how this may conflict with patient expectations that seeing a specialist results in better care. A minority of secondary care doctors also spoke of the need to continue investment in specialties and clinical academia to progress research and innovation and ultimately remain a world-leading health care system. There were also concerns that generalism wouldn’t be seen as an attractive career choice and that working across so many areas could lead to burnout.

"With the aging population, more cancers are being diagnosed and needing to be dealt with. Cancer specialists (especially surgeons) will have to become generalised practitioners instead of purely dealing with “their” specialist field (cancers only e.g breast)." - Consultant, survey respondent

Prevention was widely discussed in relation to future population health demand, with doctors discussing the need to invest in upstream prevention activity outside of the healthcare system: such as education, obesity, smoking and poverty. Some doctors spoke of the potential role of social prescribing and predictive analytics to support wider prevention approaches. Clinical academics highlighted the key contribution of the clinical research community in understanding the impact of social and political determinants on health alongside leading innovation around predictive analytics, genomics and digital screening tools to support prevention and patient-centred early intervention.

Realistic medicine was often the answer to considering the increasing demand for medical services, with doctors being the best placed people to take this forward. GPs typically held the view that the first interaction/triage of patients should be taken forward by doctors rather than a member of the wider MDT to avoid potential over-investigation and onward referral. The breadth of medical training was discussed as equipping doctors with the necessary skills to provide a holistic view of a patient and determine an appropriate course of action.

Barriers to implementing realistic medicine were stated as a lack of time with patients and a lack of continuity of care ultimately impacting patient partnerships.

Service capacity and design

In relation to the potential of AI & technology to increase service capacity, many concerns were raised about the current outdated and poor IT infrastructure, with calls to ‘get the basics right first’. Technology was seen as a potentially useful tool in freeing up capacity for doctors to spend more time with patients – either by facilitating remote consultations, teaching or by helping with transcription & referrals. Medical students and resident doctors spoke of the potential of technology to increase patient access to information, which could both be a positive and a negative – enabling self-supported care or fuelling misinformation. They also voiced concern about AI taking away learning opportunities.

"While there is a lot of hype about AI the core job of a doctor to develop and build a relationship of trust should not be undermined. AI will help with tasks ... but is not a magic bullet. To reap its benefits one must look at the basics - improving infrastructure, developing leadership roles in IT for clinicians to help them guide the needs of the NHS." - Consultant, survey respondent

There were also discussions about consultant-led care and a diversity of views on whether this should be adopted. Those who were supportive thought that consultants could be supported by a generalist tier of doctors: led by a consultant who would ultimately consult rather than deliver most care. They tended to recognise that consultants aren’t necessarily highly paid because of their service delivery, but rather their responsibility level and training. Many who were supportive also thought this would be one way of having a more financially sustainable medical workforce, and overall numbers of consultants would decrease.

Others, however, disagreed believing that consultants were more efficient due to their experience – allowing them to see more patients more quickly and offer value for money. Resident doctors also spoke of concerns about breaking an unspoken contract that you enter medical school to ultimately become a consultant or GP.

When asked the question to what extent do you agree/disagree on how the role of a doctor may need to change

• 74.5% of respondents agreed, and
• 15.3% disagreed that

"The role will focus on managing complex cases and prevention, with more consultant-led care’."

There was high agreement across all groups that there needs to be flexibility in career pathways and alternative routes and roles rather than just consultant or GP.

Survey responses to indicate agreement with statement: Not all doctors wish to assume the role of consultant and/or GP. There should be focus on ensuring flexible career pathways and ensuring SAS and locally employed roles are valued and respected by both clinical professions and public.

Responses by type of doctor indicating agreement

• Clinical academics: 81%
• Consultants: 89.7%
• SAS & specialists: 96.3%
• GPs: 86%
• Clinical leaders: 84%
• Resident doctors: 87.3%

There was also a split of views over the use, or increased use, of wider MDT members in the delivery of services. Some doctors felt that other professions are well placed to deliver the bulk of day-to-day activity. GPs typically voiced concerns that increasing the use of MDT members may reduce continuity of care and Consultants typically spoke of concerns over reducing the opportunity for trainee doctors to develop clinical judgement and risk taking. There were also concerns that if doctors only take on the complex caseload this would increase to burnout.

"I have serious concerns about the substitution of doctors with other roles such as Nurse Consultants, Physician Assistants. At the end of the day, they do not hold a medical degree and cannot act at a level of equivalence. I also worry about the responsibility placed on doctors to make decisions based on the assessment of roles such as these." - Core trainee, survey respondent

"I have seen how getting more specialist nurses, for example, who are prescribers or radiographers with extra training can really help with reducing pressures on the service and on the existing staff." - Consultant, focus group attendee

There were also discussions that undergraduate recruitment should focus on social skills and interprofessional learning rather than academic achievement given the increasingly important role of relationships with patients and other professionals in the delivery of care.

Discussions about how the workforce should be supported through this evolution of the doctor’s role focused on needing to be involved in decision making, investment in IT to allow for greater productivity, feeling valued and long-term workforce planning